ScribeAmerica Outpatient Final Exam with A+
Rating Answers
subjective vs objective - ANSWER-feeling vs fact
pain vs tenderness - ANSWER-patients feeling vs physicians assessment
benign - ANSWER-normal, nothing of concern
acute vs chronic - ANSWER-new onset vs long standing
baseline - ANSWER-an individuals normal state of being
ausculation - ANSWER-listening to sound with a stethoscope
palpation - ANSWER-act of pressing on an area (by the physician)
inpatient - ANSWER-admitted to the hospital overnight
outpatient - ANSWER-seen and sent home the same day
chief complaint - ANSWER-main reason for the patients visit
meaningful use - ANSWER-set of government mandated criteria that must be obtained
for every patient
medical decision making - ANSWER-physicians though process
Scribes can... - ANSWER-document history, physician exam, results, procedures.
access and document laboratory and radiology findings. locate and obtain PMHx,
previous charts, past results.
Scribes cannot... - ANSWER-partake in any activity that may affect patient health, touch
patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic
orders.
are physician assistants and nurse practitioners considered medical providers? -
ANSWER-YES
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWER-False
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER-
Established
,a patient made an appointment because she developed a rash a few days ago. what
type of visit would this be? - ANSWER-diagnostic
diagnostic visits consist of - ANSWER-new problems, new symptoms
health management visits consist of - ANSWER-check-ups, management visits
a patient has an appointment for management of her diabetes. what type of visit would
this be? - ANSWER-health management
who is the first person to speak with the patient after he/she is place in a room? -
ANSWER-Nurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWER-Chief
complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status
What does H&P abbreviate and who performs this evaluation? - ANSWER-history and
physical, performed by the provider
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-nope.
what information will be included in the patient's plan? give 3 examples. - ANSWER-F/U
for specialist, instructions for lifestyle, F/U for next routine appointment
name the 8 elements of the HPI - ANSWER-Location, Quality, Severity, Context,
Timing, Duration, Associated signs and symptoms, Modifying factors
polydipsia - ANSWER-excessive thirst
paresthesia - ANSWER-sensation of tingling or numbness
anticoagulant - ANSWER-a drug that prevents blood clotting
chronic illness - ANSWER-longer than 3 months
if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms
considered chronic? - ANSWER-No
Having multiple comorbidities increases the __________ of patient care - ANSWER-
complexity
List two ways comorbidity increases complexity? - 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 - ANSWER-the inadequacy of insulin in controlling the blood glucose
level (insulin resistance)
diabetes risk factors - ANSWER-obesity, high carb diet, lack of exercise, HTN, HLD,
FHx
chief complaint of diabetes - ANSWER-weight loss or gain. polyuria, polydipsia, blurred
vision, fatigue
physical exam diabetes - ANSWER-distal paresthesias, pedal edema, weight change
diagnosis of diabetes - ANSWER-fasting blood glucose, hemoglobin A1c
Diseases caused by diabetes - ANSWER-peripheral neuropathy, PVD, Diabetic
retinopathy, renal failure, cardiac disease
non-pharmacological management for DM - ANSWER-weight loss, low-carb diet,
exercise, blood glucose log
you can take oral medication for what kind of diabetes? - ANSWER-type 2 (you can do
insulin and oral meds)
what kind of medications can you take for DM? - ANSWER-Injected: Humalog, Lantus
Oral: Metformin, Glyburide
with sliding scale insulin treatment, the patient adjusts the dosage of insulin based
on____________. - ANSWER-current glucose
Name two body systems that would be at increased risk of failure if the patient had both
HTN and DM. - ANSWER-renal and cardiovascular
SOAP - ANSWER-subjective, objective, assessment, plan
History of Present Illness (HPI) - ANSWER-story of the patient's chief complaint
What are the 3 primary methods of structuring an outpatient HPI? - 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? - 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? - ANSWER-Who
Rating Answers
subjective vs objective - ANSWER-feeling vs fact
pain vs tenderness - ANSWER-patients feeling vs physicians assessment
benign - ANSWER-normal, nothing of concern
acute vs chronic - ANSWER-new onset vs long standing
baseline - ANSWER-an individuals normal state of being
ausculation - ANSWER-listening to sound with a stethoscope
palpation - ANSWER-act of pressing on an area (by the physician)
inpatient - ANSWER-admitted to the hospital overnight
outpatient - ANSWER-seen and sent home the same day
chief complaint - ANSWER-main reason for the patients visit
meaningful use - ANSWER-set of government mandated criteria that must be obtained
for every patient
medical decision making - ANSWER-physicians though process
Scribes can... - ANSWER-document history, physician exam, results, procedures.
access and document laboratory and radiology findings. locate and obtain PMHx,
previous charts, past results.
Scribes cannot... - ANSWER-partake in any activity that may affect patient health, touch
patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic
orders.
are physician assistants and nurse practitioners considered medical providers? -
ANSWER-YES
T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWER-False
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER-
Established
,a patient made an appointment because she developed a rash a few days ago. what
type of visit would this be? - ANSWER-diagnostic
diagnostic visits consist of - ANSWER-new problems, new symptoms
health management visits consist of - ANSWER-check-ups, management visits
a patient has an appointment for management of her diabetes. what type of visit would
this be? - ANSWER-health management
who is the first person to speak with the patient after he/she is place in a room? -
ANSWER-Nurse/MA
What are the meaningful use requirements the nurse/MA will obtain? - ANSWER-Chief
complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status
What does H&P abbreviate and who performs this evaluation? - ANSWER-history and
physical, performed by the provider
Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-nope.
what information will be included in the patient's plan? give 3 examples. - ANSWER-F/U
for specialist, instructions for lifestyle, F/U for next routine appointment
name the 8 elements of the HPI - ANSWER-Location, Quality, Severity, Context,
Timing, Duration, Associated signs and symptoms, Modifying factors
polydipsia - ANSWER-excessive thirst
paresthesia - ANSWER-sensation of tingling or numbness
anticoagulant - ANSWER-a drug that prevents blood clotting
chronic illness - ANSWER-longer than 3 months
if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms
considered chronic? - ANSWER-No
Having multiple comorbidities increases the __________ of patient care - ANSWER-
complexity
List two ways comorbidity increases complexity? - 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 - ANSWER-the inadequacy of insulin in controlling the blood glucose
level (insulin resistance)
diabetes risk factors - ANSWER-obesity, high carb diet, lack of exercise, HTN, HLD,
FHx
chief complaint of diabetes - ANSWER-weight loss or gain. polyuria, polydipsia, blurred
vision, fatigue
physical exam diabetes - ANSWER-distal paresthesias, pedal edema, weight change
diagnosis of diabetes - ANSWER-fasting blood glucose, hemoglobin A1c
Diseases caused by diabetes - ANSWER-peripheral neuropathy, PVD, Diabetic
retinopathy, renal failure, cardiac disease
non-pharmacological management for DM - ANSWER-weight loss, low-carb diet,
exercise, blood glucose log
you can take oral medication for what kind of diabetes? - ANSWER-type 2 (you can do
insulin and oral meds)
what kind of medications can you take for DM? - ANSWER-Injected: Humalog, Lantus
Oral: Metformin, Glyburide
with sliding scale insulin treatment, the patient adjusts the dosage of insulin based
on____________. - ANSWER-current glucose
Name two body systems that would be at increased risk of failure if the patient had both
HTN and DM. - ANSWER-renal and cardiovascular
SOAP - ANSWER-subjective, objective, assessment, plan
History of Present Illness (HPI) - ANSWER-story of the patient's chief complaint
What are the 3 primary methods of structuring an outpatient HPI? - 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? - 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? - ANSWER-Who
