SCRIBEAMERICA OUTPATIENT FINAL EXAM
QUESTIONS AND ANSWERS VERIFIED 100%
CORRECT |AGRADE
Name four items that can be included in a patient's plan: - ANSWER- 1.
Medication and treatment for each diagnosis
2. Prescriptions ordered today
3. Studies or tests ordered today
4. Follow-up with other healthcare professionals
5. Follow-up here for next appointment
Name three items that can be included in a plan for a pt with DM? - ANSWER-
Strictly follow metformin regimen as prescribed
Continue adherence to diabetic diet
If HbA1C has not improved next visit, will start insulin.
Name three items that can be included in a plan for a pt with HTN? - ANSWER-
Continue taking HCTZ as prescribed
Continue BP log
Will refill HCTZ today
Follow-up in 3 months to check BP
True/False: The scribe should only include results that are new since the last visit?
- ANSWER- True
What three items should you include when summarizing a test result? - ANSWER-
Name of test, result of test, and why the test was ordered
Name four examples of lab results: - ANSWER- CBC, lipid panel, urinalysis,
pregnancy
Name four types of imaging studies: - ANSWER- x-ray, CT, MRI, ultrasound (US)
,What is the structure of a simple statement assessment? - ANSWER- Age and sex,
PMHx if relevant, and diagnosis
Name four items besides diagnosis that are included in a comprehensive summary
assessment - ANSWER- DDx if relevant, Summary of PMHx, summary of PE,
Chief Complaint, Prognosis
True/False: A diagnosis or a differential diagnosis will always be listed in the
assessment. - ANSWER- TRUE
Name three things you can document in the General/Constitutional section for a
normal peds exam? - ANSWER- Alert, interactive, smiling, cries with tears
Why is it important that the patient is producing tears if crying? - ANSWER- That
can denote hydration
What does A&OX4 mean? - ANSWER- Alert and oriented times 4 (person, place,
time, or situation)
Name two signs of respiratory distress in a peds pt. - ANSWER- Wheezing,
stridor, nasal flares, retractions
Normal PE findings for Cardiovascular system - ANSWER- RRR, heart sounds
normal
Name normal PE findings for the pulmonary system - ANSWER- No respiratory
distress, CTAB (clear to auscultation bilaterally)
Name normal PE findings for the abdominal system - ANSWER- Soft, non tender
Name normal PE findings for the neurological system - ANSWER- A&OX4,
normal speech, Non-focal neuro exam
Name abnormal PE findings for the skin system - ANSWER- pallor, cyanosis,
jaundice, diaphoresis, abrasion, laceration
, Name abnormal PE findings for the psychiatric system - ANSWER- tearful,
anxious, depressed, paranoid, tangential speech
Name abnormal PE findings for the pulmonary system - ANSWER- rales,
wheezes, tachypnea, accessory muscle use, rhonchi, diminished breath sounds,
mild/moderate/severe respiratory distress
CVA tenderness - ANSWER- tenderness to percussion over a specific point in the
flank where the kidneys lie (back)
Paraspinal tenderness - ANSWER- muscular tenderness around the spine (back)
Pitting Pedal edema - ANSWER- Swelling of lower extremities, measured on a
scale of trace to 4+ (musculoskeletal/ extremities)
Melena - ANSWER- black stool on glove
Urticaria - ANSWER- Hives/wheals (skin)
Somnolent - ANSWER- unusually sleepiness (neurological)
5/5 strength in bilateral upper extremities - ANSWER- normal motor strength in
the upper extremities (neurological)
2+ patellar reflexes - ANSWER- knee reflexes intact and normal (neurological)
EOM palsy - ANSWER- shifting of the pupils back and forth horizontally - a sign
of benign positional vertigo (neurological)
Name 10 body systems - ANSWER- Constitutional, HEENT, cardiovascular,
respiratory, pulmonary, neurological, gastrointestinal, genitourinary,
musculoskeletal, skin, endocrine, hematologic/lymph, immunologic, psychiatric.
Name three types of HPI structures - ANSWER- Single-complaint, multiple-
complaint, and chronological
QUESTIONS AND ANSWERS VERIFIED 100%
CORRECT |AGRADE
Name four items that can be included in a patient's plan: - ANSWER- 1.
Medication and treatment for each diagnosis
2. Prescriptions ordered today
3. Studies or tests ordered today
4. Follow-up with other healthcare professionals
5. Follow-up here for next appointment
Name three items that can be included in a plan for a pt with DM? - ANSWER-
Strictly follow metformin regimen as prescribed
Continue adherence to diabetic diet
If HbA1C has not improved next visit, will start insulin.
Name three items that can be included in a plan for a pt with HTN? - ANSWER-
Continue taking HCTZ as prescribed
Continue BP log
Will refill HCTZ today
Follow-up in 3 months to check BP
True/False: The scribe should only include results that are new since the last visit?
- ANSWER- True
What three items should you include when summarizing a test result? - ANSWER-
Name of test, result of test, and why the test was ordered
Name four examples of lab results: - ANSWER- CBC, lipid panel, urinalysis,
pregnancy
Name four types of imaging studies: - ANSWER- x-ray, CT, MRI, ultrasound (US)
,What is the structure of a simple statement assessment? - ANSWER- Age and sex,
PMHx if relevant, and diagnosis
Name four items besides diagnosis that are included in a comprehensive summary
assessment - ANSWER- DDx if relevant, Summary of PMHx, summary of PE,
Chief Complaint, Prognosis
True/False: A diagnosis or a differential diagnosis will always be listed in the
assessment. - ANSWER- TRUE
Name three things you can document in the General/Constitutional section for a
normal peds exam? - ANSWER- Alert, interactive, smiling, cries with tears
Why is it important that the patient is producing tears if crying? - ANSWER- That
can denote hydration
What does A&OX4 mean? - ANSWER- Alert and oriented times 4 (person, place,
time, or situation)
Name two signs of respiratory distress in a peds pt. - ANSWER- Wheezing,
stridor, nasal flares, retractions
Normal PE findings for Cardiovascular system - ANSWER- RRR, heart sounds
normal
Name normal PE findings for the pulmonary system - ANSWER- No respiratory
distress, CTAB (clear to auscultation bilaterally)
Name normal PE findings for the abdominal system - ANSWER- Soft, non tender
Name normal PE findings for the neurological system - ANSWER- A&OX4,
normal speech, Non-focal neuro exam
Name abnormal PE findings for the skin system - ANSWER- pallor, cyanosis,
jaundice, diaphoresis, abrasion, laceration
, Name abnormal PE findings for the psychiatric system - ANSWER- tearful,
anxious, depressed, paranoid, tangential speech
Name abnormal PE findings for the pulmonary system - ANSWER- rales,
wheezes, tachypnea, accessory muscle use, rhonchi, diminished breath sounds,
mild/moderate/severe respiratory distress
CVA tenderness - ANSWER- tenderness to percussion over a specific point in the
flank where the kidneys lie (back)
Paraspinal tenderness - ANSWER- muscular tenderness around the spine (back)
Pitting Pedal edema - ANSWER- Swelling of lower extremities, measured on a
scale of trace to 4+ (musculoskeletal/ extremities)
Melena - ANSWER- black stool on glove
Urticaria - ANSWER- Hives/wheals (skin)
Somnolent - ANSWER- unusually sleepiness (neurological)
5/5 strength in bilateral upper extremities - ANSWER- normal motor strength in
the upper extremities (neurological)
2+ patellar reflexes - ANSWER- knee reflexes intact and normal (neurological)
EOM palsy - ANSWER- shifting of the pupils back and forth horizontally - a sign
of benign positional vertigo (neurological)
Name 10 body systems - ANSWER- Constitutional, HEENT, cardiovascular,
respiratory, pulmonary, neurological, gastrointestinal, genitourinary,
musculoskeletal, skin, endocrine, hematologic/lymph, immunologic, psychiatric.
Name three types of HPI structures - ANSWER- Single-complaint, multiple-
complaint, and chronological
