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Scribe Training > Course 1: PMHx; Patients says, Scribe writes. > Flashcards

Course 1: PMHx; Patients says, Scribe writes. Flashcards

1
Q

high blood pressure

A

Hypertension (HTN)

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2
Q

high cholesterol

A

hyperlipidemia (HLD)

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3
Q

thyroid problem

A

usually hypOthyroidism, sometimes hyperthyroidism

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4
Q

diabetes

A

Diabetes Mellitus (DM)

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5
Q

I take pills for my diabetes.

A

Type 1; Non-Insulin Dependent DM (NIDDM)

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6
Q

I take shots for my diabetes.

A

Type 2; Insulin Dependent DM (IDDM). More common in ED*

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7
Q

heart disease

A

coronary artery disease (CAD)

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8
Q

heart attack

A

myocardial infarction (MI) AND CAD

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9
Q

heart failure

A

congestive heart failure (CHF)

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10
Q

irregular heartbeat

A

Atrial Fibrillation (A-Fib)

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11
Q

murmur

A

heart murmur

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12
Q

episodes of abnormally fast/ racing heartbeat

A

supra ventricular tachycardia (SVT)

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13
Q

Asthma

A

Asthma

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14
Q

Emphysema/ Chronic Bronchitis

A

Chronic Obstructive Pulmonary Disease (COPD)

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15
Q

blood clot in lung

A

Pulmonary Embolism (PE)

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16
Q

Pneumonia

A

Pneumonia (PNA)

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17
Q

Reflux

A

Gastroesophageal reflux disease (GERD)

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18
Q

ulcer

A

gastric ulcer or peptic ulcer disease

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19
Q

pancreatitis

A

pancreatitis

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20
Q

hepatitis

A

hepatitis A/B/C

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21
Q

Diverticulitis

A

Diverticulitis

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22
Q

Crohn’s / UC

A

Crohn’s disease or ulcerative colitis

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23
Q

Irritable bowel

A

Irritable Bowel Syndrome (IBS) (with certain foods)

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24
Q

bladder infection

A

Urinary Tract Infection (UTI)

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25
Q

kidney infection

A

Pyelonephritis (Pyelo)

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26
Q

Kidney stones

A

renal calculi

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27
Q

I’m on dialysis.

A

Chronic Renal Failure (CRF) on dialysis

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28
Q

Enlarged prostate

A

benign prostate hypertrophy (BPH)

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29
Q

Gyno PMHx: G/P/A

A

G: number of times pregnant
P: live births
A: abortions or failed pregnancies

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30
Q

stroke

A

cerebrovascular accident (CVA)

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31
Q

mini-stroke

A

transient ischemic attack (TIA)

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32
Q

seizures

A

seizure disorder / epilepsy

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33
Q

brain bleed

A

hemorrhagic CVA

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34
Q

bipolar

A

bipolar disorder

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35
Q

schizophrenia

A

schizophrenia (or as specific as pt)

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36
Q

I drink a lot

A

ETOH abuse or alcoholism

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37
Q

blood clot in my leg

A

lower extremity DVT

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38
Q

bulge in my aorta

A

abdominal aortic aneurysm (AAA)

39
Q

bad flood flow to my legs

A

peripheral vascular disease (PVD)

40
Q

low back pain

A

chronic low back pain

41
Q

bulging/ herniated disc

A

degenerative disc disease (DDD)

42
Q

arthritis

A

osteoarthritis (OA); sometimes rheumatoid arthritis

43
Q

joint pain (chronic)

A

degenerative joint disease (DJD)

44
Q

weak/fragile bones

A

often osteoporosis

45
Q

cancer

A

Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate, Ovarian, Skin, Bone, Leukemia or Lymphoma.

46
Q

Cancer spread to my…

A

with metastases to the ..

47
Q

Chemo

A

Chemotherapy

48
Q

Radiation

A

Radiation therapy

49
Q

They cut it out. (cancer)

A

Status-post surgical resection

50
Q

It’s gone. (cancer)

A

in remission

51
Q

Tonsils removed

A

Tonsillectomy

52
Q

Adenoids removed

A

Adenoidectomy

53
Q

Ear tubes

A

pressure equalizer (P.E.) Tubes

54
Q

Heart bypass

A

coronary artery bypass graft (CABG) -> PMHx CAD

55
Q

stents

A

coronary stents -> PMHx CAD

56
Q

heart cath

A

cardiac catheterization

57
Q

balloon

A

Angioplasty -> PMHx CAD

58
Q

valve surgery

A

valve repair or replacement (bovine v mechanical)

59
Q

pacer

A

pacemaker

60
Q

defibrillator

A

automatic implanted cardiac defibrillator (AICD)

61
Q

surgery for A-Fib

A

A-Fib s/p cardiac ablation

62
Q

breast removal

A

mastectomy

63
Q

hole in my neck

A

tracheostomy

64
Q

part of my lung removed

A

partial lobectomy

65
Q

appendix removed

A

appendectomy

66
Q

gallbladder removed

A

cholescystectomy

67
Q

hernia repair

A

herniorrhaphy

68
Q

part of my colon removed

A

partial colectomy

69
Q

bag to collect stool

A

colostomy

70
Q

spleen removed

A

splenectomy

71
Q

stomach stapled

A

gastric bypass

72
Q

kidney removed

A

nephrectomy

73
Q

uterus removed

A

hysterectomy (partial v total)

74
Q

ovary removed

A

oophorectomy

75
Q

ovary and fallopian tubes removed

A

salpingo-oophorectomy

76
Q

tubes tied

A

tubal ligation (female) v vasectomy (male)

77
Q

C-Section

A

Caesarean section

78
Q

prostate removed

A

prostatectomy (most often trans-urethral removal of the prostate or TURP)

79
Q

uterine product removed

A

dilation and curettage (D&C)

80
Q

neck artery cleaned

A

carotid endarterectomy

81
Q

brain surgery

A

craniotomy (brain bleed v brain CA)

82
Q

shunt

A

ventriculoperitoneal (VP) shunt

83
Q

dialysis fistula

A

AV (arteriovenous) fistula

84
Q

dialysis graft

A

AV graft

85
Q

PICC line

A

peripherally inserted central catheter (PICC)

86
Q

Port

A

Port-a-cath or medi-port

87
Q

Clot filter (lower abdomen)

A

IVC (inferior vena cava) filter

88
Q

Clot filter (leg)

A

greenfield filter

89
Q

leg amputated

A

above knee amputation (AKA)

below knee amputation (BKA)

90
Q

joint repair

A

arthroplasty

91
Q

metal plates / pins

A

hardware

92
Q

neck fused

A

cervical spinal fusion

93
Q

back fused

A

lumbar spinal fusion

94
Q

hip surgery

A

open reduction w/ internal fixation (ORIF)

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