scribe america final Flashcards
1
Q
Scribes cannot
A
touch patients
write prescriptions
give orders
handle bodily fluids
1
Q
components of HPI
A
CC,
2
Q
Diagnostic
A
new sympotms
3
Q
health management
A
check up
4
Q
new paitent
A
no previous records
5
Q
established
A
previous records
6
Q
Clinic Flow
A
CC, History, Orders, Assessment, Check out
7
Q
Sa02
A
Oxygen saturation
8
Q
ROS
A
Review of systems
9
Q
PE
A
Physical Exam
10
Q
DDx
A
Diagnostic
11
Q
SOAP
A
Subjective Complaints, Objective Evaluation, Assessment, Plan
12
Q
S
A
HPI and ROS
13
Q
O
A
PE and orders
14
Q
PMHx
A
Past medical history
15
Q
HTN
A
Hypertension and High blood pressure
16
Q
HLD
A
Hyperlipidemia and High cholesterol
17
Q
DM
A
Diabetes Mellitus
18
Q
NIDDM
A
Non insulin dependent diabetes mellitus
19
Q
IDDM
A
Insulin Dependent diabetes mellitus
20
Q
CAD
A
Coronary artery disease and Heart disease
21
Q
MI
A
Myocardial Infarction or heart attack
22
Q
CHF
A
Congestive Heart Failure or Heart failure
23
Q
PE
A
Pulmonary Embolism or blood clot in lung
24
PNA
Pneumonia or lung infection
25
GERD
gastroesophageal reflux disease or Reflux
26
PUD
Peptic ulcer disease or Ulcers
27
IBS
Irritable bowel syndrome or Irritable bowel
28
UTI
Urinary tract infection or Bladder infection
29
Pyelonephritis
Kidney infection
30
CKD
Chronic kidney disease or on dialysis
31
BPH
Benign Prostatic Hyperplasia
32
CVA
Cerebrovascular accident or stroke
33
Ischemic CVA
Blood clot in brain
34
Hemorrhagic CVA
Brain bleed
35
TIA
Transient Ischemic attack or mini stroke
36
DVT
Deep vein thrombosis or blood clot in leg
37
PVD
Peripheral vascular disease
38
CA
Caner or carcinoma
39
True allergy
rash itching swelling or difficulty breathing
40
ectomy
removal
41
AKA
above knee amputation
42
BKA
below knee amputation
43
Angioplasty
Balloon in my heart
44
Coronary stents
Stents in heart
45
FHx
Family history
46
SHx
Social history
47
increased risk in cardiac disease (age)
55
48
Chronic disease
more than 3 months
49
more than one chronic diseases
comorbidities
50
Comorbidities are said to be
complex
51
HTN
obesity high sodium diet smoking and ETOH
52
Systolic
pressure in arteries when heart contracts
53
Diastolic
pressure in arteries when heart relaxes
54
Hypotensive
sys less than 90
Dia less than 60
55
Normal BP
Sys 90-120
Dia 60-80
56
Prehypertensive
Sys 121-140
Dia 81-90
57
Hypertensive
Sys more than 140
Dia more than 90
58
Hypertension can lead to
CVA, CHF, CAD, MI, Renal failure, impaired vision
59
HTN drugs
Lisinopril, Lotensin (ACE inhibitors) Norvasc CA channel blockers, DIurectics, ARBs
60
Type 1 DM
treated with insulin, diagnosed early in life
61
Type 2 DM
common, high glucose levels, oral meds
62
DM can lead to what else
Retinopathy, CAD, CHF, PVD, Renal failure, Neuropathy
63
DM injector drugs
Humalog, Lantus, Sliding scale
64
DM oral drugs
Metformin, Glyburide
65
HLD
Obesity, high fat diet, ETOH, physical inactivity
66
LDL
bad fats
67
HDL
Good fats
68
HLD can lead to what
CVA, CAD, pancreas
69
CAD
risk factors are HLD, DM, HTN
70
Management of CAD
cardiac catheterization, angiopasty, coronary stent, CABG
71
HPI elements
Onset, timing, location, quality, severity, modifying factors, Associated sx, context
72
Palpation
feeling
73
inspection
looking
74
auscultation
listening
75
RUQ
Right upper quadrant
76
Belongs in PE
Saw, Heard, Felt, Smelled
77
RLE
Right lower extremities
78
Anterior
Front
79
Posterior
back
80
Proximal
near point of attachment
81
Distal
far point of attachment
82
Medial
near midline
83
Lateral
far from midline
84
superior
above
85
inferior
below
86
diffuse
widespread
87
focal
one area
88
Bradycardic
low pulse
89
Tachycardic
high pulse
90
Hypotensive
low BP
91
Hypertensive
high BP
92
bradypneic
low RR
93
RR
Respiratory rate
94
Tachypneic
high RR
95
Febrile
High temp
96
Constitutional
general appearance of patient without touching
97
Nose no discharge
yellow or clear discharge
98
Normal nasal mucosa
Boggy turbinates
99
No active bleeding
site bleeding identified
100
appendicitis
positive McBurneys point RLQ
101
cholecysititis
positive Murphy's sign RUQ
102
what is the assessment
diagnoses and summary of visit
103
assessment must include
age and sex, DDx
104
two requirements for result to be included in assessment
new or relevant (history)
105
summarizing a test
name of test
result of test
why it was ordered
106
ICD code
the codes for billing that link with the diagnosis
107
Open heart surgery
CABG
108
A and P
Assessment and plan
109
If there is no definitive diagnosis
the assessment will typically include a list of differential diagnoses
110
Pale Conjunctiva
Anemia
111
Scleral Icterus
Liver failure
112
