Scribe America final exam (THOROUGH)

very thorough study set for scribe america final or for medical charting

patient complain

HPI or ROS

high blood pressure (layman’s)

Hypertension

Hypertension Abbv

HTN

high cholesterol layamn’s

hyperlipidemia

diabetes

diabetes mellitus

diabetes abbv

DM

only take pills for diabetes

non insulin dependent diabetes mellitus NIDDM

take shots for diabetes

insulin dependent diabetes mellitus IDDM

heart disease

usually coronary artery disease

heart attack

myocardial infarction (MI) and CAD

heart failure

congestive heart failure CHF

irregular heartbeat

arrhythmia

emphysema or chronic bronchitis

chronic obstructive pulmonary disease COPD

bloot clot in lungs

pulmonary embolism PE

pneumonia or lung infection

pneumonia PNA

acid reflux/ heart burn layman’s

gastroesophagael reflux disease GERD

ulcers

gastric ulcer or peptic ulcer disease PUD

irritable bowels

irritable bowel syndrome IBS

kidney infection

pyelonephritis

“im on dialysis”

chronic kidney disease CKD on dialysis

enlarged prostate

benign prostatic hyperplasia BPH

stroke

cerebrovascular accident CVA

blood clot in brain

ischemic CVA

brain bleed

hemorrhagic CVA

mini stroke

transient ischemic attack TIA

blood clot in legs

deep vain thrombosis DVT

bulge in my aorta

aortic aneurysm

bad blood flow in legs

peripheral vascular disease PVD

cancer

cancer carcinoma

spread to my…

with metastasis to the..

the cut it out

status- post surgical resection

its gone

in remission

neck arteries cleaned

carotid endarterectomy

leg amputated

above knee amputation AKA or below knee amputation BKA

joint repair

arthroplasty

ballon in my heart

angioplasty PMHx CAD

stents in my heart

coronary stents PMHx CAD

heart bypass

coronary artery bypass graft CABG PMHx CAD

breast removed

masectomy

part of my lung removed

partial lobectomy

gallbladder removed

cholecystectomy

part of colon removed

partial colectomy

spleen removed

splenectomy

kidney removed

nephrectomy

uterus removed

hysterectomy

ovaries removed

oophorectomy

ear tubes

pressure equalizer PE tube

heart cath

cardiac catheterization

what is in the RUQ

gallbladder

what is in the RLQ

appendix

what is in the LUQ

pancreas

what is in the LLQ

large intestines

ovary + fallopian tube removed

salpingo-oophorectomy

tubes tied (female)

tubal ligation

c section

cesarean section

uterine product removed (abortion)

dilation and curettage D&C

brain surgery

craniotomy (brain bleed vs brain CA)

chronic

longer than 3 months

comorbititty

2 or more chronic conditions/ diseases (more complex)

systolic blood pressure

pressure in the arteries (heart beats)

diastolic blood pressure

pressure of arteries in between heart beats

diabetes medications (injected)

humalog, Lantus, and sliding scale

diabetes medicine (oral)

metformin and glyburide

HTN etiology

an increase in blood pressure causes excess force against the arterial walls, damaging arteries over time

type 2DM etiology

the inadequacy of insulin in controlling the blood glucose level (insulin resistance)

HLD etiology

an elevated level of lipid in the blood causes plaque build up along arterial walls

CAD etiology

narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia

HTN risk factors

FHx of HTN, obesity, high sodium diet, smoking, ETOH

type2 DM risk factors

FHx of DM, obesity, high carb diet, lack of exercise

HLD risk factors

FHx of HLD, obesity, high lipid diet (high in saturated fats), ETOH, physical inactivity

CAD risk factors

HTN, HLD, DM, smoking, FHx <55 y/o

medicine for HTN

Lisinopril (Zestril)

HTN how to diagnose

blood pressure reading

DM how to diagnose

blood glucose reading/ hemoglobin A1c

HLD how to diagnose

bloodwork (lipid panel) measuring cholesterol and triglyceride levels-elevated LDC

CAD how to diagnose

cardiac catheterization by cardiologist

Medication for HLD

any medication ending in “statin” is used to treat it atorvastin

true allergic reaction symptoms

itching, swelling, rash, hives, shortness of breath

Patient complaint where to chart

HPI or ROS

past diagnoses/ surgeries where to chart

past history

physician’s observations where to chart

physical exam

labs, imaging, studies where to chart

results

current diagnoses where to chart

assessment

treatment plan where to chart

plan

high blood sugar (layman’s)

hyperglycemia

low blood sugar (layman’s)

hypoglycemia

cerebral vascular accident (abbreviation)

CVA

peripheral vascular disease (abbreviation)

PVD

chronic obstructive pulmonary disease (abbreviation)

COPD

gastroesophageal reflux disease (layman’s)

GERD

transient ischemic attack (abbreviation)

TIA

chronic kidney disease (abbreviation)

CKD

benign prostatic hyperplasia (abbreviation)

BPH

Insulin Dependent Diabetes Mellitus (abbreviation)

IDDM

Non Insulin Dependent Diabetes Mellitus (abbreviation)

NIDDM

Myocardial Infarction (abbreviation)

MI

Coronary Artery Disease (abbreviation)

CAD

Congestive Heart Failure (abbreviation)

CHF

Pulmonary Embolism (abbreviation)

PE

Pneumonia (abbreviation)

PNA