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Vituity Scribe Training Pre-Classroom Training EXAM
QUESTIONS AND ANSWERS UPDATED (202 5 /202 6 ) (VERIFIED
ANSWERS)
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
True or False: Whether a patient smokes or not should be documented in the PMFSH? ✔✔True: This is social history 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
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 anticoagulants ✔✔medication to stop blood clotting PSVT ✔✔Paroxysmal supraventricular tachycardia PVD ✔✔peripheral vascular disease GERD ✔✔gastroesophageal reflux disease (acid reflux/heartburn) ESRD ✔✔end-stage renal disease CRI ✔✔Chronic Renal Insufficiency PID ✔✔pelvic inflammatory disease
Accessory muscle use ✔✔Struggling for breath using muscles in the neck; using extra muscles to breathe (You can usually see an emphasis on use of diaphragm and intercostal muscles) Adduction ✔✔movement toward the midline of the body AED ✔✔Automated External Defibrillator Afebrile ✔✔without fever Ambulatory ✔✔able to walk about Aneurysm ✔✔Any abnormal widening of a blood vessel Angina ✔✔Chest pain due to lack of blood flow to heart muscle Unstable angina ✔✔a condition in which blood flow and oxygen in one or more of the coronary arteries is partially blocked causing chest pain Anion gap ✔✔Difference between the concentrations of serum cations and anions: determined by measuring the concentrations of sodium cations and chloride and bicarbonate anions. Anisocoria ✔✔Unequal Pupil Size Arthralgia ✔✔pain in a joint or joints Articulation ✔✔Connection between bones Atelectasis (ATX) ✔✔Partial collapse of the small airways in the lungs
Avulsion ✔✔A forcible tearing away of a part or structure Brudzinski's sign ✔✔Sign of meningitis; positive when a patient's legs lift involuntarily when lifting a patient's head Bruit ✔✔A murmur or sound heard in auscultation indicating narrowing of a vessel C/O ✔✔complains of Carotid bruit ✔✔Abnormal flow of blood through the carotid artery/Noise from carotid artery narrowing heard with stethoscope Cholecystitis ✔✔inflammation of the gall bladder Cholelithiasis ✔✔Gallstone formation in the gallbladder Cirrhosis ✔✔chronic degenerative disease of the liver CMT ✔✔cervical motion tenderness;pain with movement of cervix Colectomy ✔✔Surgical removal of part or all of the large intestine Colostomy ✔✔Surgical procedure that provides an opening between the colon and abdominal wall Conjunctiva ✔✔White area of the eye, mucous membrane lining the eyelids and covering the anterior portion of the sclera
hematochezia ✔✔passage of fresh, bright red blood from the rectum hemiparesis ✔✔slight paralysis or weakness affecting one side of the body hemiplegia ✔✔paralysis of one side of the body hepatomegaly ✔✔Liver enlargement ICH ✔✔Intracranial hemorrhage IUP ✔✔Intrauterine Pregnancy Kernig's sign ✔✔Sign of meningitis; positive when the leg is fully bent at the hip and knee, and subsequent extension of the knee leads to pain LBBB ✔✔left bundle branch block RBBB ✔✔right bundle branch block LAFB ✔✔left anterior fascicular block LNMP ✔✔Last Normal Menstrual period LVH ✔✔Left Ventricle Hypertropy Malaise ✔✔vague feeling of bodily discomfort or illness Malocclusion ✔✔any deviation from the normal positioning of the upper teeth against the lower teeth
Melena ✔✔black tarry stool Myalgia ✔✔Muscle pain Neuralgia ✔✔nerve pain cephalgia ✔✔head pain NSVD ✔✔Normal spontaneous vaginal delievery Nystagmus ✔✔Involuntary rapid eye movements; may be horizontal, vertical, or rotary Pallor ✔✔pale skin Rhinorrhea ✔✔Runny Nose Romberg's sign ✔✔Falling to one side standing with eyes closed Splenectomy ✔✔surgical removal of the spleen Splenomegaly ✔✔an abnormal enlargement of the spleen Splinting ✔✔muscle rigidity caused by pain Status epilepticus ✔✔continuous seizure activity stridor ✔✔Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
Obturator sign ✔✔pain in the lower abdomen or inside of thigh when the hip is flexed and internally rotated; a sign of appendicitis Urticaria ✔✔hives or wheals on the skin accompanied by itch papular ✔✔Pertaining to a small, red, elevated area of the skin, solid, and circumscribed. macular ✔✔Pertaining to a discoloration of a patch of skin, neither elevated nor depressed, of various colors, sizes, and shapes. otalgia ✔✔pain in the ear claudication ✔✔lameness, limping Wheal ✔✔round, localized area of edema on the skin w/u ✔✔work up r/o ✔✔rule out VBAC ✔✔Vaginal Birth After Cesarean WPW ✔✔Wolff-Parkinson-White syndrome; an abnormal ECG pattern often associated with paroxysmal tachycardia V-Fib ✔✔Ventricular fibrillation (V-Fib), a chaotic quivering of the heart muscle, is the most common dysrhythmia that results in sudden cardiac arrest (SCA). In V-Fib, the heart is not beating effectively and is not pumping blood; therefore, the patient will not have a pulse.
- ic (ex. hepatic) ✔✔means pertaining to (pertaining to the liver)
- plasty (ex. Rhinoplasty) ✔✔means surgical repair (nose repair)
- ostomy (ex. colostomy) ✔✔Means to create an opening (ex. Artificial opening between colon and abdominal wall)
- ectomy (ex. appendectomy) ✔✔means excision or removal (ex. removal of the appendix)
- otomy (ex. tracheotomy) ✔✔Means to make incision into (ex. a surgical operation that creates an opening into the trachea with a tube inserted to provide a passage for air)
- itis (ex. Tendonitis) ✔✔Means inflammation of Abduction ✔✔Movement away from the midline arthr- ✔✔joint ven- ✔✔vein oste- ✔✔bone
- ous ✔✔possessing, full of
- pathy ✔✔disease intra- ✔✔within sub- ✔✔under
dermatitis ✔✔inflammation of the skin hidradenitis ✔✔inflammation of the sweat glands paronychia ✔✔disease state around the nail Otorrhea ✔✔Ear discharge Otalgia ✔✔Ear pain Otitis Externa ✔✔External ear infection Otitis Media ✔✔Middle Ear infection DMM ✔✔Dry Mucous Membranes Appy or Appe ✔✔Appendectomy Hyst ✔✔Hysterectomy Contralateral ✔✔Occurring on the opposite side of the body Dorsiflexion ✔✔Backward flexion or bending (hand/foot) Evert ✔✔Turn outward Invert ✔✔Turn inward Ipsilateral ✔✔occurring on the same side of the body
Lateral ✔✔Farther from the median plane Medial ✔✔Nearer to the median plane Transverse (Horizontal) ✔✔Horizontal planes that pass through the body at right angles to long axis; divides body into upper (superior) and lower (inferior) parts Volar ✔✔Relating to the palm of the hand or the sole of the foot Antiemetic ✔✔medication used to relieve nausea and vomiting Antipyretic ✔✔Medication used to reduce a fever Downcodes ✔✔A reduction of reimbursement for medical services when documentation is missing in a medical chart Dyspepsia ✔✔Indigestion Dysphagia ✔✔difficulty swallowing Dyspnea ✔✔difficulty breathing Edentulous ✔✔without teeth Effusion ✔✔escape of fluid into a cavity Embolism ✔✔Obstruction of a blood vessel by a clot of blood or foreign substance
