Scribe America Final Outpatient Exam with complete solutions

HTN CC - ANSWER-asymptomatic HLD CC - ANSWER-asymptomatic DM CC - ANSWER-polyuria, polydipsia CAD CC - ANSWER-CP or pressure Asthma CC - ANSWER-SOB, wheezing How do you diagnose HTN? - ANSWER-Check BP How do you diagnose HLD? - ANSWER-Check bloodwork How do you diagnose DM? - ANSWER-Fasting blood glucose, HA1C How do you diagnose HLD? - ANSWER-Check blood work for LDL levels How do you diagnose CAD? - ANSWER-Cardiac Catheterization by cardiologist How do you diagnose asthma? - ANSWER-Peak Flow Testing How is Peak Flow measured? - ANSWER-Liters/Minute In what quadrant is the appendix located? - ANSWER-RLQ In what quadrant is the gallbladder located? - ANSWER-RUQ In what quadrant is the diverticuli located? - ANSWER-LLQ What do you test to find out if person has pancreatitis? - ANSWER-Lipase Weakness - ANSWER-Peristesia Co morbidity - ANSWER-The presence of two or more chronic conditions Etiology - ANSWER-The cause of a disease The relaxed phase of the heartbeat? - ANSWER-Diastolic Excessive Thirst? - ANSWER-Polydipsia Anticoagulant - ANSWER-A drug that prevents blood clotting How long must a patient have a disease for it to be considered chronic? - ANSWER-3 months Explain why patients with comorbidities are complex and give an example? - ANSWER-The treatment of one disease may contradict the treatment of the second, such as one medicine making their other illness worse. Complex patients often bill to a HIGHER or LOWER level? - ANSWER-Higher 100/70 BP reading. What is this? - ANSWER-Normal 150/95 BP reading. What is this? - ANSWER-Hypertensive 130/85 BP reading. What is this? - ANSWER-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? - ANSWER-Vision Loss, Epistaxis Give three examples of non-pharmacological HTN management - ANSWER-low sodium diet, decreased EtOH intake and exercise What is the abbreviation for hydrochlorothiazide - ANSWER-HCTZ The majority of diabetes patients have Type I or II diabetes? - ANSWER-Type II What are three common symptoms of diabetes? - ANSWER-Polyuria, Polydipsia, Fatigue Name one disease that can be caused by diabetes and explain how chronic hyperglycemia contributes to it's etiology? - ANSWER-Diabetic Retinopathy, damage to the small vessels of the eyes can cause them to hemorrhage, leading to blurred vision. Both Type I and Type II diabetes can be treated with insulin. Which type can also be treated with oral medication? - ANSWER-Type II Which mediation is preferred for someone with mild, new onset, type II DM: Metformin or Humalog? Why? - ANSWER-Metformin. Sometimes Type II diabetes can be treated with just oral medication Name 3 risk factors of HLD - ANSWER-Obesity, physical inactivity, FHx Why is HDL considered good cholesterol? - ANSWER-It's able to remove cholesterol from artery plaques and recycle it back to the liver. CAD and MI can be caused the HLD due to atherosclerosis of the _________ arteries - ANSWER-coronary TIA and CVA can be caused by HLD due to atherosclerosis of the __________ arteries - ANSWER-carotid What is the name of the drug group used to treat HLD? What is one brand name? - ANSWER-Statin, Lipitor What are five risk factors of CAD? - ANSWER-HTN, HLD, DM, FHx, Smoking The study that diagnoses CAD is? - ANSWER-Cardiac Catheterization What are 2 non pharmacological treatments for CAD? - ANSWER-Weight Loss, Exercise Order the following surgeries based on invasiveness: Angioplasty CABG Cardiac Catheterization Stent - ANSWER-Cardiac Catheterization, Angioplasty, Stent, CABG If a patient says, "I've had open heart surgery," what would you write in the past medical history section? - ANSWER-CABG, coronary artery bypass graft HCTZ - ANSWER-Hydrochlorothiazide Asthma is diagnosed with a device called? - ANSWER-Peak Flow Meter What is a physician likely to ask any new patient with asthma? - ANSWER-Do you have a nebulizer? Have you been prescribed steroids recently? Have you been previously hospitalized? Have you been previously intubated? Name two asthma medications that can be inhaled? - ANSWER-Albuterol, Flovent What is the difference between a nebulizer and an inhaler? - ANSWER-A nebulizer delivers a continuous aerosol mist, while an inhaler releases a puff of medication for one time use. SOAP - ANSWER-subjective objective assessment and plan subjective - ANSWER-patient's feelings Outpatient - ANSWER-A patient who is seen and sent home on the same day Baseline - ANSWER-normal Listening with a stethoscope - ANSWER-auscultation Chief Complaint (CC) - ANSWER-reason why the patient came to the clinic What are two examples of mid level providers? - ANSWER-NP and PA In a diagnostic visit, the patient has a NEW or EXISTING complaint - ANSWER-New Who typically obtains meaningful use requirements during patient check in? - ANSWER-MA H&P - ANSWER-History and Physical Who evaluates the H&P (history and physical) - ANSWER-Provider Name two items you will include in the patient's plan? - ANSWER-Follow up with specialist, instructions for lifestyle care History of Present Illness - subjective or objective? - ANSWER-subjective Review of Systems - subjective or objective? - ANSWER-subjective Physical Exam - subjective or objective? - ANSWER-objective "I have high blood pressure" - ANSWER-HTN "I take shots for my diabetes" - ANSWER-IDDM, insulin dependent DM "My doctor says my heart is failing" - ANSWER-CHF "I have acid reflux" - ANSWER-GERD "I'm not pregnant. I have two children, but I miscarried my first pregnancy." G:__/P:__/A:__ - ANSWER-3, 2, 1 Name and correctly spell the following surgery: heart bypass - ANSWER-coronary artery bypass graft Name and correctly spell the following surgery: breast removal - ANSWER-mastectomy Name and correctly spell the following surgery: gallbladder removal - ANSWER-cholecystecomy Name and correctly spell the following surgery: uterus removed - ANSWER-hysterectomy Name and correctly spell the following surgery: neck artery cleaned - ANSWER-carotid endarterectomy What are two items you could include in a social history? - ANSWER-smoker, working Name three examples of living circumstances? - ANSWER-alone, with family, senior living Follow up - ANSWER-returning to a healthcare provider on a consistent basis BID - ANSWER-Twice a day Subq - ANSWER-medication injected just under the skin prn - ANSWER-as needed a forecast of the likely course of a disease - ANSWER-prognosis The assessment will ALWAYS include what? - ANSWER-diagnosis What is the formal of a simple statement assessment? - ANSWER-Age/sex of patient, PMHx, diagnosis What are four items that are typically included in a comprehensive summary assessment? - ANSWER-age/sex of patient, PMHx, PE summary, diagnosis Two examples of lab results? - ANSWER-CBC, pregnancy urine test Three types of imaging studies? - ANSWER-x-ray, CT, MRI Where does the plan appear in the chart? - ANSWER-At the end Four items that are included in the plan for a patient? - ANSWER-Recommended treatment, prescriptions ordered, studies/tests ordered, follow-up In which format is the plan typically given? - ANSWER-bulleted list emaciated - ANSWER-cachectic widespread, over a large area - ANSWER-diffuse For each of the following exam systems, name something the doctor can observe with an external examination, without touching or listening with a stethoscope? General/Constitutional - ANSWER-Do they look like they're in pain? For each of the following exam systems, name something the doctor can observe with an external examination, without touching or listening with a stethoscope? Eyes - ANSWER-Are the sclera yellow? For each of the following exam systems, name something the doctor can observe with an external examination, without touching or listening with a stethoscope? Pulmonary - ANSWER-Are they breathing comfortably? For each of the following exam systems, name something the doctor can observe with an external examination, without touching or listening with a stethoscope? Neurologic - ANSWER-Are they answering questions appropriately? What is one tool used to evaluate the eyes? - ANSWER-PERRL PERRL - ANSWER-Pupils are equal, round and reactive to light HIPAA - ANSWER-Health Insurance Portability and Accountability Act What is meaningful use? - ANSWER-a set of government mandated criteria that must be obtained for every patient What is meaningful use enforced by? - ANSWER-CMS, Centers for Medicare and Medicaid Services Objective - ANSWER-facts benign - ANSWER-nothing of concern baseline - ANSWER-normal inpatient - ANSWER-admitted to the hospital overnight Chief Complaint - ANSWER-the main reason for the pt's visit Medical Decision Making - ANSWER-physician's thought process Two mid level providers? - ANSWER-NP, PA Can a scribe document history, results, procedures, and touch patients? - ANSWER-No Who enters home medications and drug allergies into the chart? - ANSWER-MA High Blood Pressure - ANSWER-HTN High Cholesterol - ANSWER-HLD Thyroid Problem - ANSWER-Hypothyroidism or Hyperthyroidism Diabetes - ANSWER-DM "I only take pills for my diabetes" - ANSWER-Non Insulin Dependent Diabetes Mellitus "I take shots for my diabetes" - ANSWER-Insulin Dependent Diabetes Mellitus Heart Disease - ANSWER-CAD Heart Attack - ANSWER-MI CHF - ANSWER-congestive heart failure Irregular Heartbeat - ANSWER-A-Fib Murmur - ANSWER-Heart Murmur Episodes of abnormally fast/racing heartbeat - ANSWER-SVT Emphysema, Chronic Bronchitis - ANSWER-COPD PNA - ANSWER-pneumonia Reflux - ANSWER-GERD What does a positive Murphy's Law indicate - ANSWER-Cholecystitis "I have a blood clot in my leg" - ANSWER-Lower extremity DVT I have a bulge in my aorta - ANSWER-AAA Tonsils Removed - ANSWER-Tonsillectomy Adenoids Removed - ANSWER-Adenoidectomy Ear Tubes - ANSWER-PE Tubes Heart Bypass - ANSWER-CABG Appendix Removed - ANSWER-appendectomy Gallbladder Removed - ANSWER-Cholecystectomy Hernia Repair - ANSWER-Herniorrhaphy Part of my colon Removed - ANSWER-Partial colectomy bag to collect stool - ANSWER-colostomy spleen removed - ANSWER-splenectomy stomach stapled - ANSWER-gastric bypass hole in my neck - ANSWER-tracheostomy Ovary Removed - ANSWER-Oophorectomy Ovary and Fallopian Tubes Removed - ANSWER-Salpingo-oophorectomy Tubes Tied - ANSWER-tubal litigation prostate removed - ANSWER-prostatectomy neck artery cleaned - ANSWER-carotid endarterectomy brain surgery - ANSWER-craniotomy stents - ANSWER-coronary stents stomach stapled - ANSWER-gastric bypass What is the top number of a BP reading called? - ANSWER-Systole What is the bottom number of a BP reading called? - ANSWER-Diastolic What does Systole mean? - ANSWER-phase of the heartbeat during which the muscle contracts What does Diastolic mean? - ANSWER-phase of the heartbeat during which the muscle is relaxed Diuretic - ANSWER-a substance that promotes the production of urine Parasthesia - ANSWER-sensation of tingling or numbness Etiology - ANSWER-cause of a disease An illness is typically classified as chronic when it lasts longer than _____ months - ANSWER-3 For complex patients, it's important to document: - ANSWER-symptoms in a chronological order Complex patients often bill to a higher level, so it's important to document thoroughly and accurately. T or F - ANSWER-T Having multiple comorbidities increases the __________ of patient care - ANSWER-complexity What are two ways co morbidity increases complexity? - ANSWER-contraindicative, adverse drug reactions BP meter? - ANSWER-sphygmomanometer What drugs are for HTN? - ANSWER-Diuretics, Beta-Blockers, Ca Channel Blockers, ACE Inhibitors, ARBs Can diabetes be caused by HTN? - ANSWER-No What type of drug is HCTZ? - ANSWER-Diuretic What type of medication is used to treat HLD? - ANSWER-Statin What is a brand name drug in the statin family? - ANSWER-Lipitor Four risk factors of HLD? - ANSWER-Obesity, FHx, DM, EtOH It is not uncommon to see comorbid DM, HTN and HLD in the same patient. Name on body system that is affected by all three? - ANSWER-Heart What happens during a cardiac catheterization? - ANSWER-catheter is inserted through groin or wrist and extends up to the heart. IV dye is released to outline areas of blockage