Scribe Review Study Guide Question 2025/2026
Graded A+
There is tenderness of the RUQ: - Physical Exam
The patient's mother has heart disease: - Past History
The diagnosis is upper respiratory infection: - ...
The patient will be prescribed penicillin today: - Assessment and Plan
What should you write if the patient says he has high blood pressure? - Hypertension
(HTN)
What should you write if the patient says he has Diabetes "takes pills"? - Non-insulin
dependent diabetes mellitus (NIDDM)
What should you write if the patient says he has heart attack? - Coronary Artery
Disease (CAD) and Myocardial Infarction (MI)
What should you write if the patient says he has reflux? - Gastroesophageal Reflux
Disease (GERD)
What should you write if the patient says he has stroke? - Cerebrovascular Accident
(CVA)
What should you write if the patient says she has breast cancer and they found a mass
in my brain? - Breast CA with metastasis to the brain
What should you write if the patient says he has had stents? - Coronary Stents
What should you write if the patient says he has had gallbladder removed? -
Cholecystectomy
What should you write if the patient says he has had tubes tied? - Tubal ligation
(female) or vasectomy (male)
What should you write if the patient says he has had stomach stapled? - Gastric Bypass
Brain Surgery - Craniotomy
At what age would a family member's cardiac disease indicate an increased risk for
similar heart disease in the patient? - Less than 55 y/o
What are three common general family histories your physician may ask about? - ...
, Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - Yes
Why must smoking status be documented on every patient 13 years and older? - ...
Name the three most common routes of administration of illicit drugs. - Intravenous,
inhaled, oral
The patients mother states, "the daycare called me to pick up Angela and her brother
because Angela had a fever." What are three items you can document under social
history for Angela? - Attends daycare, has brothers/sisters, has a caretaker.
Comorbidity - The simultaneous presence of two chronic diseases or conditions in a
patient.
Etiology - The cause of a disease
Systole - Phase of the heartbeat during which the muscle contracts, pumping blood to
the body.
Diastolic - Phase of the heartbeat during which muscle is relaxed and the heart fills with
blood.
Diuretic - A substance that promotes the production of urine.
Paresthesia - Sensation of tingling or numbness.
Polydipsia - Excessive thirst.
Ischemia - Loss of blood supply to tissue.
Anticoagulant - A drug that prevents blood clotting.
If a patient has had respiratory symptoms for the past 5 weeks, are the symptoms
considered chronic? - No. Symptoms must be longer than 3 months.
List two ways comorbidity increases complexity. - Adverse drug interactions and the
treatment of one disease may affect or contradict the treatment of the second.
Why is it important to document accurately and thoroughly on complex patients? -
Complex patients bill to a higher level.
Hypotensive blood pressure - Less than 90/60
Normal blood pressure - 90/60 to 120/80
Graded A+
There is tenderness of the RUQ: - Physical Exam
The patient's mother has heart disease: - Past History
The diagnosis is upper respiratory infection: - ...
The patient will be prescribed penicillin today: - Assessment and Plan
What should you write if the patient says he has high blood pressure? - Hypertension
(HTN)
What should you write if the patient says he has Diabetes "takes pills"? - Non-insulin
dependent diabetes mellitus (NIDDM)
What should you write if the patient says he has heart attack? - Coronary Artery
Disease (CAD) and Myocardial Infarction (MI)
What should you write if the patient says he has reflux? - Gastroesophageal Reflux
Disease (GERD)
What should you write if the patient says he has stroke? - Cerebrovascular Accident
(CVA)
What should you write if the patient says she has breast cancer and they found a mass
in my brain? - Breast CA with metastasis to the brain
What should you write if the patient says he has had stents? - Coronary Stents
What should you write if the patient says he has had gallbladder removed? -
Cholecystectomy
What should you write if the patient says he has had tubes tied? - Tubal ligation
(female) or vasectomy (male)
What should you write if the patient says he has had stomach stapled? - Gastric Bypass
Brain Surgery - Craniotomy
At what age would a family member's cardiac disease indicate an increased risk for
similar heart disease in the patient? - Less than 55 y/o
What are three common general family histories your physician may ask about? - ...
, Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - Yes
Why must smoking status be documented on every patient 13 years and older? - ...
Name the three most common routes of administration of illicit drugs. - Intravenous,
inhaled, oral
The patients mother states, "the daycare called me to pick up Angela and her brother
because Angela had a fever." What are three items you can document under social
history for Angela? - Attends daycare, has brothers/sisters, has a caretaker.
Comorbidity - The simultaneous presence of two chronic diseases or conditions in a
patient.
Etiology - The cause of a disease
Systole - Phase of the heartbeat during which the muscle contracts, pumping blood to
the body.
Diastolic - Phase of the heartbeat during which muscle is relaxed and the heart fills with
blood.
Diuretic - A substance that promotes the production of urine.
Paresthesia - Sensation of tingling or numbness.
Polydipsia - Excessive thirst.
Ischemia - Loss of blood supply to tissue.
Anticoagulant - A drug that prevents blood clotting.
If a patient has had respiratory symptoms for the past 5 weeks, are the symptoms
considered chronic? - No. Symptoms must be longer than 3 months.
List two ways comorbidity increases complexity. - Adverse drug interactions and the
treatment of one disease may affect or contradict the treatment of the second.
Why is it important to document accurately and thoroughly on complex patients? -
Complex patients bill to a higher level.
Hypotensive blood pressure - Less than 90/60
Normal blood pressure - 90/60 to 120/80
