ScribeAmerica OP Final Exam latest
updated questions with expert 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)
updated questions with expert 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)
