ScribeAmerica Final Exam Review "Bad blood flow in my legs" - ✔Peripheral Vascular Disease (PVD) "Blood clot in my leg" - ✔Lower Extremity Deep Vein Thrombosis "Bulge in my aorta" - ✔Abdominal Aortic Aneurysm (AAA) "I drink a lot" - ✔Alcoholism or EtOH abuse "I only take pills for my diabetes" - ✔Non-Insulin Dependent Diabetes Mellitus (NIDDM) "I take shots (insulin) for my diabetes" - ✔Insulin Dependent Diabetes Mellitus (IDDM) "I'm on dialysis" - ✔Chronic Renal Failure (CRF) on dialysis A Fib - ✔Atrial Fibrillation AAA - ✔Abdominal Aortic Aneurysm Abd - ✔Abdomen, Abdominal Abx - ✔Antibiotics Acute blockage of artery that provides blood to brain - ✔CVA (Cerebrovascular Accident) Adenoids removed - ✔Adenoidectomy AKA - ✔Above The Knee Amputation AMA - ✔Against Medical Advice AMS - ✔Altered Mental Status An erythematous TM would be abnormal for this body part. - ✔Ear --> indicates ear infection Appendix removed - ✔Appendectomy Are cough and fever related? - ✔Yes, when it could go either way, definitely put it in HPI
Arthritis - ✔Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) ASA - ✔Acetylsalicylic Acid (Aspirin) Asthma - ✔Asthma Back fused - ✔Lumbar spinal fusion Bag to collect stool - ✔Colostomy Balloon - ✔Angioplasty --> PMHx CAD BCP - ✔Birth Control Pill BID - ✔Twice Daily Bilat LE - ✔Bilateral Lower Extremities Bipolar - ✔Bipolar disorder Black tarry stools - ✔Melena Bladder infection - ✔Urinary Tract Infection (UTI) Blood clot in lung - ✔Pulmonary Embolism (PE) Blood is the urine is called what? - ✔Hematuria BM - ✔Bowel Movement BP - ✔Blood Pressure Brain bleed - ✔Hemorrhagic CVA Brain surgery - ✔Craniotomy Breast removal - ✔Mastectomy Bulging/herniated disc - ✔Degenerative Disc Disease (DDD) C-section - ✔Caesarean Section
C-spine - ✔Cervical Spine (neck) c/o - ✔complains of CA - ✔Cancer, Carcinoma CABG - ✔Coronary Artery Bypass Graft, "open heart surgery" CAD - ✔Coronary Artery Disease, "heart disease" Cancer - ✔Cancer or Carcinoma (CA) Chemo - ✔Chemotherapy CHF - ✔Congestive Heart Failure Clot filter (leg) - ✔Greenfield Filter Clot filter (lower abdomen) - ✔IVC (inferior vena cava) Filter Collapse lung due to trauma or a spontaneous small rupture of the lung ✔Pneumothorax COPD - ✔Chronic Obstructive Pulmonary Disease CP - ✔Chest Pain CPR - ✔Cardiopulmonary Resuscitation Crohn's/UC - ✔Crohn's Disease or Ulcerative Colitis CSF - ✔Cerebrospinal Fluid CT or CAT - ✔Computerized Assisted Tomography CT w/ PO - ✔CT Abd/Pel with PO contract CV - ✔Cardiovascular CVA - ✔Cerebrovascular Accident -or- Costovertebral Angle CVA is used medically as an abbreviation for a cerebral vascular accident, as well as this location of the body. - ✔Costovertebral Angle
CXR - ✔Chest X-Ray DC'd - ✔Discharged Home Defibrillator - ✔Automatic Implanted Cardiac Defibrillator (AICD) DFP - ✔Dorsal Fetal Pulse Diabetes - ✔Diabetes Mellitus (DM) Dialysis fistula - ✔AV (arteriovenous) Fistula Dialysis graft - ✔AV Graft Diverticulitis - ✔Diverticulitis DKA - ✔Diabetic Ketoacidosis DM - ✔Diabetes Mellitus DNR - ✔Do Not Resuscitate DOE - ✔Dyspnea On Exertion Drip - ✔Intravenous Drip DVT - ✔Deep Venous Thrombosis Dx - ✔Diagnosis Dz - ✔Disease Ear tubes - ✔Pressure Equalizer (P.E.) Tubes EKG/ECG - ✔Electrocardiogram Emphysema/Chronic Bronchitis - ✔Chronic Obstructive Pulmonary Disease (COPD) Enlarged prostate - ✔Benign Prostate Hypertrophy (BPH) Episodes of abnormally fast/racing heartbeat - ✔Supraventricular Tachycardia (SVT)
EtOH - ✔Alcohol Fast breathing rate - ✔Tachypnea FHx - ✔Family History Fx - ✔Fracture G/P/Ab - ✔Gravida/Para/Abortion Gallbladder removed - ✔Cholecystectomy GERD - ✔Gastro-Esophageal Reflux Disease, "acid reflux" GI - ✔Gastrointestinal GSW - ✔Gun Shot Wound gtt - ✔Drops GU - ✔Genitourinary h/o - ✔history of H&H - ✔Hemoglobin & Hematocrit H&P - ✔History of Present Illness & Physical Exam HA - ✔Headache Heart attack - ✔Myocardial Infarction (MI) and CAD Heart bypass - ✔Coronary Artery Bypass Graft (CABG) --> PMHx CAD Heart cath - ✔Cardiac catheterization Heart disease - ✔Usually Coronary Artery Disease (CAD) Heart failure - ✔Congestive Heart Failure (CHF) HEENT - ✔Head, Eyes, Ears, Nose, Throat Hepatitis - ✔Hepatitis A, Hepatitis B, or Hepatitis C
Hernia repair - ✔Herniorrhaphy High blood pressure - ✔Hypertension (HTN) High cholesterol - ✔Hyperlipidemia (HLD) hole in my neck - ✔Tracheostomy (commonly called a "trach") How do you diagnose a hemorrhagic CVA? - ✔CT of the head How do you diagnose appendicitis? - ✔CT Abdomen/Pelvis How do you diagnose gallstones? - ✔Ultrasound of RUQ How do you diagnose meningitis? - ✔Lumbar puncture How do you document a neck pulse/carotid pulse? - ✔Right carotid pulse 2+ How do you document a normal radial pulse? - ✔Right radial pulse 2+ How do you document a pulse on the heal? - ✔Posterior Tibialis Pulse 2+ How do you document a pulse on top of the foot? - ✔Dorsal pedis pulse 2+ HPI - ✔History of Present Illness HTN - ✔Hypertension Hx - ✔History I&D - ✔Incision & Drainage IDDM - ✔Insulin Dependent Diabetes Mellitus If someone comes in complaining about dyspnea, what are the 2 major diseases to worry about? - ✔PE and PNA IM - ✔Intramuscular Irregular heartbeat - ✔Atrial Fibrillation (A-Fib) Irritable bowel - ✔Irritable Bowel Syndrome (IBS)
Ischemic and infarct of the interior lateral myocardium - ✔MI It's gone - ✔In remission IUP - ✔Intrauterine Pregnancy IV - ✔Intravenous IVDA - ✔IV Drug Abuse IVP - ✔Intravenous Push IVPB - ✔Intravenous Piggy-Back Join pain (chronic) - ✔Degenerative Joint Disease (DJD) Joint repair - ✔Arthroplasty JVD - ✔Jugular Vein Distension Kidney infection - ✔Pyelonephritis (Pyelo) Kidney removal - ✔Nephrectomy Kidney stones - ✔Renal calculi L-Spine - ✔Lumbar Spine LAD - ✔Left Axis Deviation Leg amputated - ✔Above Knee Amputation (AKA) Below Knee Amputation (BKA) LLE - ✔Left Lower Extremity LLQ - ✔Left Lower Quadrant LNMP - ✔Last Normal Menstrual Period LOC - ✔Loss of Consciousness Low back pain - ✔Chronic Low Back Pain
LP - ✔Lumbar Puncture LUE - ✔Left Upper Extremity LUQ - ✔Left Upper Quadrant MCA - ✔Motorcycle Accident Metal plates/pins - ✔Hardware MI - ✔Myocardial Infarction Mini-stroke - ✔Transient Ischemic Attack (TIA) Murmur - ✔Heart murmur MVA/MVC - ✔Motor Vehicle Accident/Motor Vehicle Collision N/A - ✔Not Applicable N/V/D - ✔Nausea/Vomiting/Diarrhea NAD - ✔No Acute Disease, No Acute Distress Name the vital signs - ✔blood pressure, respiratory rate, heart rate, oxygen saturation, temperature Neb - ✔Inhaled Nebulizer Neck artery cleaned - ✔Carotid Endarterectomy Neck fused - ✔Cervical spinal fusion NIDDM - ✔Non-Insulin Dependent Diabetes Mellitus NKDA - ✔No Known Drug Allergies Nml -or- nl - ✔Normal No rebound, no guard - ✔Abdominal NSAID - ✔Non-Steroidal Anti-Inflammatory Drug
NSR - ✔Normal Sinus Rhythm NTG - ✔Nitroglycerin Number of HPI elements needed for Level 5 - ✔4 elements Number of physical exam elements needed for Level 5 - ✔8 elements (at least 1 finding in 8 different organ systems) Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5 - ✔2 elements Number of ROS elements needed for Level 5 - ✔10 elements O2 Sat - ✔Oxygen Saturation (a.k.a. SaO2) OD - ✔Overdose Ovary and fallopian tubes removed - ✔Salpingo-oophorectomy Ovary removed - ✔Oophorectomy Pacer - ✔Pacemaker Pain with urination - ✔Dysuria Pancreatitis - ✔Pancreatitis Part of my colon removed - ✔Partial colectomy Part of my lung removed - ✔Partial lobectomy Patch - ✔Transdermal PCN - ✔Penicillin PCP - ✔Primary Care Physician (a.k.a. PMD) PE - ✔Pulmonary Embolism -or- Physical Exam Pedal edema is used to describe what? - ✔CHF
PERRL - ✔Pupils are equal, round, and reactive to light PICC Line - ✔Peripherally Inserted Central Catheter (PICC) PNA - ✔Pneumonia Pneumonia - ✔Pneumonia (PNA) PO - ✔Per Os (by mouth) Port - ✔Port-a-cath or Medi-Port PR - ✔Per Rectum prn - ✔As needed Prostate removed - ✔Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) pt - ✔patient PTA - ✔Prior To Arrival PTX - ✔Pneumothorax PUD - ✔Peptic Ulcer Disease q2h - ✔Every 2 Hours qd - ✔Every Day qh - ✔Every Hour qhs - ✔At Every Bedtime QID - ✔Four Times a Day r/o - ✔Rule Out Radiation - ✔Radiation therapy RBBB is the abbreviation used to describe this medical term, which would indicate an abnormal EKG finding. - ✔Right Bundle Branch Block
Reflux - ✔Gastroesophageal Reflux Disease (GERD) RLE - ✔Right Lower Extremity RLQ - ✔Right Lower Quadrant ROM - ✔Range of Motion ROS - ✔Review of Systems RUE - ✔Right Upper Extremity Runny noise - ✔Rhinorrhea RUQ - ✔Right Upper Quadrant Rx - ✔Prescription s/p - ✔Status Post (after) SBO - ✔Small Bowel Obstruction Schizophrenia - ✔Schizophrenia Seizures - ✔Seizure disorder/Epilepsy Shunt - ✔Ventriculoperitoneal (VP) Shunt SL - ✔Sub-lingual SOB - ✔Shortness of Breath Spleen removed - ✔Splenectomy Spread to my... - ✔With metastases to the... SQ - ✔Subcutaneous STEMI - ✔ST Elevation Myocardial Infarction Stents - ✔Coronary Stents --> PMHx CAD
Stomach stapled - ✔Gastric bypass Stroke - ✔Cerebrovascular Accident (CVA) Surgery for Afib - ✔Afib s/p cardiac ablation SVT - ✔Super Ventricular Tachycardia Sweating - ✔Diaphoresis Sx - ✔Symptoms T-Spine - ✔Thoracic Spine The "H&H" comes back with this lab test. If low it would indicate the patient is anemic. ✔Hemoglobin and hematocrit. hemoglobin would be low if the patient is anemic. The presence of fluctuance would indicate this body tissue and would likely require I&D. - ✔Abscess These 2 lab test,which are part of the 7 basic chemistries, will be high in someone with renal failure. - ✔Urea and creatinine They cut it out - ✔Status-post surgical resection This abbreviation is used to describe a heart attack. - ✔MI This abbreviation is used to describe a normal heart rhythm. - ✔NSR This abbreviation is used to describe diabetes. - ✔DM This hyphenated surgery would indicate the patient is missing both an ovary and a fallopian tube. - ✔Salpingo-Oophorectomy This is the medical term used to describe redness. - ✔Erythema; injection This lab test is used to help physicians rule out PE and DVT. - ✔D-dimer This lab test will be elevated in patients with CHF. - ✔BNP This lab test will be high in patient with pancreatitis. - ✔Lipase This surgery is performed to remove a portion of the intestines - ✔Colectomy
This surgery is performed to remove the appendix. - ✔Appendectomy Thyroid problem - ✔Usually Hypothyroidism, sometimes Hyperthyroidism TIA - ✔Transient Ischemic Attack TID - ✔Three Times a Day TM - ✔Tympanic Membrane To check for JVD, what would be examined? - ✔Neck Tonsils removed - ✔Tonsillectomy Tubes tied - ✔Tubal ligation (female) or Vasectomy (male) Tx - ✔Treatment UA - ✔Urinalysis Ulcer - ✔Gastric Ulcer or Peptic Ulcer Disease URI - ✔Upper Respiratory Infection US - ✔Ultrasound UTD - ✔Up To Date Uterus removed - ✔Hysterectomy UTI - ✔Urinary Tract Infection Valve surgery - ✔Valve repair or replacement (Bovine vs. Mechanical) Weak/fragile bones - ✔Osteoporosis What are 4 things that must be documented in HPI after a syncope episode? - ✔What happened prior to episode, during episode, after episode, and their current status in the ED What are all of the possible elements of an HPI? - ✔Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity
What are examples of PHI? - ✔date of birth, social security number, diagnosis, what tests were run, what the results of the tests were What are the 4 types of focal neurological deficits? - ✔Changes in speech, vision, strength, and sensation What are the 6 rules of HIPAA? - ✔Rule #1: if a patient is not assigned to your doctor, DO NOT tough the chart. Rule #2: There is always someone watching. Rule #3: Never share your username or password. Rule #4: No cell phones or pictures. Rule #5: Your job does not belong on social media. Rule #6: Ask yourself, "Do I need to access this for my job?" What are the main differences between HPI and ROS? - ✔HPI focuses on chief complaint; ROS is a check from head to toe What do you do if someone asks for your help with a patient? - ✔We cannot touch patients. Find a nurse, a tech, etc. who can help. What does HIPAA stand for? - ✔Health Insurance Portability and Accountability Act What does HITECH stand for? - ✔The Health Information Technology for Economic and Clinical Health Act --> PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption. What does PHI stand for? - ✔Protected Health Information What is diagnosed when elevated Troponin is present? - ✔MI What is GPA? - ✔G = the total number of times the patient has been pregnant P = the number of live births (viable children) that the patient has had A = the total number of miscarriages or elective abortions What is likely the diagnosis of lower abdomen pain? - ✔Appendicitis, ectopic pregnancy What is syncope? - ✔Fainting; passing out What is the medical term for a bloody nose? - ✔Epistaxis What is the medical term for bruise? - ✔Ecchymosis
Who would read your HPI other than your doctor? - ✔PCP, lawyers, coders, insurance companies, etc. WNL - ✔Within Normal Limits