Scribe U Study Flashcards
CC
Main Reason for visit
EMR/EHR
Electronic medical/ health record
Subjective
Feeling- PT says
Objective
Factual finding, observed, Dx test, and what provider says- or observes
New Patient
Over 3 yrs since seen, or brand new - takes longer, detailed charting needed
Established Patient
Last note was less than 3yrs, shorter visit, Update chart
Types of visits
Diagnostic & Health Management
Diagnostic Visits
New Problem, CC: New Sx; Goal is to determine the cause of the problem & appropriate treatment
Health Management Visits
Check up, CC: Routine Physical or manage chronic problems; Goal is preventative care and/or assessing progress of ongoing medical problems
Whats in the assessment
Current Diagnoses, summary of visits
Whats in the plan
Instructions, medications, and when & where to f/u at
High blood pressure
High blood pressure (HTN)
High Cholesterol
Hyperlipidemia (HLD)
Diabetes Mellitus
DM
Heart Disease
Coronary Artery Disease (CAD)
Whats CAD
Narrowing of the coronary Arteries
Heart Failure
(CHF) Congestive Heart Failure
Irregular Heart beat
Arrhythmia
Emphysema
Chronic Bronchitis (COPD)
Blood clot in the lung
Pulmonary Embolism (PE)
Pneumonia or Lung Infection
PNA
Reflux/heartburn
Gastroesophageal (GERD)
Gastric ulcer
PUD
Kidney Infection
Pyelonephritis
“I’m on dialysis”
Chronic kidney Disease (CKD) on dialysis
Enlarged Prostate
Benign Prostatic Hypertrophy (BPH)
Stroke
Cerebrovascular Accident (CVA)
“Blood clot in the brain”
Ischemic Stroke ~lack of blood supply~
Brain bleed
Hemorrhagic Stroke ~blood vessel Rupture~
“mini stroke”
Transient Ischemic (TIA) ~sx last hour or less~
“Blood clot in the leg”
(DVT) Deep vein thrombosis
“bulge in the aorta”
Aortic Aneurysm
“bad blood flow in the legs”
Peripheral Vascular Disease (PVD)
“speed to my…”
With Metastases to the …
“they cut it out”
Status post surgical Resection
“its gone”
In remission
Rash, itching, swelling or difficulty breathing
True Reaction
no rash, itching, swelling or difficulty breathing
Adverse reaction
Tonsils Removed
Tonsillectomy
Adenoids Removal
Adenoidectomy
“Neck arteries cleared”
Carotid Endarterectomy
Joint Repair
Arthoplasty
“Balloon in heart”
Angioplasty (PMHx CAD)
“stents in heart”
Coronary Stents (PMHx CAD)
Heart Bypass/ “open heart surgery”
Coronary Artery Bypass Graft (CABG)
Breast Removal
Mastectomy
“part of my lung was removed”
Partial Lobectomy
Appendix Removed
Appendectomy
Gallbladder removed
Cholecystectomy
Part of the colon remove
Partial Colectomy
Spleen Removed
Splenectomy
Kidney Removed
Nephrectomy
Uterus Removed
Hysterectomy
Ovary Removed
oophorectomy
Ovary & fallopian tube removal
Salpingo-oophorectomy
Comorbidities
Two chronic diseases; increases the complexity of pt care )complex pt)
HTN
An increase of blood pressure causes excess force against the arterial walls. usually starts with headache, but usually no sx
Systolic
The pressure in the arteries when heart contracts
Diastolic
The pressure in arteries when relaxed
Hypo during HTN (states numerical)
less than 90 :sys
Less than 60: Dia
Normal BP Readings
90/60 to 120/80
Pre-hypertension
121/81 to 140/90
HTN
140/90 or over
What does HTN lead to?
Impaired vision, CVA, CAD, and Kidney Failure
Non- medication control for HTN
Low sodium diet, Exercise 30min 3x per week, no smoking & EtOH, Keep Log at home
Medications of HTN
ACE Inhibitors, Ca Channel Blockers, Diuretics, and ARBs
Diabetes type 1
Insulin Insufficiency. pancreases is unable to produce insulin. ALWAYS treated with insulin
Diabetes type 2
Insulin Resistance. Consistently high blood glucose levels cause cells to become resistant to insulin. can be treated with diet changes, non-insulin meds or insulin. SHx factors include diet & exercise.
Sx of DM 2
unusual weight gain, or loss, polyuria, polydipsia, blurred vision, N/V
What can DM lead to, related to other chronic illnesses?
Diabetic Retinopathy (hemorrhage of small vessels), CAD, Renal/ Kidney failure, Peripheral artery disease (PVD) ~decreased blood flow to extremities), neuropathy (high blood glucose causing distal paresthesia & extreme pain)
Non medical management of DM
Low carb diet, exercise, weight loss and blood glucose log
Medication of DM
Injected: Humalog, Lantus, and sliding scale
Oral: Metformin, and glyburide
What is humalog?
Rapid acting, known as “meal time insulin”
What is Lantus?
Long acting insulin, injected once daily
What is the sliding scale regarding medication?
Insulin dosage based on current glucose
What is metformin?
Long acting (insulin medication), taken w/meals
What is Glyburide?
Induces pancreas to produce insulin; taken with meals
HLD
An elevated level of lipid in the blood causes plaque build up along arterial walls
Risk factors of HLD
FHx of HLD, obesity, high lipid diet (saturated fats), etoh, physical inactivity