Scribe America OP final Exam

New Patient

No previous records, longer visit, detailed chart

established patient

Previous records available from last 3 years, shorter visit, concise chart

Diagnostic visit

New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment

health management

check up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems

Clinic Flow

1. Check-in

2. Physician Evaluation

3. Orders & Results

4. Assessment & Plan

5. Check-out

Quality Measures

chief complaint vital signs height, weight, BMI Smoking Status

What goes in the History and Physical (H&P)

HPI, ROS, PE

DDx

differential diagnosis

Patient says high blood pressure

Hypertension (HTN)

Patient says high cholesterol

Hyperlipidemia (HLD)

Patient says thyroid problem

Usually Hypothyroidism, sometimes Hyperthyroidism

Patient says diabetes

Diabetes Mellitus (DM)

Patient says "I only take pills for my diabetes"

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Patient says "I take shots for my diabetes"

Insulin Dependent Diabetes Mellitus (IDDM)

Patient says heart disease

Coronary Artery Disease (CAD)

Patient says heart attack

Myocardial Infarction (MI) and CAD

Patient says heart failure

Congestive Heart Failure (CHF)

Patient says Irregular heartbeat

arrhythmia

Patient says murmur

heart murmur

Patient says episodes of abnormally fast/racing heartbeat

supraventricular tachycardia (SVT)

Patient says asthma

asthma

Patient says Emphysema/Chronic Bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

Patient says blood clot in lung

Pulmonary Embolism (PE)

Patient says pneumonia

Pneumonia (PNA)

Patient says reflux

Gastroesophageal Reflux Disease (GERD)

Patient says ulcer

Gastric Ulcer or Peptic Ulcer Disease (PUD)

Patient says pancreatitis

pancreatitis

Patient says hepatitis

Hepatitis A, B, or C

Patient says diverticulitis

Diverticulitis

Patient says Crohn's/UC

Crohn's Disease or Ulcerative Colitis

Patient says irritable bowel

Irritable Bowel Syndrome (IBS)

Patient says bladder infection

Urinary Tract Infection (UTI)

Patient says kidney infection

Pyelonephritis (Pyelo)

Patient says kidney stones

renal calculi

Patient says I'm on dialysis

Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis

Patient says enlarged prostate

Benign Prostate Hypertrophy (BPH)

Gravida

Total number of time the patient has been pregnant

Para

number of pregnancies reaching viable gestational age (23 weeks) that the patient has had

Abortus

total number of miscarriages or elective abortions

patient says brain bleed (stroke)

Hemorrhagic CVA

Patient says stroke

Cerebrovascular Accident (CVA)

Patient says mini-stroke

Transient Ischemic Attack (TIA)

Patient says seizures

Seizure disorder/Epilepsy

Patient says bipolar

bipolar disorder

Patient says schizophrenia

schizophrenia

Patient says I drink a lot

ETOH abuse or alcoholism

Patient says I do drugs

substance abuse

Patient says Blood clot in my leg

Lower Extremity Deep Vein Thrombosis (DVT)

Patient says Bulge in my aorta

aortic aneurysm

Patient says bad flow to my legs

peripheral vascular disease (PVD)

Patient says: Numbness in my legs

peripheral neuropathy

Patient says low back pain

Chronic Low Back Pain

Patient says bulging/herniated disc

Degenerative Disc Disease (DDD)

Patient says arthritis

Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)

Patient says weak/fragile bones

Often Osteoporosis

Patient says cancer

Cancer or carcinoma (CA) (attached to the type of cancer)

Patient says spread to my

With metastases to the...

Patient says chemo

chemotherapy

Patient says radiation

radiation therapy

Patient says they cut it out

s/p surgical resection

Patient says its gone

In remission

Patient says tonsils removed

tonsillectomy

Patient says adenoids removed

Adenoidectomy

Patient says ear tubes

myringotomy or Pressure equalizing (P.E) tubes

Patient says heart bypass

Coronary Artery Bypass Graft (CABG) --> PMHx CAD

Patient says stents

Coronary Stents --> PMHx CAD

Patient says heart cath

cardiac catheterization

Patient says balloon

Angioplasty --> PMHx CAD

Patient says valve surgery

Valve repair or replacement (Bovine vs. Mechanical)

Patient says pacer

pacemaker

Patient says defibrillator

Automatic Implanted Cardiac Defibrillator (AICD)

Patient says surgery for afib

Afib s/p cardiac ablation

Patient says breast removal

mastectomy

Patient says breast removal

mastectomy

Patient says hole in my neck

tracheostomy (trach)

Patient says part of my lung removed

Partial lobectomy

Patient says appendix removed

appendectomy

Patient says Gallbladder removed

cholecystectomy

Patient says hernia repair

Herniorrhaphy

Patient says part of my colon removed

Partial colectomy

Patient says bag to collect stool

colostomy

Patient says spleen removed

splenectomy

Patient says stomach stapled

bariatric surgery

Patient says exploratory

Exploratory Laparoscopy (Ex Lap)

Patient says kidney removed

nephrectomy

Patient says uterus removed

Hysterectomy (partial vs. total)

Patient says ovary removed

oophorectomy

Patient says ovary and fallopian tubes removed

Salpingo-oophorectomy

Patient says tubes tied

Tubal ligation (female) or Vasectomy (male)

Patient says C-section

cesarean section

Patient says prostate removed

Prostatectomy or prostate resection (most often Trans-Urethral Resection of the Prostate, or TURP)

Patient says uterine product removed

Dilation and Curettage (D&C)

Patient says neck artery cleaned

carotid endarterectomy

Patient says shunt

cerebral shunt

Patient says brain surgery

Craniotomy (brain bleed vs. brain CA)

Patient says dialysis fistula

AV (arteriovenous) Fistula

Patient says dialysis graft

AV graft

Patient says PICC line

Peripherally Inserted Central Catheter (PICC)

Patient says Port

Port-a-cath or Medi-Port

Patient says clot filter (lower abdomen)

IVC (inferior vena cava) filter