SCRIBE

High blood pressure layman's

Hypertension

Hypertension (abbv)

HTN

High cholesterol layman's

Hyperlipidemia

Hyperlipidemia (abbv)

HLD

Diabetes layman's

Diabetes mellitus

Diabetes mellitus (abbv)

DM

"I only take pills for my diabetes"

NIDDM (Type 2)

"I take insulin for my diabetes"

IDDM (Type 1)

Heart disease layman's

Usually coronary artery disease

Coronary artery disease (abbv)

CAD

Heart failure layman's

Congestive heart failure

Congestive heart failure (abbv)

CHF

Irregular heartbeat layman's

Atrial fibrillation (A-fib)

Murmur layman's

Heart murmur

Episodes of abnormally fast/racing heartbeat

Supraventricular tachycardia

Supraventricular tachycardia (abbv)

SVT

Emphysema or chronic bronchitis layman's

Chronic obstructive pulmonary disease (COPD)

Blood clot in lung layman's

Pulmonary embolism (PE)

Pneumonia (abbv)

PNA

Reflux layman's

Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (abbv)

GERD

Ulcer layman's

Gastric ulcer or Peptic ulcer disease

Crohn's or UC layman's

Crohn's disease or Ulcerative colitis

Irritable bowel layman's

Irritable bowel syndrome (IBS)

Irritable bowel syndrome (abbv)

IBS

Bladder infection layman's

Urinary tract infection (UTI)

Kidney infection layman's

Pyelonephritis (Pyelo)

Kidney stones layman's

Renal calculi

"I'm on dialysis"

Chronic renal failure (CRF) or End stage renal disease (ESRD) on dialysis

Enlarged prostate layman's

Benign prostate hypertrophy (BPH)

Document GPA for a pt who is currently pregnant, has been pregnant 3 times in the past, and has 2 kids at home.

G: 4 P:2 A:1

Stroke layman's

Ischemic cerebrovascular accident (CVA)

"Mini-stroke" layman's

Transient ischemic attack (TIA)

Seizures layman's

Seizure disorder / Epilepsy

Brain bleed layman's

Hemorrhagic CVA

Bipolar layman's

Bipolar disorder

Schizophrenia layman's

Schizophrenia

"I drink a lot"

EtOH abuse or Alcoholism

"I do drugs"

Substance abuse

"Blood clot in my leg"

Lower extremity deep vein thrombosis (DVT)

"Bulge in my aorta" or "Triple A"

Abdominal aortic aneurysm (AAA)

"Bad blood flow to my legs"

Peripheral vascular disease (PVD)

"Numbness in my legs"

Peripheral neuropathy (caused by DM)

"Low back pain"

Chronic lower back pain

"Bulging/herniated disc"

Degenerative disc disease (DDD)

Osteoarthritis (abbv)

(OA)

Rheumatoid arthritis (abbv)

RA

"Chronic joint pain"

Degenerative joint disease (DJD)

"Weak/fragile bones"

Osteoporosis (usually)

"Cancer"

Cancer or carcinoma (CA) and specify which (brain, breast, lung, colon, skin...)

"Spread to my..."

With metastases to the...

"Chemo"

Chemotherapy

"Radiation"

Radiation therapy

"They cut it out"

Status-post (s/p) surgical resection

"The cancer is gone"

In remission

Tonsils removed

Tonsillectomy

Adenoids removed

Adenoidectomy

"Ear tubes"

Pressure equalizer (PE) tubes

"Heart bypass"

Coronary artery bypass graft (CABG) (also PMHx CAD)

"Stents"

Coronary stents (also PMHx CAD)

"Heart cath"

Cardiac catheterization

"Balloon"

Angioplasty (also PMHx CAD)

"Pacer"

Pacemaker

"Breast removal"

Mastectomy

"Hole in my neck"

Tracheostomy ("trach")

"Part of my lung removed"

Partial lobectomy

Gallbladder removed

Cholecystectomy

"Part of my colon removed"

Partial colectomy

Spleen removed

Splenectomy

"Stomach stapled"

Gastric bypass

What's in the RUQ?

Gallbladder

What's in the RLQ?

Appendix

What's in the LUQ?

Pancreas

What's in the LLQ?

Large intestines

Kidney removed

Nephrectomy

Uterus removed

Hysterectomy (partial vs. total)

Ovary removed

Oophorectomy

Ovary and fallopian tubes removed

Salpingo-oophorectomy

"Tubes tied"

Tubal ligation (female) or Vasectomy (male)

"C-section"

Cesarean section

Prostate removed

Prostatectomy

Uterine product removed (Abortion)

Dilation and curettage (D&C)

"Neck artery cleaned"

Carotid endarterectomy

"Brain surgery"

Craniotomy (brain bleed vs. brain CA)

"Shunt" (hydrocephalus)

Ventriculoperitoneal (VP) shunt

"Dialysis fistula"

AV (arteriovenous) fistula

"Dialysis graft"

AV (arteriovenous) graft

"PICC line"

Peripherally inserted central catheter (PICC)

"Clot filter" (lower abdomen)

IVC (inferior vena cava) filter

"Clot filter" (leg)

Greenfield filter

"Leg amputated"

Above knee amputation (AKA) or Below knee amputation (BKA)

"Joint repair"

Arthroplasty

"Metal plates/pins"

Hardware

"Neck fused"

Cervical spinal fusion

"Back fused"

Lumbar spinal fusion

"Hip surgery"

Open reduction with internal fixation (ORIF)

Characteristics of a true allergy?

Rash, itching, swelling, difficulty breathing

2/2

Secondary to / Because of

Medial term for redness

Erythema

Medical term for bruising

Ecchymosis