Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Scribing > Scribe America Outpatient Lessons > Flashcards

Scribe America Outpatient Lessons Flashcards

1
Q

Chief complaint

A

The main reason for the patient’s outpatient visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

EMR/EHR

A

Electrical Medical record / Electronic Health record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Subjective

A

Feeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Objective

A

Factual finding from the provider

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Pain

A

Patient’s feeling of discomfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tenderness

A

Doctor’s finding of reproducible pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

New Patient

A

A patient that has never been seen at the clinic, or was seen greater than 3 years ago

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Established Patient

A

A patient that has been at the clinic (by any provider) within the last 3 years

don’t have to be the same doctors/physicians

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the goal of Diagnostic Visit?

A

Determine the cause of the problem and appropriate treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the goal of Health Management Visit?

A

Preventative care and/or assessing progress of ongoing medical problems.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the order of Clinic Flow?

A
  1. Check In/ Chief Complaint
  2. History and Physical Exam
  3. Orders and Results
  4. Assessment and Plan
  5. Check out
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

List Vital signs

A
  1. HR: heart rate (bpm)
  2. BP: blood pressure (mmHg)
  3. RR: respiratory rate
  4. T: temperature
  5. SaO2: oxygen saturation (%)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Which type of visit will have differential diagnoses listed in the Assessment?

A

Diagnostic visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How is a disease classified as chronic?

A

Disease lasts longer than 3 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is comorbidity?

A

The simultaneous presence of two chronic diseases or conditions in a patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

The presence of a comorbidity increases a patient’s complexity in what ways?

A
  1. The treatment of one disease may affect or contradict the treatment of the second
  2. If both illnesses affect a specific organ system, the patient is at increased risk of organ failure.
  3. Adverse drug interactions
  4. Compounding symptoms may lead to poor compliance with treatment plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the risk factors of HTN?

A
  1. FHx of HTN
  2. Obesity
  3. High sodium diet
  4. Smoking
  5. Alcohol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the symptoms of HTN?

A

Often asymptomatic.
Headache is the most common symptom.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How can HTN be diagnosed?

A

Blood pressure reading. Take several high readings to confirm hypertension.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are two numbers of blood pressure?

A
  1. Systolic
  2. Diastolic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What does systolic blood pressure measure?

A

The pressure in the arteries when the heart contracts.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What does diastolic blood pressure measure?

A

The pressure in the arteries when relaxed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the range of normotensive blood pressure?

A

90-120/60-80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the key concept of HTN? What are valid complications of HTN?

A

Key Concept: HTN damages blood vessel.
1. Impaired vision
2. CVA
3. Renal failure
4. CAD/MI
5. CHF

25
Q

What is non-pharmacological management of HTN?

A
  1. Low sodium diet
  2. Smoking and alcohol cessation
  3. Exercise
  4. BP log at home
26
Q

What drugs are used to treat HTN? Example of each drug.

A
  1. ACE Inhibitors (Lisinopril, Lotensin)
  2. Ca Channel Blockers (Norvasc, Cardizem)
  3. Diuretics (Hydrochlorothiazide)
  4. ARBs (Cozaar, Benicar)
27
Q

What is the characteristic of Type 1 DM?

A

insulin insufficiency

28
Q

What is the characteristic of Type 2 DM?

A

insulin resistance

29
Q

Which type of diabetics can take insulin?

30
Q

What are the risk factors of Type 2 DM?

A
  1. FHx of DM
  2. Obesity
  3. High carb diet
  4. Lack of exercise
31
Q

What are symptoms of type 2 DM?

A
  1. Unusual weight loss or gain
  2. Polyuria
  3. Polydipsia
  4. Blurred vision
  5. Neurovascular (pins and needles feeling)
32
Q

How type 2 DM is diagnosed?

A

Fasting blood glucose / hemoglobin A1C

33
Q

What are the valid complications of DM?

A
  1. Diabetic Retinopathy
  2. Renal Failure
  3. Cardiac Disease
  4. PVD
  5. Neuropathy
34
Q

What is nonpharmalogical management of Type 2 DM?

A
  1. Low carb diet.
  2. Weight loss
  3. Exercise
  4. Blood glucose log
35
Q

What are two ways of pharmacological management of DM?

A
  1. Injection: humalog (rapid), lantus (long acting), sliding scale.
  2. Oral: metformin(prevent liver from dumping glucose into blood), glyburide (induce pancreases)
36
Q

What are the risk factors of HLD?

A
  1. FHx of HLD.
  2. Obesity
  3. High lipid diet
  4. ETOH
  5. Physical inactivity
37
Q

What are the symptoms of HLD?

A

Asymptomatic

38
Q

How HLD can be diagnosed?

A

Bloodwork.

39
Q

What is the function of LDL?

A

Transports cholesterol to arterial walls and aides the formation of plaques.

40
Q

What is the function of HDL?

A

Removes cholesterol from artery plaques and recycle it back to the liver.

41
Q

What are valid complications of HLD?

A
  1. Pancreatitis
  2. CVA
  3. Arterial atheroslerosis
  4. CAD/MI
42
Q

What is the nonpharmacological management of HLD?

A
  1. Low lipid diet
  2. Decrease ETOH
  3. Weight loss
  4. Exercise
  5. Close follow up
43
Q

What is the pharmacological management of HLD?

A

Statin (inhibit the production of cholesterol)

44
Q

What is etiology of CAD?

A

Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia.

45
Q

What are the risk factors of CAD?

A
  1. HTN
  2. HLD
  3. DM
  4. Smoking
  5. FHx < 55y/o
46
Q

What are the symptoms of CAD?

A
  1. Chest pain or pressure
  2. Worse with exertion (having chest pain and still exercise)
47
Q

How CAD can be diagnosed?

A

Cardiac catheterization

48
Q

What is the #1 biggest risk factor for MI?

49
Q

What is non-pharmacological management of CAD?

A
  1. Managing risk factors
  2. Smoking cessation
  3. Exercise/ weight loss
  4. Manage stress
50
Q

What is pharmacological management of CAD?

A
  1. Acetylsalicylic acid (ASA) - Aspirin - thinning blood prevent blood clotting.
  2. Nitroglycerin (NTG) - vasodilator
51
Q

What are the surgical treatments of CAD? Which one is the least invasive? most invasive?

A
  1. Angioplasty - least invasive
  2. Coronary stent
  3. CABG (open heart surgery) - most invasive
52
Q

What does subjective information include?

A
  1. Chief complaint
  2. HPI
  3. ROS
53
Q

What is the HPI?

A

The story of symptoms & events that led to the clinic visit

54
Q

What is the ROS?

A

A head-to-toe overview of the patient’s body-systems phrased in the form of positives and negatives

55
Q

What are the elements of HPI?

A
  1. Onset
  2. Timing
  3. Location
  4. Quality
  5. Severity
  6. Modifying factors
  7. Associated Sx
  8. Context
56
Q

PO short for

A

per os = by mouth

57
Q

What are three types of HPI structure?

A
  1. Single complaint
  2. Multiple complaint
  3. Chronologic

Scribing (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions