Scribe America OP Final practice questions with correct answers

Scribes CAN -document the history, physical exam, results, procedures, and physician consults -access and document laboratory results and radiology findings -access and display X-rays for the physician to review -locate and obtain PMHx, previous charts, past results, and recent studies -record physician interpretations of X-rays and ECG's Scribes CANNOT -touch patients -write orders or prescriptions -give verbal orders -partake in any activity that may affect patient health or outcome -sign or authenticate any chart or record -handle bodily fluids or specimens 00:37 01:33 Chief Complaint (CC) the main reason for the patient's visit EMR/EHR Electronic Medical Record/Electronic Health Record Subjective Feeling Objective Factual finding from the provider Pain Patient's feeling or discomfort Tenderness Doctor's finding of reproducible pain Acute New onset, likely concerning Chronic Long-standing, not of direct concern New Patient A patient that has never been seen at the clinic, or was seen greater than 3 years ago No previous records Longer visit Detailed chart Established Patient A patient that has been seen at the clinic (by any provider) within the last 3 years Previous records available Shorter visit Concise chart 00:02 01:33 Diagnostic Visit New problem Chief complaint (CC): new symptom Goal is to determine the cause of the problem and appropriate treatment Health Management Check-up Chief Complaint (CC): Routine physical or management of chronic problem(s) Goal is preventative care and/or assessing progress of ongoing medical problems Hyperlipidemia What is the medical term for, "high cholesterol." HINT: Use the full medical term, not the abbreviation. Spelling counts! Diagnostic visits Which type of visits will typically have Differential Diagnoses (DDx)? adenoidectomy The patient reportedly had an adenoid removal in 2016. What do you document in her PSHx? Type II DM, CAD, cancer The patient states that she is hard of hearing and she has Type II DM. She reports that her mother also had Type II DM, CAD, and cancer. Her step-father has HTN. Which of the following do you include in the FHx? No The patient reports nausea after taking penicillin. Should you list penicillin as a true allergy in the chart? Myocardial Infarction The patient is a 50 male with a past medical history of CAD, hyperlipidemia, hypertension, and smoking. He presents to the clinic with acute chest pain. Based on the patient's risk factors, which diagnosis is the doctor most concerned for? Quit smoking Exercise Manage stress What are ways to manage CAD? Pancreatitis, CAD, CVA Which of the following conditions can be caused by untreated HLD? (Select all that apply) CABG (Coronary Artery Bypass Graft) What is the medical abbreviation for, "heart bypass or open heart surgery?" USE THE ABBREVIATION, not the full medical term. ACE Inhibitors (Lisinopril) Ca Channel Blockers (Norvasc/amlodipine) Diuretics (HCTZ) Which of the following medications can be used to treat Hypertension? 3 days A 12 year old female presents to your clinic for a constant cough for the last 3 days. What is the onset? ROS (review of systems) A patient comes in for right arm pain but also notes a random mild toothache. The toothache belongs in the: Sore throat Rhinorrhea Myalgias 32 y/o pt presents with a dry cough for 2 weeks. Also c/o sore throat, rhinorrhea, and myalgias. He denies headache or neck pain. Reports chronic right hip from a sports injury and this has been worse with the colder weather. Which of the following would be associated symptoms? (select all that apply) Respiratory What ROS system would include hemoptysis, the medical term for "coughing up blood"? Chief complaint and onset Which is the first item in the formula for writing an HPI? McBurney's point tenderness Which of the following physical exam signs would raise concern for an appendicitis? Yes Is there a contradiction in the following exam: Regular rate and rhythm. Bradycardia. Heart sounds are normal. Pale Conjunctiva Anemia Scleral Icterus Liver Failure Dry mucous membranes Dehydration Jugular venous distention CHF Irregularly irregular rhythm Atrial fibrillation Inspiratory wheeze Asthma Well hydrated If your physician states that the patient has dry mucous membranes (DMM) on physical exam, which of the following items would want to REMOVE from the constitutional section of the exam? Acusultation Listening with a stethoscope Cachectic Very thin, emaciated, malnourished Palpation The act of pressing on an area of the body Medial Closer to the midline of the body Diffuse Widespread, over a large area of the body Distress Physician's appreciation of the patient's discomfort Follow up at your clinic What is the last line of the plan? True True or False: If the provider has not determined a definitive diagnosis, the assessment will typically include a list of differential diagnoses. Age and sex Diagnosis Physical exam Results Which details are included in the following assessment: "Patient is a 34 y/o female with Acute Pharyngitis. There was post nasal drainage on exam, with no visible signs of tonsillar exudate. Rapid strep swab was negative." Assessment & Plan What does A&P stand for? Maintain patient privacy and confidentiality HIPAA is a set of laws designed to ________. No If a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered chronic? Renal failure Coronary artery disease (CAD) Congestive heart failure (CHF) Which of the following can be caused by HTN? Hemorrhagic cerebrovascular accident (CVA) Hypertension causes high pressure through the vessels of the brain. This can cause weakening of arteries, leading to a potential rupture and ____. False True or False: Type 1 Diabetics can manage their condition with oral medication alone. Lantus Humalog Insulin medications Diabetes Mellitus (DM) Low carb diet Hyperlipidemia (HLD) Low fat diet Hypertension (HTN) low sodium diet Cardiovascular system It is not uncommon to see comorbid DM, HTN, and HLD in the same patient. What is one body system that is affected by all three? Smoking Hypertension (HTN) Hyperlipidemia (HLD) Diabetes Mellitus (DM) FHx 50 years old What are the 5 risk factors for Coronary Artery Disease (CAD)? Angioplasty A cardiologist does a cardiac catheterization and decides the patient is at risk of MI due to CAD. What is the least invasive procedure the cardiologist can perform? S - Subjective O - Objective A - Assessment P - Plan What does SOAP stand for? Visit to discuss treatment options for low hemoglobin Fix the following chief complaint to make it billable: Results of bloodwork (low hemoglobin) The patient's pain is worse with palpation of the area If the patient says, "It hurts when I touch it," what would you write in the HPI? Chronological Structure (with recap) Which HPI structure is best to use for a complex patient with multiple co-morbidities and a recent work-up? The patient's blood pressure is 150/92 The provider states that the patient as jaundice The patient's triglycerides measure high at 550mg/dL Which of the following are considered objective? Palpation Auscultation Inspection Which of the following techniques are used by the provider during a physical exam? True True or false: During the physical exam, a scribe needs to watch what the provider is doing as well as listen to what the provider is saying in order to document accurately. Somnolent Which of these physical exam findings would contradict a constitutional finding of "alert?" Rhinitis A physical exam finding of "boggy turbinates" in the nose indicates which likely problem?