ScribeAmerica OP Final Exam UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS
New Patient No previous records, longer visit, detailed chart
established patient Previous records available from last 3 years, shorter visit, concise chart
Diagnostic visit New problem, chief complaint: new symptom, goal is to determine the cause of
the problem and appropriate treatment
health management check up, CC: routine physical or management of chronic problems, goal is
preventative care and/or assessing progress of ongoing medical problems
Clinic Flow 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) HPI, ROS, PE
DDx differential diagnosis
Patient says high blood pressure Hypertension (HTN)
, Patient says high cholesterol Hyperlipidemia (HLD)
Patient says thyroid problem Usually Hypothyroidism, sometimes Hyperthyroidism
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" Insulin Dependent Diabetes Mellitus (IDDM)
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular heartbeat arrhythmia
Patient says murmur heart murmur
Patient says episodes of abnormally fast/racing heartbeat supraventricular tachycardia (SVT)
Patient says asthma asthma
Patient says Emphysema/Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD)
Patient says blood clot in lung Pulmonary Embolism (PE)
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel Irritable Bowel Syndrome (IBS)
Patient says bladder infection Urinary Tract Infection (UTI)
Patient says kidney infection Pyelonephritis (Pyelo)
ANSWERS
New Patient No previous records, longer visit, detailed chart
established patient Previous records available from last 3 years, shorter visit, concise chart
Diagnostic visit New problem, chief complaint: new symptom, goal is to determine the cause of
the problem and appropriate treatment
health management check up, CC: routine physical or management of chronic problems, goal is
preventative care and/or assessing progress of ongoing medical problems
Clinic Flow 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) HPI, ROS, PE
DDx differential diagnosis
Patient says high blood pressure Hypertension (HTN)
, Patient says high cholesterol Hyperlipidemia (HLD)
Patient says thyroid problem Usually Hypothyroidism, sometimes Hyperthyroidism
Patient says diabetes Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" Insulin Dependent Diabetes Mellitus (IDDM)
Patient says heart disease Coronary Artery Disease (CAD)
Patient says heart attack Myocardial Infarction (MI) and CAD
Patient says heart failure Congestive Heart Failure (CHF)
Patient says Irregular heartbeat arrhythmia
Patient says murmur heart murmur
Patient says episodes of abnormally fast/racing heartbeat supraventricular tachycardia (SVT)
Patient says asthma asthma
Patient says Emphysema/Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD)
Patient says blood clot in lung Pulmonary Embolism (PE)
Patient says pneumonia Pneumonia (PNA)
Patient says reflux Gastroesophageal Reflux Disease (GERD)
Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis pancreatitis
Patient says hepatitis Hepatitis A, B, or C
Patient says diverticulitis Diverticulitis
Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel Irritable Bowel Syndrome (IBS)
Patient says bladder infection Urinary Tract Infection (UTI)
Patient says kidney infection Pyelonephritis (Pyelo)
