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SCRIBE AMERICA FINAL EXAM OP VERIRIED
ACCURATESTUDY GUIDE
Scribes CAN - Answers - 1. Document the history, physical exam, results, procedures, and physician consults
- Access and document laboratory results and radiology findings
- Access and display X-Rays for the physician to review
- Locate and obtain PMHx, previous charts, past results, and recent studies
- Record physician interpretations of X-Rays and ECG's Scribes CANNOT - Answers --touch patients
- write orders or prescriptions
- give verbal orders
- partake in any activity that may affect patient health or outcome
- sign or authenticate any chart or record
- handle bodily fluids or specimens Chief Complaint (CC) - Answers - the main reason for the patient's visit EMR / EHR - Answers - Electronic Medical Record / Electronic Health Record Subjective - Answers - feelings of the patient Objective - Answers - factual findings from the provider pain - Answers - patients feeling of discomfort tenderness - Answers - doctors finding of reproducible pain acute - Answers - New onset, likely concerning chronic - Answers - Long-standing, not of direct concern new patient (NP) - Answers - a patient that has never been seen at the clinic or was seen greater than 3 years ago. no previous records. longer visits. detailed chart.
established patient (EP) - Answers - a patient that has been seen at the clinic by any provider within the last 3 years. previous records available. shorter visits. concise chart. Diagnostic visit - Answers - New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management visit - Answers - Check-up, Chief Complaint: Routine physical or management of chronic problem(s), and Goal is preventative care and/or assessing progress of ongoing medical problems History of Present Illness (HPI) - Answers - The story and context of the Chief Complaint (subjective) Review of Systems (ROS) - Answers - A head-to-toe list of positives and negatives (subjective) Past history - Answers - PMHx (medical) , PSHx (surgical) , SHx (social) , FHx (family) Physical Examination (PE) - Answers - The physician's objective findings Orders and Results - Answers - objective evaluation Assessment - Answers - current diagnoses plan - Answers - treatment plan and follow up high blood pressure - Answers - Hypertension (HTN) high cholesterol - Answers - Hyperlipidemia (HLD) diabetes - Answers - Diabetes Mellitus (DM) "I only take pills for my diabetes" - Answers - Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Cancer spread to my... - Answers - Cancer with metastasis to... chemo - Answers - chemotherapy Radiation - Answers - radiation therapy They cut it out (cancer) - Answers - Status-post surgical resection It's gone (cancer) - Answers - remission True allergy - Answers - Any medication that causes a rash, itching, swelling, or difficulty breathing. Else it is an adverse reaction. tomsils removed - Answers - tonsillectomy Adenoids removed - Answers - Adenoidectomy neck arteries cleaned - Answers - carotid endarterectomy Leg amputated - Answers - Above Knee Amputation (AKA) Below Knee Amputation (BKA) Joint repair - Answers - arthroplasty balloon in my heart - Answers - angioplasty (PMHx CAD) stents in my heart - Answers - Coronary stents Heart bypass - Answers - Coronary Artery Bypass Graft (CABG) --> PMHx CAD Breast removal - Answers - mastectomy Part of my lung removed - Answers - Partial lobectomy Appendix removed - Answers - appendectomy Gallbladder removed - Answers - cholecystectomy Part of my colon removed - Answers - Partial colectomy Spleen removed - Answers - splenectomy Kidney removed - Answers - nephrectomy
Uterus removed - Answers - hysterectomy Ovary removed - Answers - oophorectomy Family History (FHx) - Answers - A younger age of onset means higher genetic risk (under 55) any medical conditions patient BLOOD relatives have Social History (SHx) - Answers - tobacco use, alcohol use, illicit drug use, occupation, living circumstances soap structure - Answers - S: subjective O: objective A: assessment P: plan HPI ROS Past History Physical Exam Ddx Only for diagnostic visits Differential Diagnosis (DDx) - Answers - list of what other diseases or conditions could it be chronic disease - Answers - an ongoing condition or illness that lasts longer than 3 months Comorbidity - Answers - the simultaneous presence of two chronic diseases or conditions in a patient patient is more complex and higher health risk hypertension (HTN) - Answers - an increase in blood pressure causes excess force against the arterial walls, damaging arteries over time. risk factors - FHx of HTN, obesity, high sodium diet, smoking, ETOH Symptoms - often asymptomatic, headache is most common symptom diagnosis - blood pressure reading.
fasting blood glucose hemoglobin A1c diabetes mellitus DM can lead to - Answers - CAD, CHF, and diabetic cardiomyopathy PVD Neuropathy diabetic retinopathy renal failure DM management - Answers - weight loss low carb diet blood glucose log exercise 30 min/3 days week pharmacological management of DM (meds) - Answers - injected - Humalog I , Lantus I , sliding scale I oral - metformin , glyburide Hyperlipidemia (HLD) - Answers - FHx, obesity, high lipid diet, ETOH, physical inactivity asymptomatic bloodwork lipid panel measuring cholesterol and triglyceride levels - elevated LDL LDL (low density lipoprotein) - Answers - bad cholesterol HDL (High Density Lipoprotein) - Answers - good cholesterol HLD can lead to - Answers - CVA CAD arterial atherosclerosis CAD/MI Pancreatitis HLD management - Answers - low lipid diet decrease etoh
weight loss and exercise close follow up HLD meds - Answers - statin (lipitor, crestor, zocor) coronary artery disease (CAD) - Answers - HTN HLD DM smoking FHx chest pain or pressure, worse with exertion, improved with rest or nitroglycerin NTG cardiac catheterization diagnosis CAD is the biggest risk factor for - Answers - Myocardial Infarction MI CAD management - Answers - control risk factors, weight loss, manage stress and depression, smoking cessation, exercise CAD meds - Answers - acetylsalicylic acid ASA aspirin anti platelet drug nitroglycerin NTG vasodilator CAD surgeries - Answers - Cardiac catheterization - diagnoses CAD - catheter is inserted through groin or wrist and extends up to the heart. IV dye is released to outline areas of blockage Angioplasty - minimally invasive cardiac procedure - deflated balloon is inserted then inflated to open area of blockage then balloon is removed Coronary Stent - more invasive cardiac procedure - similar to angioplasty, but, a stent is inserted and left in the artery to keep it open CABG - invasive surgery - open heart surgery to bypass area of blockage usually using a vessel taken from the thigh Asthma - Answers - a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing. It usually results from an allergic reaction or other forms of hypersensitivity. wheezing SOB COPD (emphysema and chronic bronchitis) - Answers - A group of lung diseases that block airflow and make it difficult to breathe.
established patients here for follow up of a chronic illness physical exam - Answers - Inspection Palpation Percussion Auscultation Anterior - Answers - front Posterior - Answers - back Proximal - Answers - Closer to the point of attachment Distal - Answers - away from the point of attachment Medial - Answers - toward the midline Lateral - Answers - away from the midline Superior - Answers - above Inferior - Answers - below focal - Answers - Localized to one specific area. Opposite of diffuse diffuse - Answers - spread out Palmar - Answers - palm of hand plantar - Answers - sole of foot superficial - Answers - near the surface deep - Answers - Away from the body surface; more internal vital signs - Answers - temperature- 98.6F normal 97.8F low hypothermic 100.4F high febrile pulse- 60 - 100bpm N below 60bpm bradycardic above 100bpm tachycardic
respirations- 12 - 20 N below 12 bradypneic above 20 tachypneic blood pressure- 120/80 N hypotensive below 90/60 mm Hg hypertensive above 120/80 mm Hg oxygen saturation SpO2- >98% normal below 93% hypoxic Eyes - Answers - pupils equal round reactive to light PERRL extraocular movements intact EOMI no nystagmus sclerae anicteric scleral icterus = liver failure normal conjunctiva pale = anemia conjunctivitis ears - Answers - tympanic membranes TMs otitis media canal swelling or tenderness = otitis externa nose - Answers - no discharge normal nasal mucosa boggy turbinates/swelling of the nasal mucosa = rhinitis nose bleed = anterior epistaxis throat and mouth - Answers - moist mucous membranes dry = dehydration oropharynx normal pharyngeal erythema = pharyngitis exudates = pharyngitis or tonsillitis tonsillar hypertrophy = tonsillitis
positive Murphys sign RUQ = cholecystitis negative mcburneys point tenderness N positive mcburneys point tenderness RLQ = appendicitis hypoactive/hypoactive sounds no organomegaly N hepatomegaly / splenomegaly Musculoskeletal - Answers - bony tenderness = fracture soft tissue tenderness = contusion strain calf tenderness = DVT edema trace to 4+ = congestive heart failure Skin (Integumentary) - Answers - warm dry normal color no rashes no induration no fluctuant = Normal hot to touch = febrile or infection diaphoretic jaundice yellow = liver failure cyanotic blue = hypoxic pallor = anemia urticaria wheals = hives or allergic petechiae = sepsis or severe infection induration = cellulitis fluctuant = abscess purulent drainage = abscess neurological - Answers - alert, oriented x4, normal speech = normal somnolent drowsy confused responsive to voice responsive to painful stimuli disoriented to person place time or situation aphasia expressive or receptive dysarthria neurological strength sensation and reflexes - Answers - motor strength 5/5 symmetric sensation intact and reflexes 2+ and symmetric = Normal Assessment includes - Answers - age and sex of patient and diagnosis or differential diagnosis. diagnoses + summary of visit = assessment
Plan includes - Answers -- recommended treatment(s) for each diagnosis
- prescriptions ordered today
- studies or tests ordered today
- Follow-up with other healthcare professionals
- Follow-up here: when should the patient return for next appt.? ICD coding - Answers - International Classification of Diseases
- used for diagnosis coding HIPAA (Health Insurance Portability and Accountability Act) - Answers - Protected Health Information - PHI HIPAA violation = fines and jail time prognosis - Answers - a forecast of the probable likely course and outcome of a disease or situation erythmea - Answers - redness of the skin syncope - Answers - "Passing out", loss of consciousness or fainting salpingo-oophorectomy - Answers - excision of a uterine tube and ovary Pediatric patients social history - Answers - smoking history second hand smoke immunizations drug use alcohol use
- Statin - Answers - treats HLD Non-reimbursable: " check up Medication refill follow up lab results" - Answers - Reimbursable: Evaluation of medication management for HTN New Patient - Answers - detailed chart HPI Elements - Answers - Onset,
