1
Scribe America OP Final Exam . Questions with
correct answers. A+ GRADED.
established patient - ...(ANSWERS)....Previous records available from last 3 years,
shorter visit, concise chart
Diagnostic visit - ...(ANSWERS)....New problem, chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management - ...(ANSWERS)....check up, CC: routine physical or
management of chronic problems, goal is preventative care and/or assessing
progress of ongoing medical problems
Clinic Flow - ...(ANSWERS)....1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - ...(ANSWERS)....chief complaint
vital signs
height, weight, BMI
Smoking Status
, 2
What goes in the History and Physical (H&P) - ...(ANSWERS)....HPI, ROS, PE
DDx - ...(ANSWERS)....differential diagnosis
Patient says high blood pressure - ...(ANSWERS)....Hypertension (HTN)
Patient says high cholesterol - ...(ANSWERS)....Hyperlipidemia (HLD)
Patient says thyroid problem - ...(ANSWERS)....Usually Hypothyroidism,
sometimes Hyperthyroidism
Patient says diabetes - ...(ANSWERS)....Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - ...(ANSWERS)....Non-Insulin
Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" - ...(ANSWERS)....Insulin Dependent
Diabetes Mellitus (IDDM)
Patient says heart disease - ...(ANSWERS)....Coronary Artery Disease (CAD)
Patient says heart attack - ...(ANSWERS)....Myocardial Infarction (MI) and CAD
, 3
Patient says heart failure - ...(ANSWERS)....Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - ...(ANSWERS)....arrhythmia
Patient says murmur - ...(ANSWERS)....heart murmur
Patient says episodes of abnormally fast/racing heartbeat -
...(ANSWERS)....supraventricular tachycardia (SVT)
Patient says asthma - ...(ANSWERS)....asthma
Patient says Emphysema/Chronic Bronchitis - ...(ANSWERS)....Chronic Obstructive
Pulmonary Disease (COPD)
Patient says blood clot in lung - ...(ANSWERS)....Pulmonary Embolism (PE)
Patient says pneumonia - ...(ANSWERS)....Pneumonia (PNA)
Patient says reflux - ...(ANSWERS)....Gastroesophageal Reflux Disease (GERD)
Patient says ulcer - ...(ANSWERS)....Gastric Ulcer or Peptic Ulcer Disease (PUD)
Scribe America OP Final Exam . Questions with
correct answers. A+ GRADED.
established patient - ...(ANSWERS)....Previous records available from last 3 years,
shorter visit, concise chart
Diagnostic visit - ...(ANSWERS)....New problem, chief complaint: new symptom,
goal is to determine the cause of the problem and appropriate treatment
health management - ...(ANSWERS)....check up, CC: routine physical or
management of chronic problems, goal is preventative care and/or assessing
progress of ongoing medical problems
Clinic Flow - ...(ANSWERS)....1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - ...(ANSWERS)....chief complaint
vital signs
height, weight, BMI
Smoking Status
, 2
What goes in the History and Physical (H&P) - ...(ANSWERS)....HPI, ROS, PE
DDx - ...(ANSWERS)....differential diagnosis
Patient says high blood pressure - ...(ANSWERS)....Hypertension (HTN)
Patient says high cholesterol - ...(ANSWERS)....Hyperlipidemia (HLD)
Patient says thyroid problem - ...(ANSWERS)....Usually Hypothyroidism,
sometimes Hyperthyroidism
Patient says diabetes - ...(ANSWERS)....Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - ...(ANSWERS)....Non-Insulin
Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" - ...(ANSWERS)....Insulin Dependent
Diabetes Mellitus (IDDM)
Patient says heart disease - ...(ANSWERS)....Coronary Artery Disease (CAD)
Patient says heart attack - ...(ANSWERS)....Myocardial Infarction (MI) and CAD
, 3
Patient says heart failure - ...(ANSWERS)....Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - ...(ANSWERS)....arrhythmia
Patient says murmur - ...(ANSWERS)....heart murmur
Patient says episodes of abnormally fast/racing heartbeat -
...(ANSWERS)....supraventricular tachycardia (SVT)
Patient says asthma - ...(ANSWERS)....asthma
Patient says Emphysema/Chronic Bronchitis - ...(ANSWERS)....Chronic Obstructive
Pulmonary Disease (COPD)
Patient says blood clot in lung - ...(ANSWERS)....Pulmonary Embolism (PE)
Patient says pneumonia - ...(ANSWERS)....Pneumonia (PNA)
Patient says reflux - ...(ANSWERS)....Gastroesophageal Reflux Disease (GERD)
Patient says ulcer - ...(ANSWERS)....Gastric Ulcer or Peptic Ulcer Disease (PUD)
