Scribe America Outpatient Final UPDATED
Exam Questions and CORRECT Answers
What are the meaningful use requirements the nurse/MA will obtain? - CORRECT
ANSWER - Chief complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking
status
What does H&P abbreviate and who performs this evaluation? - CORRECT ANSWER -
history and physical, performed by the provider
Is a differential diagnosis necessary for a health maintenance visit? - CORRECT ANSWER -
nope.
what information will be included in the patient's plan? give 3 examples. - CORRECT
ANSWER - F/U for specialist, instructions for lifestyle, F/U for next routine appointment
name the 8 elements of the HPI - CORRECT ANSWER - Location, Quality, Severity,
Context, Timing, Duration, Associated signs and symptoms, Modifying factors
polydipsia - CORRECT ANSWER - excessive thirst
paresthesia - CORRECT ANSWER - sensation of tingling or numbness
anticoagulant - CORRECT ANSWER - a drug that prevents blood clotting
chronic illness - CORRECT ANSWER - longer than 3 months
if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered
chronic? - CORRECT ANSWER - No
,Having multiple comorbidities increases the __________ of patient care - CORRECT
ANSWER - complexity
List two ways comorbidity increases complexity? - CORRECT ANSWER - -The treatment of
one disease may affect or contradict the treatment of the second
-Adverse drug interactions
-Compounding symptoms may lead to poor compliance with treatment plan (mo' drugs, mo'
problems)
-If both illnesses affect a specific organ system, the patient is at increased risk of organ failure
Type 2 diabetes - CORRECT ANSWER - the inadequacy of insulin in controlling the blood
glucose level (insulin resistance)
diabetes risk factors - CORRECT ANSWER - obesity, high carb diet, lack of exercise, HTN,
HLD, FHx
chief complaint of diabetes - CORRECT ANSWER - weight loss or gain. polyuria,
polydipsia, blurred vision, fatigue
physical exam diabetes - CORRECT ANSWER - distal paresthesias, pedal edema, weight
change
diagnosis of diabetes - CORRECT ANSWER - fasting blood glucose, hemoglobin A1c
Diseases caused by diabetes - CORRECT ANSWER - peripheral neuropathy, PVD, Diabetic
retinopathy, renal failure, cardiac disease
non-pharmacological management for DM - CORRECT ANSWER - weight loss, low-carb
diet, exercise, blood glucose log
, you can take oral medication for what kind of diabetes? - CORRECT ANSWER - type 2 (you
can do insulin and oral meds)
what kind of medications can you take for DM? - CORRECT ANSWER - Injected: Humalog,
Lantus
Oral: Metformin, Glyburide
with sliding scale insulin treatment, the patient adjusts the dosage of insulin based
on____________. - CORRECT ANSWER - current glucose
Name two body systems that would be at increased risk of failure if the patient had both HTN
and DM. - CORRECT ANSWER - renal and cardiovascular
SOAP - CORRECT ANSWER - subjective, objective, assessment, plan
History of Present Illness (HPI) - CORRECT ANSWER - story of the patient's chief
complaint
What are the 3 primary methods of structuring an outpatient HPI? - CORRECT ANSWER -
Single complaint formula, multiple complain formula, chronological complain formula
Which HPI structure is best to use for a complex patient with multiple comorbidities and a recent
work-up? - CORRECT ANSWER - chronological
What are four important details to include in the HPI of a patient who has been evaluated by
another healthcare provider for similar symptoms? - CORRECT ANSWER - Who ordered the
test (name and specialty), specific name of test, results, diagnosis given to patient.
review of systems - CORRECT ANSWER - Head-to-toe checklist of patient's symptoms
Exam Questions and CORRECT Answers
What are the meaningful use requirements the nurse/MA will obtain? - CORRECT
ANSWER - Chief complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking
status
What does H&P abbreviate and who performs this evaluation? - CORRECT ANSWER -
history and physical, performed by the provider
Is a differential diagnosis necessary for a health maintenance visit? - CORRECT ANSWER -
nope.
what information will be included in the patient's plan? give 3 examples. - CORRECT
ANSWER - F/U for specialist, instructions for lifestyle, F/U for next routine appointment
name the 8 elements of the HPI - CORRECT ANSWER - Location, Quality, Severity,
Context, Timing, Duration, Associated signs and symptoms, Modifying factors
polydipsia - CORRECT ANSWER - excessive thirst
paresthesia - CORRECT ANSWER - sensation of tingling or numbness
anticoagulant - CORRECT ANSWER - a drug that prevents blood clotting
chronic illness - CORRECT ANSWER - longer than 3 months
if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered
chronic? - CORRECT ANSWER - No
,Having multiple comorbidities increases the __________ of patient care - CORRECT
ANSWER - complexity
List two ways comorbidity increases complexity? - CORRECT ANSWER - -The treatment of
one disease may affect or contradict the treatment of the second
-Adverse drug interactions
-Compounding symptoms may lead to poor compliance with treatment plan (mo' drugs, mo'
problems)
-If both illnesses affect a specific organ system, the patient is at increased risk of organ failure
Type 2 diabetes - CORRECT ANSWER - the inadequacy of insulin in controlling the blood
glucose level (insulin resistance)
diabetes risk factors - CORRECT ANSWER - obesity, high carb diet, lack of exercise, HTN,
HLD, FHx
chief complaint of diabetes - CORRECT ANSWER - weight loss or gain. polyuria,
polydipsia, blurred vision, fatigue
physical exam diabetes - CORRECT ANSWER - distal paresthesias, pedal edema, weight
change
diagnosis of diabetes - CORRECT ANSWER - fasting blood glucose, hemoglobin A1c
Diseases caused by diabetes - CORRECT ANSWER - peripheral neuropathy, PVD, Diabetic
retinopathy, renal failure, cardiac disease
non-pharmacological management for DM - CORRECT ANSWER - weight loss, low-carb
diet, exercise, blood glucose log
, you can take oral medication for what kind of diabetes? - CORRECT ANSWER - type 2 (you
can do insulin and oral meds)
what kind of medications can you take for DM? - CORRECT ANSWER - Injected: Humalog,
Lantus
Oral: Metformin, Glyburide
with sliding scale insulin treatment, the patient adjusts the dosage of insulin based
on____________. - CORRECT ANSWER - current glucose
Name two body systems that would be at increased risk of failure if the patient had both HTN
and DM. - CORRECT ANSWER - renal and cardiovascular
SOAP - CORRECT ANSWER - subjective, objective, assessment, plan
History of Present Illness (HPI) - CORRECT ANSWER - story of the patient's chief
complaint
What are the 3 primary methods of structuring an outpatient HPI? - CORRECT ANSWER -
Single complaint formula, multiple complain formula, chronological complain formula
Which HPI structure is best to use for a complex patient with multiple comorbidities and a recent
work-up? - CORRECT ANSWER - chronological
What are four important details to include in the HPI of a patient who has been evaluated by
another healthcare provider for similar symptoms? - CORRECT ANSWER - Who ordered the
test (name and specialty), specific name of test, results, diagnosis given to patient.
review of systems - CORRECT ANSWER - Head-to-toe checklist of patient's symptoms
