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Scribe America > Day 1: ED Flow: Part 3 (What scribe writes PSHx & SHx, FHx) > Flashcards

Day 1: ED Flow: Part 3 (What scribe writes PSHx & SHx, FHx) Flashcards

1
Q

tonsils removed

A

tonsillectomy

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2
Q

adenoids removed

A

adenoidectomy

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3
Q

ear tubes

A

pressure equalizer (P.E.) tubes

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4
Q

heart bypass

A

coronary artery bypass graft (CABG) –> PMHx CAD

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5
Q

Stents

A

Coronary Stents –> PMHx CAD

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6
Q

Heart Cath

A

Cardiac Catheterization

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7
Q

Ballon

A

Angioplasty –> PMHx CAD

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8
Q

Valve Surgery

A

Valve Repair or replacement (Bovine vs. Mechanical)

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9
Q

Pacer

A

Pacemaker

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10
Q

Defibrillator

A

Automatic Implanted cardia Defibrillator (AICD)

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11
Q

Surgery for Afib

A

AFib s/p cardiac abiation

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12
Q

Breast removal

A

Mastectomy

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13
Q

Hole in my neck

A

Tracheostomy (commonly called a “teach”)

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14
Q

Part of my lung removed

A

Partial lobectomy

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15
Q

Appendix removed

A

Appendectomy

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16
Q

Gallbladder removed

A

Cholecystectomy

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17
Q

Hernia repair

A

Herniorrhaphy

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18
Q

Part of colon removed

A

Partial colonectomy

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19
Q

Bag to collect stool

A

colostomy

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20
Q

Spleen removed

A

splenectomy

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21
Q

stomach stapled

A

gastric bypass

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22
Q

kidney removed

A

nephrectomy

23
Q

uterus removed

A

hysterectomy (partial vs. total)

24
Q

ovary removed

A

oophorectomy

25
Q

ovary and fallopian tubes removed

A

salpingo-oophorectomy

26
Q

tubes tied

A

tubal ligation (female) or vasectomy (male)

27
Q

c-section

A

cesarean section

28
Q

prostate removed

A

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

29
Q

neck artery cleaned

A

carotid endarterectomy

30
Q

brain surgery

A

craniotomy (brain bleed vs. brain cancer)

31
Q

shunt

A

ventriculoperitoneal (VP) shunt

32
Q

dialysis fistula

A

AV (arteriovenous) Fistula

33
Q

dialysis graft

A

AV Graft

34
Q

PICC line

A

Peripherally Inserted Central catheter (PICC)

35
Q

Port

A

Port-A-cath or Medi-Port

36
Q

Clot filter (lower abdomen)

A

IVC (inferior vena cava) Filter

37
Q

Clot filter (leg)

A

Greenfield Filter

38
Q

Leg amputated

A

Above Knee Amputation (AKA)

Below Knee Amputation (BKA)

39
Q

Joint Repait

A

Arthroplasty

40
Q

Metal Plates/pins

A

Hardware

41
Q

Neck fused

A

Cervical Spinal Fusion

42
Q

Back fused

A

Lumbar Spinal Fusion

43
Q

Hip Surgery

A

ORIF

44
Q

True Allergy symptoms

A

rash, itching, swelling, difficulty breathing

45
Q

Non-True Allergy

A

Adverse Reaction

46
Q

Older age of onset (50 yrs+) is likely more die to ________ than genetics

A

environment

47
Q

Social History includes

A 
Tobacco Use
Alcohol Use
Illicit Drug Use
Occupation
Living Circumstances
48
Q

Tobacco Use

A

Smoking Status?

Chewing Tobacco?

49
Q

Alcohol Use

A

How Much?

50
Q

Illicit Drug Use

A

Which Drug?
Route of Administration?
Date of Last Use?

51
Q

Occupation

A

Employed? Unemployed? On disability? Retired?

52
Q

Living Circumstances

A 
Lives alone?
With family/friends?
Nursing home/assisted living?
Hospice?
Homeless?
53
Q

Pediatrics SHx

A 
Caretaker
Attends Daycare
Attends school
Has brothers/sisters
Second-hand smoke exposure
Immunizations are up to date

Scribe America (11 decks)

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