Medical Terminology Review Guide for ScribeAmerica Exam 2024, Exams of Nursing

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ScribeAmerica Final Exam Review Question & ANSWERS 2024 AAA - Correct Answers ✅Abdominal Aortic Aneurysm A Fib - Correct Answers ✅Atrial Fibrillation Abd - Correct Answers ✅Abdomen, Abdominal Abx - Correct Answers ✅Antibiotics AMA - Correct Answers ✅Against Medical Advice AMS - Correct Answers ✅Altered Mental Status ASA - Correct Answers ✅Acetylsalicylic Acid (Aspirin) BID - Correct Answers ✅Twice Daily Bilat LE - Correct Answers ✅Bilateral Lower Extremities BM - Correct Answers ✅Bowel Movement BP - Correct Answers ✅Blood Pressure ScribeAmerica Final Exam Review Question & ANSWERS 2024 CA - Correct Answers ✅Cancer, Carcinoma CABG - Correct Answers ✅Coronary Artery Bypass Graft, "open heart surgery" CAD - Correct Answers ✅Coronary Artery Disease, "heart disease" CT or CAT - Correct Answers ✅Computerized Assisted Tomography CHF - Correct Answers ✅Congestive Heart Failure COPD - Correct Answers ✅Chronic Obstructive Pulmonary Disease CP - Correct Answers ✅Chest Pain CPR - Correct Answers ✅Cardiopulmonary Resuscitation C-section - Correct Answers ✅Caesarean Section C-spine - Correct Answers ✅Cervical Spine (neck) ScribeAmerica Final Exam Review Question & ANSWERS 2024 HEENT - Correct Answers ✅Head, Eyes, Ears, Nose, Throat HPI - Correct Answers ✅History of Present Illness HTN - Correct Answers ✅Hypertension Hx - Correct Answers ✅History H&H - Correct Answers ✅Hemoglobin & Hematocrit H&P - Correct Answers ✅History of Present Illness & Physical Exam I&D - Correct Answers ✅Incision & Drainage IDDM - Correct Answers ✅Insulin Dependent Diabetes Mellitus IUP - Correct Answers ✅Intrauterine Pregnancy IVDA - Correct Answers ✅IV Drug Abuse JVD - Correct Answers ✅Jugular Vein Distension ScribeAmerica Final Exam Review Question & ANSWERS 2024 LLE - Correct Answers ✅Left Lower Extremity LLQ - Correct Answers ✅Left Lower Quadrant LNMP - Correct Answers ✅Last Normal Menstrual Period LOC - Correct Answers ✅Loss of Consciousness LP - Correct Answers ✅Lumbar Puncture L-Spine - Correct Answers ✅Lumbar Spine LUE - Correct Answers ✅Left Upper Extremity LUQ - Correct Answers ✅Left Upper Quadrant MCA - Correct Answers ✅Motorcycle Accident MI - Correct Answers ✅Myocardial Infarction ScribeAmerica Final Exam Review Question & ANSWERS 2024 MVA/MVC - Correct Answers ✅Motor Vehicle Accident/Motor Vehicle Collision N/A - Correct Answers ✅Not Applicable NAD - Correct Answers ✅No Acute Disease, No Acute Distress NIDDM - Correct Answers ✅Non-Insulin Dependent Diabetes Mellitus NKDA - Correct Answers ✅No Known Drug Allergies Nml -or- nl - Correct Answers ✅Normal NSAID - Correct Answers ✅Non-Steroidal Anti-Inflammatory Drug NSR - Correct Answers ✅Normal Sinus Rhythm NTG - Correct Answers ✅Nitroglycerin N/V/D - Correct Answers ✅Nausea/Vomiting/Diarrhea ScribeAmerica Final Exam Review Question & ANSWERS 2024 Rx - Correct Answers ✅Prescription r/o - Correct Answers ✅Rule Out SOB - Correct Answers ✅Shortness of Breath s/p - Correct Answers ✅Status Post (after) Sx - Correct Answers ✅Symptoms TIA - Correct Answers ✅Transient Ischemic Attack TID - Correct Answers ✅Three Times a Day TM - Correct Answers ✅Tympanic Membrane T-Spine - Correct Answers ✅Thoracic Spine Tx - Correct Answers ✅Treatment ScribeAmerica Final Exam Review Question & ANSWERS 2024 UA - Correct Answers ✅Urinalysis URI - Correct Answers ✅Upper Respiratory Infection US - Correct Answers ✅Ultrasound UTD - Correct Answers ✅Up To Date UTI - Correct Answers ✅Urinary Tract Infection WNL - Correct Answers ✅Within Normal Limits AKA - Correct Answers ✅Above The Knee Amputation SBO - Correct Answers ✅Small Bowel Obstruction h/o - Correct Answers ✅history of DFP - Correct Answers ✅Dorsal Fetal Pulse PCN - Correct Answers ✅Penicillin ScribeAmerica Final Exam Review Question & ANSWERS 2024 LAD - Correct Answers ✅Left Axis Deviation SVT - Correct Answers ✅Super Ventricular Tachycardia IV - Correct Answers ✅Intravenous IVP - Correct Answers ✅Intravenous Push IVPB - Correct Answers ✅Intravenous Piggy-Back IM - Correct Answers ✅Intramuscular SQ - Correct Answers ✅Subcutaneous PR - Correct Answers ✅Per Rectum SL - Correct Answers ✅Sub-lingual gtt - Correct Answers ✅Drops ScribeAmerica Final Exam Review Question & ANSWERS 2024 PTX - Correct Answers ✅Pneumothorax PNA - Correct Answers ✅Pneumonia CV - Correct Answers ✅Cardiovascular GERD - Correct Answers ✅Gastro-Esophageal Reflux Disease, "acid reflux" What is GPA? - Correct Answers ✅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 - Correct Answers ✅Abdominal CT w/ PO - Correct Answers ✅CT Abd/Pel with PO contract DC'd - Correct Answers ✅Discharged Home ScribeAmerica Final Exam Review Question & ANSWERS 2024 Number of physical exam elements needed for Level 5 - Correct Answers ✅8 elements (at least 1 finding in 8 different organ systems) Number of HPI elements needed for Level 5 - Correct Answers ✅4 elements Number of ROS elements needed for Level 5 - Correct Answers ✅10 elements Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5 - Correct Answers ✅2 elements Name the vital signs - Correct Answers ✅blood pressure, respiratory rate, heart rate, oxygen saturation, temperature What does HIPAA stand for? - Correct Answers ✅Health Insurance Portability and Accountability Act What does PHI stand for? - Correct Answers ✅Protected Health Information ScribeAmerica Final Exam Review Question & ANSWERS 2024 What are the 6 rules of HIPAA? - Correct Answers ✅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? - Correct Answers ✅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 - Correct Answers ✅Hypertension (HTN) High cholesterol - Correct Answers ✅Hyperlipidemia (HLD) Thyroid problem - Correct Answers ✅Usually Hypothyroidism, sometimes Hyperthyroidism Diabetes - Correct Answers ✅Diabetes Mellitus (DM) ScribeAmerica Final Exam Review Question & ANSWERS 2024 Bladder infection - Correct Answers ✅Urinary Tract Infection (UTI) Kidney infection - Correct Answers ✅Pyelonephritis (Pyelo) Kidney stones - Correct Answers ✅Renal calculi "I'm on dialysis" - Correct Answers ✅Chronic Renal Failure (CRF) on dialysis Enlarged prostate - Correct Answers ✅Benign Prostate Hypertrophy (BPH) Stroke - Correct Answers ✅Cerebrovascular Accident (CVA) Mini-stroke - Correct Answers ✅Transient Ischemic Attack (TIA) Seizures - Correct Answers ✅Seizure disorder/Epilepsy Brain bleed - Correct Answers ✅Hemorrhagic CVA Bipolar - Correct Answers ✅Bipolar disorder ScribeAmerica Final Exam Review Question & ANSWERS 2024 Schizophrenia - Correct Answers ✅Schizophrenia "I drink a lot" - Correct Answers ✅Alcoholism or EtOH abuse "Blood clot in my leg" - Correct Answers ✅Lower Extremity Deep Vein Thrombosis "Bulge in my aorta" - Correct Answers ✅Abdominal Aortic Aneurysm (AAA) "Bad blood flow in my legs" - Correct Answers ✅Peripheral Vascular Disease (PVD) Low back pain - Correct Answers ✅Chronic Low Back Pain Bulging/herniated disc - Correct Answers ✅Degenerative Disc Disease (DDD) Arthritis - Correct Answers ✅Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) ScribeAmerica Final Exam Review Question & ANSWERS 2024 Join pain (chronic) - Correct Answers ✅Degenerative Joint Disease (DJD) Weak/fragile bones - Correct Answers ✅Osteoporosis Cancer - Correct Answers ✅Cancer or Carcinoma (CA) Spread to my... - Correct Answers ✅With metastases to the... Chemo - Correct Answers ✅Chemotherapy Radiation - Correct Answers ✅Radiation therapy They cut it out - Correct Answers ✅Status-post surgical resection It's gone - Correct Answers ✅In remission Tonsils removed - Correct Answers ✅Tonsillectomy Adenoids removed - Correct Answers ✅Adenoidectomy ScribeAmerica Final Exam Review Question & ANSWERS 2024 Ovary removed - Correct Answers ✅Oophorectomy Ovary and fallopian tubes removed - Correct Answers ✅Salpingo- oophorectomy Tubes tied - Correct Answers ✅Tubal ligation (female) or Vasectomy (male) Prostate removed - Correct Answers ✅Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) Neck artery cleaned - Correct Answers ✅Carotid Endarterectomy Brain surgery - Correct Answers ✅Craniotomy Shunt - Correct Answers ✅Ventriculoperitoneal (VP) Shunt Dialysis fistula - Correct Answers ✅AV (arteriovenous) Fistula Dialysis graft - Correct Answers ✅AV Graft ScribeAmerica Final Exam Review Question & ANSWERS 2024 PICC Line - Correct Answers ✅Peripherally Inserted Central Catheter (PICC) Port - Correct Answers ✅Port-a-cath or Medi-Port Clot filter (lower abdomen) - Correct Answers ✅IVC (inferior vena cava) Filter Clot filter (leg) - Correct Answers ✅Greenfield Filter Leg amputated - Correct Answers ✅Above Knee Amputation (AKA) Below Knee Amputation (BKA) Joint repair - Correct Answers ✅Arthroplasty Metal plates/pins - Correct Answers ✅Hardware Neck fused - Correct Answers ✅Cervical spinal fusion Back fused - Correct Answers ✅Lumbar spinal fusion ScribeAmerica Final Exam Review Question & ANSWERS 2024 This surgery is performed to remove a portion of the intestines - Correct Answers ✅Colectomy This hyphenated surgery would indicate the patient is missing both an ovary and a fallopian tube. - Correct Answers ✅Salpingo- Oophorectomy An erythematous TM would be abnormal for this body part. - Correct Answers ✅Ear --> indicates ear infection To check for JVD, what would be examined? - Correct Answers ✅Neck The presence of fluctuance would indicate this body tissue and would likely require I&D. - Correct Answers ✅Abscess This is the medical term used to describe redness. - Correct Answers ✅Erythema; injection Pedal edema is used to describe what? - Correct Answers ✅CHF Blood is the urine is called what? - Correct Answers ✅Hematuria ScribeAmerica Final Exam Review Question & ANSWERS 2024 What are the main differences between HPI and ROS? - Correct Answers ✅HPI focuses on chief complaint; ROS is a check from head to toe Who would read your HPI other than your doctor? - Correct Answers ✅PCP, lawyers, coders, insurance companies, etc. Are cough and fever related? - Correct Answers ✅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? - Correct Answers ✅What happened prior to episode, during episode, after episode, and their current status in the ED What is syncope? - Correct Answers ✅Fainting; passing out How do you document a normal radial pulse? - Correct Answers ✅Right radial pulse 2+ How do you document a neck pulse/carotid pulse? - Correct Answers ✅Right carotid pulse 2+ ScribeAmerica Final Exam Review Question & ANSWERS 2024 How do you document a pulse on top of the foot? - Correct Answers ✅Dorsal pedis pulse 2+ How do you document a pulse on the heal? - Correct Answers ✅Posterior Tibialis Pulse 2+ What are examples of PHI? - Correct Answers ✅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? - Correct Answers ✅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? - Correct Answers ✅PE and PNA What is diagnosed when elevated Troponin is present? - Correct Answers ✅MI What is likely the diagnosis of lower abdomen pain? - Correct Answers ✅Appendicitis, ectopic pregnancy ScribeAmerica Final Exam Review Question & ANSWERS 2024 What are all of the possible elements of an HPI? - Correct Answers ✅Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity