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40 terms

chapter 12 med transcription

STUDY
PLAY
CR
Cardiorespiratory
GU
Genitourinary
GYN
Gynecology
NP
Neuropsychiatric
GI
Gastrointestinal
EOMS
Extra ocular movements
HTN
Hypertension or high blood pressure
HEENT
head, eyes, ears, nose, throat
Gravida
number of pregnancies
Para
number of births
full block
justified to the left side of the page
modified block
tabbed over and aligned
PERLA
pupils equally react to light and accommodation
Dysmenorrhea
bad/painful/abnormal menstrual flow
Syncope
fainting
cholecystitis
inflammation of the gallbladder
tachycardia
rapid heartbeat
bradycardia
slow heartbeat
Hematemesis
vomiting blood
Tinnitus
ringing in the ear
Alopecia
baldness
Epistaxis
nosebleed
Menarche
first period for female
Metrorrhagia
excessive uterine bleeding
Glaucoma
Atrophy of the optic nerve and increased intraocular pressure
Conjunctivitis
pink eye, inflammation of the mucous membranes of the eye
Cephalocaudal
head to foot
Varicosities
varicos veins, distended, knotted or swollen veins
skin
dryness, scaling, eruptions, rash, dicoloration, palor
Diagnosis and Impression
they have the same meaning on report also called assessment or conclusion
4 parts of PE
Inspection, palpation, percussion, and auscultation
short stay record
used for outpatient or surgical center in place of an H&P
Interval History
patient returns to the hospital within a month
demographic data
name, address, phone #, SS, place of work
4 parts of a HX
CC, ROS, HPI, PFSH
CC
Chief complaint
ROS
review of systems
HPI
history of present illness
PFSH
past family social history
how do you list allergies on a report
bold/ underline could be life or death to the patient