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Exam (elaborations)

ScribeAmerica OP Final Exam Top ranked study Materials

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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...

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  • August 7, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • ScribeAmerica OP
  • ScribeAmerica OP
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IMORA
ScribeAmerica OP Final Exam Top ranked study
Materials


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

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