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scribe > welcome and patient history > Flashcards

welcome and patient history Flashcards

1
Q

emphysema or chronic bronchitis

A

chronic obstructive pulmonary disease (COPD)

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2
Q

subjective

A

feeling, comes from the patient

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3
Q

chronic

A

long-standing, not of direct concern

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4
Q

history of present illness

A

HPI

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5
Q

heart failure

A

congestive heart failure (CHF)

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6
Q

patient says: pneumonia

A

scribe writes: pneumonia

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7
Q

kidney infection

A

pyelonephritis

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8
Q

enlarged prostate

A

benign prostatic hyperplasia (BPH)

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9
Q

high cholesterol

A

hyperlipidemia

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10
Q

heart disease

A

coronary artery disease (CAD)

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11
Q

blood clot in lung

A

pulmonary embolism (PE)

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12
Q

stroke

A

cerebrovascular accident (CVA)

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13
Q

tonsils removed

A

tonsillectomy

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14
Q

ear tubes

A

pressure equalizer (P.E.) tubes

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15
Q

part of my colon removed

A

partial colectomy

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16
Q

the physiological process causing the symptoms

A

pathophysiology

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17
Q

the main reason for the patient’s outpatient visit

A

chief complaint

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18
Q

electronic medical record/electronic health record

A

EMR/EHR

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19
Q

factual finding from the provider, comes from the physician

A

objective

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20
Q

patient’s feeling of discomfort

A

pain

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21
Q

doctor’s finding of reproducible pain

A

tenderness

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22
Q

new onset, likely concerning

A

acute

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23
Q

what is the order of emergency department flow?

A

check in & triage, history & physical, differential diagnosis, orders & treatment, medical decision making, disposition

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24
Q

review of systems

A

ROS

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25
Q

what makes up past history?

A

past medical history, past surgical history, family history, social history

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26
Q

DDx

A

differential diagnosis; a variety diagnostic possibilities are being considered to diagnose the disease presented

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27
Q

combination of tests to rule out diseases, as well as medications and procedures to treat the symptoms and/or disease

A

orders and treatment

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28
Q

medical decision making

A

MDM

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29
Q

what is disposition

A

where the pt ends up; discharged to home, nursing facility, admitted, transferred, etc

30
Q

PMHx

A

past medical history

31
Q

high blood pressure

A

hypertension (HTN)

32
Q

diabetes

A

diabetes mellitus (DM)

33
Q

“I only take pills for my diabetes”

A

non-insulin dependent diabetes mellitus (NIDDM)

34
Q

“I take shots (insulin) for my diabetes”

A

insulin dependent diabetes mellitus (IDDM)

35
Q

heart attack

A

myocardial infarction (MI)

36
Q

irregular heartbeat

A

arrythmia

37
Q

reflux

A

gastroesophageal reflux disease (GERD)

38
Q

ulcers

A

gastric ulcers or peptic ulcer disease (PUD)

39
Q

patient says: pancreatitis

A

scribe writes: pancreatitis

40
Q

patient says: hepatitis

A

scribe writes: hepatitis

41
Q

patient says: irritable bowel syndrome

A

scribe writes: irritable bowel syndrome (IBS)

42
Q

bladder infection

A

urinary tract infection (UTI)

43
Q

patient says: kidney stones

A

renal calculi or nephrolithiasis

44
Q

“I’m on dialysis”

A

chronic kidney disease (CKD) on dialysis

45
Q

what is the total number of times the patient has pregnant?

A

gravida G

46
Q

the number of pregnancies that resulted in viable births

A

para P

47
Q

the total number of miscarriages or elective abortions

A

abortus A

48
Q

blockages in the brain

A

ischemia CVA

49
Q

brain bleed

A

hemorrhagic CVA

50
Q

“mini stroke”

A

transient ischemic attack (TIA)

51
Q

“bad blood flow to my legs”

A

PVD - peripheral vascular disease

52
Q

past surgical history

A

PSHx

53
Q

adenoids removed

A

adenoidectomy

54
Q

surgical repair of a blood vessel; “balloon in my heart”

A

angioplasty–> PMHx CAD

55
Q

patient says: stents in my heart

A

coronary stents–> PMHx CAD

56
Q

breast removal

A

mastectomy

57
Q

part of my lung removed

A

partial lobectomy

58
Q

appendix removed

A

appendectomy

59
Q

gallbladder removed

A

cholecystectomy

60
Q

spleen removed

A

splenectomy

61
Q

kidney removed

A

nephrectomy

62
Q

uterus removed

A

hysterectomy

63
Q

ovary removed

A

oophorectomy

64
Q

ovary and fallopian tube removed

A

salpingo-oophorectomy

65
Q

prostate removed

A

prostatectomy

66
Q

family history

A

family hx

67
Q

a younger age of onset (under __) means higher genetic risk

A

55 years

68
Q

social history

A

social hx

69
Q

what factors describe social hx

A

tobacco use/vaping, alcohol use, drug use, occupation, living circumstances

70
Q

true allergy

A

any medication that causes a rash, itching, swelling, or difficulty breathing

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