Scribeamerica Outpatient latest exam
2025 with Verified Solutions
What body system would the exam finding PERRL be documented in? ✔️✔️Eyes
T/F. It is acceptable to look up your own medical information while working in the clinic.
✔️✔️False
What condition correctly describes "mini-stroke"? Use the abbreviation ✔️✔️TIA
A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the
chart? One word only. ✔️✔️angioplasty
43. Which of the following are risk factors for developing CAD? (select all that apply)
✔️✔️*HTN
*HLD
*FHx of CAD under age 55
*DM
*smoking
What is the medical term for "slow heart rate"? ✔️✔️bradycardia
,What medical term can be used to describe "having multiple chronic conditions"?
✔️✔️comorbidity
A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record
into the chart? Hint: two words ✔️✔️partial lobectomy
47. You see the physician check the patient's pulses in four places: the right wrist, the top of the
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+ DP pulse
neck --> 2+ carotid pulse
back of ankle --> 2+ PT pulse
48. What condition correctly describes "a blood clot in the extremities"? Use the abbreviation
✔️✔️DVT
A patient requires removal of the breast to treat breast cancer. What PSHx would you record into
the chart? ✔️✔️mastectomy
, What FHx/SHx information is usually asked for pediatric patients? (Select all that apply)
✔️✔️*second hand smoke exposure
*immunization status
What is the medical term for "pass-out"? ✔️✔️syncope
Which symptom(s) would a patient most likely present with if they had HLD? (select all that
apply) ✔️✔️*Asymptomatic
T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift.
✔️✔️True
54. A 45 year old male presents to the clinic with a constant, ripping, tearing pain to his central
chest radiating straight to his back with associated nausea that began 1 hour ago. He denies any
accompanying dyspnea or diaphoresis. What elements are missing? (This indicates HPI; select
all that apply) ✔️✔️*severity
*modifying factor
*relevant context
A female patient underwent surgery to have her ovary removed. What PSHx would you record
into the chart? ✔️✔️oophorectomy
2025 with Verified Solutions
What body system would the exam finding PERRL be documented in? ✔️✔️Eyes
T/F. It is acceptable to look up your own medical information while working in the clinic.
✔️✔️False
What condition correctly describes "mini-stroke"? Use the abbreviation ✔️✔️TIA
A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the
chart? One word only. ✔️✔️angioplasty
43. Which of the following are risk factors for developing CAD? (select all that apply)
✔️✔️*HTN
*HLD
*FHx of CAD under age 55
*DM
*smoking
What is the medical term for "slow heart rate"? ✔️✔️bradycardia
,What medical term can be used to describe "having multiple chronic conditions"?
✔️✔️comorbidity
A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record
into the chart? Hint: two words ✔️✔️partial lobectomy
47. You see the physician check the patient's pulses in four places: the right wrist, the top of the
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+ DP pulse
neck --> 2+ carotid pulse
back of ankle --> 2+ PT pulse
48. What condition correctly describes "a blood clot in the extremities"? Use the abbreviation
✔️✔️DVT
A patient requires removal of the breast to treat breast cancer. What PSHx would you record into
the chart? ✔️✔️mastectomy
, What FHx/SHx information is usually asked for pediatric patients? (Select all that apply)
✔️✔️*second hand smoke exposure
*immunization status
What is the medical term for "pass-out"? ✔️✔️syncope
Which symptom(s) would a patient most likely present with if they had HLD? (select all that
apply) ✔️✔️*Asymptomatic
T/F. Scribes should complete all charts by entering a scribe attestation before leaving the shift.
✔️✔️True
54. A 45 year old male presents to the clinic with a constant, ripping, tearing pain to his central
chest radiating straight to his back with associated nausea that began 1 hour ago. He denies any
accompanying dyspnea or diaphoresis. What elements are missing? (This indicates HPI; select
all that apply) ✔️✔️*severity
*modifying factor
*relevant context
A female patient underwent surgery to have her ovary removed. What PSHx would you record
into the chart? ✔️✔️oophorectomy
