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Scribe > Urology Terms > Flashcards

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
Q

lithotomy

A

incision to remove stone

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26
Q

micturition

A

another term for urination

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27
Q

nephrectomy

A

removal of the kidney

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28
Q

nephrogram

A

record of kidney

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29
Q

nephritis

A

inflammation of the kidney

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30
Q

nephrolith

A

kidney stone

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31
Q

nephrologist

A

kidney specialist

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32
Q

nephromalacia

A

kidney softening

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33
Q

nephromegaly

A

enlarged kidney

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34
Q

nephroma

A

kidney tumor

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35
Q

nephrosis

A

abnormal condition of the kidney

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36
Q

nephroptosis

A

drooping kidney

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37
Q

nephrostomy

A

new opening in the kidney

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38
Q

nephrotomy

A

incision into kidney

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39
Q

nephropathy

A

kidney disease

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40
Q

nephropexy

A

surgical fixation of kidney

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41
Q

nephrolithiasis

A

condition of kidney stone

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42
Q

nephrosclerosis

A

kidney hardening

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43
Q

nephrology

A

diagnosis and treatment of diseases pertaining to the kidney

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44
Q

nocturia

A

nighttime urination

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45
Q

nyelogram

A

record of renal pelvis

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46
Q

oiguria

A

scanty urination

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47
Q

polyuria

A

frequent urination

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48
Q

proteinuria

A

protein in the urine

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49
Q

pyelitis

A

pus in the urine

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50
Q

renal

A

pertaining to the kidneys

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51
Q

renal colic

A

pain caused by a kidney stone

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52
Q

stricture

A

narrowing of a passageway in the urinary system

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53
Q

uremia

A

blood in the urine

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54
Q

ureteral

A

pertaining to the ureter

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55
Q

ureterectasis

A

ureter dilation

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56
Q

ureterolith

A

ureter stone

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57
Q

ureterstenosis

A

narrowing of the ureter

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58
Q

urethral

A

pertaining to the urethra

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59
Q

urethralgia

A

urethra pain

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60
Q

urethrorrhagia

A

rapid bleeding from the urethra

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61
Q

urethroscope

A

instrument to view inside of urethra

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62
Q

urethrastenosis

A

narrowing of the urethra

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63
Q

urinometer

A

instrument to measure urine

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64
Q

urinary

A

pertaining to urine

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65
Q

urinary incontinence

A

involuntary release of urine

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66
Q

urinary retention

A

inability to empty a full bladder

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67
Q

urgency

A

feeling the need to urinate immediately

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68
Q

urologist

A

urine specialist

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69
Q

urology

A

diagnosis and treatment of diseases and conditions of the urinary system

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70
Q

voiding

A

another term for urination

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71
Q

Azot

A

nitrogenous waste

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72
Q

Bacteri

A

bacteria

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73
Q

Cyst

A

bladder

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74
Q

Glomerul

A

glomerulus

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75
Q

glycos

A

sugar, glucose

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76
Q

keton

A

ketones

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77
Q

lith

A

stone

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78
Q

meat

A

meatus

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79
Q

nephr

A

kidney

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80
Q

pyel

A

renal, pelvis

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81
Q

ur

A

urine

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82
Q

vesic

A

bladder

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83
Q

lithiasis

A

condition of stone

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84
Q

ptosis

A

drooping

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85
Q

tripsy

A

crushing of stone

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86
Q

uria

A

condition of urine

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87
Q

TURP

A

transurethral resection of the prostate

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88
Q

Two medications for ED

A

Cialis, Levitra, Stendra, Viagra (Sildenafil)

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89
Q

Method of treatment for ED

A

PDE5 inhibitor

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90
Q

Side effects for ED Medications

A

headache, flushing pain, back pain, muscle pain, nauseau

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91
Q

Two medications for cystitis (and other infections)

A

Cipro, Levaquin

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92
Q

Method of treatment for cystitis and other infections

A

antibiotic

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93
Q

Side effects for antibiotic medications

A

headache, yeast infection, nausea, diarrhea

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94
Q

Two medications for OAB

A

Detrol, Ditropan, Myrbetriq, Sanctura, Toviaz, Vesicare,

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95
Q

Side effects for OAB medications

A

dry mouth, constipation, blurred vision, diarrhea, hypertension, headache

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96
Q

Method of treatment for OAB medication

A

anticholinergic

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97
Q

Two medications for prostate cancer

A

Elmiron, Eulexin, Lupron Proscar

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98
Q

Side effects for medications of prostate cancer

A

nausea, diarrhea, headache, abdominal pain

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99
Q

Two medications for BPH

A

Flomax, Jalyn, Uroxatral, Dustasteride, Doxazosin, Sildosin, Tamsulosin,

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100
Q

Side effects for BPH medication

A

Mild dizziness, weakness, dowsiness, headache, nausea, diarrhea, ED, decreased libido

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101
Q

Method of treatment for BPH medication

A

alpha blocker

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102
Q

Method of treatment for prostate cancer medication

A

5-alpha reductase inhibitor

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103
Q

Medications for treatment of UTI/ suppression

A

Bactrim, Bactrim DS, Trimethoprim, Macrodantin, Rocephin

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104
Q

method of treatment for UTI suppression medications

A

synthetic antifolate

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105
Q

side effects for UTI suppression medications

A

renal disease, GI issues,

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106
Q

Medications for resp. infections and other infections

A

Keflex, Ceftin, Doxycycline,

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107
Q

What can be used to block nerves in bladder to cause it to relax and ease OAB

A

botox

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108
Q

What can be used for testosterone replacement therapies

A

androderm, estrace, permarin, testim

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109
Q

side effects of testosterone replacement therapies

A

dizziness, headaches, nausea

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110
Q

What is abdomen

A

stomach

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111
Q

flank

A

costovertebral angle

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112
Q

ureter

A

carries urine from kidneys to bladder

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113
Q

urethra

A

a tube that connects bladder to urinary meatus

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114
Q

fistula

A

abnormal opening or surgically made connection between two hollow spaces

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115
Q

prolapse

A

organs fall out of normal location

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116
Q

libido

A

sexual activity desire

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117
Q

urinary system order

A

kidney to ureter to bladder to urethra

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118
Q

another name for urinary system

A

renal system

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119
Q

what are the functions of urinary system

A 
produces, stores, and eliminates waste products
maintaines homeostasis (pH, electrolyte fluid)
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120
Q

what is urinary system composed of

A

kidneys, ureter, bladder, urethra

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121
Q

function of kidneys

A

to filter and remove waste products

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122
Q

what is structure of kidneys

A

cortex, medulla, nephron

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123
Q

cortex

A

outer portion of kidney

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124
Q

medulla

A

inner portion of kidney

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125
Q

cortex and medulla are arranged how

A

in triangular shape

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126
Q

what is the microscopic functional unit of kidney

A

nephron

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127
Q

nephron consists of two things

A

renal corpuscle and renal tubules

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128
Q

ureter function

A

carry urine from kidney to bladder

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129
Q

what is the bladder composed of

A

elastic muscle sac

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130
Q

function of bladder

A

stores urine for voiding

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131
Q

where is bladder located

A

base of pelvis

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132
Q

function of urethra

A

carries urine outside of body

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133
Q

what is the external opening of urethra called

A

urethral meatus

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134
Q

names for releasing urine from body

A

voiding
micturition
urination

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135
Q

urine normal color is

A

staw like

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136
Q

how much of urine is water

A

95%

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137
Q

3 stages of the renal tubules

A

filtration
reabsorption
secretion

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138
Q

what is normal urine output in 24 hours

A

1000-2000mL

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139
Q

what does 3 things urine contains

A

nitrogenous waste
toxins
excess water and electrolytes

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140
Q

What is redundant prepuce

A

a condition where the penile foreskin is so long it covers the glands in the absence of an erection

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141
Q

what is phimosis

A

occurs when tight foreskin prevents itself from retraction over the glans

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142
Q

what is hidden penis/micropenis

A

a congenital condition that can lead to the obstruction o the urinary system

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143
Q

Hidden penis can also be “caused” by

A

fat growth

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144
Q

What is hypospadias

A

a birth defect in the male where the urethral meatus is abnormally located, Instead of opening at glans, it opens on underside any where

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145
Q

what is an inguinal hernia

A

a condition where a soft tissue or part of the intestine protrudes through a weak point in the abdominal muscles

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146
Q

What is scrotal varices

A

an abnormally dilated vessel with a tortuous course

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147
Q

What is testicular torsion

A

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.

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148
Q

What is a spermatoceole

A

epididymal cyst, a painless fluid filled cyst in the long, tightly coiled tube that lies above and behind each testicle

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149
Q

Benign Prostatic Hyperplasia (BPH)

A

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

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150
Q

What is erectile dysfunction

A

Inability to get or maintain an erection firm enough for sexual intercourse. Most common cause is prostate cancer.

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151
Q

What is low testosterone also called

A

hypogonadism

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152
Q

When is low testosterone also seen in

A

in most men as they approach 60 years of age

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153
Q

What is male infertility

A

a condition possible caused by low sperm production

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154
Q

What is premature ejaculation

A

man ejaculates sooner than expected in sexual intercourse

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155
Q

What is peyronie’s disease

A

an inflammatory process of the penis caused by scar tissue, called plaques that form in the penis. Causes penile curvature.

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156
Q

What is penile cancer

A

malignant growth found on the skin of the penis or the tissue of the penis

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157
Q

what is prostate cancer

A

cancer of the prostate

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158
Q

What is testicular cancer

A

a type of cancer that occurs in the testicle. Occurs when healthy cells become altered

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159
Q

What is Cushing syndrome also known as

A

hypercortisolism

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160
Q

What is cushing syndrome

A

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.

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161
Q

What is yeast infections

A

overgrowth of Candida

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162
Q

What is imperforate hyman

A

hyman without an opening

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163
Q

what is congenital vaginal obstructiion

A

congenital condition where the hymen has not formed properly resulting in covering the vaginal opening instead of surrounding the opening

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164
Q

vaginal agenesis

A

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

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165
Q

urogenital sinus is also called

A

persistant cloaca

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166
Q

What is urogenital sinus

A

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

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167
Q

ectopic kidneys

A

a kidney located below, above, or opposite of the position it should be

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168
Q

what is balanoposthitis

A

inflammation of the glans in uncircumcised males

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169
Q

what is balanitis

A

inflammation of the glans or foreskin due to lack of aeration

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170
Q

what is a sebacceous cyst

A

small bumps that develop beneath the skin that secrete oily matter

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171
Q

what is pseudohermaphroditism

A

a person has a secondary sex organ

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172
Q

what is adrenal medulla tumor

A

tumor of the adrenal medulla that produces excess adrenaline and causes hypertension

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173
Q

What is bladder prolapse

A

the pelvic floor muscles weaken resulting in the bladder dropping into the vagina

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174
Q

horseshoe kidney

A

kidneys are merged together

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175
Q

what is renal failure

A

loss of kidney function including the inability to remove waste or maintain electrolyte balance

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176
Q

what is a renal abscess

A

a localized collection of pus confined to the kidney due to bacteria in the bloodstream or by a UTI

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177
Q

meatal stenosis

A

narrowing of the opening of the urethra causing urinary blockage

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178
Q

what is overactive bladder

A

a sudden and strong urge to void this typically happens when your bladder muscles contract prior to your bladder being full causing urinary urgency

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179
Q

neurogenic bladder

A

a condition where you see a normal loss of bladder function caused by damage to parts of the nervous system

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180
Q

constipation

A

pain with bowel movements or the absence of bowel movements

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181
Q

what is renovascular disease

A

a disorder affecting the arteries of the kidneys resulting in HTN or renal disease

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182
Q

urethral cancer

A

cancer originating from the urethra

183
Q

urinary tract infection

A

UTI

184
Q

hydronephrosis

A

a condition in which one kidney becomes swollen due to the failure of normal drainage of urine from the kidney to the bladder

185
Q

pyelonephritis

A

a kidney infection that begins in the bladder or urethra and travels up to kidney

186
Q

cystitis

A

inflammation of the bladder caused by a bacterial infection

187
Q

urethritis

A

urethra inflammation

188
Q

nocturia/nocturnal enuresis

A

excessive urination at night

189
Q

urinary incontinence

A

involuntary leakage of urine

190
Q

PSA labs

A

measures prostate specific antigen in the blood stream for prostate cancer

191
Q

semen analysis

A

providers look for sperm and mobility

192
Q

testosterone level check

A

blood draw that determines testosterone levels, in patients with infertility, low libido or ED

193
Q

urine flow study

A

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
Q

urinalysis

A

dipstick that measures sugar, protein, and other substances in the urine. Microscopic detects blood, crystals, bacteria, or yeast

195
Q

urine culture

A

performed when UTI suspected, culture is incubated for several hours and growth is checked

196
Q

urodynamics

A

study is completed to assess bladder function by measuring bladder tone and nerve activity during filling bladder with water and emptying ability.

197
Q

24 hour urine study

A

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
Q

BUN

A

blood draw to evaluate kidney function

199
Q

Creatinine

A

blood draw to evaluate kidney function

200
Q

GRF

A

a blood draw to evaluate how well the kidneys are filtering

201
Q

CBC

A

blood draw to check patient’s overall health

202
Q

BMP/CMP

A

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
Q

antegrade pyelogram

A

the imaging test is performed to find obstructions in the upper resp tract

204
Q

CT scan abd/pel

A

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
Q

cystography

A

this study (xray) can help diagnose problems in the bladder

206
Q

intravenous pyelogram

A

this study is used to look at the kidneyss and the uretera

207
Q

kidney scan

A

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
Q

KUB

A

type of xray done to evaluate abdominal related concerns

209
Q

prostate/ rectal US

A

this study uses sound waves to look at your prostate and rectum

210
Q

renal venogram

A

this study looks at the veins in and around your kidney. may help identify patients with renovascular hypertension

211
Q

retrograde pyelogram

A

this study is used to look at your bladder, ureters, kidneys with an endoscope. This is done while cystoscopy is being done

212
Q

circumcision

A

surgical removal of skin at tip of penis

213
Q

cryotherapy prostate cancer

A

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
Q

cystoscopy

A

urologists to view the urinary tract, and determine early signs of cancer, disease

215
Q

kidney biopsy

A

biopsy is done to evaluate tissue under a microscope for abnormalities. the tissue is removed with a needle

216
Q

kidney cancer ablation

A

ablation is used to freeze or cook cancer cells

217
Q

laparoscopic pelvic prolapse repair

A

helps restore the pelvic floor without the need for a large incision

218
Q

laparoscopic pyeloplasty

A

provides patient with safe and easy way to correct blockage or narrowing of the ureter where it leaves the kidney

219
Q

lithotripsy

A

ultrasound energy or shock waves are sent to the urinary system to break a large stone

220
Q

partial orchiectomy

A

remove testis cancer, testes sparing

221
Q

prostate bipsy

A

perineal prostatectomy is a less invasive method of removing the prostate

222
Q

radical orchiectomy

A

the removal of the testical to treat testis cancer

223
Q

retroperitoneal lymph node dissection

A

used to remove testis cancer that has spread to the lymph nodes of the retroperitoneal

224
Q

what is robotic prostatectomy

A

prostate gland is surgically removed by a robot

225
Q

sperm retrieval process

A

men who have no sperm benefit when they want to get partners pregnant

226
Q

transurethral resection of the prostate

A

surgery to remove part of the prostate through the penis, no incisions are made

227
Q

varicoceole embolization

A

diverts blood away from an enlarged vein in the scrotum . this vein is called a varicoceole

228
Q

vasectomy

A

vas deferens is clamped, cut, and sealed. takes 30 days for sperm to be reabsorbed

229
Q

vasectomy reversal

A

reconnects the pathway for sperm to get into the semen

230
Q

penile augmentation

A

permanent fillers are placed to increase the lenght of a penis

231
Q

digital rectal exam

A

lubricated glove into rectum to check the prostate gland

232
Q

stone evaluation

A

this is done once a stone has passed or been crushed . the composition is analyzed to determine what formed the stone

233
Q

What is subjective information

A

what the patient tells you

234
Q

What is objective information

A

what the doctor tells you

235
Q

Where does subjective data go

A

in the history through ROS

236
Q

Where does objective data go

A

in physical exam and plan

237
Q

What are the 7 elements in the HPI

A 
chief complaint
onset
timing
location
quality
severity
modifying factors
associated symptoms
context
238
Q

What goes first in the HPI

A

chief complaint

239
Q

What is the standard template for charting

A 
CC
HPI
ROS
PE
Dx
Plan
240
Q

What is Caverject used for

A

Peyronie’s disease

241
Q

What are side effects of Caverject

A

penile pain, prolonged errections

242
Q

What is Cialis used for

A

ED

243
Q

What is the mechanism used by Cialis

A

PDE5 inhibitor

244
Q

What are side effects of Cialis

A

headache, naseau, flushing, back pain, muscle pain

245
Q

What is Cipro used for

A

infections

246
Q

What is the mechanism used by Cipro

A

antibiotic

247
Q

What are side effects of Cipro

A

headache, yeast infection, vaginitis, diarrhea, naseau

248
Q

What is Detrol used for

A

OAB

249
Q

What is the mechanism used by Detrol

A

anticholinergic

250
Q

What are side effects of Detrol

A

dry mouth

251
Q

What is Ditropan used for

A

OAB

252
Q

What is the mechanism used by Ditropan

A

anticholinergic

253
Q

What are side effects of Ditropan

A

dry mouth, constipation, diarrhea, blurred vision

254
Q

What is Elmiron used for

A

prostate cancer

255
Q

What is side effects of Elmiron

A

naseau headache, diarrhea

256
Q

What is Eulexin used for

A

prostate cancer

257
Q

What are side effects of Eulexin

A

nasuea, diarrhea, headache, abdominal pain, flu-like symptoms, fatigue

258
Q

What is Flomax used for

A

BPH

259
Q

What is the mechanism of Flomax

A

alpha blocker

260
Q

Side effects of Flomax

A

mild dizziness, weakness, drowsiness, decreased libido, dizziness, naseau, diarrhea

261
Q

What is Jalyn (Dutasteride)

A

BPH

262
Q

What is the mechanism of Jalyn (Dutasteride)

A

alpha blocker

263
Q

What are side effects of Jalyn (Dutasteride)

A

ejaculation disorder, decreased libido, ED, dizziness, breast tenderness

264
Q

What is Levitra used for

A

ED

265
Q

What is the mechanism of Levitra

A

PDE5 inhibitor

266
Q

What are the side effects of Levitra

A

headache, flushing, back main, muscle pain, nausea

267
Q

What is Lupron used for

A

prostate cancer

268
Q

What are side effects of Lupron

A

hot flashes, decreased libido, ED

269
Q

What is Myrbetriq used for

A

OAB

270
Q

What are side effects of Myrbetriq

A

dry mouth, hypertension, UTI, headache

271
Q

What is the mechanism of Myrbetriq

A

anticholinergic

272
Q

What is Proscar used for

A

prostate cancer, BPH

273
Q

What is Proscar mechanism

A

PDE5 inhibitor

274
Q

What are side effects

A

decreased libido, hot flashes, ED, edema, weakness, headache

275
Q

What is Sanctura used for

A

OAB and urge incontinence

276
Q

What are side effects of Sanctura

A

dry mouth, constipation, dyspepsia, headache

277
Q

What is Stendra used for

A

ED

278
Q

What is the mechanism for Stendra

A

PDE5 inhibitor

279
Q

What are side effects of Stendra

A

headache, flushing, nasal congestion, back pain

280
Q

What is Toviaz used for

A

OAB

281
Q

What is mechanism of Toviaz

A

anticholinergic

282
Q

What are side effects of Toviaz

A

dry mouth, constipation, dry eyes, UTI, abdominal pain

283
Q

What is Uroxatral used for

A

BPH

284
Q

What is the mechanism for Uroxatral

A

alpha blocker

285
Q

What are side effects of Uroxatral

A

headache, fatigue, impotence, pain

286
Q

What is Vesicare used for

A

OAB and urge incontinence

287
Q

WHat is the mechanism of Vesicare

A

anticholinergic

288
Q

What are side effects of Vesicare

A

dry mouth, dry eyes, blurred vision, urinary retention

289
Q

What is Viagra used for

A

ED

290
Q

What is the mechanism of Viagra

A

PDE5 inhibitor

291
Q

What are side effects of Viagra

A

headache, flushing, back pain, nausea

292
Q

What is Dutasteride used for

A

BPH and low grade prostate cancer

293
Q

What is mechanism of Dutasteride

A

5 alpha reductase inhibitor

294
Q

What is Doxazosin used for

A

BPH

295
Q

What is the mechanism of Doxazosin

A

alpha blocker

296
Q

WHat is Sildosin (Rapaflo) used for

A

BPH

297
Q

What is the mechanism of Sildosin (Rapaflo)

A

alpha 1 inhibitor

298
Q

What is Bactrim used for

A

UTI

299
Q

What is mechanism of Bactrim

A

antibiotic

300
Q

What is Trimethoprim used for

A

UTI

301
Q

What is mechanism of Trimethoprim

A

antibiotic

302
Q

What is Macrodantin used for

A

UTI

303
Q

What is mechanism of macrodantin

A

antibiotic

304
Q

What is Keflex used for

A

UTI, general infections

305
Q

What is mechanism of Keflex

A

antibiotic

306
Q

What is Ceftin used for

A

general infections, UTI

307
Q

What is mechanism of Ceftin

A

antibiotic

308
Q

What is Doxycycline used for

A

UTI, general infections

309
Q

What is the mechanism of Doxycycline

A

antibiotic

310
Q

What is Rocephin used for

A

UTI, general infections

311
Q

What is Rocephin mechanism

A

antibiotic

312
Q

What is Botox used for

A

OAB

313
Q

WHat is the mechanism of Botox

A

neurmuscular blocker

314
Q

What is Androgerm used for

A

testicular hypofunction

315
Q

What is side effect of Androgerm

A

breast enlargement

316
Q

What is Premarin or Estrace used for

A

estrogen replacement

317
Q

What is side effect of Premarin or Estrace

A

dizziness or headache

318
Q

What is Testim used for

A

testicular hypofunction

319
Q

What is side effect of Testim

A

dizziness, nausea

320
Q

Pain vs. tenderness

A

patient’s feeling vs physician’s assessment

321
Q

Benign

A

nothing of concern, normal

322
Q

acute vs. chronic

A

new onset vs. long standing

323
Q

Baselin

A

an individual’s normal state of being

324
Q

auscultation

A

lisetening with a stethoscop

325
Q

Palpation

A

act of pressing on an area

326
Q

impatient

A

admitted to the hospital overnight

327
Q

outpatient

A

seen and sent home the same day

328
Q

chief complaint

A

main reason for the bisit

329
Q

meaninful use

A

set of government mandated criteria that must be obtained for every patient

330
Q

Medican Decision Making

A

physicians though process

331
Q

What people are in the clinic

A

mid level provider, nurse, MA, Receptionist, Scribe

332
Q

What is a new patient

A

no previous records, or has not been seen in 3 years

333
Q

What is an established patient

A

previous records available

334
Q

Do new patients have shorter or longer visits

A

longer

335
Q

Do new patients have concise or more detailed charts

A

detailed

336
Q

Do established patients have shorter or longer visits

A

shorter

337
Q

Do established patients have concise or more deailed charts

A

concise

338
Q

What are the two types of clinic visits

A

diagnostic and health maintenance

339
Q

What is a diagnostic visit

A

new problem, new symptom

340
Q

What is the goal of a diagostic visit

A

to determine the cause of the problem and appropriate treatment

341
Q

What is a health maintenance visit

A

a check up, management of chief complaint

342
Q

What is the goal of a health maintenance visit

A

to assess progress of ongoing medical problems

343
Q

What is the clinic flow

A

Check in, physician evaluation, orders and resuls, assessment and plan, check out

344
Q

What are the meaningful use pieces

A

CC, HR, BP, T, RR, Height, weight, BMI, Smoking

345
Q

What section does assessment cover

A

diagnoses

346
Q

What section does H &P (history and physical cover)

A

chief complaint, HPI, PE

347
Q

What are the 4 sections of the chart

A

SOAP

348
Q

What does SOAP stand for

A

subjective
objective
assessment
plan

349
Q

What goes in the subjective section of the chart

A

HPI and ROS

350
Q

What goes in objective

A

PE, Orders and results

351
Q

What goes in Assessment

A

diagnosis

352
Q

What goes in plan

A

treatment and follow up

353
Q

What are General PMHx

A 
high blood pressure
high cholesterol
thyroid problem
diabetes
DM
354
Q

What are Cardiac PMHx

A 
A-Fib
CAD
MI
CHF
heart murmur
SVT
355
Q

What are Pulmonary PMHx

A

asthma
COPD
PE
pneumonia

356
Q

What are Gastrointestinal PMHx

A

Diverticulitis, Hepatitis, Pancreatics, Ulcer, GERD, Chron’s disease, IBS

357
Q

What are Genitourinary PMHx

A

UTI, pyelonephritis, renal calculi, CRF, BPH

358
Q

What are Gynecologic PMHx

A

GPA

359
Q

What are neurological PMHx

A

CVA
TIA
Seizure disorder
Hemorrhagic CVA

360
Q

What are Psychological PMHx

A

schizophrenia, alcoholism, bipolar disorder, depression

361
Q

What are Vascular PMHx

A

DVT
Aortic Aneurysm
Peripheral Vascular Disease

362
Q

WHat are Musculoskeletal PMHx

A

low back pain
Degenerative disk disease
osteoarhritis, RA
Osteoporosis

363
Q

At what age would a family member’s disease indicate an increased risk

A

less than 50

364
Q

a younger age of onset of disease means what

A

higher genetic risk

365
Q

Social history includes

A

alcohol, occupation, drug use, lving circumstances, tobacco use

366
Q

What does comorbidity means

A

simultaneous presence of two chronic diseases or conditions in a patient

367
Q

What does etiology mean

A

cause of disease

368
Q

What does systole mean

A

phase of the heartbeat during which the muscle contracts, pumping blood to body

369
Q

What does diastolic mean

A

phase of the heartbeat during which muscle is relaxed and the heart fills with blood

370
Q

What is diuretic

A

substance that promotes the production of urine

371
Q

What does parestehsia

A

sensation of tingling or numbness

372
Q

What is ischemia

A

loss of blood supply to a tissue

373
Q

What is an anticoagulant

A

a drug that prevents blood clotting

374
Q

When is an illness classified as chronic

A

lasts longer than 3 months

375
Q

What are the 5 comorbidity diseases

A

asthma, CAD, DM, HLD, HTN

376
Q

Patients with comorbitities are what

A

complex

377
Q

For patients with complexitiy how should 1 chart

A

symptoms in chronological order
status and progress of each illness
level of compliance with treatment plan

378
Q

How doe comorbidity increase complexity

A

compounding symptoms, drug interaction

379
Q

Why is it important to document accurately and thoroughly on complex patients

A

for billing, they bill to higher level

380
Q

What is History of present illness

A

the story of patient’s chief complaint

381
Q

What is review of sysems

A

ead to toe checklist of patient’s symptoms

382
Q

what is intermittent

A

comes and goes

383
Q

What is waxing and waning

A

always present but changing in intensity

384
Q

what is a modifying facotry

A

something that makes a symptom better or worse

385
Q

what is exacerbate

A

to make worse

386
Q

What is SOAP method

A

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
Q

What is the first section the scribe documents

A

subjective

388
Q

What does subjective info include

A

chief complaint, HPI, ROS

389
Q

WHy must you have a chief complaint

A

billing

390
Q

What two things does the HPI contain

A

subjective info and chief complaint/ things related to complaint

391
Q

What 8 elements does a complete HPI contain

A

element, onset, timing, location, quality, severity, modifying facotrs, associated symptoms, context

392
Q

What are the 3 primary methods of structuring HPI

A

single complaint formula, multiple complaint formula, chronologic

393
Q

THe ROS is what

A

head to toe checklist of the patient’s body systems

394
Q

What is cachectic

A

emaciated, malnourished

395
Q

What does objective infor include

A

vital signs, physical exam, orders and results

396
Q

What are the 5 vital signs

A 
heart rate
blood pressure
o2 saturation
temperature
respiration rate
397
Q

What 6 things can be observed by looking

A 
general appearance
eyes
pulmonary/ breathing
skin
neurological
psychiatric
398
Q

What is follow up

A

the establishment or maintenance of consistent contact with healthcare providers in order to address an ongoing health concern

399
Q

What is QD

A

once daily

400
Q

What is BID

A

twice daily

401
Q

What is TID

A

three times daily

402
Q

What is subq

A

medication injected under the skin

403
Q

prn

A

as needed

404
Q

prognosis

A

a forecast of the likely course of a disease or ailment

405
Q

What is included in the assessment

A

diagnoses and summary of visit

406
Q

the assessment will always include

A

diagnosis

407
Q

What are the different ways an assessment can be structured

A

simple
brief
comprehensive

408
Q

What are the two types of results

A

labs and imaging

409
Q

What does the plan include

A 
recommended treatments for each diagnosis
prescriptions ordered
studies or tests ordered
follow up with other healthcare
follow up here
410
Q

What is superbill

A

a bill, submitted to the insurance company that reflects the services provided to the patient

411
Q

What is ICD

A

international classification of diseases

412
Q

What is WHO

A

world health organization

413
Q

What is v code

A

a billing code for prevenatitive care

414
Q

What is CPT

A

current procedural terminology

415
Q

What is E&M

A

evaluation and management

416
Q

What is LOS

A

level of service

417
Q

What is problem focuses

A

a visit, history, or exam that focuses solely on the CC

418
Q

What is inhouse

A

a lab or study that can be done in clinic, during an appointment

419
Q

What is a new patient

A

patient who has had no care by any member of the billing physician’s specialyt or practice group within 3 years

420
Q

How many E&M levels

A

5

421
Q

What is level 1 E&M

A

minimal

422
Q

What is level 2 E&M

A

problem focused visit

423
Q

What is level 3 E&M

A

expanded problem focused

424
Q

What is level 4 E&M

A

detailed

425
Q

What is level 5 E&M

A

comprehensive

426
Q

MOst commonly used E&M levels are

A

3 and 4

427
Q

FOr a new patient, how many HPI elements for level 4

A

4

428
Q

For a estab. patient how many HPI elements for level 4

A

2

429
Q

For a new patient how many ROS elements

A

10

430
Q

For a estab. patient how many ROS elements

A

2

431
Q

FOr a new patient how many PMHx

A

3

432
Q

For a estab. patient how many PMHx

A

1

433
Q

FOr a new patient how many PE

A

10

434
Q

For a Estab.. patient how many PE

A

2

435
Q

For a new patient how many assessment/plan

A

1

436
Q

For a estab. patient how many assessment/plan

A

2

437
Q

What are the HPI elements

A

location quality duration timing severity context modifying factors, associated symptoms, pertinent denials

438
Q

What are ROS Elements

A 
constitutional
eyes
ENT
cardiovascular
respiratory
GI
GU
Musculoskeletal
neurological
skin and breast
psych
heme/lymph
endocrine
immuno/allergy
439
Q

What falls under PMHx/FHx/SHx

A

medical surgical, family, social

440
Q

A new patient needs how many bullets from how many systems in PE

A

18 bullets from 9 systems

441
Q

An estab. patient needs how many bullets from how many systems

A

12 bullets from 2 systems

442
Q

What is included in assessment and plan

A

review of orders and labs
review of images and studies
obtained old med records
reviewed and summarized old medical records

443
Q

What is low risk E&M code

A

two or more minor problems,
one stable chronic illness
acute uncomplicated illness

444
Q

What is moderate risk E&M code

A

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
Q

What is high risk E&M code

A

one or more chronic illness with severe exacerbation or progression
acute or chronic illness or injuries which powe a threat to life

446
Q

What does MU mean

A

meaningful use

447
Q

What is CMS

A

centers for medicare

448
Q

What is CPOE

A

computerized physician order entry

449
Q

What is EHR

A

electronic health record

450
Q

What is EMR

A

electronic medical recored

451
Q

What is e-Prescribing

A

SUbmitting prescriptions electronically to local pharmacies

452
Q

What is HIPAA

A

health insurance portability and accountability act

453
Q

What is PHI

A

protected health information

454
Q

What is HITECH

A

health information technology for economic and clinical health act

Scribe (2 decks)

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