Final exam Flashcards
Herniorrhaphy
hernia repair
cholecystectomy
gallblader removal
Appendectomy
appendix removal
partial lobectomy
partial lung removal
Tracheostomy
Hole in neck
Mastectomy
Breast removal
Afib s/p cardiac ablation
surgery for Afib
Afib
Atrial fibrillation
AICD
Automated Implanted Cardiac Defibrillator
Pacer
Pacemaker
Angioplasty
The balloon surgery
Coronary Stent
Inserting a stent into coronary artery
Established Pt.
Seen at the clinic/practice within the last three years
Diagnostic Visit
A visit where the CC is a new symptom
HM visit
a visit where the CC is a routine physical or management of a chronic problem
What is the clinic flow (1-5)
Check in, physician evaluaiton, Order/results, Assessment/plan, check out
Quality Measures
vitals, CC, height, weight, BMI, smoking status
Vitals
O2 sat, BP, HR, respiratory rate
H and P
HIstory and physical evaluation performed by the physician
HPI
History of present illness
PE
Physical Exam
PE (Medical Issue)
Pulmonary Embolism
ROS
Review of systems
DDX
differential diagnoses
SOAP
Subjection, Objective, Assessment, Plan
Subjective portion of chart
HPI, ROS, part of the PHx
Objective Portion of chart
PE, orders, results
Subsections of Past history
PMHX, PSHx, SHx, FHx
PMHx
Patient Medical History
Hypertension (what is it)
High blood pressure
HTN
hypertension
Hyperlipidemia (what is it)
high cholesterol
HLD
hyperlipidemia
Hyper/Hypothyroidism
issues with thyroid fxn
DM
diabetes mellitus
DM treated with pills
NIDDM
NIDDM
Non insulin dependent diabetes mellitus
IDDM
Insulin dependent diabetes mellitus
DM treated with shots
IDDM
CAD
Coronary artery disease
Allergy vs Adverse Reaction
Allergy is immune response and adverse rxn is a side effect
Age cutoff for genetic risk
onset prior to 55 Y/o
Smoking Status (5 of them)
Current, former, never, 2nd hand, ecig
Alcohol Use (4 of them)
Never, occasionally, daily, chronic
2 factors to document in drug use
type of drug and route of admin
Pediatric SHx (6 factors)
Caretaker, Daycare, School, Siblings, 2nd hand smoke, Vaccines
New Pt.
Not seen at this clinic or practice for at least 3 years
Hx
History
Tx
Treatment
Dx
Diagnoses
MLP
Mid level provider
MDM
Medical decision making
CC
Chief complaint
OP
Outpatient
Inpatient
A patient who is admitted to the hospital overnight
Palpation
when a physician presses on an area
Ausculation
Listening with a stethoscope
Baseline
normal state of being
Chronic
Problem lasting longer than 3 months
Acute
New problem within last three months
Benign
Normal, or not of concern
Objective
Information from the physician
Subjective
Info from the Pt.
Osteoporosis
Weakening of the bones
RA
Rheumatoid Arthritis
OA
osteoarthritis
DDD
degenerative disc disease
peripheral neuropathy
numbness in legs
PVD
peripheral vascular disease
Aortic aneurysm
bulge in the aorta
DVT
Deep vein thrombosis
TIA
Transient Ischemic Attack (ministroke)
CVA
Cardiovascular accident (stroke)
Hemorrhagic CVA
stroke caused by brain bleed
GPA
used in OBGYN: G is total pregnancies, P is pregnancies that reached 23 weeks, and A is abortions or miscarriages
BPH
Benign Prostatic Hypertrophy
CRF
Chronic Renal Failure
ESRD
End stage renal disease
Renal calculi
Kidney stones
pyelonephritis
kidney infection
UTI
urinary tract infection
UC
ulcerative colitis
IBS
irritable bowel syndrome
PUD
Peptic ulcer disease
GERD
gastroesophageal reflux disease
PNA
Pneumonia
COPD
chronic obstructive pulmonary disorder
FHx
Family history
Tachycardia
Episodes of fast heartbeat
SVT
supraventricular tachycardia
CHF
Congestive Heart Failure
MI
myocardial infarction
CABG
Coronary Artery bypass graft
Cardiac Catheterization
Heart cath to Dx CAD
PE Tubes
Pressure equalizing tubes
Adenoidectomy
Adenoid removal
Tonsillectomy
Tonsil removal
Spinal fusion
back fused
Cervical spinal fusion
Neck fused
Hardware
refers to placement of metal plates/pins
Athroplasty
Joint repair
AKA
Above knee amputation
BKA
below knee amputation
IVC
inferior vena cava
PICC
peripherally inserted central catheter
AV
arterioivenous
craniotomy
brain surgery
Cerebral Shunt
a shunt to allow passage of fluid in brain
Carotid endarterectomy
Cleaning of the neck artery
Dilation and Curretage (D and C)
Removal of uterine product
Prostatectomy
Prostate removal
Tubal ligation
tubes tied femal