Scribeology Common Diagnoses & Procedures

Amputation

Surgical or traumatic removal of an appendage

Angioplasty

Surgical opening up of a coronary artery

Appendectomy

Surgical removal of the appendix

Auscultation

the process of listening to the body using a stethoscope

Biopsy

Sampling of tissue from an abnormal area such as a lump or tumor

CABG

Coronary Artery Bypass Graft - usage of a mechanical or organic vessel to repair a blocked coronary artery

Cataract surgery

Surgical removal of a clouded lens of the eye

Cesarean section

delivery of a baby through a surgical incision in the abdomen

Cholecystectomy

surgical removal of the gall bladder

Colostomy

Surgical hole in the colon allowing fecal matter to be removed without passing through the rectum

CPR

Cardiopulmonary resuscitation - rescue breaths and chest compressions to restore breathing after the heart stops

Cystectomy

Surgical removal of the bladder

Debridement

Removal of dead tissue or foreign material from an open wound

Discharge

Doctor's order that a patient is ready to go home from a hospital or surgical facility

Gastric Balloon

Weight loss surgery - balloon placed inside the stomach to reduce space for food

Gastric Banding

Weight loss surgery - surgical band placed at the top of the stomach restricting maximum food intake

Hemorrhoidectomy

Surgical removal of an inflamed vein in the rectum or anus

Hernia repair

Surgical correction of an intestine that has pushed into a muscle or body cavity

Hysterectomy

Surgical removal of the uterus

Informed consent

Written permission for a procedure indicating understanding of its purpose risks and benefits

Injection

Introduction of a medication or chemical into the body by way of a needle

Internal/External Fixation

Surgical repair and setting of a bone

Intubation

Placement of a tube down the trachea to facilitate breathing

Joint replacement

Replacement of a knee hip or shoulder joint with an artificial one

Lithotripsy

Breaking up kidney stones with sound waves so they can be passed in urine

Lumbar Puncture

Withdrawal of cerebrospinal fluid through a needle inserted between L4 and L5 vertebrae - also called spinal tap

Mastectomy

Surgical removal of one or both breasts

Nephrectomy

Surgical removal of a kidney

Oophorectomy

Surgical removal of the ovaries

Orchiectomy

Surgical removal of the testicle

Paracentesis

Perforation of a body cavity or cyst to remove extraneous fluid or gas

Pericardiocentesis

Procedure where a syringe is inserted into the chest to drain fluid from the pericardium

Roux en Y Gastric Bypass

Weight loss surgery - surgical bypass of the stomach and part of the small intestine

Spinal Fusion

Back surgery

Stent Placement

Placement of a hollow tube into a blocked or collapsed blood vessel or ureter

Tonsillectomy

Surgical removal of one or both pharyngeal tonsils

Tracheotomy

An incision in the windpipe made to relieve an obstruction to breathing

Tubal Ligation

Tying off of the Fallopian tubes

Vertical Sleeve Gastrectomy

Weight loss surgery - stapling of the stomac

Cataract

Clouding of eye lens

Conjunctivitis

Inflammation of outer membrane of the eye

Corneal Abrasion

Scratch on the cornea

Nystagmus

Involuntary irregular eye movement

Orbital fracture

A fracture of the bony socket that holds the eyeball

Ptosis

Drooping of the eyelid

Retinal Detachment

When the back color sensitive part of the eye pulls away from the supportive tissue

Stye

Red painful lump near the edge of the eyelid

Allergic Rhinitis

allergic response causing itchy watery eyes and sneezing

Dental Abscess

bacterial infection of the soft tissue around a tooth

Dental Caries

cavity

Dental Fracture

broken tooth

Dysphagia

difficulty or discomfort in swallowing

Epistaxis

Nosebleed

Hemotympanum

blood behind the eardrum

Middle Ear Effusion

fluid buildup within the middle ear

Otitis externa

An infection of the outer ear

Otitis media

An infection of the middle ear

Peritonsillar Abscess

bacterial infection of pharynx around the tonsils secondary to a streptococcus infection

Pharyngitis

Inflammation of the mucous membranes and parts of the pharynx

Tympanic Rupture

tear in the eardrum

Asthma

Inflammation of the airways and production of extra mucous causing shortness of breath

Atelectasis

Partial or total collapse of the lung

Bronchitis

Inflammation of the bronchi

Chronic Obstructive Pulmonary Disease

A group of lung diseases that block airflow and make it difficult to breathe most commonly associated with long term smoking

Cystic Fibrosis

a lung disease that causes production of thick mucus in the lungs hampering breathing

Hemothorax

Blood in the lung cavity

Pleurisy

Inflammation of the pleural cavity

Pneumonia

Infection and inflammation of the air sacs in one or both lungs due to fluid buildup

Pneumothorax

Air in the pleural cavity outside of the lung organs

Upper Respiratory Infection

Bacterial or Viral Infection of the pharynx

Abdominal Aortic Aneurysm

Enlargement and rupture of the lower part of the aorta

Anemia

a condition in which the blood does not have enough red blood cells

Angina Pectoris

Cardiac chest pain that is not a Myocardial Infarction

Arrhythmia

Improper heartbeat

Asystole

condition where the heart is no longer beating

Atrial Fibrillation

Irregular rapid heart rate caused by irregular electrical activity in the heart

Cardiomegaly

Enlarged heart

Congestive Heart Failure

Chronic condition where the heart loses its ability to effectively pump blood

Costochondritis

Inflammation of the costal cartilage

Deep venous thrombosis

blood clot in a deep vein most typically in the legs

Hypertension

High Blood Pressure

Myocardial infarction

heart attack - coronary artery occluded

Palpitation

Awareness of one's own heartbeat or feelings of heart racing

Peripheral Vascular Disease

Condition of narrowing of the outer blood vessels reducing blood flow to the limbs

Pulmonary Embolus

When one of the major arteries in the lungs becomes blocked with a blood clot

STEMI (ST Elevation Myocardial Infarction)

Heart Attack characterized by elevation of the ST wave on an EKG

Ventricular Tachycardia

Pulse of more than 100 bpm with at least 3 irregular heartbeats in a row

Anal Fissure

Small tear in the lining of the anus

Appendicitis

inflammation of the appendix

Ascites

Accumulation of serous fluid in the abdominal cavity

Cholecystitis

Infection or Inflammation of the lining of the gallbladder

Cholelithiasis

gall stones

Cirrhosis

Chronic liver damage causing scarring and liver failure

Diverticulitis

Inflammation or infection of the diverticula in the intestines

Diverticulosis

Condition of having small pouches in the lining of the colon that bulge outward through weak spots

Gastritis

inflammation of the stomach lining

Gastroesophageal reflux disease

Disease caused by the regurgitation of bile from the stomach into the esophagus

Gastroenteritis

Inflammation of the GI tract involving stomach and small intestine

Hemorrhoids

swollen and inflamed veins in the rectum and anus causing discomfort and bleeding

Hepatosplenomegaly

Enlargement of spleen and liver