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Scribe > The patients History > Flashcards

The patients History Flashcards

1
Q

What is the abveration for Past Medical History?

A

PMHx

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2
Q

What are some prefixes and suffix used for past medical history?

A

Prefix:

  1. Artho - joint
  2. Oseteo - bone
  3. Chole - bile

Suffix:

  1. algia - pain
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3
Q

When a patient says highblood pressure what does the scribe write?

A

Hypertension (HTN)

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4
Q

When a patient says high cholesterol what does a scribe write?

A

Hyperlipidemia (HLD)

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5
Q

When a patient says Diabetes what does a scribe write?

A

Diabetes Mellitus (DM)

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6
Q

When a patient says “I only take pills for my diabetes” what does a scribe write?

A

Non-insulin dependent diabetes mellitus (NIDDM)

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7
Q

When a patient says “I take shots (insulin) for my diabetes” what does a scribe writes?

A

Insulin dependent diabetes mellitus (IDDM) (Can be both type 1 & type 2 diabetes)

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8
Q

When a patient says cancer a scribe writes what?

A

Cancer or carcinoma (CA)

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9
Q

If a patient had a heart attack means they also had what?

A

Had a heart disease to be able to have heart a attack

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10
Q

When a patient say heart disease scribe writes what?

A

Coronary Artery disease (CAD)

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11
Q

When a patient says heart failure a scribe writes what?

A

Congestive heart failure (CHF)

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12
Q

When a patient says heart attack a scribe writes what?

A

Myocardial infarction (MI)

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13
Q

When a patient says abnormal rhytm a scribe writes what?

A

Arrhythmias

(Ex . Atrial fibrillation)

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14
Q

When a patient says Asthma a scribe writes what?

A

Asthma

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15
Q

When a patient says emphsema or chrontic bronchitis a scribe writes what?

A

Chronic obstructive pulmonary disease (COPD)

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16
Q

When a patient says blood clot in lung a scribe writes what?

A

Pulmonary embolisim (PE)

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17
Q

When a patient says Pneumunia a scribe writes what?

A

Pneumonia (PNA)

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18
Q

When a patient says Reflux a scribe writes what?

A

Gastroesophageal Reflux disease (GERD)

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19
Q

When a patient says pancreatitis a scribe writes what?

A

Pancreatitis

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20
Q

When a patient says hepatitis a scribe writes what?

A

Hepatitis

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21
Q

When a patient says diverticulitis a scribe writes what?

A

Diverticulitis

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22
Q

When a patient says Crohn’s/ UC a scribe writes what?

A

Crohn’s disease or Ulcerative Colitis

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23
Q

When a patient says Irritable bowel a scribe writes what?

A

Irritable bowel syndrome (IBs)

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24
Q

The prefix Hepta refers to what?

A

Liver

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25
Q

Whne a patient says Bladder infection a scribe writes what?

A

Urinary trac infection (UTI)

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26
Q

When a patient says kidney infection a scribe writes what?

A

Pyelonephritis (Pyclo)

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27
Q

When a patient says kidney stones a scribe writes what?

A

Renal Calculi

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28
Q

When a patient says “Im on dialysis” a scribe writes what?

A

Chronic kidney disease (CKD) ( End stage of renal disease (ESRD) on dialysis

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29
Q

When a patient says enlarged prostate a scribe writes what?

A

Benign prostatic hypertrophy (BPH)

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30
Q

What is the convention used for documenting past pregnacies?

A

G:(Gravida is the total number of times a patient got pregnant)

P:(Para is the number of pregnanices that resulted in a living baby) (Only the number of births not the number of kids)

A:(Abortus is the number of miscarrages or elective abortions)

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31
Q

When a patient says stroke a scribe writes what?

A

Cerebrovascular accident (CVA)

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32
Q

When a patient say brain bleed a scribe writes what?

A

Hemorrhagic cerebrovascular accident (HCVA)

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33
Q

When a patient says brain blockage or clot a scribe writes what?

A

Ischemic cerebrovascular accident (ICVA)

34
Q

When a patient says mini stroke a scribe writes what?

A

Transient ischemic attack (TIA)

35
Q

When a patient says “blood clot in my legs” a scribe writes what?

A

Lower extremity deep vein thrombosic (DVT)

36
Q

When a patient says “Buldge in my aorta” a scribe writes what?

A

Aortic aneurysm (common name is abdominal aortic aneurysm) (AAA)

37
Q

When a patient says “Bad blood flow in my legs” a scribe writes what?

A

Peripheral vascular disease (PVD)

38
Q

When a patient says “numbness in my legs” a scribe writes what?

A

Peripheral neuropathy

39
Q

When a patient says low back pain a scribe writes what?

A

Chronic low back pain

40
Q

When a patient says Arthritis a scribe writes what?

A

Usually osteocarthritis (OA) or rheumatiod orthritis (RA)

41
Q

When patient says weak or fragile bones a scirbe writes what?

A

Osteoporosis

42
Q

What suffixes are used in past surgical history (PSHx)

A
  1. ectomy - removal
  2. ostomy - creating opening / hole
  3. otomy - incision cutting into
  4. rraphy or plasty - surgical repair
43
Q

When a patient says tonsils removes a scribe writes what?

A

Tonsillectomy

44
Q

When a patient say Adenoids removed a scribes writes what?

A

Adeniodectomy

45
Q

When a patient says ear tubes a scirbe writes what?

A

Pressure equalizing (P.E.) tubes

46
Q

When a patient says heart cath a scribe writes what?

A

Cardiac catheterization (diagnose CAD)

47
Q

When a patient says balloon a scribe writes what?

A

Angroplasty (PMHx CAD)

48
Q

When a patient says stents a scribe writes what?

A

Coronary stents (PMHx CAD)

49
Q

When a patient says heart bypass a scribe wrties what?

A

Coronary artery bypass graft (CABG) (PMHx CAD)

50
Q

What does the prfix angio mean?

A

Means vesicle

51
Q

When a patient say breast removal a scribe writes what?

A

Mastectomy

52
Q

Hole in my neck

A

Tracheostomy (Trach)

53
Q

What does the prefix mast refer to?

A

Breast

54
Q

Appendix removal

A

Appendectomy

55
Q

Gallbladder removal

A

Cholecystectomy

56
Q

Hernia repair

A

Heniorrhaphy

57
Q

Part of my colon removed

A

Partial colectomy

58
Q

Bag to collect stool

A

Colostomy

59
Q

Spleen removed

A

Splenectomy

60
Q

Stomach stapled

A

Bariatria surgey

61
Q

Kidney removed

A

Nephrectomy

62
Q

Uterus removed

A

Hysterectomy

63
Q

Ovary removed

A

Oophorectomy

64
Q

Ovary & pallopain tubes removed

A

salpingo - oophorectomy

65
Q

Tubes tied

A

Tubal ligation (female) or vasectomy (male)

66
Q

C-section

A

Cesarean section

67
Q

Prostate removed

A

Prostatectomy (transurethral restruction of the prostate or TURP)

68
Q

uterine product removed

A

Dilation and curettage(D&C)

69
Q

Neck artery cleaned

A

Carotid endarterectomy

70
Q

Shunt

A

Cerebral shunt

71
Q

Brain surgery

A

Craniotomy

72
Q

Dialysis fistula

A

AU (Arteriovenous ) fistula

73
Q

Dialysis graft

A

AV graft

74
Q

PICC line

A

Peripherally inserted rental catheter (PICC)

75
Q

Port

A

Part - a - cath pr medi - port

76
Q

clot filter (lower abdomen)

A

IVC ( Inferior wena cava) filter

77
Q

Leg amputated

A

Above knee amputation (AKA) or below knee amputation (BKA)

78
Q

Joint repair

A

Arthroplasty

79
Q

Metal plates/ pins

A

Hardware

80
Q

Sign of adverse reaction

A
  1. Nausea/ vomitting
  2. Abdominal pain
  3. Diarrhea
  4. Dizziness

Scribe (4 decks)

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