Vituity scribe EXAM 1&2 Questions and
Answers Graded A+
Plantar ✔✔Sole side of foot
Plantar flexion ✔✔Foot movement when toes flex down
(pointing your toes)
Supine ✔✔Body lying face up (chest up and back down)
Afebrile ✔✔without fever
diaphoresis ✔✔excessive sweating
dysuria ✔✔painful urination
emesis ✔✔vomiting
epistaxis ✔✔bleeding from the nose
gait ✔✔a person’s manner of walking
hematochezia ✔✔Bright red, bloody stools
hematuria ✔✔blood in the urine
hemoptysis ✔✔coughing up blood
incontinence ✔✔inability to control bowel movements or urine
myocardial infarction (MI) ✔✔heart attack
pruritis ✔✔itching
syncope ✔✔fainting
vertigo ✔✔Condition of dizziness, “room spinning”
cyanosis ✔✔bluish discoloration of the skin
laceration ✔✔to cut
Bradycardia ✔✔slow heart rate
Tachycardia ✔✔fast heart rate
apnea ✔✔absence of breathing
gravid ✔✔pregnant
melena ✔✔Black tarry stool
colectomy ✔✔surgical removal of the colon
mastectomy ✔✔surgical removal of a breast
ABG ✔✔arterial blood gas
Vituity Scribe Training Pre-Classroom
Training Exam Latest 2022 100% Pass
ALOC ✔✔Altered Level of Consciousness
BM ✔✔bowel movement
DOE ✔✔Dyspnea on exertion
EOMI ✔✔Extraocular Movement Intact (Appropriate function of the extra ocular muscles,
tested with “follow my finger”)
HA ✔✔headache
MI ✔✔Myocardial infarction
NAD ✔✔no acute distress
NSR ✔✔Normal Sinus Rhythm
PNA ✔✔pneumonia
UTI ✔✔Urinary Tract Infection
ASA ✔✔Aspirin
CA ✔✔Cancer
PCN ✔✔Penicillin
DM ✔✔Diabetes Mellitus
PTX ✔✔Pneumothorax
SOB ✔✔Shortness of breath
FB ✔✔Foreign Body
CVA ✔✔Cerebral Vascular Accident (Stroke) – Can be ischemic or hemorrhagic)
TIA ✔✔transient ischemic attack (mini stroke)
TX ✔✔treatment
earwax ✔✔cerumen
runny nose ✔✔rhinorrhea
Vomiting blood ✔✔hematemesis
fainting ✔✔syncope
Sweating ✔✔diaphoresis
bruising ✔✔ecchymosis
itchiness ✔✔pruritus
cardiac bypass ✔✔CABG (coronary artery bypass graft)
Hernia repair ✔✔herniorrhaphy
Removal of gallbladder ✔✔cholecystectomy
Removal of uterus ✔✔hysterectomy
Rales ✔✔wet, crackling sound with respirations (aka crackles)
Four main components of the medical chart you are responsible for? ✔✔1. HPI
- ROS
- PMhxFhxShx
- PE
Name the 8 elements of the HPI ✔✔1. Location - Quality
- Severity
- Context
- Timing
- Duration
- associated signs and symptoms
- modifying factors
True or False: The HPI and ROS are subjective ✔✔True: these are from the patient’s perspective
True or False: Patient’s past surgeries should be documented in the Physical Exam (PE)?
✔✔False: Should be in past medical history
True or False: Whether a patient smokes or not should be documented in the PMFSH? ✔✔True:
This is social history
True or False: The physical exam is objective ✔✔True: From the doctor’s point of view
Fever ✔✔febrile
vomiting ✔✔emesis
pain with urination ✔✔dysuria
RRR ✔✔Regular Rate and Rhythm (cardio finding)
CVAT ✔✔Costal Vertebral Angle Tenderness (Back finding sometimes GU)
BS present ✔✔bowel sounds present
SNF ✔✔Skilled Nursing Facility
BIBA ✔✔brought in by ambulance
CP ✔✔chest pain, cerebral palsy
ATX ✔✔atelectasis
Pregnancy ✔✔Gravid
oophorectomy ✔✔surgical removal of one of both ovaries
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What does ROS stand for? ✔✔Review of symptoms, head to toe checklist of symptoms
The HPI and ROS are considered what type of information? ✔✔Subjective
The physical exam is what type of information? ✔✔Objective
If a physician told you a patients abdomen was nontender or the patients skin was plale, where
would you document this information ✔✔Physical Exam (PE)
What section focuses directly on the chief complaint? ✔✔HPI (History of present illness)
What are the 5 vital signs? ✔✔1. Heart rate (HR)
- Respiratory rate (RR)
- Blood pressure (BP)
- Temperature (T)
- Oxygen Saturation (SpO2)
Surgical Hx example ✔✔CABG (Coronary artery bypass graft)
Social Hx example ✔✔Smoker 1 ppd
Family Hx example ✔✔Brother diagnosed with CAD < 55 y/o
Removal of appendix ✔✔Appendectomy
Removal of gallbladder ✔✔Cholecystectomy
Removal of uterus ✔✔Hysterectomy
Removal of tonsils ✔✔Tonsillectomy
What are the 2 types of heart attacks and how are they diagnosed? ✔✔STEMI – EKG
Non-STEMI – Troponin
What are 3 cardiac risk factors? ✔✔HTN, HLD, Smoking, CAD, DM, FHx CAD < 55 y/o
Chest pain, dyspnea, cough and fever correlated to which DDx?
What study would be ordered? ✔✔PNA (Pneumonia)
CXR
What are 3 symptoms a patient with an Ischemic CVA would present with? ✔✔Unilateral
weakness/numbness, slurred speech, vision changes
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is the
disease diagnosed? ✔✔Irregularly irregular rhythm (A-Fib)
EKG
Name 2 risk factors to hemorrhagic CVA ✔✔Head Trauma, anticoagulants (blood thinner
medication), uncontrolled HTN
How is AMS different from a focal neurological deficit?
What is the major cause of AMS in the elderly? ✔✔AMS (confusion, lethargy,
unresponsiveness) affects the whole brain (drugs, EtOH) and FND (one sided
weakness/numbness, speech changes, vision changes) affects a small portion/localized of the
brain
AMS in elderly – UTI
Layman’s term for GERD ✔✔Heartburn, Indigestion, Acid Reflux
Most common cause for seizures in children? ✔✔Fever
Which drug causes smooth muscle relaxation, causing vasodilation and increase blood supply to
heart muscle? ✔✔NTG (Nitroglycerin)
Describe the significance of an HPI ✔✔Explains patients CC and answers “Why did the patient
seek treatment?”
CC of a headache, name 5 elements of the HPI and provide an applicable example of each
element ✔✔Onset – 3 weeks ago
Timing – intermittent
Quality – pressure
Severity – 9/10
location – frontal/forehead
Modifying factors – worse with light, better after Excedrin
Context – does not take a blood thinner, no recent head injuries, Hx of similar HA
True or False:
Patients entire ED visit is based on their answers to the questions asked during the interview?
✔✔True
True or False:
Accurate chronology is not important in an HPI ✔✔False
What is the main different between HPI and ROS? ✔✔HPI – story of the CC
ROS – head-to-toe checklist of subjective Sx
True or False:
Symptoms listed in ROS can contradict the Sx discussed in the HPI ✔✔False
How would you document GPA for a patient who is currently pregnant, has been pregnant 4 time
in the past, and has one child at home? ✔✔G – 5
P – 1
A – 3
List 5 body systems found in the ROS and provide 2 symptoms for each system. ✔✔Skin –
Rashes, itching, redness
General – fever, chills, weight loss
Scribe America Final Exam Review
Questions and Answers 100% Pass
AAA ✔✔Abdominal Aortic Aneurysm
A Fib ✔✔Atrial Fibrillation
Abd ✔✔Abdomen, Abdominal
Abx ✔✔Antibiotics
AMA ✔✔Against Medical Advice
AMS ✔✔Altered Mental Status
ASA ✔✔Acetylsalicylic Acid (Aspirin)
BID ✔✔Twice Daily
Bilat LE ✔✔Bilateral Lower Extremities
BM ✔✔Bowel Movement
BP ✔✔Blood Pressure
CA ✔✔Cancer, Carcinoma
CABG ✔✔Coronary Artery Bypass Graft, “open heart surgery”
CAD ✔✔Coronary Artery Disease, “heart disease”
CT or CAT ✔✔Computerized Assisted Tomography
CHF ✔✔Congestive Heart Failure
COPD ✔✔Chronic Obstructive Pulmonary Disease
CP ✔✔Chest Pain
CPR ✔✔Cardiopulmonary Resuscitation
C-section ✔✔Caesarean Section
C-spine ✔✔Cervical Spine (neck)
CSF ✔✔Cerebrospinal Fluid
CVA ✔✔Cerebrovascular Accident -or- Costovertebral Angle
CXR ✔✔Chest X-Ray
c/o ✔✔complains of
DKA ✔✔Diabetic Ketoacidosis
DM ✔✔Diabetes Mellitus
DNR ✔✔Do Not Resuscitate
DOE ✔✔Dyspnea On Exertion
DVT ✔✔Deep Venous Thrombosis
Dx ✔✔Diagnosis
Dz ✔✔Disease
EKG/ECG ✔✔Electrocardiogram
EtOH ✔✔Alcohol
FHx ✔✔Family History
Fx ✔✔Fracture
GI ✔✔Gastrointestinal
G/P/Ab ✔✔Gravida/Para/Abortion
GSW ✔✔Gun Shot Wound
GU ✔✔Genitourinary
HA ✔✔Headache
HEENT ✔✔Head, Eyes, Ears, Nose, Throat
Scribe America Final Exam ED
Questions and Answers Already Graded
A+
High blood pressure layman’s✔✔Hypertension
Hypertension (abbv)✔✔HTN
High cholesterol layman’s✔✔Hyperlipidemia
Hyperlipidemia (abbv)✔✔HLD
Diabetes layman’s✔✔Diabetes mellitus
Diabetes mellitus (abbv)✔✔DM
“I only take pills for my diabetes”✔✔NIDDM (Type 2)
“I take insulin for my diabetes”✔✔IDDM (Type 1)
Heart disease layman’s✔✔Usually coronary artery disease
Coronary artery disease (abbv)✔✔CAD
Heart failure layman’s✔✔Congestive heart failure
Congestive heart failure (abbv)✔✔CHF
Irregular heartbeat layman’s✔✔Atrial fibrillation (A-fib)
Murmur layman’s✔✔Heart murmur
Episodes of abnormally fast/racing heartbeat✔✔Supraventricular tachycardia
Supraventricular tachycardia (abbv)✔✔SVT
Emphysema or chronic bronchitis layman’s✔✔Chronic obstructive pulmonary disease (COPD)
Blood clot in lung layman’s✔✔Pulmonary embolism (PE)
Pneumonia (abbv)✔✔PNA
Reflux layman’s✔✔Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (abbv)✔✔GERD
Ulcer layman’s✔✔Gastric ulcer or Peptic ulcer disease
Crohn’s or UC layman’s✔✔Crohn’s disease or Ulcerative colitis
Irritable bowel layman’s✔✔Irritable bowel syndrome (IBS)
Irritable bowel syndrome (abbv)✔✔IBS
Bladder infection layman’s✔✔Urinary tract infection (UTI)
Kidney infection layman’s✔✔Pyelonephritis (Pyelo)
Kidney stones layman’s✔✔Renal calculi
“I’m on dialysis”✔✔Chronic renal failure (CRF) or End stage renal disease (ESRD) on dialysis
Enlarged prostate layman’s✔✔Benign prostate hypertrophy (BPH)
Document GPA for a pt who is currently pregnant, has been pregnant 3 times in the past, and has
2 kids at home.✔✔G: 4 P:2 A:1
Stroke layman’s✔✔Ischemic cerebrovascular accident (CVA)
“Mini-stroke” layman’s✔✔Transient ischemic attack (TIA)
Seizures layman’s✔✔Seizure disorder / Epilepsy
Brain bleed layman’s✔✔Hemorrhagic CVA
Bipolar layman’s✔✔Bipolar disorder
Schizophrenia layman’s✔✔Schizophrenia
“I drink a lot”✔✔EtOH abuse or Alcoholism
“I do drugs”✔✔Substance abuse
“Blood clot in my leg”✔✔Lower extremity deep vein thrombosis (DVT)
“Bulge in my aorta” or “Triple A”✔✔Abdominal aortic aneurysm (AAA)
ScribeAmerica Final Exam Questions
and Answers Graded A+
A patient is seen in the emergency department complaining of dysuria and tells you that she is 23
weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the
best diagnosis? ✔✔acute urinary tract infection in pregnancy, 2nd trimester
A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency
department to have sutures placed. The doctor tells you there is no tendon injury and circulatory,
sensory and motor is intact. What is the best diagnosis for his complaint? ✔✔Uncomplicated
laceration of the left foot – initial encounter
What does AMS stand for? ✔✔altered mental status
What does GCS stand for? ✔✔glasgow coma scale
What does DNR stand for? ✔✔do not resuscitate
What does AAA stand for? ✔✔abdominal aortic aneurysm
What does PE stand for in the diagnosis section of the chart? ✔✔pulmonary embolism
What does DP stand for in “DP pulse”? ✔✔dorsalis pedis
What does DVT stand for? ✔✔deep vein thrombosis
What does NTG stand for? ✔✔nitroglycerin
What does URI stand for? ✔✔upper respiratory infection
What does CHF stand for? ✔✔congestive heart failure
What does s/p stand for? ✔✔status post
What does GERD stand for? ✔✔gastroesophageal reflux disease
What does EOMI stand for? ✔✔extraocular movements intact
What does DOE stand for? ✔✔dyspnea on exertion
What does LBBB stand for? ✔✔left bundle branch block
What does CVA stand for? ✔✔costovertebral angle
What does CSF stand for? ✔✔cerebrospinal fluid
What does PTX stand for? ✔✔pneumothorax
What does COPD stand for? ✔✔chronic obstructive pulmonary disease
What does PNA stand for? ✔✔pneumonia
What does CBC stand for? ✔✔complete blood count
What does IDDM stand for? ✔✔insulin dependent diabetes mellitus
What does TIA stand for? ✔✔transient ischemic attack
A 43 y/o male presents to the ED with vomiting that began 5 hours ago. He has a history of Type
II DM and is s/p right BKA. On objective evaluation it is found that he is hyperglycemic and has
elevated ketones and so he will be admitted for DKA. Match the details to the correct section of
the chart.
5 hours ago, DKA, vomiting, admit, Type II DM, right BKA, hyperglycemia & elevated ketones,
Onset:
Disposition:
ED Course:
CC:
PMHx:
Diagnosis:
PSHx: ✔✔Onset: 5 hours ago
Disposition: admit
ED Course: hyperglycemia and elevated ketones
CC: vomiting
PMHx: Type II DM
Diagnosis: DKA
PSHx: right BKA
Match the following description to the appropriate team member.
Unit Secretary, ED tech, Scribe, Mid-level Provider, charge nurse, RT, ED nurse
: Documents the patient’s visits on behalf of the physician
: Answers phone calls, pages other specialists/ doctors, and organizes the patient’s
paperwork
Scribe America Final Exam ED
Questions and Answers Already Passed
What are the 3 types of dispositions? ✔✔Discharge, Admit, Transfer
What does HPI stand for? ✔✔history of present illness
What does ROS stand for? ✔✔review of systems
The HPI and ROS are considered what type of information? ✔✔subjective
The physical exam is what type of information? ✔✔objective
If a physician told you a patient’s abdomen was non tender, where would you document this?
✔✔PE
What section focuses directly on the chief complaint? ✔✔HPI
If someone has a hx of CABG or MI, what is something you can also always document in the
PMHx section of the chart? ✔✔CAD
Name an example of something you may write in the Social Hx portion of the chart. ✔✔smokes
1 pack/day
Name an example of something you may write in the Family Hx portion of the chart. ✔✔Mother
had Hx of CAD at age 46
What are the abbreviations for the following past medical history terms?
Hypertension
Stroke
Diabetes
Heart Attack
High Cholesterol ✔✔HTN
CVA (cerebrovascular accident)
DM
MI
HLD
What are the medical terms for the following past surgical terms?
Removal of the appendix
Removal of the gallbladder
Removal of the uterus
Removal of a fallopian tube
Removal of the tonsils
Removal of the breast ✔✔appendectomy
cholecystectomy
hysterectomy
Salpingo-oophorectomy
tonsillectomy
mastectomy
What are the five vital signs? ✔✔Blood pressure (BP), heart rate (HR), oxygen saturation
(SaO2), respiratory rate (RR), temperature (C or F)
What does NKDA stand for? ✔✔no known drug allergies
What does LNMP stand for? ✔✔Last Normal Menstrual Period
If the doctor said the exam was “benign”, what does this mean? ✔✔this means that the exam was
normal and of no concern
Explain acute vs chronic. ✔✔acute: serious, new condition, that could potentially be lifethreatening
chronic: not of much concern, long-lasting condition, typically not a death threat
What are the medical terms for the following pathophysiology abbreviations?
CAD
AAA
COPD
PNA
URI ✔✔coronary artery disease
abdominal aortic aneurysm
chronic obstructive pulmonary disease
pneumonia
upper respiratory disease
How are the following diseases diagnosed?
-CHF (two answers)
-PE (three answers)
-Cholecystitis
-Pancreatitis
-Appendicitis
-Hemorrhagic CVA (two answers)
-DVT ✔✔-chest x-ray, bnp (b-type natriuretic peptide)
-CT chest with IV contrast (CTA chest), VQ scan, D-dimer
-abdominal ultrasound (US) of RUQ
-elevated lipase lab test
-CT AP w/ PO
Scribe America Final exam guide (AA)
Latest 2022
- CAD: ✔✔Coronary Artery Disease
- HTN: ✔✔Hypertension
- DM ✔✔Diabetes Mellitus
- MI: ✔✔Myocardial infarction
- CHF: ✔✔Congestive heart failure
- AFIB: ✔✔Atrial fibrillation
- PE: ✔✔Physical exam or pulmonary embolism
- DVT: ✔✔Deep Vein thrombosis
- DKA: ✔✔Diabetic Ketoacidosis
- PTX: ✔✔Pneumothorax
- COPD: ✔✔Chronic Obstructive Pulmonary Disease
- PNA: ✔✔Pneumonia
- GERD: ✔✔Gastroesophageal Reflux Disease
- CVA(Stroke): ✔✔Cerebrovascular Accident
- TIA: ✔✔Transient Ischemic Attack
- URI: ✔✔Upper respiratory Infection
- UTI: ✔✔Urinary tract Infection
- AAA: ✔✔Abdominal Aortic Aneurysm
- SBO: ✔✔Small bowel Obstruction
- DNR: ✔✔Do not resuscitate
- Symptom abbreviation
CP: ✔✔Chest pain - SOB: ✔✔Shortness of Breath
- N/V/D: ✔✔Nausea/Vomiting/Diarrhea
- HA: ✔✔Headache
- DOE: ✔✔Dyspnea on exertion
- BM: ✔✔Bowel Movement
Scribe 101 Questions and Answers with
Complete Solutions
True or False: In order to take the final exam, I must complete each lesson quiz in order with a
passing score of 100% before I can attempt the final. ✔✔TRUE
What happens if you do not complete the course in 15 days and/or fail the final exam twice?
✔✔On the 15th day after passing the initial quiz, my course progress will be reset back to 0%. I
will then be able to re-progress through the course.
When does my certificate for passing Scribe101 expire? ✔✔My certificate for completing
Scribe101 is good for 90 days, from the date I passed the final.
I have previous medical experience. Do I need to complete the Scribe101 course? ✔✔No. All
individuals will be given the option to test out of Scribe101. To test out, please access the
“Scribe101 – Test Out” course. The “Scribe101 – Test Out” course is composed of a 100 question
final. You will have 1 attempt to pass this final and test out. If you do not pass this final, you will
need to complete the Scribe101 course.
Vital signs are: ✔✔A series of measures that give an overview of a patient’s overall health
Heart rate is defined as: ✔✔The rate that your heart is pumping blood
Blood pressure is defined as: ✔✔The pressure at which blood is being pumped throughout your
body
Which of the following is NOT a vital sign: ✔✔Body Weight
Someone who is breathing really fast and short of breath is MOST likely: ✔✔Tachypneic
ED Scribe – FINAL EXAM QUESTIONS
AND ANSWERS ALREADY PASSED
Medical Decision Making (MDM) ✔✔The physician’s thought process
Pain vs. Tenderness ✔✔Patient’s feeling vs. physician’s assessment
What does distress mean? ✔✔The doctor’s judgment of discomfort
Baseline ✔✔An individual’s normal state of being
What does Auscultation mean? ✔✔Listening with a stethoscope
Palpation ✔✔The act of pressing on an area by the doctor
Inpatient ✔✔Admitted to the hospital overnight
Outpatient ✔✔Seen and sent home the same day
What is the ED flow (overview)? ✔✔1. Check in and Chief Complaint 2. Physician assessment
- Objective orders and results 4. Medical Decision Making 5. Disposition
What is the ED flow before orders are made? ✔✔1. Arrival 2. Triage 3. Vital Signs / Bed
Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE
What is the ED flow after orders are made? ✔✔1. Differential Dx 2. Physician orders > labs,
imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition
What is the general documentation template? ✔✔HPI > ROS > PHx > PE > ED course >
Disposition
Thyroid problem means.. ✔✔Usually Hypothyroidism, sometimes hyperthyroidism
“I only take pills for my diabetes” means.. ✔✔Non-Insulin Dependent Diabetes Mellitus –
NIDDM
“I take shots (insulin) for my diabetes” means.. ✔✔Insulin Dependent Diabetes Mellitus – IDDM
Heart disease means.. ✔✔Usually Coronary Artery Disease – CAD
Heart attack means.. ✔✔Myocardial Infarction – MI and CAD
Irregular heartbeat means.. ✔✔Atrial Fibrillation (A-Fib)
Murmur means.. ✔✔Heart murmur
Episodes of abnormally fast/racing heartbeat means.. ✔✔Supraventricular Tachycardia – SVT
Emphysema/Chronic Bronchitis means.. ✔✔Chronic Obstructive Pulmonary Disease – COPD
Blood clot in lung means.. ✔✔Pulmonary Embolism – PE
Reflux means.. ✔✔Gastroesophageal Reflux Disease – GERD
Ulcer means.. ✔✔Gastric Ulcer or Peptic Ulcer Disease
Hepatitis means.. ✔✔Hepatitis A, Hepatitis B, or Hepatitis C
Crohn’s/UC means.. ✔✔Crohn’s Disease or Ulcerative Colitis
Kidney infection means.. ✔✔Pyelonephritis – Pyelo
Kidney stones means.. ✔✔Renal calculi
“I’m on dialysis” means.. ✔✔Chronic Renal Failure – CRF or End Stage Renal Disease – ESRD
on dialysis
Enlarged prostate means.. ✔✔Benign Prostate Hypertrophy – BPH
What is the convention for documenting gynecological PMHx? ✔✔G: P: A:
Stroke means.. ✔✔Ischemic Cerebrovascular Accident – CVA
Mini-stroke means.. ✔✔Transient Ischemic Attack – TIA
Seizures means.. ✔✔Seizure disorder/Epilepsy
Brain bleed means.. ✔✔Hemorrhagic CVA
“I drink a lot” means.. ✔✔ETOH abuse or Alcoholism
“I do drugs” means.. ✔✔Substance abuse
“Blood clot in my leg” means.. ✔✔DVT
“Bulge in my aorta” or “Triple A” ✔✔Abdominal Aortic Aneurysm
“Bad blood flow to my legs” means.. ✔✔Peripheral Vascular Disease – PVD
“Numbness in my legs” means.. ✔✔Peripheral Neuropathy
Bulging/Herniated disc means.. ✔✔Degenerative Disc Disease – DDD
What does Arthritis mean? ✔✔Osteoarthritis, Rheumatoid Arthritis
Joint pain (chronic) means.. ✔✔Degenerative Joint Disease -DJD
Weak/fragile bones means.. ✔✔Osteoporosis
Spread to my means.. ✔✔With metastases to the..
“They cut it out” (in regards to cancer) means.. ✔✔Status-post surgical resection
“It’s gone” (in regards to cancer) means.. ✔✔In remission
Tonsils removed means.. ✔✔Tonsillectomy
Adenoids removed means.. ✔✔Adenoidectomy
Ear tubes means.. ✔✔Pressure Equalizer Tubes
Heart bypass means.. ✔✔Coronary Artery Bypass Graft – CABG > PMHx CAD
Stents means.. ✔✔Coronary Stents
Medical Scribe- Final exam review
questions and answers 100% pass
What are the 5 vital signs? ✔✔1. Heart rate
- Blood pressure
- Respiratory rate
- Temperature
- Oxygen saturation
The HPI and the ROS are what type of information? ✔✔
The physical exam is what kind of information? ✔✔
While evaluating a patient complaining of chest pain, your physician tells you that the heart
sounds are normal. Would you document this in the HPI, ROS, or PE? ✔✔Physical exam
Would you be contradicting yourself if you wrote, ” the patient has abdominal pain”, in the HPI,
but then later in the physical exam documented, “the abdomen is non-tender”, why or why not?
✔✔No, because the patient stating that they have abdominal pain is a subjective complaint. A
non-tender abdomen is an objective finding.
What is the difference between the HPI, and the ROS? ✔✔HPI focuses on the details related to
their chief complaint, ROS is a head to toe checklist of symptoms. It includes the chief
complaint, associated symptoms, and all other complaints the patient may have.
What does disposition (dispo) mean? ✔✔The patient’s destination after they leave the ED.
What subcategories are included within the past history section of the template? ✔✔PMHx: Past
medical history- HTN, DM, HLD, CAD, MI
PSHx: Past surgical history- appendectomy, cholecystectomy, CABG
FHx: Family history- Hx of CAD<55 years old
SHx: Social history- ETOH, smoking, drug abuse, occupation
What is the abbrieviation for heart attack? ✔✔MI- myocardial infarction
What is the abbreviation for high blood pressure? ✔✔HTN- hypertension
What is the medical term for acid reflux? ✔✔Gastroesophageal reflux disease
What is the medical term for stroke? ✔✔CVA- cerebral vascular accident
What is the term for gallbladder removal? ✔✔Cholecystectomy
What does NKDA stand for? ✔✔No know drug allergies
What is the medical term for redness? ✔✔Erythema
What is the medical term for bruising? ✔✔Ecchymosis
If the doctor says the exam was “benign”, what does that mean? ✔✔Normal- nothing of concern
What is CAD? ✔✔coronary artery disease
What other past histories would suggest that a patient has CAD? ✔✔MI, angina, CABG, stent,
angioplasty
Does a PMHx of CVA mean the patient has CAD? ✔✔No
Scribe Final Exam Questions and
Answers Rated A
SOAP ✔✔Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient’s point of view)
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.)
Assessment-Diagnosis (determined by combining subjective/objective info)
Plan-Disposition (Admission, Discharge, Transfer instructions)
7 Parts of the HPI ✔✔1. Context
- Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent,
etc.); duration = total time symptoms have been present - Location
- Quality
- Severity
- Modifying Factors
- Pertinent positive and negatives
Level 5 Chart ✔✔HPI: 4-7
ROS: 10+
PFSH: 2+
PEx: 8+ systems
Supination ✔✔Turning the hand so that the palm faces upward.
Volar ✔✔Pertaining to the palm of the hand or the sole of the foot.
Inferior ✔✔Situated below or further away from the head.
Midline ✔✔Line that divides the body into right and left halves.
Abduction ✔✔Moving away from the midline.
ACLS ✔✔Advanced cardiac life support.
AMA ✔✔Against medical advice.
DNR ✔✔do not resuscitate
DOA ✔✔Dead on arrival
OSH ✔✔Outside hospital
PCP ✔✔Primary care physician
PTA ✔✔Prior to arrival
UTD ✔✔Up to date (as in immunizations)
WNL ✔✔within normal limits
yo ✔✔year old
B/L ✔✔bilateral
D/C ✔✔discharge
H&P ✔✔history & physical
nl ✔✔normal
s/p ✔✔status post
TTP ✔✔tenderness to palpation
Proximal ✔✔closer to the body
Lateral ✔✔farther from the midline
Extension ✔✔straightening out
Distal ✔✔farther from the body
Adduction ✔✔Draws toward the midline
Pronation ✔✔turning of the hand so the palm faces downward
Posterior ✔✔situated behind or directed towards the rear
Plantar ✔✔referring to the sole of the foot
Inverted ✔✔turned inward
Deep ✔✔Farther from the surface
Flexion ✔✔bending or angulation
Percussion ✔✔physician taps on a surface to determine the underlying structure
ScribeAmerica Final Exam Questions
and Answers Already Passed
Which of the following would belong in a psychiatric exam? ✔✔Affect
Certain words or phrases act as “red flags” to grab your provider’s attention to let them know that
a patient may require timely and comprehensive medical action. Which of the following words
or phrases are NOT considered “red flags”? ✔✔nocturia in a 65 year old male
What does LBBB stand for? ✔✔Left Bundle Branch Block
What does URI stand for? ✔✔Upper Respiratory Infection
What does IDDM stand for? ✔✔Insulin Dependent Diabetes Mellitus
What term describes “the patient destination is home?” ✔✔Discharged
If a patient signs a waiver giving you permission to capture photo of their unique rash, would
you be committing a HIPAA violation by using your cellphone to capture the photo? ✔✔Yes
because the phone is not an approved hospital device and it is not encrypted.
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? ✔✔CSMT
What condition correctly describes “A vascular change that temporarily deprives a part of the
brain of oxygen but does not result in any long lasting deficits?” ✔✔TIA
What FHx/SHx information is usually asked for pediatric patients? ✔✔Immunization status
Second hand smoke exposure
What does AMS stand for? ✔✔Altered Mental Status
Expand the following medical abbreviation. DNR ✔✔Do Not Resuscitate
What does GCS stand for? ✔✔Glasgow Coma Scale
What is the medical term for infection of the gall bladder? ✔✔Cholecystitis
How would you diagnose AFIB? ✔✔EKG
A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed on to his outstretched right hand and subsequently
experienced localized pains and swelling to his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note? ✔✔-
F/u with specialist or PCP
-Condition at time of disposition
-Timing of disposition
-Time period for f/u
-Specific conditions for return to the ED
An ROS has marked positive for head trauma with accompanying LOC. What DDx would your
provider be concerned about? ✔✔Hemorrhagic CVA
Which of the following are considered to be cardiac risk factors for CP patients? ✔✔-Tobacco
use
-DM
-CAD
Scribe Final Review Questions and
Answers Already Graded A
How would you diagnose Hemorrhagic CVA? ✔✔LP and Head CT
Which of the following lab results need to be monitored closely for efficiency? ✔✔d-dimer,
troponin
Which of the following tests would likely be immediately ordered for a Cardiac Workup in the
ED? ✔✔troponin, EKG, CXR
What procedure would be used to diagnose Meningitis? Expand the abbreviation. ✔✔lumbar
puncture
Which of the following would be ordered to investigate thyroid disease? ✔✔TSH, T4, T3
How would you diagnose AFIB? Use the abbreviation to answer the question. ✔✔EKG
Which of the following diseases may be diagnosed using a CXR? ✔✔CHF, PTX, PE, Rib
fracture, PNA
How would you diagnose an AAA? ✔✔CT A/P with IV contrast
How would you diagnose a pneumothorax? ✔✔CXR
Consent should be documented any time a procedure is performed, but there maybe certain
situations in which consent is unobtainable. In that case, consent is precluded by clinical
urgency. During which of the following procedures would consent usually be unobtainable?
✔✔CPR
Select the EKG interpretation documentation guidelines. ✔✔2 positive or negative findings, rate
and rhythm
Select terms you might find on an x-ray interpretation. ✔✔pneumothorax
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? ✔✔CSMT
Match the oxygen administration route to the corresponding definition. ✔✔nonrebreather maska plastic mask fit over the nose and mouth
RA- this means the patient is not on oxygen
NC- a plastic tube placed into the patient’s nostrils
BVM- a large facial mask held in place by hand and attached to an Ambu-bag used to manually
inflate the patient’s lungs
Intubation- an EET goes through the patient’s mouth and down the trachea
FM- a facial mask with a reservoir bag attached
A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed onto his outstretched right hand and subsequently
experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that the results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note?
✔✔F/U with specialist or PCP, Specific conditions for return to the ED, Condition at time of
disposition, Time period for f/u, Timing of disposition, patient mental capacity
What abbreviation describes the scenario in which a patient declines a hospital stay and decides
to go home instead? ✔✔AMA
Scribe Final Review Questions and
Answers Already Graded A
How would you diagnose Hemorrhagic CVA? ✔✔LP and Head CT
Which of the following lab results need to be monitored closely for efficiency? ✔✔d-dimer,
troponin
Which of the following tests would likely be immediately ordered for a Cardiac Workup in the
ED? ✔✔troponin, EKG, CXR
What procedure would be used to diagnose Meningitis? Expand the abbreviation. ✔✔lumbar
puncture
Which of the following would be ordered to investigate thyroid disease? ✔✔TSH, T4, T3
How would you diagnose AFIB? Use the abbreviation to answer the question. ✔✔EKG
Which of the following diseases may be diagnosed using a CXR? ✔✔CHF, PTX, PE, Rib
fracture, PNA
How would you diagnose an AAA? ✔✔CT A/P with IV contrast
How would you diagnose a pneumothorax? ✔✔CXR
Consent should be documented any time a procedure is performed, but there maybe certain
situations in which consent is unobtainable. In that case, consent is precluded by clinical
urgency. During which of the following procedures would consent usually be unobtainable?
✔✔CPR
Select the EKG interpretation documentation guidelines. ✔✔2 positive or negative findings, rate
and rhythm
Select terms you might find on an x-ray interpretation. ✔✔pneumothorax
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? ✔✔CSMT
Match the oxygen administration route to the corresponding definition. ✔✔nonrebreather maska plastic mask fit over the nose and mouth
RA- this means the patient is not on oxygen
NC- a plastic tube placed into the patient’s nostrils
BVM- a large facial mask held in place by hand and attached to an Ambu-bag used to manually
inflate the patient’s lungs
Intubation- an EET goes through the patient’s mouth and down the trachea
FM- a facial mask with a reservoir bag attached
A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed onto his outstretched right hand and subsequently
experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that the results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note?
✔✔F/U with specialist or PCP, Specific conditions for return to the ED, Condition at time of
disposition, Time period for f/u, Timing of disposition, patient mental capacity
What abbreviation describes the scenario in which a patient declines a hospital stay and decides
to go home instead? ✔✔AMA
Scribe U Final Questions and Answers
Already Passed
What does DOE stand for? ✔✔Dyspnea on Exertion
A 43-year-old male presents to the ED with vomiting that began 5 hours ago. He has a history of
Type II DM and is s/p right BKA. On objective evaluation it is found that he is hyperglycemic
and has elevated ketones and so he will be admitted for DKA. Match the details to the correct
section of the chart ✔✔PSHx: Right BKA
ED Course: Hyperglycemia and elevated ketones
Diagnosis : DKA
CC: Vomiting
Onset: 5 hours ago
Disposition: Admit
PMHx: Type II DM
A patient is seen in the emergency department complaining of dysuria and tells you that she is 23
weeks pregnant. Â Your doctor diagnoses her with a UTI. Â Which of the following would be
the best diagnosis? ✔✔Acute urinary tract infection in pregnancy, 2nd trimester
Medical terminology. What is the medical term for infection of the gall bladder?
✔✔Cholecystitis
You see the physician check the patient’s pulses in four places; the right wrist, the top of the right
foot, the back of the right foot and the left neck. The doctor states “The pulses are fine”. Match
the location with the appropriate pulse that you would document in the physical exam?
✔✔Wrist: 2+ radial pulse
Top of foot: 2+ DDP
Neck: 2+ Carotid
Back of foot: 2+ PTP
What do you need to make sure to document for every admitted patient? (select the best option.)
✔✔A consultation note indicating the admitting physician
Quality is an important descriptor that can paint a picture for concerning DDx. Match the
following HPI detail with the corresponding DDx. ✔✔Chest pains when taking a deep breath:
PTX
Sharp, stabbing pains that alternately becomes a dull heavy pressure like an elephant sitting on
the chest, but regardless of quality, pain is always brought on by exertion: CAD/MI
Burning Chest pain: GERD
Medical terminology. What is the medical term for stones in the gallbladder? ✔✔Cholelithiasis
A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest
radiating straight to his back with associated nausea that began 1 hour ago. What element is
constant? ✔✔Timing
You are starting your shift and your physician immediately picks up 3 patients. The first patient
is presenting with a productive cough steadily worsening since onset 4 weeks ago. The second
patient has had abdominal discomfort slowly localizing into the right lower abdomen with
accompanying fever over the last 6 hours and on PE, the patient has RLQ tenderness on
palpation. The third patient has urinary sx and urinedip has already resulted and is positive for
leukocytes and bacteria. Given the information, what might the most likely diagnoses’ end up
being for these patients? ✔✔PNA, Appendicitis, UTI
What does “PE” stand for in the Diagnosis section of the chart? ✔✔Pulmonary Embolism