ScribeAmerica Hospitalist Practice Exam

These questions are part of the practice quiz. Start practicing

• How many body systems must be included in the ROS to code for a level 3 chart?
• True or False: If any part of the patient care is not documented, then the physician cannot legally be reimbursed for their time or expertise.
• Which of the following best describes the documentation of a patient's physical exam?
• Which of the following is designed to reduce nausea and vomiting?
• What is the primary role of antihistamines?
• What type of note should be written for a patient who has been admitted for several days and has a scheduled surgery?
• Which of the following medications is NOT considered critical care?
• If a patient has a left ventricular ejection fraction of 65%, what type of heart failure is indicated?
• What type of drug is ASA, commonly known as aspirin?
• What is the term for the removal of the uterus?
• Which of the following medications is classified as a diuretic?
• What is a critical lab finding to monitor trend for patients on anticoagulants?
• Before performing imaging studies with IV contrast due to a positive D-Dimer, which lab value must be assessed?
• Which of the following is not considered an element for billing in the History of Present Illness (HPI)?
• True or False: Symptoms listed in the ROS can contradict those discussed in the HPI.
• What are common skin-related symptoms?
• Which symptom is NOT typically part of a respiratory assessment?
• Which imaging study is best to evaluate a patient with positive urine hCG and abnormal vaginal bleeding?
• What condition is suggested by neck stiffness and nuchal rigidity?
• Slurred speech and unilateral weakness may indicate what urgent medical condition?
• What does HPI stand for in medical terminology?
• True or False: Writing +Nausea, +Melena, and +Abdominal Pain counts as three elements in the ROS.
• Which symptom is typically NOT associated with genitourinary disorders?
• What is the primary use of Toradol medication?
• What is the expected finding for bilateral dorsal pedis pulses?
• In a medical context, what is myalgia?
• In diagnosing STEMI and NSTEMI in the ED, which tests are primarily required?
• If a patient presents with calf tenderness and swelling, what is likely on the differential diagnosis?
• Which of the following conditions is characterized by eardrum inflammation?
• What is the next diagnostic step if a 35-year-old female taking birth control pills has a positive D-Dimer?
• Which of the following medications is a corticosteroid?
• What type of condition would a patient with a family history of CAD and personal smoking habits likely be at risk for?
• A flat affect in a patient is primarily indicative of which type of evaluation?
• Which of the following is the most common cause of pancreatitis?
• What diagnostic test is most likely to be ordered to monitor a patient for seizure activity?
• What is a characteristic physical exam finding for liver failure?
• What condition might a patient with scleral icterus likely present with?
• What type of headache is characterized by sudden onset and stiff neck?
• Which condition is indicated by the presence of irregularly irregular heart rhythms?
• Which type of medication is primarily used to treat allergies by blocking histamine receptors?
• What lab value is essential to check for monitoring therapeutic levels of Coumadin?
• Which physical exam sign is commonly associated with appendicitis?
• What does the abbreviation AMA stand for in a medical context?
• Which of the following symptoms is NOT typically associated with musculoskeletal issues?
• Which symptom did the patient deny experiencing?
• What is the primary role of Physical/Occupational Therapists post-surgery?
• If a patient’s history is limited due to being in distress, what should you document?
• What is the primary purpose of administering TPA in a medical setting?
• What describes the expected finding for bilateral femoral pulses?
• What do bilateral radial pulses of 2+ indicate during a physical examination?
• What should be the primary focus in the care of a patient with a small bowel obstruction until recovery?
• What is indicated by an elevated Troponin level in a patient?
• When managing a patient with a small bowel obstruction (SBO), what procedure should be followed until signs of improvement are noted?
• Which cardiovascular symptom may indicate a heart condition?
• What class of drugs is used to prevent or control seizures?
• CVA tenderness can indicate which of the following conditions?
• When is a caveat necessary in medical documentation?
• Which of the following is NOT considered a critical care oxygen route?
• What type of medication is known to reduce anxiety?
• What is the life-threatening systemic condition that can develop when an infection, like an abscess with surrounding cellulitis, moves into the bloodstream?
• Which type of medication is most likely to cause drowsiness as a side effect?
• A patient with slurred speech and left leg weakness likely experienced which type of stroke?
• Which clinical term describes a feeling of general discomfort or uneasiness?
• Which term is synonymous with the word "red"?
• Which neurological symptom could indicate impending stroke?
• When evaluating a suspected case of vertigo, which abnormal findings might a physician anticipate?
• What is indicated by a fever with a temperature greater than 100.4°F in relation to SIRS?
• What condition is associated with scleral icterus?
• Using a Complete Blood Count (CBC), which diagnoses can be identified?
• In terms of medical protocols, what is the role of an inpatient scribe?
• A patient reports a history of smoking one pack per day. What risk factor does this represent?
• What is a common diagnosis for a patient with shortness of breath and a long history of smoking?
• What type of medication is ondansetron?
• What symptom is NOT typically associated with appendicitis?
• Succinylcholine is used primarily as what type of drug?
• Bilateral pitting pedal edema is most commonly associated with which condition?
• True or False: Patients with end stage liver disease are generally managed with hemodialysis.
• What is the effect of using a vasodilator like nitroglycerin?
• Which medication is known primarily as pain relievers?
• What is a primary concern in a patient with suspected meningitis?
• What does ROS refer to in a medical context?
• What is the correct term for the surgical removal of the tonsils?
• What are the common symptoms associated with genitourinary issues?
• What is the medical term for the surgical removal of a breast?
• Which symptom is associated with the HENT system?
• True or False: Each diagnosis becomes a permanent part of the patient's medical record.
• Which modifying factor did the patient report regarding her pain?
• Which of the following best describes a patient's condition if they have an elevated heart rate greater than 90 bpm?
• Which gastrointestinal symptom might indicate a serious issue?
• Which of the following is NOT a constitutional symptom?
• What laboratory test is critical for diagnosing pancreatitis?
• Which medication is typically administered as a long-acting insulin for IDDM?
• Which is typically a more concerning finding in a clinical assessment?
• Hypoactive bowel sounds could indicate which gastrointestinal condition?
• Which condition is characterized by burning epigastric pain exacerbated by acidic foods?
• What type of drug is Ambien classified as?
• Fluctuance and induration during physical exam may indicate what?
• Which of the following is a common proton pump inhibitor (PPI)?
• Rhonchi is most commonly associated with which respiratory condition?
• What must be documented when the patient's history is limited?
• Which finding on a physical exam would suggest diverticulitis?
• What does the tympanic membrane refer to?
• Which class of medications is primarily used as anti-inflammatory agents that treat skin inflammation?
• What is the main therapeutic effect of antidepressants?
• In a patient presenting with a headache and neck stiffness, which condition is most likely if the patient has positive nuchal rigidity?
• What does unilateral weakness in a patient most likely suggest?
• True or False: When writing a discharge summary, it is unnecessary to reiterate the patient's chief complaint and ED workup because that's already part of the HPI in the History and Physical Note.
• What is the abbreviation for the route of administration that means directly under the skin?
• Which of the following surgical procedures is specifically intended to remove the gallbladder?
• What is the classification of the medication nitroglycerin?
• Which vital signs/conditions are part of the Systemic Inflammatory Response Syndrome (SIRS) criteria?
• What antibiotic would likely be included for managing right lower extremity cellulitis?
• What abnormalities can be diagnosed using a Basic Metabolic Panel (BMP)?
• How would you document the GPA for a patient who is currently pregnant, has been pregnant two times in the past, and has one child at home?
• Which medication is classified as a neuromuscular blocker?
• What is the normal finding for bilateral posterior tibial pulses?
• What is the role of Propofol in medical treatment?
• In the example of the female patient presenting with abdominal pain, what was the location of her pain?
• What is the normal finding for bilateral carotid pulses?
• What does a positive Murphy's sign indicate?
• Which condition is indicated by jaundice?
• What is the full medical term for a heart attack?
• What imaging study is most appropriate for diagnosing cholecystitis?
• Which symptom is indicative of possible respiratory issues?
• What category of medical history is represented by a patient who had a heart attack and has family members diagnosed with CAD?
• What characteristic signs might indicate an ischemic cerebrovascular accident (CVA)?
• Which condition is characterized by expiratory wheezing and requires bronchodilation therapy?
• What type of surgery would be performed to address obesity and metabolic disorders by removing part of the stomach?
• Which of the following would NOT be considered a neurological symptom?
• What does "nuchal rigidity" refer to in a clinical context?
• Which condition describes the presence of blood in vomit?
• What condition is indicated by cough, shortness of breath, and fever?
• What does a rating of 2+ for a pulse indicate?
• Unilateral weakness often indicates which of the following conditions?
• What finding is typically observed in patients with congestive heart failure?
• A patient with jaundice and abdominal distension may require which lab to assess for liver failure?
• What condition is often associated with jugular vein distension?
• How long had the patient been experiencing abdominal pain upon arrival?
• What is the primary function of the History of Present Illness (HPI) in medical documentation?
• For documentation purposes, how many organ systems must be included for full compensation under the "critical care exclusion" statement?
• What laboratory test is most useful in confirming a diagnosis of cholecystitis?
• What was the patient's pertinent negative symptom related to her abdominal pain?
• For the HPI of a patient with RLQ abdominal pain, how does it meet level 3 billing criteria?
• In a progress note, what essential information should be documented regarding a concerning symptom?
• A patient has a history of IDDM. Which medication could be prescribed for managing this condition?
• Which of the following statements about the Review of Systems (ROS) is true?
• What is the medical term for "passing out"?
• Which of the following is a common sign of liver damage?
• What does GPA stand for in the context of pregnancy documentation?
• Which medication type is primarily utilized in acute pain management?
• What was the severity of the pain described by the patient?
• Which term refers to the high sugar levels in the blood typically associated with diabetes?
• Which of the following statements regarding the workflow of an inpatient scribe is false?
• Which section of a medical report focuses directly on the chief complaint of the patient?
• When documenting a critical care exclusion for an intubated patient, what is required for full compensation?
• Which of the following is a potential presenting symptom of a deep vein thrombosis?
• What does the term "edentulous" refer to in a medical context?
• Which element must be included in the review of systems (ROS) for a Level 3 chart?
• What type of healthcare professionals are typically involved in patient recovery and mobility post hip arthroplasty?
• Which medication is commonly ordered for DVT prophylaxis?
• Which set of physical exam findings is contradictory?
• Which pain could suggest a lower urinary tract infection?
• Which respiratory symptom suggests a potential infection?
• Which imaging modality is typically used to evaluate for deep vein thrombosis?
• The combination of Tegretol, Depakote, and Keppra is used to manage which neurologic condition?
• What does a detection of "fluctuance" in a physical exam usually imply?
• What does ecchymosis refer to?
• In assessing a patient with intermittent pain, what characteristic should also be noted in the medical record?
• What is the medical term for "blood with coughing"?
• What is an exemplar symptom of gastrointestinal distress?
• True or False: Documenting "regular rate and rhythm, with normal heart sounds" fulfills 3 elements for billing purposes.
• What is the full medical term for hypertension?
• What does the abbreviation SBO stand for in medical terminology?
• Which medication combination would be effective for seizure management?
• What signifies that a patient with a SBO is ready to begin oral intake again?
• What was one of the associated symptoms the patient experienced along with her abdominal pain?
• What class of medication is Haldol categorized as?
• Which test is used to diagnose congestive heart failure (CHF)?
• Which of the following is the full medical term for diabetes?
• In the context of acute chest conditions, what does CT Angiography assess?
• Which of the following indicates a potential thrombotic condition requiring treatment?
• Expiratory wheezes are a classic sign of which respiratory condition?
• The PERRL finding would be documented in which body system?
• Which three-letter abbreviation represents a thrombolytic medication used to break apart clots?
• Which medication is a common treatment for hypertension and heart failure?
• What symptoms would be indicative of a true allergic reaction to Motrin?
• Which symptoms are primarily indicative of neurological concerns?
• What common skin condition can develop in bed-bound patients due to lack of position changes?
• What is the medical term for a physician's appreciation of a patient's discomfort, likely secondary to pain?
• Calf tenderness could be a sign of which medical condition?
• For a patient admitted with right upper quadrant pain, which term describes the timing of the pain?
• What is the medical term for the surgical removal of the gallbladder?