ScribeAmerica Final Exam Top Ranked Study
Materials(A+ GRADE)
SOAP - ANSWER-subjective, objective, assessment, plan
Examples of subjective data - ANSWER-HPI, ROS, PHx (medical, surgical, social,
family
Examples of objective data - ANSWER-Physical exams, orders and results
Chief Complaint - ANSWER-The main reason for the patient's visit
EMR/EHR - ANSWER-Electronic Medical Record/Electronic Health Record
Subjective - ANSWER-Feeling
Objective - ANSWER-Factual information from provider
Pain - ANSWER-Feeling of discomfort
Tenderness - ANSWER-Doctor's finding of reproducible pain
Acute - ANSWER-New onset, likely concerning
Chronic - ANSWER-Long-standing, not of direct concern
Diagnostic Visit - ANSWER-New problem, chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - ANSWER-Check-up, Chief Complaint: Routine physical or
management of chronic problem(s), and Goal is preventative care and/or assessing
progress of ongoing medical problems
Clinic Flow - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Laboratory Studies - ANSWER-Bloodwork, Urainalysis, Microscopy, Cultures
Imaging Studies - ANSWER-EKG, X-Ray, CT, Ultrasound
Procedures - ANSWER-Sutures, Joint Reduction, Splints
, What are 3 things you should known about each disease? - ANSWER-Layman's term,
medical term, abbreviation
Hypertension - ANSWER-HTN
high cholesterol - ANSWER-Hyperlipidemia (HLD)
Diabetes - ANSWER-Diabetes Mellitus (DM)
Pill consumption for insulin - ANSWER-Non-Insulin Dependent Mellitus (NIDDM)
Shots of insulin - ANSWER-Insulin Dependent Diabetes Mellitus (IDDM)
Heart Disease - ANSWER-Coronary Artery Disease (CAD)
Heart Attack - ANSWER-Myocardial Infarction (MI)
Heart failure - ANSWER-Congestive Heart Failure (CHF)
Irregular heartbeat - ANSWER-arrhythmia
Emphysema or Chronic Bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease
(COPD)
Blood Clot in Lung - ANSWER-Pulmonary Embolism (PE)
Pnuemonia or lung infection - ANSWER-PNA
Reflux - ANSWER-Gastroesophageal Reflux Disease (GERD)
Ulcers - ANSWER-Gastric or Peptic Ulcer Disease (PUD)
Irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS)
Bladder infection - ANSWER-Urinary Tract Infection (UTI)
Kidney Infection - ANSWER-Pyelonephritis (Pyelo)
Dialysis helps treat - ANSWER-Chronic Kidney Disease (CKD)
Enlarged prostate - ANSWER-Benign Prostate Hypertrophy (BPH)
Stroke - ANSWER-Cerebrovascular Accident (CVA)
Blood clot in brain - ANSWER-ischemic stroke
Brain bleed - ANSWER-Hemorrhagic CVA
Materials(A+ GRADE)
SOAP - ANSWER-subjective, objective, assessment, plan
Examples of subjective data - ANSWER-HPI, ROS, PHx (medical, surgical, social,
family
Examples of objective data - ANSWER-Physical exams, orders and results
Chief Complaint - ANSWER-The main reason for the patient's visit
EMR/EHR - ANSWER-Electronic Medical Record/Electronic Health Record
Subjective - ANSWER-Feeling
Objective - ANSWER-Factual information from provider
Pain - ANSWER-Feeling of discomfort
Tenderness - ANSWER-Doctor's finding of reproducible pain
Acute - ANSWER-New onset, likely concerning
Chronic - ANSWER-Long-standing, not of direct concern
Diagnostic Visit - ANSWER-New problem, chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
Health Management Visit - ANSWER-Check-up, Chief Complaint: Routine physical or
management of chronic problem(s), and Goal is preventative care and/or assessing
progress of ongoing medical problems
Clinic Flow - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Laboratory Studies - ANSWER-Bloodwork, Urainalysis, Microscopy, Cultures
Imaging Studies - ANSWER-EKG, X-Ray, CT, Ultrasound
Procedures - ANSWER-Sutures, Joint Reduction, Splints
, What are 3 things you should known about each disease? - ANSWER-Layman's term,
medical term, abbreviation
Hypertension - ANSWER-HTN
high cholesterol - ANSWER-Hyperlipidemia (HLD)
Diabetes - ANSWER-Diabetes Mellitus (DM)
Pill consumption for insulin - ANSWER-Non-Insulin Dependent Mellitus (NIDDM)
Shots of insulin - ANSWER-Insulin Dependent Diabetes Mellitus (IDDM)
Heart Disease - ANSWER-Coronary Artery Disease (CAD)
Heart Attack - ANSWER-Myocardial Infarction (MI)
Heart failure - ANSWER-Congestive Heart Failure (CHF)
Irregular heartbeat - ANSWER-arrhythmia
Emphysema or Chronic Bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease
(COPD)
Blood Clot in Lung - ANSWER-Pulmonary Embolism (PE)
Pnuemonia or lung infection - ANSWER-PNA
Reflux - ANSWER-Gastroesophageal Reflux Disease (GERD)
Ulcers - ANSWER-Gastric or Peptic Ulcer Disease (PUD)
Irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS)
Bladder infection - ANSWER-Urinary Tract Infection (UTI)
Kidney Infection - ANSWER-Pyelonephritis (Pyelo)
Dialysis helps treat - ANSWER-Chronic Kidney Disease (CKD)
Enlarged prostate - ANSWER-Benign Prostate Hypertrophy (BPH)
Stroke - ANSWER-Cerebrovascular Accident (CVA)
Blood clot in brain - ANSWER-ischemic stroke
Brain bleed - ANSWER-Hemorrhagic CVA
