Vituity Scribe Training Pre-Classroom Training Exam

ALOC

Altered Level of Consciousness

BM

bowel movement

DOE

Dyspnea on exertion

EOMI

Extraocular Movement Intact (Appropriate function of the extra ocular muscles, tested with "follow my finger")

HA

headache

MI

Myocardial infarction

NAD

no acute distress

NSR

Normal Sinus Rhythm

PNA

pneumonia

UTI

Urinary Tract Infection

ASA

Aspirin

CA

Cancer

PCN

Penicillin

DM

Diabetes Mellitus

PTX

Pneumothorax

SOB

Shortness of breath

FB

Foreign Body

CVA

Cerebral Vascular Accident (Stroke) - Can be ischemic or hemorrhagic)

TIA

transient ischemic attack (mini stroke)

TX

treatment

earwax

cerumen

runny nose

rhinorrhea

Vomiting blood

hematemesis

fainting

syncope

Sweating

diaphoresis

bruising

ecchymosis

itchiness

pruritus

cardiac bypass

CABG (coronary artery bypass graft)

Hernia repair

herniorrhaphy

Removal of gallbladder

cholecystectomy

Removal of uterus

hysterectomy

Rales

wet, crackling sound with respirations (aka crackles)

Four main components of the medical chart you are responsible for?

1. HPI

2. ROS

3. PMhxFhxShx

4. PE

Name the 8 elements of the HPI

1. Location

2. Quality

3. Severity

4. Context

5. Timing

6. Duration

7. associated signs and symptoms

8. modifying factors

True or False: The HPI and ROS are subjective

True: these are from the patient's perspective

True or False: Patient's past surgeries should be documented in the Physical Exam (PE)?

False: Should be in past medical history

true

True or False: Whether a patient smokes or not should be documented in the PMFSH?

True or False: The physical exam is objective

True: From the doctor's point of view

Fever

febrile

vomiting

emesis

pain with urination

dysuria

RRR

Regular Rate and Rhythm (cardio finding)

CVAT

Costal Vertebral Angle Tenderness (Back finding sometimes GU)

BS present

bowel sounds present

SNF

Skilled Nursing Facility

BIBA

brought in by ambulance

CP

chest pain, cerebral palsy

ATX

atelectasis

Pregnancy

Gravid

oophorectomy

surgical removal of one of both ovaries

Tubal pregnancy

Ectopic

Tying of tubes

tubal ligation

clipping of vas deferens

vasectomy

tonsil removal

tonsillectomy

CAD

Coronary Artery Disease

DVT

Deep Vein Thrombosis

PE

Pulmonary Embolism

PUD

Peptic Ulcer Disease

PTA

Prior to Arrival

NTG

Nitroglycerin

FS

Fingerstick (blood sugar)

AMS

Altered Mental Status

a-fib

atrial fibrillation

abnormal heart rhythm

Arrhythmia

blood in urine

hematuria

VB

vaginal bleeding

COPD

Chronic Obstructive Pulmonary Disease (chronic bronchitis, emphysema)

JVD

Jugular vein distention

breathing tube placement

endotracheal intubation

FX

fracture

Bi-PAP

Bilevel Positive Airway Pressure

NEB

nebulizer

peripheral numbness, abnormal tactile sensation described as creeping, burning, tingling or numbness

paresthesia

HTN

Hypertension

High cholesterol

hyperlipidemia

DKA

Diabetic Ketoacidosis

MTF

Metabolize to Freedom

ETOH

alcohol

BKA

Below knee amputation

AKA

above knee amputation

TKA

Total knee arthroplasty

LOC

loss of consciousness

HGB

hemoglobin

induration

a hardened area of normally soft tissue

fluctuance

Movable and compressible

cachectic

Physically wasting, extremely thin

rash from a virus

viral exanthem

Tachypneic

increased rate of respiration

Bradypneic

Slow breathing rate (less than 16 per minute)

retractions

Movements in which the skin pulls in around the ribs during inspiration.

erythema/erythematous

redness of the skin

cellulitis

an inflammation of body tissue (especially that below the skin) characterized by fever and swelling and redness and pain

afebrile

no fever

ablation

partial destruction of the pathway of the electrical conduction system of the heart to treat irregular heart rhythms

PND

Paroxysmal Nocturnal Dyspnea (intermittent nighttime difficulty breathing)

Paroxysmal

Intermittent, Beginning suddenly or abruptly. (A-Fib can be)

fibroids

benign tumors in the uterus

excessive urination

polyuria

excessive thirst

polydipsia

irregularly irregular

no predictable pattern to cardiac cycle, A-Fib typically