Medical Scribe (Scribe101) Exam Study Guide Graded A+

vital signs - ANSWER-a series of measures that give an overview of a patient's overall health; heart rate, respiratory rate, blood pressure, body temperature, oxygen saturation heart rate - ANSWER-the rate that your heart is pumping blood (beats per minute) (normal: 60-100 bpm) respiratory rate - ANSWER-rate of someone's breathing (breaths per minute) (normal: 12-20 breaths per minute) blood pressure - ANSWER-the pressure at which blood is being pumped throughout your body (normal 90/60-140/90) (systolic over diastolic) body temperature - ANSWER-measure of your body's ability to make and get rid of heat (normal: 98.6-100.4) oxygen saturation - ANSWER-the saturation of oxygen in your blood (normal: 95-100%) tachycardic - ANSWER-fast heart rate, above 100 bpm bradycardic - ANSWER-slow heart rate, below 60 bpm tachypneic - ANSWER-fast respiratory rate, above 20 breaths per minute bradypnea - ANSWER-slow respiratory rate, below 12 breaths per minute hypertensive - ANSWER-high blood pressure (>140/90) hypotensive - ANSWER-low blood pressure (<90/60) afebrile - ANSWER-no fever febrile - ANSWER-high body temperature, fever (>98.6) hypothermic - ANSWER-low body temperature (<98.6) hypoxic - ANSWER-low oxygen saturation (<95%) emergency care - ANSWER-life threatening conditions that require hospitalization urgent care - ANSWER-illness or injury that does not appear to be life threatening but can't wait until the next day in-patient care - ANSWER-care of patients whose condition requires admission to a hospital out-patient care - ANSWER-medical procedures, tests, and services that can be provided to the patient in a setting that doesn't involve an overnight hospital stay provider - ANSWER-They have usually obtained a doctoral degree in medicine or the specialty they practice. They diagnose and treat the patient. (physician or specialist doctor) advanced practice providers - ANSWER-People who studied and obtained a medical degree that allows them to see patients, sometimes under the supervision of a physician or sometimes on their own (nurse practitioner, P.A.) nurses or medical assistants - ANSWER-Nurses are trained in assisting with medical care, procedures, administering medicine, and more. Medical Assistants are more common in Outpatient clinics, as they do not need to perform the full scope of tasks as nurses do. They require less training. technicians - ANSWER-Trained in either certain equipment, specialties, or to assist with patients! For example, a respiratory technician helps the ER with emergency cases, coming in where patients can't breathe and require respiratory equipment. medical scribe - ANSWER-Responsible for charting the patient's visit and making sure it's accurate and represents the providers efforts and what the patient told us. The chart should make sense with what the patient came in with and their diagnosis! While scribes don't do patient care, we make sure that patient's are taken care of by us taking care of the provider! tachy - ANSWER-fast brady - ANSWER-slow hyper - ANSWER-above hypo - ANSWER-below itis - ANSWER-infection/inflammation osis - ANSWER-disease of ectomy - ANSWER-surgical removal of arthro - ANSWER-joint osteo - ANSWER-bone chole - ANSWER-bile otomy - ANSWER-hole or opening algia - ANSWER-pain subjective - ANSWER-what the patient tells us, ex. pain objective - ANSWER-what the provider and results tell us, ex. tenderness medical history - ANSWER-any prior medical problems that include chronic medical problems, past surgeries, allergies to medications family history - ANSWER-direct family members with a medical problem and includes all of the same medical histories; always note age of family history to determine if genetic social history - ANSWER-any history that occurs in daily life including alcohol use, smoking or tobacco/nicotine, occupation, and living status high blood pressure - ANSWER-Hypertension (HTN) high cholesterol - ANSWER-Hyperlipidemia (HLD) diabetes - ANSWER-Diabetes Mellitus (DM) only pills for diabetes - ANSWER-Non-Insulin dependent diabetes Mellitus (NIDDM) (type II) insulin shots for diabetes - ANSWER-Insulin Dependent Diabetes Mellitus (IDDM) (type I or type II) cancer - ANSWER-cancer or carcinoma (CA) heart disease - ANSWER-Coronary Artery Disease (CAD) heart attack - ANSWER-Myocardial Infarction (MI) and CAD heart failure - ANSWER-Congestive Heart Failure (CHF) abnormal rhythm - ANSWER-Arrhythmias, ex. atrial fibrillation asthma - ANSWER-asthma Emphysema/Chronic Bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease (COPD) blood clot in lung - ANSWER-Pulmonary Embolism (PE) pneumonia - ANSWER-Pneumonia (PNA) reflux - ANSWER-Gastroesophageal Reflux Disease (GERD) pancreatitis - ANSWER-pancreatitis hepatitis - ANSWER-hepatitis Diverticulitis - ANSWER-Diverticulitis Crohn's/UC - ANSWER-Crohn's Disease or Ulcerative Colitis irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS) bladder infection - ANSWER-Urinary Tract Infection (UTI) kidney infection - ANSWER-Pyelonephritis (Pyelo) can happen when unresolved UTI goes to kidney kidney stones - ANSWER-renal calculi i'm on dialysis - ANSWER-chronic kidney disease (CKD) end stage renal disease (ESRD) on dialysis enlarged prostate - ANSWER-Benign Prostate Hypertrophy (BPH) GPA - ANSWER-G (gravida)- total number of times patient has been pregnant P (para)- number of pregnancies resulting in live birth A (abortus)- number of miscarriages or abortions stroke - ANSWER-Cerebrovascular Accident (CVA) brain bleed - ANSWER-Hemorrhagic Cerebrovascular Accident (CVA) brain blockage or clot - ANSWER-Ischemic Cerebrovascular Accident (CVA) mini-stroke - ANSWER-Transient Ischemic Attack (TIA) blood clot in leg - ANSWER-Lower Extremity Deep Vein Thrombosis (DVT) bulge in aorta - ANSWER-Aortic Aneurysm ex. Abdominal Aortic Aneurysm (AAA) bad blood flow to legs - ANSWER-Peripheral Vascular Disease (PVD) numbness in legs - ANSWER-Peripheral Neuropathy low back pain - ANSWER-Chronic Low Back Pain arthritis - ANSWER-Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) Weak/fragile bones - ANSWER-osteoporosis tomy - ANSWER-incision cutting into ectomy - ANSWER-removal ostomy - ANSWER-creating opening/hole rrhaphy or plasty - ANSWER-surgical repair tonsils removed - ANSWER-Tonsillectomy adenoids removed - ANSWER-Adenoidectomy ear tubes - ANSWER-Pressure Equalizer (P.E.) Tubes heart cath - ANSWER-cardiac catherization (diagnoses CAD) balloon - ANSWER-Angioplasty --> PMHx CAD stents - ANSWER-Coronary Stents --> PMHx CAD heart bypass - ANSWER-Coronary Artery Bypass Graft (CABG) --> PMHx CAD breast removal - ANSWER-mastectomy hole in neck - ANSWER-Tracheostomy (commonly called a "trach") part of lung removed - ANSWER-Partial lobectomy appendix removed - ANSWER-appendectomy gallbladder removed - ANSWER-cholecystectomy hernia repair - ANSWER-Herniorrhaphy part of colon removed - ANSWER-Partial colectomy bag to collect stool - ANSWER-colostomy spleen removed - ANSWER-splenectomy stomach stapled - ANSWER-bariatric surgery kidney removed - ANSWER-nephrectomy uterus removed - ANSWER-hysterectomy ovary removed - ANSWER-Oophorectomy Ovary and fallopian tubes removed - ANSWER-Salpingo-oophorectomy tubes tied - ANSWER-Tubal ligation (female) or Vasectomy (male) c-section - ANSWER-cesarean section prostate removed - ANSWER-Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) uterine product removed - ANSWER-Dilation and Curettage (D&C) neck artery cleaned - ANSWER-carotid endarterectomy shunt - ANSWER-cerebral shunt brain surgery - ANSWER-Craniotomy (brain bleed vs. brain CA) dialysis fistula - ANSWER-AV (arteriovenous) Fistula dialysis graft - ANSWER-AV graft PICC line - ANSWER-Peripherally Inserted Central Catheter (PICC) port - ANSWER-Port-a-cath or Medi-Port Clot filter (lower abdomen) - ANSWER-IVC (inferior vena cava) filter leg amputated - ANSWER-Above Knee Amputation (AKA) Below Knee Amputation (BKA) joint repair - ANSWER-arthroplasty Metal plates/pins - ANSWER-hardware signs of a true allergic reaction - ANSWER-swelling, SOB (dyspnea) due to airway swelling, itching, rash (SIR) signs of an adverse reaction - ANSWER-nausea/vomiting, abdominal pain, diarrhea, dizziness Pathophysiology - ANSWER-bodily processes associated with diseases or injuries associated symptoms - ANSWER-symptoms that a patient has pertinent negatives - ANSWER-specific symptoms that are not present which cause the physician to doubt certain diagnoses chronic - ANSWER-having a symptom or disease for 3 months or longer acute - ANSWER-injuries and illnesses that started less than 3 months ago comorbidity - ANSWER-the simultaneous presence of two chronic diseases or conditions in a patient comorbidities increase health risk - ANSWER-1. treatment of one disease may affect or contradict treatment of second 2. increased risk of organ failure if illnesses affect specific organ system 3. symptoms may lead to poor compliance with treatment plan Hypertension (HTN)- High blood pressure - ANSWER-pressure of blood coming from heart is too high; causes thinning of arteries because of constant pressure on artery walls HTN risk factors - ANSWER-FHx of HTN, obesity, DM (diabetes), high sodium diet, smoking, ETOH (alcohol) CC (common complaints) of HTN - ANSWER-- often asymptomatic - hypertension (measuring at home) - headache, chest pain, palpitations, blurred vision, epistaxis (usually present when HTN begins to affect other organ systems) PE (physical examination) of HTN - ANSWER-congestive heart failure (CHF), lower extremity edema, carotid bruit, jugular vein distention (JVD), abnormal heart sounds Dx of HTN by - ANSWER-BP check and monitoring with sphygmomanometer Treatment of HTN - ANSWER-lifestyle changes and medication lifestyle changes include: weight loss, regular exercise, smoking cessation, maintaining a low sodium diet Diametes Mellitus (DM)- diabetes - ANSWER-glucose or sugar content in blood is too high Type I DM - ANSWER-pancreas unable to produce insulin, autoimmune disease, strong FHx, only 5% of DM patients, need to take shots of insulin, IDDM Type II DM - ANSWER-high blood glucose levels in blood, SHx factors, 95% of DM patients, treated with diet change, non-insulin meds, or insulin (bc can be IDDM or NIDDM) Symptoms of DM - ANSWER-frequent thirst, frequent urination, poor healing, blurred vision, neuropathy, paresthesia Diagnoses of DM - ANSWER-measuring glucose levels in blood Treatment of Type I DM - ANSWER-insulin (insulin shots or insulin pump) Treatment of Type II DM - ANSWER-lifestyle changes: losing weight, exercise, low carb and low sugar diet medication: oral meds or eventually insulin shots Hyperlipidemia (HLD)- High cholesterol - ANSWER-fats fro food turn into fatty deposits in arteries that cause decrease blood flow or complete blockage Risk Factors of HLD - ANSWER-obesity, high lipid diet, physical inactivity, FHx, DM, ETOH use Dx of HLD by - ANSWER-bloodwork measuring cholesterol and triglyceride levels- elevated LDL (low density lipoprotein) Symptoms of HLD - ANSWER-asymptomatic Diagnoses of HLD - ANSWER-checking levels of cholesterol through fasting blood work. Test is called total cholesterol, and LDL and HDL tell us if proportions of good vs. bad cholesterol are okay. Treatment of HLD - ANSWER-Medications: statins Coronary Artery Disease (CAD)- Heart disease - ANSWER-coronary arteries become hard and narrow due to cholesterol and fatty deposits Risk Factors of CAD - ANSWER-HTN, DM, HLD, cigarette smoking, obesity, lack of physical activity, FHx Symptoms of CAD - ANSWER-chest pain, aggravated by activity and exertion Diagnoses of CAD - ANSWER-cardiac catheterization- catheter inserted into vein and dye reveals blockages or narrow vessels Treatment of CAD - ANSWER-medicine to open up blood vessels and thin blood, medications to help w blockages and buildup, lifestyle changes like smoking cessation, better diet, regular exercise Surgical Treatments for CAD - ANSWER-cardiac catheterization, angioplasty (balloon), coronary stents, coronary artery bypass graft (CABG) ENT - ANSWER-ear, nose, throat Strep Pharyngitis - ANSWER-sore throat and redness with difficulty swallowing; bacterial infection so treated with antibiotics Otitis Media - ANSWER-ear infection of the middle ear; decreasing hearing; can lead to eardrum rupture; generally resolve on their own, but antibiotics given after 48 hours; can become chronic and then need to be treated with ear tubes Musculoskeletal System - ANSWER-muscles around the skeleton Back Pain - ANSWER-injury or strain on muscle Bulging Discs - ANSWER-herniated; spines intervertebral disc becomes misaligned and bulges out, which pinches and pushes against nerve; treatment includes medication for inflammation and pain or even surgery Degenerative Disc Disease (DDD) - ANSWER-deterioration of cushioning between discs; treatments include medication for pain and inflammation or even surgery to remove damaged disk fragments or replace them the extremities - ANSWER-outer parts of body like arms and legs; broken bones; evaluated w xrays or MRIs; treatment includes pain and inflammation management Genitourinary System - ANSWER-GU, urination and genitals Urinary Tract Infection (UTI) - ANSWER-part of urinary tract is infection, often the urethra;