ScribeAmerica ED [2026/2027] | UPDATED ACTUAL
Exam Question and Answer | A+ Verified
• 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
life-threatening
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
-CTA w/ IV contrast, LP (lumbar puncture)
-ultrasound (US)
, • What are the two types of heart attacks and how are they diagnosed? -✓✓ STEMI (ST
elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction)
STEMI: EKG
NSTEMI: troponin
• What are three cardiac risk factors? -✓✓ HTN, DM, HLD, CAD, Smoking, FHx CAD <
55 y/o
• What are four associated symptoms of an MI other than CP? (Hint: catch phrase) -✓✓
Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB
• What are three symptoms a patient with an Ischemic CVA might present with? -✓✓
Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or
changes in speech/vision
• What are the only three symptoms of a true allergic reaction? -✓✓ SOB (difficulty
breathing), rash, itching/swelling
• What heart rhythm would a physician hear if the patient were in atrial fibrillation and
how is this disease diagnosed? -✓✓ an irregularly irregular rhythm, this is diagnosed by
and EKG
• What physical exam finding is associated with asthma? -✓✓ wheezes (while inspiring
or expiring)
• How is altered mental status different from a focal neurological deficit? -✓✓ AMS is
very different than a focal neurological deficit. AMS is generalized and is typically
caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological
deficits are localized weakness/numbness in one specific area, corresponding with
damage at one specific site in the brain. The most common cause of AMS for patients
without a Hx of dementia is from infection, most often caused by a UTI.
• What is the major cause of AMS in the elderly? -✓✓ UTI
• Name one medication associated with seizures. -✓✓ Dilantin, Tegretol, Keppra,
Depakote, Neurontin
• What question is every patient asked who comes in with a chief complaint of syncope?
-✓✓ Document what happened prior, during, and after the syncopal episode, as well as
how the patient currently feels
• What is the medication administered for CVAs and when is it used vs when would it
not be indicated? -✓✓ Ischemic CVA: tPA or another anticoagulant (not used for a
Exam Question and Answer | A+ Verified
• 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
life-threatening
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
-CTA w/ IV contrast, LP (lumbar puncture)
-ultrasound (US)
, • What are the two types of heart attacks and how are they diagnosed? -✓✓ STEMI (ST
elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction)
STEMI: EKG
NSTEMI: troponin
• What are three cardiac risk factors? -✓✓ HTN, DM, HLD, CAD, Smoking, FHx CAD <
55 y/o
• What are four associated symptoms of an MI other than CP? (Hint: catch phrase) -✓✓
Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB
• What are three symptoms a patient with an Ischemic CVA might present with? -✓✓
Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or
changes in speech/vision
• What are the only three symptoms of a true allergic reaction? -✓✓ SOB (difficulty
breathing), rash, itching/swelling
• What heart rhythm would a physician hear if the patient were in atrial fibrillation and
how is this disease diagnosed? -✓✓ an irregularly irregular rhythm, this is diagnosed by
and EKG
• What physical exam finding is associated with asthma? -✓✓ wheezes (while inspiring
or expiring)
• How is altered mental status different from a focal neurological deficit? -✓✓ AMS is
very different than a focal neurological deficit. AMS is generalized and is typically
caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological
deficits are localized weakness/numbness in one specific area, corresponding with
damage at one specific site in the brain. The most common cause of AMS for patients
without a Hx of dementia is from infection, most often caused by a UTI.
• What is the major cause of AMS in the elderly? -✓✓ UTI
• Name one medication associated with seizures. -✓✓ Dilantin, Tegretol, Keppra,
Depakote, Neurontin
• What question is every patient asked who comes in with a chief complaint of syncope?
-✓✓ Document what happened prior, during, and after the syncopal episode, as well as
how the patient currently feels
• What is the medication administered for CVAs and when is it used vs when would it
not be indicated? -✓✓ Ischemic CVA: tPA or another anticoagulant (not used for a
