The patients History

Question 1

What is the abveration for Past Medical History?

Answer 1

PMHx

Question 2

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

Answer 2

Prefix:

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

Suffix:

1. algia - pain

Question 3

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

Answer 3

Hypertension (HTN)

Question 4

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

Answer 4

Hyperlipidemia (HLD)

Question 5

When a patient says Diabetes what does a scribe write?

Answer 5

Diabetes Mellitus (DM)

Question 6

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

Answer 6

Non-insulin dependent diabetes mellitus (NIDDM)

Question 7

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

Answer 7

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

Question 8

When a patient says cancer a scribe writes what?

Answer 8

Cancer or carcinoma (CA)

Question 9

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

Answer 9

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

Question 10

When a patient say heart disease scribe writes what?

Answer 10

Coronary Artery disease (CAD)

Question 11

When a patient says heart failure a scribe writes what?

Answer 11

Congestive heart failure (CHF)

Question 12

When a patient says heart attack a scribe writes what?

Answer 12

Myocardial infarction (MI)

Question 13

When a patient says abnormal rhytm a scribe writes what?

Answer 13

Arrhythmias

(Ex . Atrial fibrillation)

Question 14

When a patient says Asthma a scribe writes what?

Answer 14

Asthma

Question 15

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

Answer 15

Chronic obstructive pulmonary disease (COPD)

Question 16

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

Answer 16

Pulmonary embolisim (PE)

Question 17

When a patient says Pneumunia a scribe writes what?

Answer 17

Pneumonia (PNA)

Question 18

When a patient says Reflux a scribe writes what?

Answer 18

Gastroesophageal Reflux disease (GERD)

Question 19

When a patient says pancreatitis a scribe writes what?

Answer 19

Pancreatitis

Question 20

When a patient says hepatitis a scribe writes what?

Answer 20

Hepatitis

Question 21

When a patient says diverticulitis a scribe writes what?

Answer 21

Diverticulitis

Question 22

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

Answer 22

Crohn’s disease or Ulcerative Colitis

Question 23

When a patient says Irritable bowel a scribe writes what?

Answer 23

Irritable bowel syndrome (IBs)

Question 24

The prefix Hepta refers to what?

Answer 24

Liver

Question 25

Whne a patient says Bladder infection a scribe writes what?

Answer 25

Urinary trac infection (UTI)

Question 26

When a patient says kidney infection a scribe writes what?

Answer 26

Pyelonephritis (Pyclo)

Question 27

When a patient says kidney stones a scribe writes what?

Answer 27

Renal Calculi

Question 28

When a patient says "Im on dialysis" a scribe writes what?

Answer 28

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

Question 29

When a patient says enlarged prostate a scribe writes what?

Answer 29

Benign prostatic hypertrophy (BPH)

Question 30

What is the convention used for documenting past pregnacies?

Answer 30

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)

Question 31

When a patient says stroke a scribe writes what?

Answer 31

Cerebrovascular accident (CVA)

Question 32

When a patient say brain bleed a scribe writes what?

Answer 32

Hemorrhagic cerebrovascular accident (HCVA)

Question 33

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

Answer 33

Ischemic cerebrovascular accident (ICVA)

Question 34

When a patient says mini stroke a scribe writes what?

Answer 34

Transient ischemic attack (TIA)

Question 35

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

Answer 35

Lower extremity deep vein thrombosic (DVT)

Question 36

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

Answer 36

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

Question 37

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

Answer 37

Peripheral vascular disease (PVD)

Question 38

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

Answer 38

Peripheral neuropathy

Question 39

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

Answer 39

Chronic low back pain

Question 40

When a patient says Arthritis a scribe writes what?

Answer 40

Usually osteocarthritis (OA) or rheumatiod orthritis (RA)

Question 41

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

Answer 41

Osteoporosis

Question 42

What suffixes are used in past surgical history (PSHx)

Answer 42

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

Question 43

When a patient says tonsils removes a scribe writes what?

Answer 43

Tonsillectomy

Question 44

When a patient say Adenoids removed a scribes writes what?

Answer 44

Adeniodectomy

Question 45

When a patient says ear tubes a scirbe writes what?

Answer 45

Pressure equalizing (P.E.) tubes

Question 46

When a patient says heart cath a scribe writes what?

Answer 46

Cardiac catheterization (diagnose CAD)

Question 47

When a patient says balloon a scribe writes what?

Answer 47

Angroplasty (PMHx CAD)

Question 48

When a patient says stents a scribe writes what?

Answer 48

Coronary stents (PMHx CAD)

Question 49

When a patient says heart bypass a scribe wrties what?

Answer 49

Coronary artery bypass graft (CABG) (PMHx CAD)

Question 50

What does the prfix angio mean?

Answer 50

Means vesicle

Question 51

When a patient say breast removal a scribe writes what?

Answer 51

Mastectomy

Question 52

Hole in my neck

Answer 52

Tracheostomy (Trach)

Question 53

What does the prefix mast refer to?

Answer 53

Breast

Question 54

Appendix removal

Answer 54

Appendectomy

Question 55

Gallbladder removal

Answer 55

Cholecystectomy

Question 56

Hernia repair

Answer 56

Heniorrhaphy

Question 57

Part of my colon removed

Answer 57

Partial colectomy

Question 58

Bag to collect stool

Answer 58

Colostomy

Question 59

Spleen removed

Answer 59

Splenectomy

Question 60

Stomach stapled

Answer 60

Bariatria surgey

Question 61

Kidney removed

Answer 61

Nephrectomy

Question 62

Uterus removed

Answer 62

Hysterectomy

Question 63

Ovary removed

Answer 63

Oophorectomy

Question 64

Ovary & pallopain tubes removed

Answer 64

salpingo - oophorectomy

Question 65

Tubes tied

Answer 65

Tubal ligation (female) or vasectomy (male)

Question 66

C-section

Answer 66

Cesarean section

Question 67

Prostate removed

Answer 67

Prostatectomy (transurethral restruction of the prostate or TURP)

Question 68

uterine product removed

Answer 68

Dilation and curettage(D&C)

Question 69

Neck artery cleaned

Answer 69

Carotid endarterectomy

Question 70

Shunt

Answer 70

Cerebral shunt

Question 71

Brain surgery

Answer 71

Craniotomy

Question 72

Dialysis fistula

Answer 72

AU (Arteriovenous ) fistula

Question 73

Dialysis graft

Answer 73

AV graft

Question 74

PICC line

Answer 74

Peripherally inserted rental catheter (PICC)

Question 75

Port

Answer 75

Part - a - cath pr medi - port

Question 76

clot filter (lower abdomen)

Answer 76

IVC ( Inferior wena cava) filter

Question 77

Leg amputated

Answer 77

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

Question 78

Joint repair

Answer 78

Arthroplasty

Question 79

Metal plates/ pins

Answer 79

Hardware

Question 80

Sign of adverse reaction

Answer 80

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