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Scribe America > Scribe U Study > Flashcards

Scribe U Study Flashcards

1
Q

CC

A

Main Reason for visit

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2
Q

EMR/EHR

A

Electronic medical/ health record

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3
Q

Subjective

A

Feeling- PT says

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4
Q

Objective

A

Factual finding, observed, Dx test, and what provider says- or observes

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5
Q

New Patient

A

Over 3 yrs since seen, or brand new - takes longer, detailed charting needed

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6
Q

Established Patient

A

Last note was less than 3yrs, shorter visit, Update chart

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7
Q

Types of visits

A

Diagnostic & Health Management

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8
Q

Diagnostic Visits

A

New Problem, CC: New Sx; Goal is to determine the cause of the problem & appropriate treatment

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9
Q

Health Management Visits

A

Check up, CC: Routine Physical or manage chronic problems; Goal is preventative care and/or assessing progress of ongoing medical problems

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10
Q

Whats in the assessment

A

Current Diagnoses, summary of visits

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11
Q

Whats in the plan

A

Instructions, medications, and when & where to f/u at

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12
Q

High blood pressure

A

High blood pressure (HTN)

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13
Q

High Cholesterol

A

Hyperlipidemia (HLD)

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14
Q

Diabetes Mellitus

A

DM

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15
Q

Heart Disease

A

Coronary Artery Disease (CAD)

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16
Q

Whats CAD

A

Narrowing of the coronary Arteries

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17
Q

Heart Failure

A

(CHF) Congestive Heart Failure

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18
Q

Irregular Heart beat

A

Arrhythmia

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19
Q

Emphysema

A

Chronic Bronchitis (COPD)

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20
Q

Blood clot in the lung

A

Pulmonary Embolism (PE)

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21
Q

Pneumonia or Lung Infection

A

PNA

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22
Q

Reflux/heartburn

A

Gastroesophageal (GERD)

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23
Q

Gastric ulcer

A

PUD

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24
Q

Kidney Infection

A

Pyelonephritis

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25
Q

“I’m on dialysis”

A

Chronic kidney Disease (CKD) on dialysis

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26
Q

Enlarged Prostate

A

Benign Prostatic Hypertrophy (BPH)

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27
Q

Stroke

A

Cerebrovascular Accident (CVA)

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28
Q

“Blood clot in the brain”

A

Ischemic Stroke ~lack of blood supply~

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29
Q

Brain bleed

A

Hemorrhagic Stroke ~blood vessel Rupture~

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30
Q

“mini stroke”

A

Transient Ischemic (TIA) ~sx last hour or less~

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31
Q

“Blood clot in the leg”

A

(DVT) Deep vein thrombosis

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32
Q

“bulge in the aorta”

A

Aortic Aneurysm

33
Q

“bad blood flow in the legs”

A

Peripheral Vascular Disease (PVD)

34
Q

“speed to my…”

A

With Metastases to the …

35
Q

“they cut it out”

A

Status post surgical Resection

36
Q

“its gone”

A

In remission

37
Q

Rash, itching, swelling or difficulty breathing

A

True Reaction

38
Q

no rash, itching, swelling or difficulty breathing

A

Adverse reaction

39
Q

Tonsils Removed

A

Tonsillectomy

40
Q

Adenoids Removal

A

Adenoidectomy

41
Q

“Neck arteries cleared”

A

Carotid Endarterectomy

42
Q

Joint Repair

A

Arthoplasty

43
Q

“Balloon in heart”

A

Angioplasty (PMHx CAD)

44
Q

“stents in heart”

A

Coronary Stents (PMHx CAD)

45
Q

Heart Bypass/ “open heart surgery”

A

Coronary Artery Bypass Graft (CABG)

46
Q

Breast Removal

A

Mastectomy

47
Q

“part of my lung was removed”

A

Partial Lobectomy

48
Q

Appendix Removed

A

Appendectomy

49
Q

Gallbladder removed

A

Cholecystectomy

50
Q

Part of the colon remove

A

Partial Colectomy

51
Q

Spleen Removed

A

Splenectomy

52
Q

Kidney Removed

A

Nephrectomy

53
Q

Uterus Removed

A

Hysterectomy

54
Q

Ovary Removed

A

oophorectomy

55
Q

Ovary & fallopian tube removal

A

Salpingo-oophorectomy

56
Q

Comorbidities

A

Two chronic diseases; increases the complexity of pt care )complex pt)

57
Q

HTN

A

An increase of blood pressure causes excess force against the arterial walls. usually starts with headache, but usually no sx

58
Q

Systolic

A

The pressure in the arteries when heart contracts

59
Q

Diastolic

A

The pressure in arteries when relaxed

60
Q

Hypo during HTN (states numerical)

A

less than 90 :sys
Less than 60: Dia

61
Q

Normal BP Readings

A

90/60 to 120/80

62
Q

Pre-hypertension

A

121/81 to 140/90

63
Q

HTN

A

140/90 or over

64
Q

What does HTN lead to?

A

Impaired vision, CVA, CAD, and Kidney Failure

65
Q

Non- medication control for HTN

A

Low sodium diet, Exercise 30min 3x per week, no smoking & EtOH, Keep Log at home

66
Q

Medications of HTN

A

ACE Inhibitors, Ca Channel Blockers, Diuretics, and ARBs

67
Q

Diabetes type 1

A

Insulin Insufficiency. pancreases is unable to produce insulin. ALWAYS treated with insulin

68
Q

Diabetes type 2

A

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.

69
Q

Sx of DM 2

A

unusual weight gain, or loss, polyuria, polydipsia, blurred vision, N/V

70
Q

What can DM lead to, related to other chronic illnesses?

A

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)

71
Q

Non medical management of DM

A

Low carb diet, exercise, weight loss and blood glucose log

72
Q

Medication of DM

A

Injected: Humalog, Lantus, and sliding scale
Oral: Metformin, and glyburide

73
Q

What is humalog?

A

Rapid acting, known as “meal time insulin”

74
Q

What is Lantus?

A

Long acting insulin, injected once daily

75
Q

What is the sliding scale regarding medication?

A

Insulin dosage based on current glucose

76
Q

What is metformin?

A

Long acting (insulin medication), taken w/meals

77
Q

What is Glyburide?

A

Induces pancreas to produce insulin; taken with meals

78
Q

HLD

A

An elevated level of lipid in the blood causes plaque build up along arterial walls

79
Q

Risk factors of HLD

A

FHx of HLD, obesity, high lipid diet (saturated fats), etoh, physical inactivity

Scribe America (4 decks)

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