SCRIBEAMERICA OUTPATIENT ACTUAL FINAL EXAM
QUESTIONS AND ANSWERS SURE A+
✔✔Bipolar - ✔✔Bipolar disorder
✔✔"I drink a lot" - ✔✔ETOH abuse or alcoholism
✔✔"Blood clot in my leg" - ✔✔Lower extremity DVT
✔✔"Bulge in my aorta" - ✔✔Aortic Aneurysm (AA)
✔✔"Bad blood flow to my legs" - ✔✔Peripheral Vascular Disease (PVD)
✔✔"Numbness in my legs" - ✔✔Peripheral Neuropathy
✔✔Low back pain - ✔✔Chronic Low Back Pain
✔✔Bulging disc - ✔✔Herniated Disk [Note: Patient may also have
Degenerative Disc Disease (DDD)]
✔✔Arthritis - ✔✔Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
✔✔Weak/fragile bones - ✔✔Often Osteoporosis
✔✔Cancer - ✔✔Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate,
Ovary, Skin, Bone, Leukemia, or Lymphoma
✔✔Spread to my... - ✔✔With metastasis to the ...
✔✔Chemo - ✔✔Chemotherapy
✔✔Radiation - ✔✔Radiation therapy
✔✔They cut it out - ✔✔Status-post surgical resection
✔✔It's gone - ✔✔In remission
✔✔PSHx: COMMON SURGERIES - ✔✔-For "removal" surgeries, the patient will say
what body part was removed and you will have to know the medical name and spelling
of the surgery (usually ending in "-ectomy")
-For other types of surgery, the patient typically describes what was done and you will
need to recognize and spell the name of the procedure
✔✔Tonsils removed - ✔✔Tonsillectomy
, ✔✔Adenoids removed - ✔✔Adenoidectomy
✔✔Ear tubes - ✔✔Myringotomy or Pressure Equalizing (P.E.) tubes
✔✔Heart bypass - ✔✔Coronary Artery Bypass Graft (CABG) → PMHx CAD
✔✔Stent (heart) - ✔✔Coronary Stent → PMHx CAD
✔✔Heart Cath - ✔✔Cardiac catheterization
✔✔Balloon - ✔✔Angioplasty → PMHx CAD
✔✔Valve surgery - ✔✔Valve repair or replacement (bovine vs. mechanical)
✔✔Pacer - ✔✔Pacemaker
✔✔Defibrillator - ✔✔Automatic Implantable Cardioverter-Defibrillator (AICD)
✔✔Surgery for Afib - ✔✔Afib s/p cardiac ablation
✔✔Breast removal - ✔✔Mastectomy
✔✔Hole in my neck - ✔✔Tracheostomy (commonly called a "trach")
✔✔Part of my lung removed - ✔✔Partial lobectomy
✔✔Appendix removed - ✔✔Appendectomy
✔✔Gallbladder removed - ✔✔Cholecystectomy
✔✔Hernia repair - ✔✔Herniorrhaphy
✔✔Part of my colon removed - ✔✔Partial colectomy
✔✔Bag to collect stool - ✔✔Colostomy
✔✔Spleen removed - ✔✔Splenectomy
✔✔Stomach stapled - ✔✔Bariatric Surgery (Note: Patient may have had gastric banding
or Sleeve gastrectomy)
✔✔Exploratory - ✔✔Exploratory Laparoscopy
QUESTIONS AND ANSWERS SURE A+
✔✔Bipolar - ✔✔Bipolar disorder
✔✔"I drink a lot" - ✔✔ETOH abuse or alcoholism
✔✔"Blood clot in my leg" - ✔✔Lower extremity DVT
✔✔"Bulge in my aorta" - ✔✔Aortic Aneurysm (AA)
✔✔"Bad blood flow to my legs" - ✔✔Peripheral Vascular Disease (PVD)
✔✔"Numbness in my legs" - ✔✔Peripheral Neuropathy
✔✔Low back pain - ✔✔Chronic Low Back Pain
✔✔Bulging disc - ✔✔Herniated Disk [Note: Patient may also have
Degenerative Disc Disease (DDD)]
✔✔Arthritis - ✔✔Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
✔✔Weak/fragile bones - ✔✔Often Osteoporosis
✔✔Cancer - ✔✔Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate,
Ovary, Skin, Bone, Leukemia, or Lymphoma
✔✔Spread to my... - ✔✔With metastasis to the ...
✔✔Chemo - ✔✔Chemotherapy
✔✔Radiation - ✔✔Radiation therapy
✔✔They cut it out - ✔✔Status-post surgical resection
✔✔It's gone - ✔✔In remission
✔✔PSHx: COMMON SURGERIES - ✔✔-For "removal" surgeries, the patient will say
what body part was removed and you will have to know the medical name and spelling
of the surgery (usually ending in "-ectomy")
-For other types of surgery, the patient typically describes what was done and you will
need to recognize and spell the name of the procedure
✔✔Tonsils removed - ✔✔Tonsillectomy
, ✔✔Adenoids removed - ✔✔Adenoidectomy
✔✔Ear tubes - ✔✔Myringotomy or Pressure Equalizing (P.E.) tubes
✔✔Heart bypass - ✔✔Coronary Artery Bypass Graft (CABG) → PMHx CAD
✔✔Stent (heart) - ✔✔Coronary Stent → PMHx CAD
✔✔Heart Cath - ✔✔Cardiac catheterization
✔✔Balloon - ✔✔Angioplasty → PMHx CAD
✔✔Valve surgery - ✔✔Valve repair or replacement (bovine vs. mechanical)
✔✔Pacer - ✔✔Pacemaker
✔✔Defibrillator - ✔✔Automatic Implantable Cardioverter-Defibrillator (AICD)
✔✔Surgery for Afib - ✔✔Afib s/p cardiac ablation
✔✔Breast removal - ✔✔Mastectomy
✔✔Hole in my neck - ✔✔Tracheostomy (commonly called a "trach")
✔✔Part of my lung removed - ✔✔Partial lobectomy
✔✔Appendix removed - ✔✔Appendectomy
✔✔Gallbladder removed - ✔✔Cholecystectomy
✔✔Hernia repair - ✔✔Herniorrhaphy
✔✔Part of my colon removed - ✔✔Partial colectomy
✔✔Bag to collect stool - ✔✔Colostomy
✔✔Spleen removed - ✔✔Splenectomy
✔✔Stomach stapled - ✔✔Bariatric Surgery (Note: Patient may have had gastric banding
or Sleeve gastrectomy)
✔✔Exploratory - ✔✔Exploratory Laparoscopy
