Medical scribe 101 Actual final exam Graded A+

normal heart rate - ANSWER-60-100 bpm normal heart rate for infants/babies - ANSWER-120-160 bpm tachy - ANSWER-too fast tachy for adults - ANSWER->100 tacky for infants/babies - ANSWER->160 brady - ANSWER-too slow Brady for adults - ANSWER-<60 Brady for infants/babies - ANSWER-<120 respiratory rate - ANSWER-12-20 bpm respiratory rate for infants/babies - ANSWER-30-50 bpm tachypneic for adults - ANSWER->20 tachypneic for infants/babies - ANSWER->50 bradypneic for adults - ANSWER-<12 bradypneic for infants/babies - ANSWER->30 normal blood pressure for adults - ANSWER-90/60-140/90 hypertensive for adults - ANSWER->140/90 hypotensive for adults - ANSWER-<90/60 hypertensive for infants/babies - ANSWER->120 hypotensive for s - ANSWER-<50 normal body temperature - ANSWER-97-99 degrees afebrile - ANSWER-98.6-100.4 fever is higher than...? - ANSWER-100.4 high temperature is also called - ANSWER-ferbrile low temperature is also called - ANSWER-hypothermic oxygen saturation - ANSWER->96% 95-100 oxygen saturation is... - ANSWER-the amount of oxygen your body needs for balance. fraction saturated hemoglobin relative to total hemoglobin in the blood. basically how much oxygen is in your blood emergency versus urgent care - ANSWER-emergency is life or death and urgent care is where you can't wait for an appointment the team - ANSWER-provider, advance practice providers, nurses or medical assistants, technicians, and scribe -itis - ANSWER-infection/inflammation -osis - ANSWER-disease of -ectomy - ANSWER-surgical removal of -otomy - ANSWER-hole or opening subjective - ANSWER-what the patient tells you objective - ANSWER-what the provider says pain - ANSWER-what the patient tells us they have tenderness - ANSWER-something a provider finds on an exam past medical history abbreviation - ANSWER-PMHx arthroscopic- - ANSWER-joint osteo- - ANSWER-bone -algia - ANSWER-pain myo- - ANSWER-muscle A- - ANSWER-not hepa- - ANSWER-liver hypertension abbreviation - ANSWER-HTN hyperlipidernia (high cholesterol) abbreviation - ANSWER-HTD diabetes mellitus abvreviation - ANSWER-DM non-insulin dependent diabetes mellitus abbreviation - ANSWER-NIDDM NIDDM - ANSWER-type 2 diabetes, from lack of exercise/poor diet, only takes pill insulation dependent diabetes mellitus abbreviation - ANSWER-IDDM IDDM - ANSWER-either type 1 or 2, takes shots of insulin cancer abbreviation - ANSWER-CA heart disease abbreviation - ANSWER-CAD, coronary artery disease heart attack abbreviation - ANSWER-MI, myocardial infarction heart failure abbreviation - ANSWER-CHF, congestive heart failure abnormal rhythm is called - ANSWER-arrhythmias emphysema/chronic bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease (COPD) blood clot in the lung - ANSWER-Pulmonary Embolism (PE) pneumonia abbreviation - ANSWER-PNA reflux is - ANSWER-Gastroesophageal Reflux Disease (GERD) pancreatitis - ANSWER-inflammation of the pancreas Hepatitis - ANSWER-inflammation of the liver Diverticulitis - ANSWER-inflammation of the diverticula Crohn's disease/ ulcerative colitis - ANSWER-Crohn's Disease or UC Irritale Bowel Syndrome abbreviation - ANSWER-IBS kidney infection is called - ANSWER-pyelonephritis (pyelo) kidney stones are also called - ANSWER-renal calculi chronic kidney disease abbreviation - ANSWER-CKD end stage renal disease abbreviation - ANSWER-ERSD benign prostatic hypertrphy abbreviation - ANSWER-BPH, enlarged prostate what does GPA stand for? - ANSWER-gravida, para, abortus gravida - ANSWER-total number of times the patient has been pregnant para - ANSWER-number of pregnancies that resulted in viable births abortus - ANSWER-total number of miscarriages or elective abortions stroke is also called - ANSWER-Cerebrovascular Accident (CVA) Brain bleed, also a stroke - ANSWER-hermorrhagic cerebrovascular accident (CVA) brain blockage or clot is also called - ANSWER-ischemic cerebrovascular accident (CVA) mini stroke is also called - ANSWER-transient ischemic attack, TIA lower extremity deep vein thrombosis - ANSWER-DVT "blood clot in the lung" aortic aneurysm - ANSWER-bulge in aorta most common aortic aneurysm - ANSWER-abdominal aortic aneurysm, AAA peripheral vascular disease abbreviation - ANSWER-PVD, "bad blood flow in the legs" peripheral neuropathy - ANSWER-"numbness in my legs" weak/fragile bones is a condition called - ANSWER-osteoporosis patho means - ANSWER-relating to disease physiology means... - ANSWER-the branch of biology persistent positives - ANSWER-associated to chief complaints persistent negative - ANSWER-what someone doesn't have chronic - ANSWER-3 or more months acute - ANSWER-less than 3 months comorbities - ANSWER-simultaneous presence of two chronic diseases or conditions in a patient hypertension risks factors - ANSWER-Fix of HTN, obesity, DM, high sodium diet, smoking, and ETOH chief complaints of HTN - ANSWER-headache, chest pain, palpitations, blurred vision, epistaxis physical examination OF HTN - ANSWER-lower extremity edema, carotid bruit, JVD, abnormal heart sounds JVD - ANSWER-jugular vein distention type 1 diabetes - ANSWER-when your body can't make insulin, more rare, only 5%, strong family component and a autoimmune process type 2 diabetes - ANSWER-difficult using insulin, more common, still a family history component, largely based on social history symptoms of DM - ANSWER-frequent thirst, urination, poor healing, and blurred vision due to poor circulation what is hyperlipidernia? - ANSWER-when fats from food turn into fatty deposits in your arteries. fat travels to your blood and starts to stick to the sides of the arteries, eventually causing decrease blood flow or complete blockage bad cholesterol abbreviation - ANSWER-LDL good cholesterol abbreviation - ANSWER-HDL hyperlipidernia risk factors - ANSWER-obesity, high lipid diet, physical inactivity, Fox, DM, ETOH use hyperlipidernia Dx by - ANSWER-blood work measuring cholesterol and triglyceride levels LDL (low density lipoprotein) Hypertension Dx by - ANSWER-BP check and monitoring with sphygmomanometer treatment of HLD - ANSWER-getting fatty deposits and plaques out, done with statins what is CAD? - ANSWER-when he coronary arteries become hard and narrow due to cholesterol and fatty deposits. strains the walls and denies the body sufficient blood and oxygen CAD risk factors - ANSWER-HTN, DM, and HLD. smoking, obesity, lack of physical activity, or injury to heart muscle CAD symptoms - ANSWER-chest pain, typically aggravated by activity and exertion CAD Dx by - ANSWER-a cardiologist during a procedure called cardiac cauterization, inserts a flexible tube or Cather into patients peripheral veins. Catheter is then threaded up to the here injecting dye CAD treatment - ANSWER-meds and lifestyle changes angioplasty is with the - ANSWER-balloon what's a myocardial infarction - ANSWER-a heart attack, generally caused by a blockage which then causes lack of blood and muscle unjust and death strep pharyngitis - ANSWER-infection in the throat. bacterial therefore treated with antibiotics otitis media - ANSWER-ear infection, in the middle ear with fluid build up degenerative disc disease, DDD - ANSWER-deterioration in the cushioning between disc ectopic pregnancies - ANSWER-when a women becomes pregnant, the egg is suppose to to attach and develop in the uterus, instead the egg attaches outside the uterus, most commonly in the Fallopian tube Ectopic Pregnancy Risk Factors - ANSWER-sexual infections, past tubal surgeries, smoking, past use of an IUD, and fertility treatments ectopic pregnancy treatments - ANSWER-meds or surgical removal of the tissue torsion - ANSWER-act of twisting; stress due to twisting forces exerted on a body, cutting off blood supply Cellulitis - ANSWER-Infection of skin cells C.diff - ANSWER-opportunistic bacteria that causes persistent diarrhea gastroenteritis - ANSWER-vomiting or diarrhea, "GI bug", often viral or bacterial gastritis - ANSWER-irritated stomach with vomiting, "stomach ache" pericarditis - ANSWER-inflammation of the sac surrounding the heart causing CP pleurisy - ANSWER-inflammation of the sac surrounding the lungs causing pleuritic CP costochondritis - ANSWER-irritation of the ribs causing CP worsened by pressing on the sternum pleural effusion - ANSWER-fluid collecting around the lungs causing SOB or CP S.O.A.P - ANSWER-subjective, objective, assessment, plan CC - ANSWER-chief complaint HPI - ANSWER-history of present illness ROS - ANSWER-review of systems pt - ANSWER-patient c/o - ANSWER-complains of y/o - ANSWER-years old c - ANSWER-with s - ANSWER-without auscultation - ANSWER-listening, usually with a stethoscope palpatation - ANSWER-the act of pressing on an area of the body Auscultation of the heart - ANSWER-heart rate, rhythm, and heart sounds auscultating of the lungs - ANSWER-patient's lung sounds anterior - ANSWER-toward the front of the body posterior - ANSWER-toward the back of the body medial - ANSWER-toward the midline lateral - ANSWER-away from the midline