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Scribe > DAY1 > Flashcards

DAY1 Flashcards

1
Q

Define chief complaint

A

the main reason for the patient’s outpatient visit

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2
Q

Define EMR/EHR

A

Electronic medical record/ electronic health record

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3
Q

Define subjective

A

feeling

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4
Q

Define Objective

A

factual finding from the provider

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5
Q

Define Pain

A

Patient’s feeling of discomfort

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6
Q

Define Tenderness

A

Doctor’s finding of reproducible pain

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7
Q

Define acute

A

new onset, likely concerning

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8
Q

Define chronic

A

long-standing, not of direct concern

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9
Q

What are the 2 types of patients

A

new and established

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10
Q

Define new patient

A

1) a patient that has never been seen at the clinic or was seen greater than 3 years ago
2) no previous records
3) longer visit
4) detailed chart

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11
Q

Define established patient

A

1) a patient that has been seen at the clinic ( by any provider) within the last 3 years
2) previous records available
3) shorter visit
4) concise chart

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12
Q

What are the 2 types of visits

A

diagnostic and health management

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13
Q

Define diagnostic visits

A

1) new problems
2) chief complaint: new symptoms
3) goal is to determine the cause of the problem and appropriate treatment

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14
Q

Define health management visit

A

1) check up
2) chief complaint: routine physical or management of chronic problems
3) goal is preventative care and or assessing progress of ongoing medical problems

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15
Q

What is the flow of the clinic

A

1) Check in and Chief complaint
2) History and Physical
3) Orders and Results
4) Assessment and plan
5) Check out

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16
Q

What is part of the Physician: History and Physical ( H & P)

A

History of Present Illness ( HPI)
Review of Systems ( ROS)
Past History
Physical Exam (PE)
DDx ( only for diagnostic visits)

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17
Q

What are the component of the Medical Chart

A

S: history of present illness (HPI) and Review of Systems ( ROS)
O: Physical Examination (PE) and Orders and Results
A: Assessment
P: Plan

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18
Q

Where would you find the chief complaint in the chart

A

HPI OR ROS ( Subjective complaint)

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19
Q

Where would you find past diagnoses and surgeries

A

past history

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20
Q

Where would you find physician’s observations

A

physical exam ( objective evaluation)

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21
Q

Where would you find labs, imaging,studies

A

results

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22
Q

where would you find current diagnoses

A

assessment

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23
Q

where would you find treatment plan

A

plan

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24
Q

Medical term for high blood pressure?

A

Hypertension (HTN)

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25
Q

Medical term for high cholestrol

A

hyperlipidemia (HLD)

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26
Q

Medical term for diabetes

A

Diabetes Mellitus (DM)

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27
Q

If a patient take pills for diabetes

A

Non-insulin dependent diabetes mellitus
( NIDDM)

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28
Q

If patients take insulin for diabetes

A

Insulin Dependent diabetes mellitus (IDDM)

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29
Q

Medical term for heart disease

A

Coronary Artery Disease (CAD)

30
Q

Medical term for heart attack

A

Myocardial Infarction (MI) and CAD

31
Q

Medical term for heart failure

A

Congestive heart failure (CHF)

32
Q

Medial irregular heartbeat

A

Arrhythmia

33
Q

Medical term for emphysema or Chronic bronchitis

A

Chronic Obstructive Pulmonary Disease
(COPD)

34
Q

Medical term for blood clot of lung

A

Pulmonary Embolism (PE)

35
Q

Pneumonia or lung infection

A

Pneumonia (PNA)

36
Q

Medical term for reflux

A

Gastroesophageal Reflex Disease (GERD)

37
Q

Medical term for ulcers

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

38
Q

Medical term for irritable bowels

A

Irritable Bowel Syndrome (IBS)

39
Q

Medical term for bladder infection

A

urinary tract infection (UTI)

40
Q

Medical term for kidney infection

A

pyelonephritis

41
Q

Medical term for a patient on dialysis

A

Chronic Kidney Disease ( CKD) on dialysis

42
Q

Medical term for large prostate

A

Benign Prostatic Hypertrophy (BPH)

43
Q

Medical term for stroke

A

Cerebrovascular Accident (CVA)

44
Q

Medical term for blood clot in brain

A

Ischemic CVA

45
Q

Medical term for brain bleed

A

hemorrhagic CVA

46
Q

Medical term for mini stroke

A

transient ischemic attack ( TIA)

47
Q

Medical term for blood clot in leg

A

deep vein thrombosis (DVT)

48
Q

medical term for bulge in my aorta

A

Aortic Aneurysm

49
Q

medical term for “ bad blood flow in my legs “

A

peripheral vascular disease ( PVD)

50
Q

medical term for cancer

A

cancer or carcinoma (CA)

51
Q

medical term for cancer that spread

A

with metastasis to the

52
Q

medical term for cutting out cancer

A

status post-surgical resection

53
Q

What are the symptoms of a true allergy

A

rash, itching,swelling, or difficult breathing

54
Q

What is it called when the tonsils are removed

A

tonsillectomy

55
Q

What is it called when the adenoids are removed

A

adenoidectomy

56
Q

What is it called when the neck arteries are cleaned

A

carotid endarterectomy

57
Q

what is called when a leg is amputated

A

above knee amputation (AKA)
below knee amputation (BKA)

58
Q

What is it called when a joint is repaired

A

arthroplasty

59
Q

What is “ balloon in heart”

A

angioplasty > PMHx CAD

60
Q

What is “stent in heart”

A

coronary stents > PMHx CAD

61
Q

Medical term for heart bypass

A

coronary artery bypass graft (CABG) > PMHx CAD

62
Q

Medical term for removal of breast

A

mastectomy

63
Q

Medical term for removing part of a lung

A

partial lobectomy

64
Q

Medical term for removing the appendix

A

appendectomy

65
Q

Medical term for removing the gallbladder

A

cholecystectomy

66
Q

Medical term for part of the colon being removed

A

partial colectomy

67
Q

medical term for removal of spleen

A

splenectomy

68
Q

medical term for removal of kidney

A

nephrectomy

69
Q

medical term for removal of uterus

A

hysterectomy

70
Q

medical term for removal of ovary

A

oophorectomy

71
Q

Why is the age of onset for family diseases so important ?

A

Younger age of onset ( under 55) means higher genetic risk

72
Q

What is part of social hx

A

Alcohol use
tobacco use /vaping
drug use
occupation
living circumstances

Scribe (2 decks)

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