(solved 2023/2024) ScribeAmerica OP Final Exam with complete solutions

New Patient - ANSWER-No previous records, longer visit, detailed chart established patient - ANSWER-Previous records available from last 3 years, shorter visit, concise chart Diagnostic visit - ANSWER-New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management - ANSWER-check up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems Clinic Flow - ANSWER-1. Check-in 2. Physician Evaluation 3. Orders & Results 4. Assessment & Plan 5. Check-out Quality Measures - ANSWER-chief complaint vital signs height, weight, BMI Smoking Status What goes in the History and Physical (H&P) - ANSWER-HPI, ROS, PE DDx - ANSWER-differential diagnosis Patient says high blood pressure - ANSWER-Hypertension (HTN) Patient says high cholesterol - ANSWER-Hyperlipidemia (HLD) Patient says thyroid problem - ANSWER-Usually Hypothyroidism, sometimes Hyperthyroidism Patient says diabetes - ANSWER-Diabetes Mellitus (DM) Patient says "I only take pills for my diabetes" - ANSWER-Non-Insulin Dependent Diabetes Mellitus (NIDDM) Patient says "I take shots for my diabetes" - ANSWER-Insulin Dependent Diabetes Mellitus (IDDM) Patient says heart disease - ANSWER-Coronary Artery Disease (CAD) Patient says heart attack - ANSWER-Myocardial Infarction (MI) and CAD Patient says heart failure - ANSWER-Congestive Heart Failure (CHF) Patient says Irregular heartbeat - ANSWER-arrhythmia Patient says murmur - ANSWER-heart murmur Patient says episodes of abnormally fast/racing heartbeat - ANSWER-supraventricular tachycardia (SVT) Patient says asthma - ANSWER-asthma Patient says Emphysema/Chronic Bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease (COPD) Patient says blood clot in lung - ANSWER-Pulmonary Embolism (PE) Patient says pneumonia - ANSWER-Pneumonia (PNA) Patient says reflux - ANSWER-Gastroesophageal Reflux Disease (GERD) Patient says ulcer - ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD) Patient says pancreatitis - ANSWER-pancreatitis Patient says hepatitis - ANSWER-Hepatitis A, B, or C Patient says diverticulitis - ANSWER-Diverticulitis Patient says Crohn's/UC - ANSWER-Crohn's Disease or Ulcerative Colitis Patient says irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS) Patient says bladder infection - ANSWER-Urinary Tract Infection (UTI) Patient says kidney infection - ANSWER-Pyelonephritis (Pyelo) Patient says kidney stones - ANSWER-renal calculi Patient says I'm on dialysis - ANSWER-Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis Patient says enlarged prostate - ANSWER-Benign Prostate Hypertrophy (BPH) Gravida - ANSWER-Total number of time the patient has been pregnant Para - ANSWER-number of pregnancies reaching viable gestational age (23 weeks) that the patient has had Abortus - ANSWER-total number of miscarriages or elective abortions patient says brain bleed (stroke) - ANSWER-Hemorrhagic CVA Patient says stroke - ANSWER-Cerebrovascular Accident (CVA) Patient says mini-stroke - ANSWER-Transient Ischemic Attack (TIA) Patient says seizures - ANSWER-Seizure disorder/Epilepsy Patient says bipolar - ANSWER-bipolar disorder Patient says schizophrenia - ANSWER-schizophrenia Patient says I drink a lot - ANSWER-ETOH abuse or alcoholism Patient says I do drugs - ANSWER-substance abuse Patient says Blood clot in my leg - ANSWER-Lower Extremity Deep Vein Thrombosis (DVT) Patient says Bulge in my aorta - ANSWER-aortic aneurysm Patient says bad flow to my legs - ANSWER-peripheral vascular disease (PVD) Patient says: Numbness in my legs - ANSWER-peripheral neuropathy Patient says low back pain - ANSWER-Chronic Low Back Pain Patient says bulging/herniated disc - ANSWER-Degenerative Disc Disease (DDD) Patient says arthritis - ANSWER-Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) Patient says weak/fragile bones - ANSWER-Often Osteoporosis Patient says cancer - ANSWER-Cancer or carcinoma (CA) (attached to the type of cancer) Patient says spread to my - ANSWER-With metastases to the... Patient says chemo - ANSWER-chemotherapy Patient says radiation - ANSWER-radiation therapy Patient says they cut it out - ANSWER-s/p surgical resection Patient says its gone - ANSWER-In remission Patient says tonsils removed - ANSWER-tonsillectomy Patient says adenoids removed - ANSWER-Adenoidectomy Patient says ear tubes - ANSWER-myringotomy or Pressure equalizing (P.E) tubes Patient says heart bypass - ANSWER-Coronary Artery Bypass Graft (CABG) -- PMHx CAD Patient says stents - ANSWER-Coronary Stents -- PMHx CAD Patient says heart cath - ANSWER-cardiac catheterization Patient says balloon - ANSWER-Angioplasty -- PMHx CAD Patient says valve surgery - ANSWER-Valve repair or replacement (Bovine vs. Mechanical) Patient says pacer - ANSWER-pacemaker Patient says defibrillator - ANSWER-Automatic Implanted Cardiac Defibrillator (AICD) Patient says surgery for afib - ANSWER-Afib s/p cardiac ablation Patient says breast removal - ANSWER-mastectomy Patient says breast removal - ANSWER-mastectomy Patient says hole in my neck - ANSWER-tracheostomy (trach) Patient says part of my lung removed - ANSWER-Partial lobectomy Patient says appendix removed - ANSWER-appendectomy Patient says Gallbladder removed - ANSWER-cholecystectomy Patient says hernia repair - ANSWER-Herniorrhaphy Patient says part of my colon removed - ANSWER-Partial colectomy Patient says bag to collect stool - ANSWER-colostomy Patient says spleen removed - ANSWER-splenectomy Patient says stomach stapled - ANSWER-bariatric surgery Patient says exploratory - ANSWER-Exploratory Laparoscopy (Ex Lap) Patient says kidney removed - ANSWER-nephrectomy Patient says uterus removed - ANSWER-Hysterectomy (partial vs. total) Patient says ovary removed - ANSWER-oophorectomy Patient says ovary and fallopian tubes removed - ANSWER-Salpingo-oophorectomy Patient says tubes tied - ANSWER-Tubal ligation (female) or Vasectomy (male) Patient says C-section - ANSWER-cesarean section Patient says prostate removed - ANSWER-Prostatectomy or prostate resection (most often Trans-Urethral Resection of the Prostate, or TURP) Patient says uterine product removed - ANSWER-Dilation and Curettage (D&C) Patient says neck artery cleaned - ANSWER-carotid endarterectomy Patient says shunt - ANSWER-cerebral shunt Patient says brain surgery - ANSWER-Craniotomy (brain bleed vs. brain CA) Patient says dialysis fistula - ANSWER-AV (arteriovenous) Fistula