Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Scribe America > Scribe U Study > Flashcards

Scribe U Study Flashcards

(79 cards)

Start Studying
1
Q

CC

A

Main Reason for visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

EMR/EHR

A

Electronic medical/ health record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Subjective

A

Feeling- PT says

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Objective

A

Factual finding, observed, Dx test, and what provider says- or observes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

New Patient

A

Over 3 yrs since seen, or brand new - takes longer, detailed charting needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Established Patient

A

Last note was less than 3yrs, shorter visit, Update chart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Types of visits

A

Diagnostic & Health Management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Diagnostic Visits

A

New Problem, CC: New Sx; Goal is to determine the cause of the problem & appropriate treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Health Management Visits

A

Check up, CC: Routine Physical or manage chronic problems; Goal is preventative care and/or assessing progress of ongoing medical problems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Whats in the assessment

A

Current Diagnoses, summary of visits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Whats in the plan

A

Instructions, medications, and when & where to f/u at

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

High blood pressure

A

High blood pressure (HTN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

High Cholesterol

A

Hyperlipidemia (HLD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Diabetes Mellitus

A

DM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Heart Disease

A

Coronary Artery Disease (CAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Whats CAD

A

Narrowing of the coronary Arteries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Heart Failure

A

(CHF) Congestive Heart Failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Irregular Heart beat

A

Arrhythmia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Emphysema

A

Chronic Bronchitis (COPD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Blood clot in the lung

A

Pulmonary Embolism (PE)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Pneumonia or Lung Infection

A

PNA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Reflux/heartburn

A

Gastroesophageal (GERD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Gastric ulcer

A

PUD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Kidney Infection

A

Pyelonephritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
"I'm on dialysis"
Chronic kidney Disease (CKD) on dialysis
26
Enlarged Prostate
Benign Prostatic Hypertrophy (BPH)
27
Stroke
Cerebrovascular Accident (CVA)
28
"Blood clot in the brain"
Ischemic Stroke ~lack of blood supply~
29
Brain bleed
Hemorrhagic Stroke ~blood vessel Rupture~
30
"mini stroke"
Transient Ischemic (TIA) ~sx last hour or less~
31
"Blood clot in the leg"
(DVT) Deep vein thrombosis
32
"bulge in the aorta"
Aortic Aneurysm
33
"bad blood flow in the legs"
Peripheral Vascular Disease (PVD)
34
"speed to my..."
With Metastases to the …
35
"they cut it out"
Status post surgical Resection
36
"its gone"
In remission
37
Rash, itching, swelling or difficulty breathing
True Reaction
38
no rash, itching, swelling or difficulty breathing
Adverse reaction
39
Tonsils Removed
Tonsillectomy
40
Adenoids Removal
Adenoidectomy
41
"Neck arteries cleared"
Carotid Endarterectomy
42
Joint Repair
Arthoplasty
43
"Balloon in heart"
Angioplasty (PMHx CAD)
44
"stents in heart"
Coronary Stents (PMHx CAD)
45
Heart Bypass/ "open heart surgery"
Coronary Artery Bypass Graft (CABG)
46
Breast Removal
Mastectomy
47
"part of my lung was removed"
Partial Lobectomy
48
Appendix Removed
Appendectomy
49
Gallbladder removed
Cholecystectomy
50
Part of the colon remove
Partial Colectomy
51
Spleen Removed
Splenectomy
52
Kidney Removed
Nephrectomy
53
Uterus Removed
Hysterectomy
54
Ovary Removed
oophorectomy
55
Ovary & fallopian tube removal
Salpingo-oophorectomy
56
Comorbidities
Two chronic diseases; increases the complexity of pt care )complex pt)
57
HTN
An increase of blood pressure causes excess force against the arterial walls. usually starts with headache, but usually no sx
58
Systolic
The pressure in the arteries when heart contracts
59
Diastolic
The pressure in arteries when relaxed
60
Hypo during HTN (states numerical)
less than 90 :sys Less than 60: Dia
61
Normal BP Readings
90/60 to 120/80
62
Pre-hypertension
121/81 to 140/90
63
HTN
140/90 or over
64
What does HTN lead to?
Impaired vision, CVA, CAD, and Kidney Failure
65
Non- medication control for HTN
Low sodium diet, Exercise 30min 3x per week, no smoking & EtOH, Keep Log at home
66
Medications of HTN
ACE Inhibitors, Ca Channel Blockers, Diuretics, and ARBs
67
Diabetes type 1
Insulin Insufficiency. pancreases is unable to produce insulin. ALWAYS treated with insulin
68
Diabetes type 2
Insulin Resistance. Consistently high blood glucose levels cause cells to become resistant to insulin. can be treated with diet changes, non-insulin meds or insulin. SHx factors include diet & exercise.
69
Sx of DM 2
unusual weight gain, or loss, polyuria, polydipsia, blurred vision, N/V
70
What can DM lead to, related to other chronic illnesses?
Diabetic Retinopathy (hemorrhage of small vessels), CAD, Renal/ Kidney failure, Peripheral artery disease (PVD) ~decreased blood flow to extremities), neuropathy (high blood glucose causing distal paresthesia & extreme pain)
71
Non medical management of DM
Low carb diet, exercise, weight loss and blood glucose log
72
Medication of DM
Injected: Humalog, Lantus, and sliding scale Oral: Metformin, and glyburide
73
What is humalog?
Rapid acting, known as "meal time insulin"
74
What is Lantus?
Long acting insulin, injected once daily
75
What is the sliding scale regarding medication?
Insulin dosage based on current glucose
76
What is metformin?
Long acting (insulin medication), taken w/meals
77
What is Glyburide?
Induces pancreas to produce insulin; taken with meals
78
HLD
An elevated level of lipid in the blood causes plaque build up along arterial walls
79
Risk factors of HLD
FHx of HLD, obesity, high lipid diet (saturated fats), etoh, physical inactivity

Scribe America (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions