Sample Transcription and Medical Terminology
ROOT WORDS, SUFFIXES & PREFIXES
This is an introductory exercise to familiarize yourself with the basic forms of root words, but it is not necessary to memorize. The following are prefixes and suffixes that we have found most common in our transcription through the years. Especially noteworthy are those prefixes or suffixes that sound alike, such as "colo" and "chole." It can be confusing when words sound alike on an audio recording. A medical transcripitonist must often be able to distinguish words from context and root terms.
(Note: sometimes a prefix or suffix will apply to more than one category). Some prefixes and suffixes can be used more than once, overlap, or differ slightly.There is an insert in your binder that provides an answer key for matching or you can go online to (https://www.msu.edu/~defores1/gre/roots/gre_rts_afx2.htm) or (http://www.awrsd.org/oak/Library/greek_and_latin_root_words.htm).
|amni||pertaining to embryonic sac|
|broncho||pertaining to bronchial|
|(Note: Often "chole" meaning gallbladder and "colo" meaning colon are confused. Be especially careful to note context when using these prefixes.)|
|col||colon or large intestine|
|duct||to lead, carry|
COMMON ANATOMICAL TERMINOLOGY
Including Terms Referring to Parts/Divisions of Body
There are many more anatomical terms than are listed here. The following are the most commonly used terms in medical dictation. Some definitions can be obtained by context, the sample sentence and root words. If the term is more obscure, recognizing it as a body part is adequate.
abdomen/abdominal _______________ _______________________________________________ _______________________________________________
Ex.: The abdomen is soft without masses or tenderness.
abductor digiti quinti _______________ _______________________________________________ _______________________________________________
Ex.: Examination demonstrates that he had weakness in three muscles, including abductor pollicis,
abductor digiti quinti and opponens digiti minimi.
acetabulum _______________ _______________________________________________ _______________________________________________
Ex.: Flattening bony deformity of the left acetabulum and femoral head with associated slight left
hip joint space narrowing.
Achilles _______________ _______________________________________________ _______________________________________________
Ex.: The Achilles reflexes are symmetrically depressed.
LABORATORY & PATHOLOGY
electronystagmography _______________ _______________________________________________________________ _______________________________________________________________
Ex.: I believe that further studies to pursue etiologic causes should be undertaken, and to this end,
would suggest ENT evaluation with electronystagmography.
EMG _______________ _______________________________________________________________ _______________________________________________________________
Ex.: The plan is to consider the patient for EMG, as well as MRI of the spine and abdomen.
extracorporeal shock wave lithotripsy (ESWL) _______________ _______________________________________________________________ _______________________________________________________________
Ex.: This patient underwent extra corporeal shock wave lithotripsy for renal lithiasis.
FEV1 _______________ _______________________________________________________________ _______________________________________________________________
Ex.: He also had an FEV1 done, which was consistent with some chronic obstructive pulmonary
five-view (not "5-u" as may be heard on tape) a type of x-ray
Ex.: A five-view chest x-ray series was obtained.
These same formats are used to teach terminology for each specialty covered in our program. The next few pages will show you some samples of the dictation you will be typing during the program.
The patient is a 35-year-old G2 P2 female seen for annual care and pap smear. Her only gyn complaint is several days prior to the onset of menses, she will have premenstrual spotting. She continues on Ortho-Tricyclen without significant problems otherwise. She is seriously considering permanent sterilization to solve the spotting problem.
Neck – Supple, thyroid normal.
Lung fields – Clear to auscultation.
Heart – Normal sinus rhythm without murmurs, rubs or gallops.
Breasts – Symmetrical without masses or tenderness.
Abdomen – Soft without organs, masses or tenderness.
External genitalia – Normal female.
Vagina – Rugae without discharge.
Cervix Parous and unremarkable.
Uterus – Retroverted, 90-100 gm, mobile, nontender.
Adnexa – Palpably normal.
Impression: Normal gyn exam.
Ortho-Cyclen x 12 mo.
Tubal sterilization and laparoscopy, including procedure risks, indications and failure rate, are discussed with the patient. She will consider and verbally acknowledges risks associated.
I discussed the pathology report of adenomatous hyperplasia with Audrey over the telephone. There was no evidence of atypia and at this point in time, we may simply attempt to treat this condition with monthly progestational agents to see if it will reverse the adenomatous hyperplasia. It was stressed to Audrey that she must have follow-up, however, because this can be a precancerous condition and that in six to 12 months, she should have an endometrial sampling repeated. If her heavy bleeding continues or increases, hysterectomy would be a viable option. Audrey will come by the office to pick up a prescription for Provera 10 mg to be taken days 15 to 26 each month.
SOCIAL HISTORY: He is an occasional tobacco user. He does admit to drinking quite heavily and admits to consumption of approximately a 12-pack of beer a day and up to 48 beers per weekend. He states that he is unable to quit and has been to Alcoholics Anonymous and counseling in the past. His last liver check was one year ago. His occupation is an engineer.
FAMILY HISTORY: Multiple for diabetes mellitus.
REVIEW OF SYSTEMS: Noncontributory.
PHYSICAL EXAMINATION: Examination on this date revealed an alert, oriented, white male who is obese, in no apparent distress. HEENT was unremarkable. Heart was regular rate and rhythm S1 greatest at the base. There were no murmurs noted. Lungs were clear to auscultation. Abdomen was soft. Liver approximately 5 cm. beneath the right costal margin and nontender. Extremities are with crepitus and painful range of motion at the right knee. He did have good range of motion of the left knee.
Lab analysis on this date revealed elevated glucose at 193, BUN and creatinine .9 and 4 respectively. Alkaline phosphatase is elevated to 130, GGT is markedly elevated at 185, H&H is 17.1 and 50.2 respectively. Due to the initial elevation of the random blood sugar, the patient was referred for a five-hour glucose tolerance test, which was positive.
Diagnosis other than the torn medial meniscus include 1) noninsulin dependent diabetes mellitus Type II 2) exogenous obesity, 3) tobacco abuse, 4) alcoholism with alcohol abuse, 5) elevated liver enzymes secondary to #4.
I certainly agree with your plan to perform an arthroscopy on this patient.
The patient will return to our office to further discuss his medical problems and perhaps a trial of oral hypoglycemics will be instituted, as I don’t feel this patient would be compliant with diet.
I have encouraged this patient to obtain further counseling for his alcohol abuse and we will be following his liver enzymes with periodic checks.
S: John has noted a recurrence of his preangioplasty chest discomfort occurring at low levels of activity. He is now on Cardizem, 60 p.o. q.i.d. and topical nitrites in addition to his aspirin a day.
O: Pulse is 64 and regular. Blood pressure is 130/70. Lungs clear. Heart - atrial gallop. 12- lead EKG is normal.
A: Suspected stenosis of previously angioplastied LAD segment.
P: 1) Maintain his activity at the low level over the weekend. 2) Continue his medications as above. 3) Call back for any interim questions or problems. 4) Anticipate proceeding with recatheterization and possible angioplasty this upcoming
weekend under the auspices of Dr. Smith.
S: She had a bit of a nonproductive cough over the last few days. Her rings have been a bit
tighter and she was advised to increase her Lasix to 120 mg a day for yesterday and today. She continues on her Capoten 25 mg p.o. t.i.d.; Micro-K 70 mg a day but taking an extra potassium with the extra Lasix per day and Lanoxin 0.25 mg p.o. q.d. in addition to
Tamoxifen and Diabinese 250 mg p.o. q.d.
O: Pulse is about 94 and regular. Blood pressure 110/60. Lungs are actually fairly clear.
Heart demonstrates prominent atrial and ventricular gallops with perhaps a bit of an increase in her friction rub. No distal edema is noted.
A: 1) Severe end-stage congestive and probable restrictive cardiomyopathy. 2) Probable mild congestive heart failure. 3) Type II diabetes mellitus. 4) Metastatic breast carcinoma.
P: 1) I have advised her to take the 120 mg of Lasix for today and depending on how she
feels tomorrow, either resume her usual 40 p.o. b.i.d. of Lasix versus an additional day
of 120 mg of Lasix.
2) We will set her up for a follow-up echocardiogram within the next week or so and see her for follow-up on a more or less p.r.n. basis.
Pertinent Physical Findings:
Reveal visual acuity for distance vision with his present glasses at 20/20 -2 with the right eye and 20/20 –1 in the left eye. The intraocular pressures are 19mm Hg in each eye by applantation, which is within the upper limits of normal. Confrontation of visual fields reveal a peripheral scotoma occupying both the upper and lower quarters of the left visual field in the left eye. This is macula sparing. There is some question about there being a possible lesser scotoma in the left visual field of the right eye. External examination revealed normal findings. The pupils are round and regularly react to light, directly and indirectly to convergence. He is orthophoric. His fixation is good central and maintained bilaterally. Slit lamp exam reveals completion of the sclerotic cataract in the right eye. He has pseudophakia in the left eye. Mydreatic fundoscopy, as well as indirect in the 90 diopter lens examination revealed the retina in both eyes to be intact. There are no holes or tears. These are essentially normal fundoscopic findings. He does have posterior vitreous detachments in both eyes which are within normal limits.
1. Blepharoconjunctivitis left eye. Pseudophakia of the left eye. Cataract to the right eye.
Ordered visual fields be done on the patient both central and peripheral. Have him be seen by Dr. Carter on the following day to confirm whether or not there is truly a visual field loss in one or both eyes. The visual fields as observed by Dr. Carter the following day, reveal the peripheral vision of the right eye was not involved. The left eye showed field changes which were more typically that of glaucoma and upon reviewing the history of this patient, he was worked up for possible glaucoma and seen by a glaucoma specialist, Dr. O’Neal. Dr. Carter accordingly referred back to Dr. O’Neal for a re-evaluation regarding glaucoma. The one concern I have, if the patient is really having a loss of temporal vision that is macula sparing in the left eye, which apparently was transient, then the patient needs an evaluation of his cartoid arteries, since that could possibly cause a transient visual field loss
Your patient, Faye Keller, returned to my office yesterday.
She has improved in the interim since her last visit. Her leg strength is improving. She is no longer requiring a cane and she is walking stably. Iliopsoas strength is between 5- and 5 bilaterally (probably a little less on the left than on the right). She says that she’s had some shadows in her vision, but no true diplopia. I can’t find specific extraocular muscle problem on her exam today. She is also complaining of some fatigue and discomfort, but she says that her medications partially mitigate these problems.
Continue Neurontin 900 mg per day in divided dosage.
Continue amantadine 100 mg TID.
Request once monthly IV methylprednisolone infusion, until the effect of Copaxone can independently be protected as an immuno-modulating agent.
Return visit in December, or sooner, if problems arise in the interim.
AP PELVIS, LATERAL RIGHT HIP: 10/29. Compared with 10/20. Left hip prosthesis again noted in place, showing no obvious interval change in position or bony alignment. Small amount of heterotopic soft tissue calcifications surrounding the greater trochanter of the proximal left femur. Osteoporosis and degenerative changes, as well as atherosclerotic vascular calcifications.
PORTABLE CHEST: Heart and mediastinum are normal to position. Two left chest tubes are seen in place. There is a small left pleural effusion and minimal linear atelectasis at the left base.
A small left apical pneumothorax is seen. The pneumothorax is slightly smaller than on the previous exam of 07/09.
S: Phyllis Bevins has continued to experience multiple symptoms including malaise, fatigue, as well as chest pain and exertional dyspnea and chronic back pain. She has chronic headaches. She is on no specific medication. She has had a longstanding history of chest pain and shortness of breath dating back to 1999. I did review all of her records that she brought in which showed, as we had obtained from her history previously, negative cardiology and pulmonary evaluations.
O: Temp 99.6 F, BP 128/70. Weight 152 pounds.
We did review extensive laboratory studies done through our office. CBC, ESR and chemistry profiles were all normal. C-reactive protein was normal. TSH normal. Cryoglobulins were negative as were ANCA studies. Urinalysis showed no protein or casts. Rheumatoid factor was negative. ANA was 1:320 homogeneous pattern; however, all autoantibody studies were negative and complement levels were normal. CPK normal.
A: ANA seropositivity without evidence clinically of connective tissue disease, inflammatory arthritis or other autoimmune illness.
P: Observation only at this time. We will follow up more on an as-needed basis should she develop additional signs, symptoms or laboratory findings of connective tissue disease or autoimmune illness.
S: Belinda Stanford is seen today. She is unchanged with regard to the symptoms in her knees. She also describes a more diffuse musculoskeletal pain and states that she has been diagnosed previously with “fibromyalgia.” Her current medications include Celexa, Mobic 15 mg daily and temazepam.
O: The MRI of the knees shows a process that seems most consistent with osteoarthritis.
Osteoarthritis of the knees.
Secondary fibromyalgia syndrome.
P: Continue the current treatment program. We will also add a trial of supplemental analgesia with tramadol. We have discussed a trial of intra-articular hyaluronate injections to the knees, although the osteoarthritis does appear to be somewhat severe, especially involving the right knee.