Scribe America Outpatient Exam Bundle Graded A+

ICD - Answer-international classification of diseases ptosis - Answer-is a drooping or falling of the upper eyelid. The drooping may be worse after being awake longer when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to the co...

SOAP - Answer-subjective, objective, assessment, plan subjective - Answer-based on the patient's feeling (HPI and ROS) Objective - Answer-Factual information from provider (PE) History of Present Illness (1 simple def) - Answer-The story of the patient's chief complaint Review of Sy...

What is the assessment? - Answer-diagnoses + summary of the visit used by the provider as a "note to self" for any follow ups What is ALWAYS included in the assessment? - Answer-age/sex of the patient Diagnosis or differential diagnosis (ddx) What else could be included in the assessment? ...

Abrasion - Answer-Scrape of the skin due to something abrasive Acute - Answer-New, usually of rapid onset and of concern, opposite of chronic Ambulate - Answer-To walk from place to place Anterior - Answer-Located towards the front of the body Artery - Answer-Blood vessel carrying blood ...

Subjective - Answer-from patient, HPI, ROS Objective - Answer-from physician, PE, Lab, imaging Pain - Answer-subjective from patient Tenderness - Answer-objective from physician Benign - Answer-Normal, nothing of concern Acute - Answer-New onset, <3 months Chronic - Answer-Long ...

Strain - Answer-Stretching or tearing of the muscles or tendons Tear - Answer-Partial disruption Rupture - Answer-Complete disruption with separation of the two ends (retraction) Sprain - Answer-Stretching or tearing of the ligaments of a joint, ranges from partial to complete tears Subl...

What is PE? - Answer-PE is the objective evaluation of patient's anatomy, physiology and current function by physician. Why is PE important? - Answer-PE information can aid in arriving at final Dx as well as determine treatment. 5 vital signs - Answer-Heart rate (HR) blood pressure(BP) resp...

Diagnosis - Answer-What the physician has determined to be the most likely cause of the patient's symptoms Assessment - Answer-A list of the patient's current diagnoses Plan - Answer-The currently laid out course of action to address the patient's condition Prognosis - Answer-A forecast ...

neonate - Answer-less than 4 weeks infant - Answer-1 month to 1 year toddler - Answer-1 year to 4 years pre-schoolers - Answer-3 years to 5 years kindergartener - Answer-age 5 first grader - Answer-age 6 second grader - Answer-age 7 third grader - Answer-age 8 middle schooler...

2.0 Comorbidity - Answer-the simultaneous presence of two chronic diseases 2.0 Etiology - Answer-the cause of a disease 2.0 Systole - Answer-phase of the heartbeat during which muscle is relaxed and the heart fills with blood; measures the pressure in he arteries when the heart CONTRACTS (beat...

subjective vs. objective - Answer-feeling vs. fact pain vs. tenderness - Answer-patients feelings vs. physician's assessment benign - Answer-normal, nothing of concern acute vs. chronic - Answer-new onset vs. long standing (3 mos. or longer) baseline - Answer-an individual's normal sta...

Subjective - Answer-Feeling (patient) Objective - Answer-Fact (provider) Benign - Answer-Normal, nothing of concern Acute - Answer-New onset Chronic - Answer-Long-standing Baseline - Answer-An individual's normal state of being Auscultation - Answer-Listening with a stethoscope ...