SCRIBEAMERICA FINAL EXAM 2026 EXAM
STUDY GUIDE WITH COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
⫸ Hip surgery - Open Reduction with Internal Fixation (ORIF)
⫸ Stents - Coronary Stents>> PMHx CAD
⫸ Brain surgery - Craniotomy (brain bleed vs brain CA)
⫸ True allergy - Rash, itching, swelling, or difficulty breathing
⫸ Age of Onset that makes it more likely to be environment than
genetics? - 50 y/o + (also higher genetic risk if more family members
have it)
⫸ Age of Onset for CAD? - 54 and younger would be genetic and 55
and older would be environment.
⫸ What are the three common general family histories your physician
may ask about? - Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
⫸ Two pulmonary FHx - PE and Asthma
,⫸ Two Gastrointestinal FHx - Crohn's and IBS
⫸ Three Neurological FHx - CVA, Aneurysm, Seizures
⫸ Two Miscellaneous FHx - Sickle Cell Anemia and DVT
⫸ Social History list... - Tobacco use, Drug use, Alcohol use, living
circumstances, occupation
⫸ Smoking status (Current) - #ppd or #yr
⫸ Smoking status (Former) - year quit
⫸ Second hand exposure - (pediatrics)
⫸ If Chronic alcoholic need.. - Number of drinks/day and type of
alcohol
⫸ Illicit Drug Use need... - Which Drug, Route of Administration, Date
of last use
⫸ Social History for pediatrics - Need Caretaker, attends daycare,
attends school, siblings, second hand smoke exposure, immunizations
,⫸ Why must smoking status be documented on every patient 13 yrs and
older? - Government standard require this
⫸ Would PMHx of chronic alcoholism belong in the SHx section as
well as the PMHx section? - Yes
⫸ Name the three most common routes of administration of illicit drug
use - Oral, Intravenous, Inhaled
⫸ Living Circumstances - Doc will ask if pt: lives alone, with
family/friends, nursing home/assisted living, hospice, homeless/shelter
⫸ Occupation - Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
⫸ Identify ED flow: - Walk-in > Triage > Bed > Physician Assessment
> Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis > Consults
> Disposition
⫸ What are the 5 vital signs? - Blood Pressure, Respiratory Rate,
Temperature, Heart Rate, Oxygen Saturation
⫸ What does disposition (dispo) mean? - Destination of the patient
following the ED evaluation. Admitted to the hospital, discharged or
transferred to another facility.
, ⫸ What subcategories are included in the Past History section of the
template? - PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
⫸ What is the term for gallbladder removal? - Cholesystectomy
⫸ What is the medical term for redness? - Erythema/Erythematous
⫸ That is the medical term for bruising? - Eccymosis
⫸ Pertinent Positives - present symptoms that point to a diagnosis
⫸ Catch Phase for CAD - Chest pain with physical exertion
⫸ Nitroglycerin - NTG
⫸ sublingual - put meds under tongue
⫸ Chief Complaint of CAD - CP (worse with exertion, better with
rest/NTG)
STUDY GUIDE WITH COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
⫸ Hip surgery - Open Reduction with Internal Fixation (ORIF)
⫸ Stents - Coronary Stents>> PMHx CAD
⫸ Brain surgery - Craniotomy (brain bleed vs brain CA)
⫸ True allergy - Rash, itching, swelling, or difficulty breathing
⫸ Age of Onset that makes it more likely to be environment than
genetics? - 50 y/o + (also higher genetic risk if more family members
have it)
⫸ Age of Onset for CAD? - 54 and younger would be genetic and 55
and older would be environment.
⫸ What are the three common general family histories your physician
may ask about? - Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
⫸ Two pulmonary FHx - PE and Asthma
,⫸ Two Gastrointestinal FHx - Crohn's and IBS
⫸ Three Neurological FHx - CVA, Aneurysm, Seizures
⫸ Two Miscellaneous FHx - Sickle Cell Anemia and DVT
⫸ Social History list... - Tobacco use, Drug use, Alcohol use, living
circumstances, occupation
⫸ Smoking status (Current) - #ppd or #yr
⫸ Smoking status (Former) - year quit
⫸ Second hand exposure - (pediatrics)
⫸ If Chronic alcoholic need.. - Number of drinks/day and type of
alcohol
⫸ Illicit Drug Use need... - Which Drug, Route of Administration, Date
of last use
⫸ Social History for pediatrics - Need Caretaker, attends daycare,
attends school, siblings, second hand smoke exposure, immunizations
,⫸ Why must smoking status be documented on every patient 13 yrs and
older? - Government standard require this
⫸ Would PMHx of chronic alcoholism belong in the SHx section as
well as the PMHx section? - Yes
⫸ Name the three most common routes of administration of illicit drug
use - Oral, Intravenous, Inhaled
⫸ Living Circumstances - Doc will ask if pt: lives alone, with
family/friends, nursing home/assisted living, hospice, homeless/shelter
⫸ Occupation - Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
⫸ Identify ED flow: - Walk-in > Triage > Bed > Physician Assessment
> Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis > Consults
> Disposition
⫸ What are the 5 vital signs? - Blood Pressure, Respiratory Rate,
Temperature, Heart Rate, Oxygen Saturation
⫸ What does disposition (dispo) mean? - Destination of the patient
following the ED evaluation. Admitted to the hospital, discharged or
transferred to another facility.
, ⫸ What subcategories are included in the Past History section of the
template? - PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
⫸ What is the term for gallbladder removal? - Cholesystectomy
⫸ What is the medical term for redness? - Erythema/Erythematous
⫸ That is the medical term for bruising? - Eccymosis
⫸ Pertinent Positives - present symptoms that point to a diagnosis
⫸ Catch Phase for CAD - Chest pain with physical exertion
⫸ Nitroglycerin - NTG
⫸ sublingual - put meds under tongue
⫸ Chief Complaint of CAD - CP (worse with exertion, better with
rest/NTG)
