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Scribe America Outpatient Lessons Flashcards

1
Q

Chief complaint

A

The main reason for the patient’s outpatient visit

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2
Q

EMR/EHR

A

Electrical Medical record / Electronic Health record

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3
Q

Subjective

A

Feeling

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4
Q

Objective

A

Factual finding from the provider

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5
Q

Pain

A

Patient’s feeling of discomfort

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6
Q

Tenderness

A

Doctor’s finding of reproducible pain

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7
Q

New Patient

A

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

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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

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9
Q

What is the goal of Diagnostic Visit?

A

Determine the cause of the problem and appropriate treatment

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10
Q

What is the goal of Health Management Visit?

A

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

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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
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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 (%)
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13
Q

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

A

Diagnostic visit

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14
Q

How is a disease classified as chronic?

A

Disease lasts longer than 3 months

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15
Q

What is comorbidity?

A

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

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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
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17
Q

What are the risk factors of HTN?

A
  1. FHx of HTN
  2. Obesity
  3. High sodium diet
  4. Smoking
  5. Alcohol
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18
Q

What are the symptoms of HTN?

A

Often asymptomatic.
Headache is the most common symptom.

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19
Q

How can HTN be diagnosed?

A

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

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20
Q

What are two numbers of blood pressure?

A
  1. Systolic
  2. Diastolic
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21
Q

What does systolic blood pressure measure?

A

The pressure in the arteries when the heart contracts.

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22
Q

What does diastolic blood pressure measure?

A

The pressure in the arteries when relaxed.

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23
Q

What is the range of normotensive blood pressure?

A

90-120/60-80

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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
What is non-pharmacological management of HTN?
1. Low sodium diet 2. Smoking and alcohol cessation 3. Exercise 4. BP log at home
26
What drugs are used to treat HTN? Example of each drug.
1. ACE Inhibitors (Lisinopril, Lotensin) 2. Ca Channel Blockers (Norvasc, Cardizem) 3. Diuretics (Hydrochlorothiazide) 4. ARBs (Cozaar, Benicar)
27
What is the characteristic of Type 1 DM?
insulin insufficiency
28
What is the characteristic of Type 2 DM?
insulin resistance
29
Which type of diabetics can take insulin?
Both type
30
What are the risk factors of Type 2 DM?
1. FHx of DM 2. Obesity 3. High carb diet 4. Lack of exercise
31
What are symptoms of type 2 DM?
1. Unusual weight loss or gain 2. Polyuria 3. Polydipsia 4. Blurred vision 5. Neurovascular (pins and needles feeling)
32
How type 2 DM is diagnosed?
Fasting blood glucose / hemoglobin A1C
33
What are the valid complications of DM?
1. Diabetic Retinopathy 2. Renal Failure 3. Cardiac Disease 4. PVD 5. Neuropathy
34
What is nonpharmalogical management of Type 2 DM?
1. Low carb diet. 2. Weight loss 3. Exercise 4. Blood glucose log
35
What are two ways of pharmacological management of DM?
1. Injection: humalog (rapid), lantus (long acting), sliding scale. 2. Oral: metformin(prevent liver from dumping glucose into blood), glyburide (induce pancreases)
36
What are the risk factors of HLD?
1. FHx of HLD. 2. Obesity 3. High lipid diet 4. ETOH 5. Physical inactivity
37
What are the symptoms of HLD?
Asymptomatic
38
How HLD can be diagnosed?
Bloodwork.
39
What is the function of LDL?
Transports cholesterol to arterial walls and aides the formation of plaques.
40
What is the function of HDL?
Removes cholesterol from artery plaques and recycle it back to the liver.
41
What are valid complications of HLD?
1. Pancreatitis 2. CVA 3. Arterial atheroslerosis 4. CAD/MI
42
What is the nonpharmacological management of HLD?
1. Low lipid diet 2. Decrease ETOH 3. Weight loss 4. Exercise 5. Close follow up
43
What is the pharmacological management of HLD?
Statin (inhibit the production of cholesterol)
44
What is etiology of CAD?
Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia.
45
What are the risk factors of CAD?
1. HTN 2. HLD 3. DM 4. Smoking 5. FHx < 55y/o
46
What are the symptoms of CAD?
1. Chest pain or pressure 2. Worse with exertion (having chest pain and still exercise)
47
How CAD can be diagnosed?
Cardiac catheterization
48
What is the #1 biggest risk factor for MI?
CAD
49
What is non-pharmacological management of CAD?
1. Managing risk factors 2. Smoking cessation 3. Exercise/ weight loss 4. Manage stress
50
What is pharmacological management of CAD?
1. Acetylsalicylic acid (ASA) - Aspirin - thinning blood prevent blood clotting. 2. Nitroglycerin (NTG) - vasodilator
51
What are the surgical treatments of CAD? Which one is the least invasive? most invasive?
1. Angioplasty - least invasive 2. Coronary stent 3. CABG (open heart surgery) - most invasive
52
What does subjective information include?
1. Chief complaint 2. HPI 3. ROS
53
What is the HPI?
The story of symptoms & events that led to the clinic visit
54
What is the ROS?
A head-to-toe overview of the patient's body-systems phrased in the form of positives and negatives
55
What are the elements of HPI?
1. Onset 2. Timing 3. Location 4. Quality 5. Severity 6. Modifying factors 7. Associated Sx 8. Context
56
PO short for
per os = by mouth
57
What are three types of HPI structure?
1. Single complaint 2. Multiple complaint 3. Chronologic
58

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