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Exam (elaborations)

ScribeAmerica Outpatient Final Exam with A+ Rating Answers

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subjective vs objective - ANSWER-feeling vs fact pain vs tenderness - ANSWER-patients feeling vs physicians assessment benign - ANSWER-normal, nothing of concern acute vs chronic - ANSWER-new onset vs long standing baseline - ANSWER-an individuals normal state of being ausculation - ...

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  • August 7, 2024
  • 16
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • ScribeAmerica Outpatient
  • ScribeAmerica Outpatient
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IMORA
ScribeAmerica Outpatient Final Exam with A+
Rating Answers

subjective vs objective - ANSWER-feeling vs fact

pain vs tenderness - ANSWER-patients feeling vs physicians assessment

benign - ANSWER-normal, nothing of concern

acute vs chronic - ANSWER-new onset vs long standing

baseline - ANSWER-an individuals normal state of being

ausculation - ANSWER-listening to sound with a stethoscope

palpation - ANSWER-act of pressing on an area (by the physician)

inpatient - ANSWER-admitted to the hospital overnight

outpatient - ANSWER-seen and sent home the same day

chief complaint - ANSWER-main reason for the patients visit

meaningful use - ANSWER-set of government mandated criteria that must be obtained
for every patient

medical decision making - ANSWER-physicians though process

Scribes can... - ANSWER-document history, physician exam, results, procedures.
access and document laboratory and radiology findings. locate and obtain PMHx,
previous charts, past results.

Scribes cannot... - ANSWER-partake in any activity that may affect patient health, touch
patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic
orders.

are physician assistants and nurse practitioners considered medical providers? -
ANSWER-YES

T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning
purposes and under the supervision of the physician. - ANSWER-False

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? - ANSWER-
Established

,a patient made an appointment because she developed a rash a few days ago. what
type of visit would this be? - ANSWER-diagnostic

diagnostic visits consist of - ANSWER-new problems, new symptoms

health management visits consist of - ANSWER-check-ups, management visits

a patient has an appointment for management of her diabetes. what type of visit would
this be? - ANSWER-health management

who is the first person to speak with the patient after he/she is place in a room? -
ANSWER-Nurse/MA

What are the meaningful use requirements the nurse/MA will obtain? - ANSWER-Chief
complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status

What does H&P abbreviate and who performs this evaluation? - ANSWER-history and
physical, performed by the provider

Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-nope.

what information will be included in the patient's plan? give 3 examples. - ANSWER-F/U
for specialist, instructions for lifestyle, F/U for next routine appointment

name the 8 elements of the HPI - ANSWER-Location, Quality, Severity, Context,
Timing, Duration, Associated signs and symptoms, Modifying factors

polydipsia - ANSWER-excessive thirst

paresthesia - ANSWER-sensation of tingling or numbness

anticoagulant - ANSWER-a drug that prevents blood clotting

chronic illness - ANSWER-longer than 3 months

if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms
considered chronic? - ANSWER-No

Having multiple comorbidities increases the __________ of patient care - ANSWER-
complexity

List two ways comorbidity increases complexity? - ANSWER--The treatment of one
disease may affect or contradict the treatment of the second
-Adverse drug interactions
-Compounding symptoms may lead to poor compliance with treatment plan (mo' drugs,
mo' problems)

, -If both illnesses affect a specific organ system, the patient is at increased risk of organ
failure

Type 2 diabetes - ANSWER-the inadequacy of insulin in controlling the blood glucose
level (insulin resistance)

diabetes risk factors - ANSWER-obesity, high carb diet, lack of exercise, HTN, HLD,
FHx

chief complaint of diabetes - ANSWER-weight loss or gain. polyuria, polydipsia, blurred
vision, fatigue

physical exam diabetes - ANSWER-distal paresthesias, pedal edema, weight change

diagnosis of diabetes - ANSWER-fasting blood glucose, hemoglobin A1c

Diseases caused by diabetes - ANSWER-peripheral neuropathy, PVD, Diabetic
retinopathy, renal failure, cardiac disease

non-pharmacological management for DM - ANSWER-weight loss, low-carb diet,
exercise, blood glucose log

you can take oral medication for what kind of diabetes? - ANSWER-type 2 (you can do
insulin and oral meds)

what kind of medications can you take for DM? - ANSWER-Injected: Humalog, Lantus
Oral: Metformin, Glyburide

with sliding scale insulin treatment, the patient adjusts the dosage of insulin based
on____________. - ANSWER-current glucose

Name two body systems that would be at increased risk of failure if the patient had both
HTN and DM. - ANSWER-renal and cardiovascular

SOAP - ANSWER-subjective, objective, assessment, plan

History of Present Illness (HPI) - ANSWER-story of the patient's chief complaint

What are the 3 primary methods of structuring an outpatient HPI? - ANSWER-Single
complaint formula, multiple complain formula, chronological complain formula

Which HPI structure is best to use for a complex patient with multiple comorbidities and
a recent work-up? - ANSWER-chronological

What are four important details to include in the HPI of a patient who has been
evaluated by another healthcare provider for similar symptoms? - ANSWER-Who

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