Urology Terms Flashcards

1
Q

anuria

A

no urine

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2
Q

azotemia

A

nitrogenous waste in the bloodstream

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3
Q

bacteriuria

A

bacteria in the urine

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4
Q

calculus

A

stone formed within an organ from mineral salts

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5
Q

catheter

A

flexible tube inserted into the body, commonly through urethra into bladder

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6
Q

cystalgia

A

bladder pain

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7
Q

cystectomy

A

excision of bladder

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8
Q

cystogram

A

record of bladder

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9
Q

cystic

A

pertaining to the bladder

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10
Q

cystitis

A

bladder inflammation

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11
Q

cystolith

A

bladder stone

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12
Q

cystostomy

A

new opening in the bladder

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13
Q

cystorrhagia

A

rapid bleeding from the bladder

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14
Q

cystoplasty

A

surgical repairing of the bladder

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15
Q

cystoscope

A

instrument to examine the inside of the bladder

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16
Q

diuresis

A

increased formation and secretion of urine

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17
Q

dysuria

A

difficult or painful urination

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18
Q

enuresis

A

involuntary discharge of urine, also called bed-wetting at night

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19
Q

frequency

A

greater urge to urinate, no increase in total volume of urine

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20
Q

glycosuria

A

glucose in the urine

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21
Q

hematuria

A

blood in the urine

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22
Q

hesitancy

A

decreased in force of urine stream, often with difficulty initiating the flow

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23
Q

ketonuria

A

ketones in the urine

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24
Q

lithotripsy

A

surgical crushing of stone

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25
lithotomy
incision to remove stone
26
micturition
another term for urination
27
nephrectomy
removal of the kidney
28
nephrogram
record of kidney
29
nephritis
inflammation of the kidney
30
nephrolith
kidney stone
31
nephrologist
kidney specialist
32
nephromalacia
kidney softening
33
nephromegaly
enlarged kidney
34
nephroma
kidney tumor
35
nephrosis
abnormal condition of the kidney
36
nephroptosis
drooping kidney
37
nephrostomy
new opening in the kidney
38
nephrotomy
incision into kidney
39
nephropathy
kidney disease
40
nephropexy
surgical fixation of kidney
41
nephrolithiasis
condition of kidney stone
42
nephrosclerosis
kidney hardening
43
nephrology
diagnosis and treatment of diseases pertaining to the kidney
44
nocturia
nighttime urination
45
nyelogram
record of renal pelvis
46
oiguria
scanty urination
47
polyuria
frequent urination
48
proteinuria
protein in the urine
49
pyelitis
pus in the urine
50
renal
pertaining to the kidneys
51
renal colic
pain caused by a kidney stone
52
stricture
narrowing of a passageway in the urinary system
53
uremia
blood in the urine
54
ureteral
pertaining to the ureter
55
ureterectasis
ureter dilation
56
ureterolith
ureter stone
57
ureterstenosis
narrowing of the ureter
58
urethral
pertaining to the urethra
59
urethralgia
urethra pain
60
urethrorrhagia
rapid bleeding from the urethra
61
urethroscope
instrument to view inside of urethra
62
urethrastenosis
narrowing of the urethra
63
urinometer
instrument to measure urine
64
urinary
pertaining to urine
65
urinary incontinence
involuntary release of urine
66
urinary retention
inability to empty a full bladder
67
urgency
feeling the need to urinate immediately
68
urologist
urine specialist
69
urology
diagnosis and treatment of diseases and conditions of the urinary system
70
voiding
another term for urination
71
Azot
nitrogenous waste
72
Bacteri
bacteria
73
Cyst
bladder
74
Glomerul
glomerulus
75
glycos
sugar, glucose
76
keton
ketones
77
lith
stone
78
meat
meatus
79
nephr
kidney
80
pyel
renal, pelvis
81
ur
urine
82
vesic
bladder
83
lithiasis
condition of stone
84
ptosis
drooping
85
tripsy
crushing of stone
86
uria
condition of urine
87
TURP
transurethral resection of the prostate
88
Two medications for ED
Cialis, Levitra, Stendra, Viagra (Sildenafil)
89
Method of treatment for ED
PDE5 inhibitor
90
Side effects for ED Medications
headache, flushing pain, back pain, muscle pain, nauseau
91
Two medications for cystitis (and other infections)
Cipro, Levaquin
92
Method of treatment for cystitis and other infections
antibiotic
93
Side effects for antibiotic medications
headache, yeast infection, nausea, diarrhea
94
Two medications for OAB
Detrol, Ditropan, Myrbetriq, Sanctura, Toviaz, Vesicare,
95
Side effects for OAB medications
dry mouth, constipation, blurred vision, diarrhea, hypertension, headache
96
Method of treatment for OAB medication
anticholinergic
97
Two medications for prostate cancer
Elmiron, Eulexin, Lupron Proscar
98
Side effects for medications of prostate cancer
nausea, diarrhea, headache, abdominal pain
99
Two medications for BPH
Flomax, Jalyn, Uroxatral, Dustasteride, Doxazosin, Sildosin, Tamsulosin,
100
Side effects for BPH medication
Mild dizziness, weakness, dowsiness, headache, nausea, diarrhea, ED, decreased libido
101
Method of treatment for BPH medication
alpha blocker
102
Method of treatment for prostate cancer medication
5-alpha reductase inhibitor
103
Medications for treatment of UTI/ suppression
Bactrim, Bactrim DS, Trimethoprim, Macrodantin, Rocephin
104
method of treatment for UTI suppression medications
synthetic antifolate
105
side effects for UTI suppression medications
renal disease, GI issues,
106
Medications for resp. infections and other infections
Keflex, Ceftin, Doxycycline,
107
What can be used to block nerves in bladder to cause it to relax and ease OAB
botox
108
What can be used for testosterone replacement therapies
androderm, estrace, permarin, testim
109
side effects of testosterone replacement therapies
dizziness, headaches, nausea
110
What is abdomen
stomach
111
flank
costovertebral angle
112
ureter
carries urine from kidneys to bladder
113
urethra
a tube that connects bladder to urinary meatus
114
fistula
abnormal opening or surgically made connection between two hollow spaces
115
prolapse
organs fall out of normal location
116
libido
sexual activity desire
117
urinary system order
kidney to ureter to bladder to urethra
118
another name for urinary system
renal system
119
what are the functions of urinary system
``` produces, stores, and eliminates waste products maintaines homeostasis (pH, electrolyte fluid) ```
120
what is urinary system composed of
kidneys, ureter, bladder, urethra
121
function of kidneys
to filter and remove waste products
122
what is structure of kidneys
cortex, medulla, nephron
123
cortex
outer portion of kidney
124
medulla
inner portion of kidney
125
cortex and medulla are arranged how
in triangular shape
126
what is the microscopic functional unit of kidney
nephron
127
nephron consists of two things
renal corpuscle and renal tubules
128
ureter function
carry urine from kidney to bladder
129
what is the bladder composed of
elastic muscle sac
130
function of bladder
stores urine for voiding
131
where is bladder located
base of pelvis
132
function of urethra
carries urine outside of body
133
what is the external opening of urethra called
urethral meatus
134
names for releasing urine from body
voiding micturition urination
135
urine normal color is
staw like
136
how much of urine is water
95%
137
3 stages of the renal tubules
filtration reabsorption secretion
138
what is normal urine output in 24 hours
1000-2000mL
139
what does 3 things urine contains
nitrogenous waste toxins excess water and electrolytes
140
What is redundant prepuce
a condition where the penile foreskin is so long it covers the glands in the absence of an erection
141
what is phimosis
occurs when tight foreskin prevents itself from retraction over the glans
142
what is hidden penis/micropenis
a congenital condition that can lead to the obstruction o the urinary system
143
Hidden penis can also be "caused" by
fat growth
144
What is hypospadias
a birth defect in the male where the urethral meatus is abnormally located, Instead of opening at glans, it opens on underside any where
145
what is an inguinal hernia
a condition where a soft tissue or part of the intestine protrudes through a weak point in the abdominal muscles
146
What is scrotal varices
an abnormally dilated vessel with a tortuous course
147
What is testicular torsion
an acute vascular event in which the spermatic cord becomes twisted on its axis, such that the blood flow to the testes becomes impeded. This results in ischema.
148
What is a spermatoceole
epididymal cyst, a painless fluid filled cyst in the long, tightly coiled tube that lies above and behind each testicle
149
Benign Prostatic Hyperplasia (BPH)
also known as lower urinary tract symptoms, caused by the non cancerous enlargement of the prostate gland in aging men. PSA checks are not indicated in men over 90
150
What is erectile dysfunction
Inability to get or maintain an erection firm enough for sexual intercourse. Most common cause is prostate cancer.
151
What is low testosterone also called
hypogonadism
152
When is low testosterone also seen in
in most men as they approach 60 years of age
153
What is male infertility
a condition possible caused by low sperm production
154
What is premature ejaculation
man ejaculates sooner than expected in sexual intercourse
155
What is peyronie's disease
an inflammatory process of the penis caused by scar tissue, called plaques that form in the penis. Causes penile curvature.
156
What is penile cancer
malignant growth found on the skin of the penis or the tissue of the penis
157
what is prostate cancer
cancer of the prostate
158
What is testicular cancer
a type of cancer that occurs in the testicle. Occurs when healthy cells become altered
159
What is Cushing syndrome also known as
hypercortisolism
160
What is cushing syndrome
caused by excess levels of cortisol in the body secondary to use of medications with cortisol-like synthetic compound called glucocorticoid or cortisol-like steroid drugs, or a benign tumor of adrenal cortex produces excess cortisol.
161
What is yeast infections
overgrowth of Candida
162
What is imperforate hyman
hyman without an opening
163
what is congenital vaginal obstructiion
congenital condition where the hymen has not formed properly resulting in covering the vaginal opening instead of surrounding the opening
164
vaginal agenesis
congenital condition. vagina and the muscular canal connecting the cervix of the uterus to the vulva stops developing because the vaginal plate fails to form the channel
165
urogenital sinus is also called
persistant cloaca
166
What is urogenital sinus
it is part of the human body which is only present during the development of the urinary and the reproductive organs. Rare birth defect where the vagina and urethra open into a common channel
167
ectopic kidneys
a kidney located below, above, or opposite of the position it should be
168
what is balanoposthitis
inflammation of the glans in uncircumcised males
169
what is balanitis
inflammation of the glans or foreskin due to lack of aeration
170
what is a sebacceous cyst
small bumps that develop beneath the skin that secrete oily matter
171
what is pseudohermaphroditism
a person has a secondary sex organ
172
what is adrenal medulla tumor
tumor of the adrenal medulla that produces excess adrenaline and causes hypertension
173
What is bladder prolapse
the pelvic floor muscles weaken resulting in the bladder dropping into the vagina
174
horseshoe kidney
kidneys are merged together
175
what is renal failure
loss of kidney function including the inability to remove waste or maintain electrolyte balance
176
what is a renal abscess
a localized collection of pus confined to the kidney due to bacteria in the bloodstream or by a UTI
177
meatal stenosis
narrowing of the opening of the urethra causing urinary blockage
178
what is overactive bladder
a sudden and strong urge to void this typically happens when your bladder muscles contract prior to your bladder being full causing urinary urgency
179
neurogenic bladder
a condition where you see a normal loss of bladder function caused by damage to parts of the nervous system
180
constipation
pain with bowel movements or the absence of bowel movements
181
what is renovascular disease
a disorder affecting the arteries of the kidneys resulting in HTN or renal disease
182
urethral cancer
cancer originating from the urethra
183
urinary tract infection
UTI
184
hydronephrosis
a condition in which one kidney becomes swollen due to the failure of normal drainage of urine from the kidney to the bladder
185
pyelonephritis
a kidney infection that begins in the bladder or urethra and travels up to kidney
186
cystitis
inflammation of the bladder caused by a bacterial infection
187
urethritis
urethra inflammation
188
nocturia/nocturnal enuresis
excessive urination at night
189
urinary incontinence
involuntary leakage of urine
190
PSA labs
measures prostate specific antigen in the blood stream for prostate cancer
191
semen analysis
providers look for sperm and mobility
192
testosterone level check
blood draw that determines testosterone levels, in patients with infertility, low libido or ED
193
urine flow study
determines the rate and force of urination as it measures the length of time it takes a patient to urinate. abnormal study may indicate obstruction due to enlarged prostate or poor bladder tone
194
urinalysis
dipstick that measures sugar, protein, and other substances in the urine. Microscopic detects blood, crystals, bacteria, or yeast
195
urine culture
performed when UTI suspected, culture is incubated for several hours and growth is checked
196
urodynamics
study is completed to assess bladder function by measuring bladder tone and nerve activity during filling bladder with water and emptying ability.
197
24 hour urine study
study can be completed to evaluate for multiple conditions. the patient is to collect urine for 24 hours in large container. the urine is then analyzed
198
BUN
blood draw to evaluate kidney function
199
Creatinine
blood draw to evaluate kidney function
200
GRF
a blood draw to evaluate how well the kidneys are filtering
201
CBC
blood draw to check patient's overall health
202
BMP/CMP
this is a blood draw to check overall metabolic function. in regards to blood sugar, kidney function, liver function, electrolytes, pH, and blood proteins
203
antegrade pyelogram
the imaging test is performed to find obstructions in the upper resp tract
204
CT scan abd/pel
A CT scan make detailed imaging of any part of the body. this study can help evaluate for renal, bladder, urethral tumors or abnormalities
205
cystography
this study (xray) can help diagnose problems in the bladder
206
intravenous pyelogram
this study is used to look at the kidneyss and the uretera
207
kidney scan
this is a specialize radiology program used to assess the function and structure of the kidneys, as well as the perfusion (blood flow) to the kidneys
208
KUB
type of xray done to evaluate abdominal related concerns
209
prostate/ rectal US
this study uses sound waves to look at your prostate and rectum
210
renal venogram
this study looks at the veins in and around your kidney. may help identify patients with renovascular hypertension
211
retrograde pyelogram
this study is used to look at your bladder, ureters, kidneys with an endoscope. This is done while cystoscopy is being done
212
circumcision
surgical removal of skin at tip of penis
213
cryotherapy prostate cancer
cryotherapy involves freezing cancer cells by cutting their blood supply . tiny needles are placed and argon gas is passed through the needle and exchanged with helium to cause freezing and warming cycles
214
cystoscopy
urologists to view the urinary tract, and determine early signs of cancer, disease
215
kidney biopsy
biopsy is done to evaluate tissue under a microscope for abnormalities. the tissue is removed with a needle
216
kidney cancer ablation
ablation is used to freeze or cook cancer cells
217
laparoscopic pelvic prolapse repair
helps restore the pelvic floor without the need for a large incision
218
laparoscopic pyeloplasty
provides patient with safe and easy way to correct blockage or narrowing of the ureter where it leaves the kidney
219
lithotripsy
ultrasound energy or shock waves are sent to the urinary system to break a large stone
220
partial orchiectomy
remove testis cancer, testes sparing
221
prostate bipsy
perineal prostatectomy is a less invasive method of removing the prostate
222
radical orchiectomy
the removal of the testical to treat testis cancer
223
retroperitoneal lymph node dissection
used to remove testis cancer that has spread to the lymph nodes of the retroperitoneal
224
what is robotic prostatectomy
prostate gland is surgically removed by a robot
225
sperm retrieval process
men who have no sperm benefit when they want to get partners pregnant
226
transurethral resection of the prostate
surgery to remove part of the prostate through the penis, no incisions are made
227
varicoceole embolization
diverts blood away from an enlarged vein in the scrotum . this vein is called a varicoceole
228
vasectomy
vas deferens is clamped, cut, and sealed. takes 30 days for sperm to be reabsorbed
229
vasectomy reversal
reconnects the pathway for sperm to get into the semen
230
penile augmentation
permanent fillers are placed to increase the lenght of a penis
231
digital rectal exam
lubricated glove into rectum to check the prostate gland
232
stone evaluation
this is done once a stone has passed or been crushed . the composition is analyzed to determine what formed the stone
233
What is subjective information
what the patient tells you
234
What is objective information
what the doctor tells you
235
Where does subjective data go
in the history through ROS
236
Where does objective data go
in physical exam and plan
237
What are the 7 elements in the HPI
``` chief complaint onset timing location quality severity modifying factors associated symptoms context ```
238
What goes first in the HPI
chief complaint
239
What is the standard template for charting
``` CC HPI ROS PE Dx Plan ```
240
What is Caverject used for
Peyronie's disease
241
What are side effects of Caverject
penile pain, prolonged errections
242
What is Cialis used for
ED
243
What is the mechanism used by Cialis
PDE5 inhibitor
244
What are side effects of Cialis
headache, naseau, flushing, back pain, muscle pain
245
What is Cipro used for
infections
246
What is the mechanism used by Cipro
antibiotic
247
What are side effects of Cipro
headache, yeast infection, vaginitis, diarrhea, naseau
248
What is Detrol used for
OAB
249
What is the mechanism used by Detrol
anticholinergic
250
What are side effects of Detrol
dry mouth
251
What is Ditropan used for
OAB
252
What is the mechanism used by Ditropan
anticholinergic
253
What are side effects of Ditropan
dry mouth, constipation, diarrhea, blurred vision
254
What is Elmiron used for
prostate cancer
255
What is side effects of Elmiron
naseau headache, diarrhea
256
What is Eulexin used for
prostate cancer
257
What are side effects of Eulexin
nasuea, diarrhea, headache, abdominal pain, flu-like symptoms, fatigue
258
What is Flomax used for
BPH
259
What is the mechanism of Flomax
alpha blocker
260
Side effects of Flomax
mild dizziness, weakness, drowsiness, decreased libido, dizziness, naseau, diarrhea
261
What is Jalyn (Dutasteride)
BPH
262
What is the mechanism of Jalyn (Dutasteride)
alpha blocker
263
What are side effects of Jalyn (Dutasteride)
ejaculation disorder, decreased libido, ED, dizziness, breast tenderness
264
What is Levitra used for
ED
265
What is the mechanism of Levitra
PDE5 inhibitor
266
What are the side effects of Levitra
headache, flushing, back main, muscle pain, nausea
267
What is Lupron used for
prostate cancer
268
What are side effects of Lupron
hot flashes, decreased libido, ED
269
What is Myrbetriq used for
OAB
270
What are side effects of Myrbetriq
dry mouth, hypertension, UTI, headache
271
What is the mechanism of Myrbetriq
anticholinergic
272
What is Proscar used for
prostate cancer, BPH
273
What is Proscar mechanism
PDE5 inhibitor
274
What are side effects
decreased libido, hot flashes, ED, edema, weakness, headache
275
What is Sanctura used for
OAB and urge incontinence
276
What are side effects of Sanctura
dry mouth, constipation, dyspepsia, headache
277
What is Stendra used for
ED
278
What is the mechanism for Stendra
PDE5 inhibitor
279
What are side effects of Stendra
headache, flushing, nasal congestion, back pain
280
What is Toviaz used for
OAB
281
What is mechanism of Toviaz
anticholinergic
282
What are side effects of Toviaz
dry mouth, constipation, dry eyes, UTI, abdominal pain
283
What is Uroxatral used for
BPH
284
What is the mechanism for Uroxatral
alpha blocker
285
What are side effects of Uroxatral
headache, fatigue, impotence, pain
286
What is Vesicare used for
OAB and urge incontinence
287
WHat is the mechanism of Vesicare
anticholinergic
288
What are side effects of Vesicare
dry mouth, dry eyes, blurred vision, urinary retention
289
What is Viagra used for
ED
290
What is the mechanism of Viagra
PDE5 inhibitor
291
What are side effects of Viagra
headache, flushing, back pain, nausea
292
What is Dutasteride used for
BPH and low grade prostate cancer
293
What is mechanism of Dutasteride
5 alpha reductase inhibitor
294
What is Doxazosin used for
BPH
295
What is the mechanism of Doxazosin
alpha blocker
296
WHat is Sildosin (Rapaflo) used for
BPH
297
What is the mechanism of Sildosin (Rapaflo)
alpha 1 inhibitor
298
What is Bactrim used for
UTI
299
What is mechanism of Bactrim
antibiotic
300
What is Trimethoprim used for
UTI
301
What is mechanism of Trimethoprim
antibiotic
302
What is Macrodantin used for
UTI
303
What is mechanism of macrodantin
antibiotic
304
What is Keflex used for
UTI, general infections
305
What is mechanism of Keflex
antibiotic
306
What is Ceftin used for
general infections, UTI
307
What is mechanism of Ceftin
antibiotic
308
What is Doxycycline used for
UTI, general infections
309
What is the mechanism of Doxycycline
antibiotic
310
What is Rocephin used for
UTI, general infections
311
What is Rocephin mechanism
antibiotic
312
What is Botox used for
OAB
313
WHat is the mechanism of Botox
neurmuscular blocker
314
What is Androgerm used for
testicular hypofunction
315
What is side effect of Androgerm
breast enlargement
316
What is Premarin or Estrace used for
estrogen replacement
317
What is side effect of Premarin or Estrace
dizziness or headache
318
What is Testim used for
testicular hypofunction
319
What is side effect of Testim
dizziness, nausea
320
Pain vs. tenderness
patient's feeling vs physician's assessment
321
Benign
nothing of concern, normal
322
acute vs. chronic
new onset vs. long standing
323
Baselin
an individual's normal state of being
324
auscultation
lisetening with a stethoscop
325
Palpation
act of pressing on an area
326
impatient
admitted to the hospital overnight
327
outpatient
seen and sent home the same day
328
chief complaint
main reason for the bisit
329
meaninful use
set of government mandated criteria that must be obtained for every patient
330
Medican Decision Making
physicians though process
331
What people are in the clinic
mid level provider, nurse, MA, Receptionist, Scribe
332
What is a new patient
no previous records, or has not been seen in 3 years
333
What is an established patient
previous records available
334
Do new patients have shorter or longer visits
longer
335
Do new patients have concise or more detailed charts
detailed
336
Do established patients have shorter or longer visits
shorter
337
Do established patients have concise or more deailed charts
concise
338
What are the two types of clinic visits
diagnostic and health maintenance
339
What is a diagnostic visit
new problem, new symptom
340
What is the goal of a diagostic visit
to determine the cause of the problem and appropriate treatment
341
What is a health maintenance visit
a check up, management of chief complaint
342
What is the goal of a health maintenance visit
to assess progress of ongoing medical problems
343
What is the clinic flow
Check in, physician evaluation, orders and resuls, assessment and plan, check out
344
What are the meaningful use pieces
CC, HR, BP, T, RR, Height, weight, BMI, Smoking
345
What section does assessment cover
diagnoses
346
What section does H &P (history and physical cover)
chief complaint, HPI, PE
347
What are the 4 sections of the chart
SOAP
348
What does SOAP stand for
subjective objective assessment plan
349
What goes in the subjective section of the chart
HPI and ROS
350
What goes in objective
PE, Orders and results
351
What goes in Assessment
diagnosis
352
What goes in plan
treatment and follow up
353
What are General PMHx
``` high blood pressure high cholesterol thyroid problem diabetes DM ```
354
What are Cardiac PMHx
``` A-Fib CAD MI CHF heart murmur SVT ```
355
What are Pulmonary PMHx
asthma COPD PE pneumonia
356
What are Gastrointestinal PMHx
Diverticulitis, Hepatitis, Pancreatics, Ulcer, GERD, Chron's disease, IBS
357
What are Genitourinary PMHx
UTI, pyelonephritis, renal calculi, CRF, BPH
358
What are Gynecologic PMHx
GPA
359
What are neurological PMHx
CVA TIA Seizure disorder Hemorrhagic CVA
360
What are Psychological PMHx
schizophrenia, alcoholism, bipolar disorder, depression
361
What are Vascular PMHx
DVT Aortic Aneurysm Peripheral Vascular Disease
362
WHat are Musculoskeletal PMHx
low back pain Degenerative disk disease osteoarhritis, RA Osteoporosis
363
At what age would a family member's disease indicate an increased risk
less than 50
364
a younger age of onset of disease means what
higher genetic risk
365
Social history includes
alcohol, occupation, drug use, lving circumstances, tobacco use
366
What does comorbidity means
simultaneous presence of two chronic diseases or conditions in a patient
367
What does etiology mean
cause of disease
368
What does systole mean
phase of the heartbeat during which the muscle contracts, pumping blood to body
369
What does diastolic mean
phase of the heartbeat during which muscle is relaxed and the heart fills with blood
370
What is diuretic
substance that promotes the production of urine
371
What does parestehsia
sensation of tingling or numbness
372
What is ischemia
loss of blood supply to a tissue
373
What is an anticoagulant
a drug that prevents blood clotting
374
When is an illness classified as chronic
lasts longer than 3 months
375
What are the 5 comorbidity diseases
asthma, CAD, DM, HLD, HTN
376
Patients with comorbitities are what
complex
377
For patients with complexitiy how should 1 chart
symptoms in chronological order status and progress of each illness level of compliance with treatment plan
378
How doe comorbidity increase complexity
compounding symptoms, drug interaction
379
Why is it important to document accurately and thoroughly on complex patients
for billing, they bill to higher level
380
What is History of present illness
the story of patient's chief complaint
381
What is review of sysems
ead to toe checklist of patient's symptoms
382
what is intermittent
comes and goes
383
What is waxing and waning
always present but changing in intensity
384
what is a modifying facotry
something that makes a symptom better or worse
385
what is exacerbate
to make worse
386
What is SOAP method
of organizng clinical information in apatient's chart. Closely follows the workflow of the clinic so that each portion of the note is documented consecultively as information is obtained
387
What is the first section the scribe documents
subjective
388
What does subjective info include
chief complaint, HPI, ROS
389
WHy must you have a chief complaint
billing
390
What two things does the HPI contain
subjective info and chief complaint/ things related to complaint
391
What 8 elements does a complete HPI contain
element, onset, timing, location, quality, severity, modifying facotrs, associated symptoms, context
392
What are the 3 primary methods of structuring HPI
single complaint formula, multiple complaint formula, chronologic
393
THe ROS is what
head to toe checklist of the patient's body systems
394
What is cachectic
emaciated, malnourished
395
What does objective infor include
vital signs, physical exam, orders and results
396
What are the 5 vital signs
``` heart rate blood pressure o2 saturation temperature respiration rate ```
397
What 6 things can be observed by looking
``` general appearance eyes pulmonary/ breathing skin neurological psychiatric ```
398
What is follow up
the establishment or maintenance of consistent contact with healthcare providers in order to address an ongoing health concern
399
What is QD
once daily
400
What is BID
twice daily
401
What is TID
three times daily
402
What is subq
medication injected under the skin
403
prn
as needed
404
prognosis
a forecast of the likely course of a disease or ailment
405
What is included in the assessment
diagnoses and summary of visit
406
the assessment will always include
diagnosis
407
What are the different ways an assessment can be structured
simple brief comprehensive
408
What are the two types of results
labs and imaging
409
What does the plan include
``` recommended treatments for each diagnosis prescriptions ordered studies or tests ordered follow up with other healthcare follow up here ```
410
What is superbill
a bill, submitted to the insurance company that reflects the services provided to the patient
411
What is ICD
international classification of diseases
412
What is WHO
world health organization
413
What is v code
a billing code for prevenatitive care
414
What is CPT
current procedural terminology
415
What is E&M
evaluation and management
416
What is LOS
level of service
417
What is problem focuses
a visit, history, or exam that focuses solely on the CC
418
What is inhouse
a lab or study that can be done in clinic, during an appointment
419
What is a new patient
patient who has had no care by any member of the billing physician's specialyt or practice group within 3 years
420
How many E&M levels
5
421
What is level 1 E&M
minimal
422
What is level 2 E&M
problem focused visit
423
What is level 3 E&M
expanded problem focused
424
What is level 4 E&M
detailed
425
What is level 5 E&M
comprehensive
426
MOst commonly used E&M levels are
3 and 4
427
FOr a new patient, how many HPI elements for level 4
4
428
For a estab. patient how many HPI elements for level 4
2
429
For a new patient how many ROS elements
10
430
For a estab. patient how many ROS elements
2
431
FOr a new patient how many PMHx
3
432
For a estab. patient how many PMHx
1
433
FOr a new patient how many PE
10
434
For a Estab.. patient how many PE
2
435
For a new patient how many assessment/plan
1
436
For a estab. patient how many assessment/plan
2
437
What are the HPI elements
location quality duration timing severity context modifying factors, associated symptoms, pertinent denials
438
What are ROS Elements
``` constitutional eyes ENT cardiovascular respiratory GI GU Musculoskeletal neurological skin and breast psych heme/lymph endocrine immuno/allergy ```
439
What falls under PMHx/FHx/SHx
medical surgical, family, social
440
A new patient needs how many bullets from how many systems in PE
18 bullets from 9 systems
441
An estab. patient needs how many bullets from how many systems
12 bullets from 2 systems
442
What is included in assessment and plan
review of orders and labs review of images and studies obtained old med records reviewed and summarized old medical records
443
What is low risk E&M code
two or more minor problems, one stable chronic illness acute uncomplicated illness
444
What is moderate risk E&M code
one or more chronic illness with mild progression two or more stable chronic diseases undiagnoses new problem with uncertain prognosis acutre illness with systemic symptoms acute complicated injury prescription drug management
445
What is high risk E&M code
one or more chronic illness with severe exacerbation or progression acute or chronic illness or injuries which powe a threat to life
446
What does MU mean
meaningful use
447
What is CMS
centers for medicare
448
What is CPOE
computerized physician order entry
449
What is EHR
electronic health record
450
What is EMR
electronic medical recored
451
What is e-Prescribing
SUbmitting prescriptions electronically to local pharmacies
452
What is HIPAA
health insurance portability and accountability act
453
What is PHI
protected health information
454
What is HITECH
health information technology for economic and clinical health act