Download Medical Terminology and Abbreviations and more Exams Advanced Education in PDF only on Docsity! Vituity scribe EXAM 1&2 Questions and Answers Plantar - Answer- Sole side of foot Plantar flexion - Answer- Foot movement when toes flex down (pointing your toes) Supine - Answer- Body lying face up (chest up and back down) Afebrile - Answer- without fever diaphoresis - Answer- excessive sweating dysuria - Answer- painful urination emesis - Answer- vomiting epistaxis - Answer- bleeding from the nose gait - Answer- a person's manner of walking hematochezia - Answer- Bright red, bloody stools hematuria - Answer- blood in the urine hemoptysis - Answer- coughing up blood incontinence - Answer- inability to control bowel movements or urine myocardial infarction (MI) - Answer- heart attack pruritis - Answer- itching syncope - Answer- fainting vertigo - Answer- Condition of dizziness, "room spinning" cyanosis - Answer- bluish discoloration of the skin laceration - Answer- to cut Bradycardia - Answer- slow heart rate Tachycardia - Answer- fast heart rate apnea - Answer- absence of breathing gravid - Answer- pregnant melena - Answer- Black tarry stool colectomy - Answer- surgical removal of the colon mastectomy - Answer- surgical removal of a breast ABG - Answer- arterial blood gas Afib - Answer- atrial fibrillation AMI - Answer- acute myocardial infarction CAD - Answer- coronary artery disease CBC - Answer- complete blood count COPD - Answer- chronic obstructive pulmonary disease CSF - Answer- cerebrospinal fluid CXR - Answer- chest x-ray DKA - Answer- diabetic ketoacidosis DNR - Answer- do not resuscitate DVT - Answer- deep vein thrombosis GERD - Answer- gastroesophageal reflux disease GSW - Answer- gun shot wound I&D - Answer- incision and drainage LMP - Answer- last menstrual period MI - Answer- myocardial infarction ROS definition - Answer- A list of question arranged by organ system that the provider asks a patient during the process of taking a history. It is designated to uncover dysfunction and disease social history, SHX - Answer- Tobacco use, alcohol use (ETOH), illicit drug use, occupation, living circumstances PMHx, PSHx, FHx, SHx - Answer- Past medical history, past surgical history, family history, social history HPI - Answer- subjective information, third person epigastric region, periumbilical region, pelvic region - Answer- superior to the umbilical region ESI - Answer- Emergency Severity Index Level 5 chart - Answer- HPI- 4 ROS-10 PFSH-2 PE-8 ESI-1 RED Cardiac arrest Level 4 chart - Answer- HPI- 4 ROS-2-9 PFSH-1 PE-2-7 ESI-2 Orange Level 3 chart - Answer- HPI- 1-3 ROS-1 PFSH-0 PE-2 ESI-3 YELLOW Level 2 chart - Answer- HPI- 1-3 ROS-1 PFSH-0 PE-2 ESI-4 Laceration GREEN Level 1 Chart - Answer- HPI- 1-3 ROS-0 PFSH-0 PE-0 ESI-5 Medication refill BLUE DM - Answer- diabetes mellitus HLD - Answer- hyperlipidemia (high cholesterol) hysterectomy - Answer- surgical removal of the uterus oophorectomy - Answer- surgical removal of an ovary SOAP - Answer- subjective, objective, assessment, plan Subjective - Answer- information from the patient Includes: HPI, Chief Complaint, ROS Objective - Answer- Information from the provider Includes: Vital signs, PE, orders, results Assessment - Answer- the patients diagnosis A short description of progress since last visit Plan - Answer- Follow-up and treatment plan for each diagnosis Chief Complaint (CC) - Answer- The primary reason(s) that brought the patient to the ED Does every level of billing require a chief complaint - Answer- PQRST - Answer- palliative/provoking, quality, radiation, severity, timing O-PQRST - Answer- Onset of the event Provocation or palliation Quality of the plan Region and radiation Severity Time (history) PMFSH - Answer- past medical, family, social history ICD-10 - Answer- A system to classify and code diagnoses, symptoms, and procedures The patients diagnosis
