VCRT Final Exam Study Guide (Updated fall 2022) A+
guarantee in your Exam, (Answered)
Subjective vs. objective
Feeling vs. fact
Pain vs. tenderness
Patient's feeling vs. physician's assessment
Benign
Normal, nothing of concern
Acute vs. chronic
New onset vs. long standing
Baseline
An individual's normal state of being
Auscultation
Listening with a stethoscope
Palpation
The act of pressing on an area (by the physician)
Inpatient
Admitted to the hospital overnight
Outpatient
Seen and sent home the same day
Chief complaint
The main reason for the patient's visit
Meaningful use
A set of government mandated criteria that must be obtained for every patient
Medical decision making
The physician's thought process
Mid-level providers
Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision
of a physician to diagnose and treat patients
Nurse or Medical Assistant
Records medical histories and symptoms, monitors the patient, completes meaningful
use requirements, administers medications, assists with procedures
Scribe
Documents the patient's visit on behalf of the physician; an unlicensed person
performing documentation and other non-clinical tasks under the direction of a
healthcare provider
New patient
No previous records, longer visit, detailed chart
Established patient
Previous records available, shorter visit, concise chart
Diagnostic visit
,New problem, chief complaint = new symptom, goal is to determine cause of the
problem and appropriate treatment
Health maintenance visit
Check-up, chief complaint = management of a chronic problem, goal is to assess
progress of ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient?
Established
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be?
Diagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be?
Health maintenance
Clinic flow
Check-in -> physician evaluation -> orders & results -> assessment & plan -> check-out
Who obtains meaningful use information?
Nurse/MA
Meaningful use information
Chief complaint, vital signs (HR, temp., BP, RR), height, weight, BMI, smoking status
Differential diagnosis
DDx; ONLY for a diagnostic visit; possible Dx that may be causing symptoms
Who is the first person to speak with the patient after s/he is placed in a room?
Nurse/MA
What doe H&P abbreviate and who performs this evaluation?
History & physical; the physician
Is a differential diagnosis necessary for a health maintenance visit?
No; only for a diagnostic visit
What information will be included in the patient's plan? Give 3 examples.
Follow-up with specialist if necessary, instructions for lifestyle and preventative care,
follow-up for next routine appointment
HPI or ROS contains...
Patient complaint
Past history contains...
Past diagnosis or surgery
Physical exam contains...
Physician's observation
Results contains...
Study
Assessment contains...
Current diagnosis
True allergy
Any medication that causes a rash, itching, swelling, or difficulty breathing; adverse
reaction is NOT
Home medications and allergies are typically entered by the ________ or ________,
not by the ________
, Nurse or MA; scribe
"High blood pressure"
Hypertension (HTN)
"High cholesterol"
Hyperlipidemia (HLD)
"Thyroid problem"
Hypothyroidism (usually), or Hyperthyroidism
"Diabetes"
Diabetes Mellitus (DM)
"I only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
"Heart disease"
Coronary Artery Disease (CAD)
"Heart attack"
Myocardial Infarction (MI) or CAD
"Heart failure"
Congestive Heart Failure (CHF)
"Irregular heartbeat"
Atrial Fibrillation (A-Fib)
"Murmur"
Heart murmur
"Episodes of abnormally fast/racing heartbeat"
Supraventricular Tachycardia (SVT)
"Asthma"
Asthma
"Emphysema/Chronic Bronchitis"
Chronic Obstructive Pulmonary Disease (COPD)
"Blood clot in lung"
Pulmonary Embolism (PE)
"Pneumonia"
Pneumonia (PNA)
"Reflux"
Gastroesophageal Reflux Disease (GERD)
"Ulcer"
Gastric Ulcer or Peptic Ulcer Disease (PUD)
"Pancreatitis"
Pancreatitis
"Hepatitis"
Hepatitis A, B, or C
"Diverticulitis"
Diverticulitis
"Crohn's/UC"
Crohn's Disease or Ulcerative Collitis
"Irritable bowel"
guarantee in your Exam, (Answered)
Subjective vs. objective
Feeling vs. fact
Pain vs. tenderness
Patient's feeling vs. physician's assessment
Benign
Normal, nothing of concern
Acute vs. chronic
New onset vs. long standing
Baseline
An individual's normal state of being
Auscultation
Listening with a stethoscope
Palpation
The act of pressing on an area (by the physician)
Inpatient
Admitted to the hospital overnight
Outpatient
Seen and sent home the same day
Chief complaint
The main reason for the patient's visit
Meaningful use
A set of government mandated criteria that must be obtained for every patient
Medical decision making
The physician's thought process
Mid-level providers
Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision
of a physician to diagnose and treat patients
Nurse or Medical Assistant
Records medical histories and symptoms, monitors the patient, completes meaningful
use requirements, administers medications, assists with procedures
Scribe
Documents the patient's visit on behalf of the physician; an unlicensed person
performing documentation and other non-clinical tasks under the direction of a
healthcare provider
New patient
No previous records, longer visit, detailed chart
Established patient
Previous records available, shorter visit, concise chart
Diagnostic visit
,New problem, chief complaint = new symptom, goal is to determine cause of the
problem and appropriate treatment
Health maintenance visit
Check-up, chief complaint = management of a chronic problem, goal is to assess
progress of ongoing/chronic medical problems
Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine
appointment with Dr. Heart. Is Lucy a new or established patient?
Established
A patient made an appointment because she developed a rash a few days ago. What
type of visit would this be?
Diagnostic
A patient has an appointment for management of her diabetes. What type of visit would
this be?
Health maintenance
Clinic flow
Check-in -> physician evaluation -> orders & results -> assessment & plan -> check-out
Who obtains meaningful use information?
Nurse/MA
Meaningful use information
Chief complaint, vital signs (HR, temp., BP, RR), height, weight, BMI, smoking status
Differential diagnosis
DDx; ONLY for a diagnostic visit; possible Dx that may be causing symptoms
Who is the first person to speak with the patient after s/he is placed in a room?
Nurse/MA
What doe H&P abbreviate and who performs this evaluation?
History & physical; the physician
Is a differential diagnosis necessary for a health maintenance visit?
No; only for a diagnostic visit
What information will be included in the patient's plan? Give 3 examples.
Follow-up with specialist if necessary, instructions for lifestyle and preventative care,
follow-up for next routine appointment
HPI or ROS contains...
Patient complaint
Past history contains...
Past diagnosis or surgery
Physical exam contains...
Physician's observation
Results contains...
Study
Assessment contains...
Current diagnosis
True allergy
Any medication that causes a rash, itching, swelling, or difficulty breathing; adverse
reaction is NOT
Home medications and allergies are typically entered by the ________ or ________,
not by the ________
, Nurse or MA; scribe
"High blood pressure"
Hypertension (HTN)
"High cholesterol"
Hyperlipidemia (HLD)
"Thyroid problem"
Hypothyroidism (usually), or Hyperthyroidism
"Diabetes"
Diabetes Mellitus (DM)
"I only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
"Heart disease"
Coronary Artery Disease (CAD)
"Heart attack"
Myocardial Infarction (MI) or CAD
"Heart failure"
Congestive Heart Failure (CHF)
"Irregular heartbeat"
Atrial Fibrillation (A-Fib)
"Murmur"
Heart murmur
"Episodes of abnormally fast/racing heartbeat"
Supraventricular Tachycardia (SVT)
"Asthma"
Asthma
"Emphysema/Chronic Bronchitis"
Chronic Obstructive Pulmonary Disease (COPD)
"Blood clot in lung"
Pulmonary Embolism (PE)
"Pneumonia"
Pneumonia (PNA)
"Reflux"
Gastroesophageal Reflux Disease (GERD)
"Ulcer"
Gastric Ulcer or Peptic Ulcer Disease (PUD)
"Pancreatitis"
Pancreatitis
"Hepatitis"
Hepatitis A, B, or C
"Diverticulitis"
Diverticulitis
"Crohn's/UC"
Crohn's Disease or Ulcerative Collitis
"Irritable bowel"
