SCRIBE AMERICA FINAL OUTPATIENT 2026
FINAL ASSESSMENT PAPER HEALTH RECORD
ACCURACY COMPREHENSIVE QUESTIONS
AND ANSWERS VERIFIED A+
◉ ROS stands for Answer: review of systems
◉ What section focuses directly on the chief complaint? Answer: HPI
◉ Write the full medical term for the following past medical history
term:
High blood pressure Answer: Hypertension
◉ Write the full medical term for the following past medical history
term:
Diabetes Answer: Diabetes mellitus
◉ Write the full medical term for the following past medical history
term:
,heart attack Answer: Myocardial infarction
◉ Removal of the gallbladder Answer: cholecystectomy
◉ Removal of the uterus Answer: hysterectomy
◉ Removal of the breast Answer: mastectomy
◉ Removal of the tonsils Answer: tonsillectomy
◉ Removal of the appendix Answer: appendectomy
◉ Which of the following are not considered vital signs? Answer:
I&O
Height and weight
◉ HPI and ROS are considered what type of information? Answer:
subjective
◉ If a physician told you "the patient has no respiratory distress",
where would you document this? Answer: PE
, ◉ Which of the following are considered cardiac risk factors? Select
all that apply. Answer: PHX of : Angioplasty with 2 stents
smoking 2 cigars a day
HTN, HLD, DM
MI at 42 years
CABG
◉ A 70 year old female has a history of a large Aortic Aneurysm and
is complaining of a tearing pain that radiates to her back. What life-
threatening diagnosis is at the top of your DDx? Answer: aortic
dissection
◉ Patient was admitted with bilateral pedal edema and also
exhibited symptoms such as dyspnea on exertion (DOE), orthopnea,
and paroxysmal nocturnal dyspnea (PND). ED workup included
elevated B-type Natriuretic Peptide and CXR showing enlarged
cardiac silhouette.
What DDx are we investigating? Answer: Chf
◉ An 18 year old female on Birth Control Pills (BCP's) complains of
LLE pain and swelling since this morning. During the physical exam,
the patient suddenly feels SOB and has pain when breathing. What is
the most likely cause of her new symptoms? Answer: DVT traveled
to the lung causing a PE
FINAL ASSESSMENT PAPER HEALTH RECORD
ACCURACY COMPREHENSIVE QUESTIONS
AND ANSWERS VERIFIED A+
◉ ROS stands for Answer: review of systems
◉ What section focuses directly on the chief complaint? Answer: HPI
◉ Write the full medical term for the following past medical history
term:
High blood pressure Answer: Hypertension
◉ Write the full medical term for the following past medical history
term:
Diabetes Answer: Diabetes mellitus
◉ Write the full medical term for the following past medical history
term:
,heart attack Answer: Myocardial infarction
◉ Removal of the gallbladder Answer: cholecystectomy
◉ Removal of the uterus Answer: hysterectomy
◉ Removal of the breast Answer: mastectomy
◉ Removal of the tonsils Answer: tonsillectomy
◉ Removal of the appendix Answer: appendectomy
◉ Which of the following are not considered vital signs? Answer:
I&O
Height and weight
◉ HPI and ROS are considered what type of information? Answer:
subjective
◉ If a physician told you "the patient has no respiratory distress",
where would you document this? Answer: PE
, ◉ Which of the following are considered cardiac risk factors? Select
all that apply. Answer: PHX of : Angioplasty with 2 stents
smoking 2 cigars a day
HTN, HLD, DM
MI at 42 years
CABG
◉ A 70 year old female has a history of a large Aortic Aneurysm and
is complaining of a tearing pain that radiates to her back. What life-
threatening diagnosis is at the top of your DDx? Answer: aortic
dissection
◉ Patient was admitted with bilateral pedal edema and also
exhibited symptoms such as dyspnea on exertion (DOE), orthopnea,
and paroxysmal nocturnal dyspnea (PND). ED workup included
elevated B-type Natriuretic Peptide and CXR showing enlarged
cardiac silhouette.
What DDx are we investigating? Answer: Chf
◉ An 18 year old female on Birth Control Pills (BCP's) complains of
LLE pain and swelling since this morning. During the physical exam,
the patient suddenly feels SOB and has pain when breathing. What is
the most likely cause of her new symptoms? Answer: DVT traveled
to the lung causing a PE
