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ScribeAmerica Final Exam Review
Terms in this set (285)
Abdominal Aortic Aneurysm
Against Medical Advice
Altered Mental Status
Acetylsalicylic Acid (Aspirin)
Bilateral Lower Extremities
Coronary Artery Bypass Graft, "open heart surgery"
Coronary Artery Disease, "heart disease"
CT or CAT
Computerized Assisted Tomography
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
Cervical Spine (neck)
Cerebrovascular Accident -or- Costovertebral Angle
Do Not Resuscitate
Dyspnea On Exertion
Deep Venous Thrombosis
Gun Shot Wound
Head, Eyes, Ears, Nose, Throat
History of Present Illness
Hemoglobin & Hematocrit
History of Present Illness & Physical Exam
Incision & Drainage
Insulin Dependent Diabetes Mellitus
IV Drug Abuse
Jugular Vein Distension
Left Lower Extremity
Left Lower Quadrant
Last Normal Menstrual Period
Loss of Consciousness
Left Upper Extremity
Left Upper Quadrant
Motor Vehicle Accident/Motor Vehicle Collision
No Acute Disease, No Acute Distress
Non-Insulin Dependent Diabetes Mellitus
No Known Drug Allergies
Nml -or- nl
Non-Steroidal Anti-Inflammatory Drug
Normal Sinus Rhythm
Oxygen Saturation (a.k.a. SaO2)
Primary Care Physician (a.k.a. PMD)
Pulmonary Embolism -or- Physical Exam
Pupils are equal, round, and reactive to light
Per Os (by mouth)
Prior To Arrival
Peptic Ulcer Disease
At Every Bedtime
Every 2 Hours
Four Times a Day
Right Lower Extremity
Right Lower Quadrant
Range of Motion
Review of Systems
Right Upper Extremity
Right Upper Quadrant
Shortness of Breath
Status Post (after)
Transient Ischemic Attack
Three Times a Day
Upper Respiratory Infection
Up To Date
Urinary Tract Infection
Within Normal Limits
Above The Knee Amputation
Small Bowel Obstruction
Dorsal Fetal Pulse
Left Axis Deviation
Super Ventricular Tachycardia
These 2 lab test,which are part of the 7 basic chemistries, will be high in someone with renal failure.
Urea and creatinine
The "H&H" comes back with this lab test. If low it would indicate the patient is anemic.
Hemoglobin and hematocrit. hemoglobin would be low if the patient is anemic.
This lab test will be high in patient with pancreatitis.
This lab test is used to help physicians rule out PE and DVT.
This lab test will be elevated in patients with CHF.
This abbreviation is used to describe a heart attack.
This abbreviation is used to describe diabetes.
This abbreviation is used to describe a normal heart rhythm.
RBBB is the abbreviation used to describe this medical term, which would indicate an abnormal EKG finding.
Right Bundle Branch Block
CVA is used medically as an abbreviation for a cerebral vascular accident, as well as this location of the body.
This surgery is performed to remove the appendix.
ST Elevation Myocardial Infarction
Birth Control Pill
Gastro-Esophageal Reflux Disease, "acid reflux"
What is GPA?
G = the total number of times the patient has been pregnant
P = the number of live births (viable children) that the patient has had
A = the total number of miscarriages or elective abortions
No rebound, no guard
CT w/ PO
CT Abd/Pel with PO contract
Number of physical exam elements needed for Level 5
8 elements (at least 1 finding in 8 different organ systems)
Number of HPI elements needed for Level 5
Number of ROS elements needed for Level 5
Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5
Name the vital signs
blood pressure, respiratory rate, heart rate, oxygen saturation, temperature
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What does PHI stand for?
Protected Health Information
What are the 6 rules of HIPAA?
Rule #1: if a patient is not assigned to your doctor, DO NOT tough the chart.
Rule #2: There is always someone watching.
Rule #3: Never share your username or password.
Rule #4: No cell phones or pictures.
Rule #5: Your job does not belong on social media.
Rule #6: Ask yourself, "Do I need to access this for my job?"
What does HITECH stand for?
The Health Information Technology for Economic and Clinical Health Act --> PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption.
High blood pressure
Usually Hypothyroidism, sometimes Hyperthyroidism
Diabetes Mellitus (DM)
"I only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
"I take shots (insulin) for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
Usually Coronary Artery Disease (CAD)
Myocardial Infarction (MI) and CAD
Congestive Heart Failure (CHF)
Atrial Fibrillation (A-Fib)
Episodes of abnormally fast/racing heartbeat
Supraventricular Tachycardia (SVT)
Chronic Obstructive Pulmonary Disease (COPD)
Blood clot in lung
Pulmonary Embolism (PE)
Gastroesophageal Reflux Disease (GERD)
Gastric Ulcer or Peptic Ulcer Disease
Hepatitis A, Hepatitis B, or Hepatitis C
Crohn's Disease or Ulcerative Colitis
Irritable Bowel Syndrome (IBS)
Urinary Tract Infection (UTI)
"I'm on dialysis"
Chronic Renal Failure (CRF) on dialysis
Benign Prostate Hypertrophy (BPH)
Cerebrovascular Accident (CVA)
Transient Ischemic Attack (TIA)
"I drink a lot"
Alcoholism or EtOH abuse
"Blood clot in my leg"
Lower Extremity Deep Vein Thrombosis
"Bulge in my aorta"
Abdominal Aortic Aneurysm (AAA)
"Bad blood flow in my legs"
Peripheral Vascular Disease (PVD)
Low back pain
Chronic Low Back Pain
Degenerative Disc Disease (DDD)
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
Join pain (chronic)
Degenerative Joint Disease (DJD)
Cancer or Carcinoma (CA)
Spread to my...
With metastases to the...
They cut it out
Status-post surgical resection
Pressure Equalizer (P.E.) Tubes
Coronary Artery Bypass Graft (CABG) --> PMHx CAD
Coronary Stents --> PMHx CAD
Angioplasty --> PMHx CAD
Valve repair or replacement (Bovine vs. Mechanical)
Automatic Implanted Cardiac Defibrillator (AICD)
Surgery for Afib
Afib s/p cardiac ablation
hole in my neck
Tracheostomy (commonly called a "trach")
Part of my lung removed
Part of my colon removed
Bag to collect stool
Ovary and fallopian tubes removed
Tubal ligation (female) or Vasectomy (male)
Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP)
Neck artery cleaned
Ventriculoperitoneal (VP) Shunt
AV (arteriovenous) Fistula
Peripherally Inserted Central Catheter (PICC)
Port-a-cath or Medi-Port
Clot filter (lower abdomen)
IVC (inferior vena cava) Filter
Clot filter (leg)
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
Cervical spinal fusion
Lumbar spinal fusion
This surgery is performed to remove a portion of the intestines
This hyphenated surgery would indicate the patient is missing both an ovary and a fallopian tube.
An erythematous TM would be abnormal for this body part.
Ear --> indicates ear infection
To check for JVD, what would be examined?
The presence of fluctuance would indicate this body tissue and would likely require I&D.
This is the medical term used to describe redness.
Pedal edema is used to describe what?
Blood is the urine is called what?
What is the medical term for bruise?
What is the medical term for a bloody nose?
Fast breathing rate
Black tarry stools
Pain with urination
Acute blockage of artery that provides blood to brain
CVA (Cerebrovascular Accident)
Collapse lung due to trauma or a spontaneous small rupture of the lung
Ischemic and infarct of the interior lateral myocardium
How do you diagnose a hemorrhagic CVA?
CT of the head
How do you diagnose appendicitis?
How do you diagnose gallstones?
Ultrasound of RUQ
How do you diagnose meningitis?
What are the 4 types of focal neurological deficits?
Changes in speech, vision, strength, and sensation
What are the main differences between HPI and ROS?
HPI focuses on chief complaint; ROS is a check from head to toe
Who would read your HPI other than your doctor?
PCP, lawyers, coders, insurance companies, etc.
Are cough and fever related?
Yes, when it could go either way, definitely put it in HPI
What are 4 things that must be documented in HPI after a syncope episode?
What happened prior to episode, during episode, after episode, and their current status in the ED
What is syncope?
Fainting; passing out
How do you document a normal radial pulse?
Right radial pulse 2+
How do you document a neck pulse/carotid pulse?
Right carotid pulse 2+
How do you document a pulse on top of the foot?
Dorsal pedis pulse 2+
How do you document a pulse on the heal?
Posterior Tibialis Pulse 2+
What are examples of PHI?
date of birth, social security number, diagnosis, what tests were run, what the results of the tests were
What do you do if someone asks for your help with a patient?
We cannot touch patients. Find a nurse, a tech, etc. who can help.
If someone comes in complaining about dyspnea, what are the 2 major diseases to worry about?
PE and PNA
What is diagnosed when elevated Troponin is present?
What is likely the diagnosis of lower abdomen pain?
Appendicitis, ectopic pregnancy
What are all of the possible elements of an HPI?
Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity
THIS SET IS OFTEN IN FOLDERS WITH...
Scribe America HPI
Scribe America Final Exam
Scribe America Pathophysiology Review
ScribeAmerica Scribe Workbook
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