Vituity Scribe Training Pre-Classroom
Training Exam with Complete Solutions
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 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
Training Exam with Complete Solutions
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 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
