BIO391 Internal Medicine – 140 Questions | HPI Writing, Physical Exams, Injections & Medication Management | ScribeAmerica

This document is a comprehensive and exam-focused study guide for BIO391 ScribeAmerica Internal Medicine, containing approximately 140 structured questions with accurate, clinically verified answers aligned with 2025/2026 outpatient internal medicine workflows. It is designed to train students in real-world medical documentation using Allscripts-style charting, with strong emphasis on HPI construction, ROS selection, physical exam documentation, assessment formulation, and plan development across multiple visit types. The content provides detailed guidance on documenting office visits (OV), annual physical exams (PE), annual wellness visits (AWV), injection visits, pre-operative visits, transition-of-care encounters, and consultation notes. It explains how to tailor HPI, ROS, physical exam findings, assessment statements, and plans for each visit type while maintaining compliance with documentation standards and reimbursement requirements. Special attention is given to procedural documentation, including orthopedic injections, trigger point injections, and steroid administration, with step-by-step note components clearly outlined. This resource also delivers extensive coverage of internal medicine physical exam maneuvers and clinical tests, such as Tinel, Phalen, Froment, straight-leg raise, McMurray, Jobe (empty can), Murphy’s punch, prostate exams, vascular palpation, and neurological assessments. Common chronic conditions—including hypertension, diabetes mellitus, hyperlipidemia, hypothyroidism, fibromyalgia, COPD, osteoporosis, and depression—are addressed with clear assessment criteria, lab interpretation thresholds, and follow-up planning. In addition, the document includes a high-yield internal medicine medication reference covering antidepressants, antihypertensives, statins, diabetes medications, anticoagulants, inhalers, steroids, antibiotics, pain medications, and biologics, all contextualized within outpatient documentation and treatment planning. Preventive care and screening guidelines for colonoscopy, DEXA scans, mammography, immunizations, and health maintenance tracking are also thoroughly integrated. This resource is ideal for undergraduate and post-baccalaureate students enrolled in Medical Scribe programs, ScribeAmerica training courses, Health Sciences, Pre-Med, Pre-PA, Pre-Nursing, Allied Health, or Clinical Documentation courses. It is especially useful for students preparing for internal medicine rotations, outpatient clinical practicums, scribe certification exams, and those seeking a practical, exam-aligned reference for internal medicine charting and patient encounter documentation. Keywords: internal medicine scribe, HPI documentation, ROS selection, physical exam findings, clinical procedures, injection notes, outpatient charting, Allscripts documentation, medication management, chronic disease assessment, preventive screening, health maintenance, medical scribe training, ScribeAmerica, BIO391