Scribe OP final Exam Study Guide Question
2025/2026 Graded A+
subjective vs objective - feeling vs. fact
H&P stands for _____ & ______ and is part of the ________ evaluation - history &
physical, provider
name two items you will include in the patient's plan - medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? - physical
exam
"I have high blood pressure" --> you would write.... - HTN
"I take shots for my diabetes" --> you would write.... - IDDM
"My doctor says my heart is failing." --> you would write.... - CHF
"I have acid reflux" --> you would write.... - GERD
"I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would
write.... - G: 3/ P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - TIA
heart bypass surgery - coronary artery bypass graft
breast removal surgery - mastectomy
gallbladder removed surgery - cholecystectomy
uterus removed surgery - tubal ligation
neck artery cleaned surgery - carotid endarterectomy
common general family histories that physicians frequently ask about - HTN, DM, CA
SHx Living Circumstances - lives alone, with family/friends, nursing home/assisted
living, hospice, homeless/shelter
Comorbidity - the simultaneous presence of two chronic diseases or conditions in a
patient
etiology - cause of disease
, systole - the phase of the heartbeat when the heart muscle contracts and pumps blood
from the chambers into the arteries.; pumping blood to the body
diastolic - phase of the heartbeat during which muscle is relaxed and the heart fills with
blood
diuretic - A substance that promotes the production of urine
paresthesia - sensation of tingling or numbness
polydipsia - excessive thirst
ischemia - loss of blood supply to tissue
anticoagulant - a drug that prevents blood clotting (blood thinner)
how long must a patient have a disease for it to be considered chronic? - 3 months
explain why patients with comorbidities are complex and give an example - -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
-if both illnesses affect a specific organ system, the patient is at increased risk of organ
failure
ex: might have DM and high BP
Complex patients often bill to a______level, so it's important to document thoroughly
and accurately - higher
label the following BP readings as hypotensive, normal, pre-hypertensive, or
hypertensive:
100/70
150/95
130/85 - normal, hypertensive, pre-hypertensive
patients with HTN often become symptomatic when the HTN is chronic and worsening.
Name two symptoms a patient with severe HTN may experience: - edema, HA, CP,
palpitations, blurred vision, epistaxis
giev three examples of non-pharmacological HTN management - BP log, Decreased
ETOH intake, low-sodium diet, smoking cessation, exercise
abbreviation of hydrochlorothiazide - HCTZ
2025/2026 Graded A+
subjective vs objective - feeling vs. fact
H&P stands for _____ & ______ and is part of the ________ evaluation - history &
physical, provider
name two items you will include in the patient's plan - medications, treatment
If the doctor tells you, "The lungs are clear," where would you document this? - physical
exam
"I have high blood pressure" --> you would write.... - HTN
"I take shots for my diabetes" --> you would write.... - IDDM
"My doctor says my heart is failing." --> you would write.... - CHF
"I have acid reflux" --> you would write.... - GERD
"I'm not pregnant. I have two children, but I miscarried my first pregnancy" --> you would
write.... - G: 3/ P:2 / A:1
"I had a mini-stroke last year" --> you would write.... - TIA
heart bypass surgery - coronary artery bypass graft
breast removal surgery - mastectomy
gallbladder removed surgery - cholecystectomy
uterus removed surgery - tubal ligation
neck artery cleaned surgery - carotid endarterectomy
common general family histories that physicians frequently ask about - HTN, DM, CA
SHx Living Circumstances - lives alone, with family/friends, nursing home/assisted
living, hospice, homeless/shelter
Comorbidity - the simultaneous presence of two chronic diseases or conditions in a
patient
etiology - cause of disease
, systole - the phase of the heartbeat when the heart muscle contracts and pumps blood
from the chambers into the arteries.; pumping blood to the body
diastolic - phase of the heartbeat during which muscle is relaxed and the heart fills with
blood
diuretic - A substance that promotes the production of urine
paresthesia - sensation of tingling or numbness
polydipsia - excessive thirst
ischemia - loss of blood supply to tissue
anticoagulant - a drug that prevents blood clotting (blood thinner)
how long must a patient have a disease for it to be considered chronic? - 3 months
explain why patients with comorbidities are complex and give an example - -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
-if both illnesses affect a specific organ system, the patient is at increased risk of organ
failure
ex: might have DM and high BP
Complex patients often bill to a______level, so it's important to document thoroughly
and accurately - higher
label the following BP readings as hypotensive, normal, pre-hypertensive, or
hypertensive:
100/70
150/95
130/85 - normal, hypertensive, pre-hypertensive
patients with HTN often become symptomatic when the HTN is chronic and worsening.
Name two symptoms a patient with severe HTN may experience: - edema, HA, CP,
palpitations, blurred vision, epistaxis
giev three examples of non-pharmacological HTN management - BP log, Decreased
ETOH intake, low-sodium diet, smoking cessation, exercise
abbreviation of hydrochlorothiazide - HCTZ
