ScribeAmerica Final Exam Review, Exams of Advanced Education

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ScribeAmerica Final Exam Review key words

AAA - Abdominal Aortic Aneurysm A Fib - Atrial Fibrillation Abd - Abdomen, Abdominal Abx - Antibiotics AMA - Against Medical Advice AMS - Altered Mental Status ASA - Acetylsalicylic Acid (Aspirin) BID - Twice Daily Bilat LE - Bilateral Lower Extremities BM - Bowel Movement BP - Blood Pressure CA - Cancer, Carcinoma CABG - Coronary Artery Bypass Graft, "open heart surgery" CAD - Coronary Artery Disease, "heart disease" CT or CAT - Computerized Assisted Tomography CHF - Congestive Heart Failure COPD - Chronic Obstructive Pulmonary Disease CP - Chest Pain CPR - Cardiopulmonary Resuscitation

C-section - Caesarean Section C-spine - Cervical Spine (neck) CSF - Cerebrospinal Fluid CVA - Cerebrovascular Accident - or- Costovertebral Angle CXR - Chest X-Ray c/o - complains of DKA - Diabetic Ketoacidosis DM - Diabetes Mellitus DNR - Do Not Resuscitate DOE - Dyspnea On Exertion DVT - Deep Venous Thrombosis Dx - Diagnosis Dz - Disease EKG/ECG - Electrocardiogram EtOH - Alcohol FHx - Family History Fx - Fracture GI - Gastrointestinal G/P/Ab - Gravida/Para/Abortion GSW - Gun Shot Wound GU - Genitourinary HA - Headache

HEENT - Head, Eyes, Ears, Nose, Throat HPI - History of Present Illness HTN - Hypertension Hx - History H&H - Hemoglobin & Hematocrit H&P - History of Present Illness & Physical Exam I&D - Incision & Drainage IDDM - Insulin Dependent Diabetes Mellitus IUP - Intrauterine Pregnancy IVDA - IV Drug Abuse JVD - Jugular Vein Distension LLE - Left Lower Extremity LLQ - Left Lower Quadrant LNMP - Last Normal Menstrual Period LOC - Loss of Consciousness LP - Lumbar Puncture L-Spine - Lumbar Spine LUE - Left Upper Extremity LUQ - Left Upper Quadrant MCA - Motorcycle Accident MI - Myocardial Infarction MVA/MVC - Motor Vehicle Accident/Motor Vehicle Collision

N/A - Not Applicable NAD - No Acute Disease, No Acute Distress NIDDM - Non-Insulin Dependent Diabetes Mellitus NKDA - No Known Drug Allergies Nml - or- nl - Normal NSAID - Non-Steroidal Anti-Inflammatory Drug NSR - Normal Sinus Rhythm NTG - Nitroglycerin N/V/D - Nausea/Vomiting/Diarrhea O2 Sat - Oxygen Saturation (a.k.a. SaO2) OD - Overdose PCP - Primary Care Physician (a.k.a. PMD) PE - Pulmonary Embolism - or- Physical Exam PERRL - Pupils are equal, round, and reactive to light PO - Per Os (by mouth) prn - As needed pt - patient PTA - Prior To Arrival PUD - Peptic Ulcer Disease qd - Every Day qh - Every Hour qhs - At Every Bedtime

q2h - Every 2 Hours QID - Four Times a Day RLE - Right Lower Extremity RLQ - Right Lower Quadrant ROM - Range of Motion ROS - Review of Systems RUE - Right Upper Extremity RUQ - Right Upper Quadrant Rx - Prescription r/o - Rule Out SOB - Shortness of Breath s/p - Status Post (after) Sx - Symptoms TIA - Transient Ischemic Attack TID - Three Times a Day TM - Tympanic Membrane T-Spine - Thoracic Spine Tx - Treatment UA - Urinalysis URI - Upper Respiratory Infection US - Ultrasound UTD - Up To Date

UTI - Urinary Tract Infection WNL - Within Normal Limits AKA - Above The Knee Amputation SBO - Small Bowel Obstruction h/o - history of DFP - Dorsal Fetal Pulse PCN - Penicillin LAD - Left Axis Deviation SVT - Super Ventricular Tachycardia IV - Intravenous IVP - Intravenous Push IVPB - Intravenous Piggy-Back IM - Intramuscular SQ - Subcutaneous PR - Per Rectum SL - Sub-lingual gtt - Drops Drip - Intravenous Drip Neb - Inhaled Nebulizer Patch - Transdermal These 2 lab test,which are part of the 7 basic chemistries, will be high in someone with renal failure. - Urea and creatinine

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. This lab test will be high in patient with pancreatitis. - Lipase 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 abbreviation is used to describe a heart attack. - MI This abbreviation is used to describe diabetes. - DM This abbreviation is used to describe a normal heart rhythm. - NSR RBBB is the abbreviation used to describe this medical term, which would indicate an abnormal EKG finding. - Right Bundle Branch Block CVA is used medically as an abbreviation for a cerebral vascular accident, as well as this location of the body. - Costovertebral Angle This surgery is performed to remove the appendix. - Appendectomy STEMI - ST Elevation Myocardial Infarction BCP - Birth Control Pill PTX - Pneumothorax PNA - Pneumonia CV - Cardiovascular GERD - Gastro-Esophageal Reflux Disease, "acid reflux" 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 No rebound, no guard - Abdominal CT w/ PO - CT Abd/Pel with PO contract DC'd - Discharged Home

Number of physical exam elements needed for Level 5 - 8 elements (at least 1 finding in 8 different organ systems) Number of HPI elements needed for Level 5 - 4 elements Number of ROS elements needed for Level 5 - 10 elements Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5 - 2 elements Name the vital signs - blood pressure, respiratory rate, heart rate, oxygen saturation, temperature What does HIPAA stand for? - Health Insurance Portability and Accountability Act What does PHI stand for? - Protected Health Information 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 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. High blood pressure - Hypertension (HTN) High cholesterol - Hyperlipidemia (HLD) Thyroid problem - Usually Hypothyroidism, sometimes Hyperthyroidism Diabetes - Diabetes Mellitus (DM) "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) Heart disease - Usually Coronary Artery Disease (CAD)

Heart attack - Myocardial Infarction (MI) and CAD Heart failure - Congestive Heart Failure (CHF) Irregular heartbeat - Atrial Fibrillation (A-Fib) Murmur - Heart murmur Episodes of abnormally fast/racing heartbeat - Supraventricular Tachycardia (SVT) Asthma - Asthma Emphysema/Chronic Bronchitis - Chronic Obstructive Pulmonary Disease (COPD) Blood clot in lung - Pulmonary Embolism (PE) Pneumonia - Pneumonia (PNA) Reflux - Gastroesophageal Reflux Disease (GERD) Ulcer - Gastric Ulcer or Peptic Ulcer Disease Pancreatitis - Pancreatitis Hepatitis - Hepatitis A, Hepatitis B, or Hepatitis C Diverticulitis - Diverticulitis Crohn's/UC - Crohn's Disease or Ulcerative Colitis Irritable bowel - Irritable Bowel Syndrome (IBS) Bladder infection - Urinary Tract Infection (UTI) Kidney infection - Pyelonephritis (Pyelo) Kidney stones - Renal calculi "I'm on dialysis" - Chronic Renal Failure (CRF) on dialysis Enlarged prostate - Benign Prostate Hypertrophy (BPH) Stroke - Cerebrovascular Accident (CVA)

Mini-stroke - Transient Ischemic Attack (TIA) Seizures - Seizure disorder/Epilepsy Brain bleed - Hemorrhagic CVA Bipolar - Bipolar disorder Schizophrenia - Schizophrenia "I drink a lot" - Alcoholism or EtOH abuse "Blood clot in my leg" - Lower Extremity Deep Vein Thrombosis "Bulge in my aorta" - Abdominal Aortic Aneurysm (AAA) "Bad blood flow in my legs" - Peripheral Vascular Disease (PVD) Low back pain - Chronic Low Back Pain Bulging/herniated disc - Degenerative Disc Disease (DDD) Arthritis - Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) Join pain (chronic) - Degenerative Joint Disease (DJD) Weak/fragile bones - Osteoporosis Cancer - Cancer or Carcinoma (CA) Spread to my... - With metastases to the... Chemo - Chemotherapy Radiation - Radiation therapy They cut it out - Status-post surgical resection It's gone - In remission Tonsils removed - Tonsillectomy Adenoids removed - Adenoidectomy

Ear tubes - Pressure Equalizer (P.E.) Tubes Heart bypass - Coronary Artery Bypass Graft (CABG) --> PMHx CAD Stents - Coronary Stents --> PMHx CAD Heart cath - Cardiac catheterization Balloon - Angioplasty --> PMHx CAD Valve surgery - Valve repair or replacement (Bovine vs. Mechanical) Pacer - Pacemaker Defibrillator - Automatic Implanted Cardiac Defibrillator (AICD) Surgery for Afib - Afib s/p cardiac ablation Breast removal - Mastectomy hole in my neck - Tracheostomy (commonly called a "trach") Part of my lung removed - Partial lobectomy Appendix removed - Appendectomy Gallbladder removed - Cholecystectomy Hernia repair - Herniorrhaphy Part of my colon removed - Partial colectomy Bag to collect stool - Colostomy Spleen removed - Splenectomy Stomach stapled - Gastric bypass Uterus removed - Hysterectomy Ovary removed - Oophorectomy Ovary and fallopian tubes removed - Salpingo-oophorectomy

Tubes tied - Tubal ligation (female) or Vasectomy (male) Prostate removed - Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) Neck artery cleaned - Carotid Endarterectomy Brain surgery - Craniotomy Shunt - Ventriculoperitoneal (VP) Shunt Dialysis fistula - AV (arteriovenous) Fistula Dialysis graft - AV Graft PICC Line - Peripherally Inserted Central Catheter (PICC) Port - Port-a-cath or Medi-Port Clot filter (lower abdomen) - IVC (inferior vena cava) Filter Clot filter (leg) - Greenfield Filter Leg amputated - Above Knee Amputation (AKA) Below Knee Amputation (BKA) Joint repair - Arthroplasty Metal plates/pins - Hardware Neck fused - Cervical spinal fusion Back fused - Lumbar spinal fusion This surgery is performed to remove a portion of the intestines - Colectomy This hyphenated surgery would indicate the patient is missing both an ovary and a fallopian tube. - Salpingo-Oophorectomy An erythematous TM would be abnormal for this body part. - Ear --> indicates ear infection To check for JVD, what would be examined? - Neck

The presence of fluctuance would indicate this body tissue and would likely require I&D. - Abscess This is the medical term used to describe redness. - Erythema; injection Pedal edema is used to describe what? - CHF Blood is the urine is called what? - Hematuria What is the medical term for bruise? - Ecchymosis What is the medical term for a bloody nose? - Epistaxis Kidney removal - Nephrectomy Fast breathing rate - Tachypnea Black tarry stools - Melena Runny noise - Rhinorrhea Sweating - Diaphoresis Pain with urination - Dysuria Acute blockage of artery that provides blood to brain - CVA (Cerebrovascular Accident) Collapse lung due to trauma or a spontaneous small rupture of the lung - Pneumothorax Ischemic and infarct of the interior lateral myocardium - MI 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 What are the 4 types of focal neurological deficits? - Changes in speech, vision, strength, and sensation What are the main differences between HPI and ROS? - HPI focuses on chief complaint; ROS is a check from head to toe

Who would read your HPI other than your doctor? - PCP, lawyers, coders, insurance companies, etc. Are cough and fever related? - Yes, when it could go either way, definitely put it in HPI 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 is syncope? - Fainting; passing out How do you document a normal radial pulse? - Right radial pulse 2+ How do you document a neck pulse/carotid pulse? - Right carotid pulse 2+ How do you document a pulse on top of the foot? - Dorsal pedis pulse 2+ How do you document a pulse on the heal? - Posterior Tibialis Pulse 2+ What are examples of PHI? - date of birth, social security number, diagnosis, what tests were run, what the results of the tests were 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. If someone comes in complaining about dyspnea, what are the 2 major diseases to worry about? - PE and PNA What is diagnosed when elevated Troponin is present? - MI What is likely the diagnosis of lower abdomen pain? - Appendicitis, ectopic pregnancy What are all of the possible elements of an HPI? - Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity