SCRIBE U LATEST 2026 EVALUATION TEST QUESTIONS
AND SOLUTIONS GUARANTEE A+
✔✔chronic obstructive pulmonary disease (COPD) - ✔✔Etiology: longterm damage to
the lung's alveoli (emphysema) along with inflammation and mucus production (chronic
bronchitis)
Risk factors: smoking
CC: SOB
PE: decreased breath sounds, wheezes, rales
Assoc. meds: Home O2 (document how much O2 they use at baseline)
diagnosed by CXR and hx of smoking
✔✔asthma (reactive airway disease) - ✔✔Etiology: constricting of the airway due tot
inflammation and muscular contraction of the bronchioles, known as bronchospasm
CC: SOB/wheezing, improved by nebulizer breathing treatments (bronchodilators)
P/E: wheezes (inspiratory or expiratory)
Assoc. meds: inhalers, nebulizers, corticosteroids
Diagnosed clinically
Scribe Alert: The physician will ask the asthma pt...
1. Doe they have a home nebulizer?
2. Have they been on steroids recently?
3. Hx of hospitalization of asthma
4. Hx of intubation/breathing tube
5. asthma triggers?
✔✔Abdominal aortic Aneurysm (AAA) - ✔✔segments of a blood vessel are weakened
and form a bulge, which a stretched tissue. This is at risk of rupture and may need
surgery for repair.
symptoms: midline abd pain
Diagnosed by CT A/P with IV contrast dye
✔✔Aortic dissection - ✔✔Separation of the muscular wall from the membrane of the
artery (different layers), putting the pt at risk of rupture and death
"ripping" or "tearing" chest pain radiating to the back (aorta runs to the spine)
,diagnosed by CT chest with IV contrast dye
✔✔deep vein thrombosis (DVT) - ✔✔Slow-flowing blood is more likely to clot. Once
formed, the clot can block the vein or translocate to other parts of the body - can lead to
PE
extremity pain and swelling (atraumatic)
diagnosed by US of the extremity
✔✔sepsis - ✔✔systemic inflammatory response to infection, can cause septic shock
and death. IV abx, IV fluids, admission
Fever, altered mental status (AMS), tachycardia, hypotension, current infectious
symptoms
✔✔Complete blood count (CBC) - ✔✔sepsis lab
high WBC --> leukocytosis
High bands--> bandemia
possible sepsis
✔✔Lactic acid (lactate) - ✔✔sepsis lab
High lactate
Sepsis or cell death in the body occuring
✔✔Blood Cx (blood cultures) - ✔✔sepsis lab
positive growth
definitive sepsis
✔✔Ischemic cerebrovascular accident (CVA) - ✔✔blockage of the arteries supplying
blood to the brain resulting in permanent brain damage. Document pt's "last known well"
time (3hrs) to indicate tPA eligibility.
diagnosed clinically, CT head is often done to rule out any other acute abnormality
Causes FND
tPA is an anticoagulant to help with blood clots
,✔✔focal neurological deficit (FND) - ✔✔when the brain suffers an injury, damage
typically affects a focal region of the brain. this causes very specific deficits and
dysfunction dependent on the area of the brain that was injured and the function that
area of the brain performs.
Common examples of FND include one-sided weakness/numbness, changes in
speech/vision
✔✔hemorrhagic stroke (CVA) - ✔✔"brain bleed", often a traumatic etiology. Causes
severe, sudden headache ("worse of life") and may be accompanied by other
neurological symptoms. tPA contraindicated (would not be considered since they are
already bleeding; they would bleed out faster)
diagnosed by CT head or lumbar puncture
causes FND
✔✔Transient ischemic attack (TIA) - ✔✔not a TRUE stroke
vascular changes are temporary. known as "mini-stroke" as symptoms usually last <1
hour and there is no permanent brain damage. tPA not indicated
diagnosed clinically
can cause FND, but goes away
✔✔meningitis - ✔✔inflammation and infection of the meninges; the sac surround the
brain and spinal cord
CC: headache and neck pain
Assoc Sx: fever, neck pain, neck stiffness, AMS, photophobia
P/E: meningismus, nuchal rigidity
diagnosed by lumbar puncture (LP)
✔✔spinal cord injury - ✔✔etiology: injury to the spinal cord may create weakness or
numbness in the extremities past the site of the injury
CC: neck pain or back pain, bilateral extremity weakness
P/E: midline bony tenderness, deformities, or step-offs, bilateral extremity weakness,
numbness, decreased rectal tone
diagnosed by CT cervical spine (neck), CT thoracic spine (upper back), CT lumbar
spine (lower back)
, scribe alert: remember that during the initial P/E the spine is often immobilized with a C-
collar and backboard; document accordingly
✔✔Seizure (SZ) - ✔✔etiology: abnormal electrical activity in the brain leading to
abnormal physical manifestations. Often caused by epilepsy, ETOH withdrawals, or
febrile seizure in pediatric pts
CC: seizure activity, syncope
Assoc Sx: injuries (tongue bite), confusion, headache, incontinence (urinary or fecal,
cant control)
P/E: somnolent, confused (postictal)
Meds: dilantin, tegretol, keppra, depakote, neurontin
Scribe Alert: the physician will ask:
1. has the pt had a similar sz in the past?
2. does the pt have a hx of sz?
3. what was the date of their last sz?
✔✔Headache (HA), cephalalgia - ✔✔Etiology: various causes including hypertensive
headaches (from high blood pressure), recurrent diagnosed migraines, sinusitis, etc.
CC: headache (gradual onset), pressure, throbbing
Pertinent negs: no fever, no neck stiffness, no numbness/weakness; no changes in
speech or vision
scribe alert: always remember to document if the HA is similar or dissimilar to any prior
HA. Never doc "worst headache of life"
✔✔altered mental status (AMS) - ✔✔etiology: multiple causes: most common are
hypoglyxemia (diabetic and arent maintain blood sugar), infection, intoxication, and
neurological
risk factors: diabetic, elderly, demented, EtOH use, drug use
CC: confusion, decreased responsiveness, unresponsive
diagnosed case dependent
AMS is very different than a FND, it is generalized and is typically caused by things that
affect the whole brain (drugs, low blood sugar)
AND SOLUTIONS GUARANTEE A+
✔✔chronic obstructive pulmonary disease (COPD) - ✔✔Etiology: longterm damage to
the lung's alveoli (emphysema) along with inflammation and mucus production (chronic
bronchitis)
Risk factors: smoking
CC: SOB
PE: decreased breath sounds, wheezes, rales
Assoc. meds: Home O2 (document how much O2 they use at baseline)
diagnosed by CXR and hx of smoking
✔✔asthma (reactive airway disease) - ✔✔Etiology: constricting of the airway due tot
inflammation and muscular contraction of the bronchioles, known as bronchospasm
CC: SOB/wheezing, improved by nebulizer breathing treatments (bronchodilators)
P/E: wheezes (inspiratory or expiratory)
Assoc. meds: inhalers, nebulizers, corticosteroids
Diagnosed clinically
Scribe Alert: The physician will ask the asthma pt...
1. Doe they have a home nebulizer?
2. Have they been on steroids recently?
3. Hx of hospitalization of asthma
4. Hx of intubation/breathing tube
5. asthma triggers?
✔✔Abdominal aortic Aneurysm (AAA) - ✔✔segments of a blood vessel are weakened
and form a bulge, which a stretched tissue. This is at risk of rupture and may need
surgery for repair.
symptoms: midline abd pain
Diagnosed by CT A/P with IV contrast dye
✔✔Aortic dissection - ✔✔Separation of the muscular wall from the membrane of the
artery (different layers), putting the pt at risk of rupture and death
"ripping" or "tearing" chest pain radiating to the back (aorta runs to the spine)
,diagnosed by CT chest with IV contrast dye
✔✔deep vein thrombosis (DVT) - ✔✔Slow-flowing blood is more likely to clot. Once
formed, the clot can block the vein or translocate to other parts of the body - can lead to
PE
extremity pain and swelling (atraumatic)
diagnosed by US of the extremity
✔✔sepsis - ✔✔systemic inflammatory response to infection, can cause septic shock
and death. IV abx, IV fluids, admission
Fever, altered mental status (AMS), tachycardia, hypotension, current infectious
symptoms
✔✔Complete blood count (CBC) - ✔✔sepsis lab
high WBC --> leukocytosis
High bands--> bandemia
possible sepsis
✔✔Lactic acid (lactate) - ✔✔sepsis lab
High lactate
Sepsis or cell death in the body occuring
✔✔Blood Cx (blood cultures) - ✔✔sepsis lab
positive growth
definitive sepsis
✔✔Ischemic cerebrovascular accident (CVA) - ✔✔blockage of the arteries supplying
blood to the brain resulting in permanent brain damage. Document pt's "last known well"
time (3hrs) to indicate tPA eligibility.
diagnosed clinically, CT head is often done to rule out any other acute abnormality
Causes FND
tPA is an anticoagulant to help with blood clots
,✔✔focal neurological deficit (FND) - ✔✔when the brain suffers an injury, damage
typically affects a focal region of the brain. this causes very specific deficits and
dysfunction dependent on the area of the brain that was injured and the function that
area of the brain performs.
Common examples of FND include one-sided weakness/numbness, changes in
speech/vision
✔✔hemorrhagic stroke (CVA) - ✔✔"brain bleed", often a traumatic etiology. Causes
severe, sudden headache ("worse of life") and may be accompanied by other
neurological symptoms. tPA contraindicated (would not be considered since they are
already bleeding; they would bleed out faster)
diagnosed by CT head or lumbar puncture
causes FND
✔✔Transient ischemic attack (TIA) - ✔✔not a TRUE stroke
vascular changes are temporary. known as "mini-stroke" as symptoms usually last <1
hour and there is no permanent brain damage. tPA not indicated
diagnosed clinically
can cause FND, but goes away
✔✔meningitis - ✔✔inflammation and infection of the meninges; the sac surround the
brain and spinal cord
CC: headache and neck pain
Assoc Sx: fever, neck pain, neck stiffness, AMS, photophobia
P/E: meningismus, nuchal rigidity
diagnosed by lumbar puncture (LP)
✔✔spinal cord injury - ✔✔etiology: injury to the spinal cord may create weakness or
numbness in the extremities past the site of the injury
CC: neck pain or back pain, bilateral extremity weakness
P/E: midline bony tenderness, deformities, or step-offs, bilateral extremity weakness,
numbness, decreased rectal tone
diagnosed by CT cervical spine (neck), CT thoracic spine (upper back), CT lumbar
spine (lower back)
, scribe alert: remember that during the initial P/E the spine is often immobilized with a C-
collar and backboard; document accordingly
✔✔Seizure (SZ) - ✔✔etiology: abnormal electrical activity in the brain leading to
abnormal physical manifestations. Often caused by epilepsy, ETOH withdrawals, or
febrile seizure in pediatric pts
CC: seizure activity, syncope
Assoc Sx: injuries (tongue bite), confusion, headache, incontinence (urinary or fecal,
cant control)
P/E: somnolent, confused (postictal)
Meds: dilantin, tegretol, keppra, depakote, neurontin
Scribe Alert: the physician will ask:
1. has the pt had a similar sz in the past?
2. does the pt have a hx of sz?
3. what was the date of their last sz?
✔✔Headache (HA), cephalalgia - ✔✔Etiology: various causes including hypertensive
headaches (from high blood pressure), recurrent diagnosed migraines, sinusitis, etc.
CC: headache (gradual onset), pressure, throbbing
Pertinent negs: no fever, no neck stiffness, no numbness/weakness; no changes in
speech or vision
scribe alert: always remember to document if the HA is similar or dissimilar to any prior
HA. Never doc "worst headache of life"
✔✔altered mental status (AMS) - ✔✔etiology: multiple causes: most common are
hypoglyxemia (diabetic and arent maintain blood sugar), infection, intoxication, and
neurological
risk factors: diabetic, elderly, demented, EtOH use, drug use
CC: confusion, decreased responsiveness, unresponsive
diagnosed case dependent
AMS is very different than a FND, it is generalized and is typically caused by things that
affect the whole brain (drugs, low blood sugar)
