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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

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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
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?

A

Both type

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?

A

CAD

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
58
Q
A

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