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Scribe America > ScribeU Outline > Flashcards

ScribeU Outline Flashcards

1
Q

New Patient

A

A patient that has never been seen at the clinic, or was seen greater than three years ago
-no previous records
-Longer visit
-Detailed chart

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2
Q

Established Patient

A

A patient that has been seen at the clinic by any provider within the last three years
-previous records available
-shorter visit
-concise chart

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3
Q

Diagnostic visit

A

-New problem
-CC of new symptom
-goal is to determine the cause of the problem and the appropriate treatment

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4
Q

Health Management Visit

A

-Check up
-CC of routine physical management or chronic problems
-Goal is preventative care and/or assessing progress of ongoing medical problems

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5
Q

DDx

A

Differential diagnosis

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6
Q

What is the correct order of the SOAP note?

A

-Subjective complains
-Objective evaluation
-Assessment
-Plan

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7
Q

HPI

A

Hx of the present illness
-story and context of the CC

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8
Q

ROS

A

Review of Systems
-head to toe list of positive and negatives

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9
Q

Past History

A

-medical
-surgical
-social
-family

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10
Q

PE

A

Physical exam
-the physician’s objective findings

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11
Q

Orders and results

A

any results from labs/xrays/bloodwork

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12
Q

Assessment

A

current diagnosis

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13
Q

Plan

A

Treatment plan and follow up

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14
Q

HTN

A

Hypertension
high blood pressure

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15
Q

HLD

A

Hyperlipidemia
high cholesterol

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16
Q

DM

A

Diabetes mellitus

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17
Q

CAD

A

Coronary Artery Disease
heart disease

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18
Q

MI

A

myocardial infarction
heart attack

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19
Q

CHF

A

Congestive heart failure
heart failure

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20
Q

Arrhythmia

A

irregular heartbeat

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21
Q

COPD

A

chronic obstructive pulmonary disease
-emphysema
-chronic bronchitis

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22
Q

PE (PMHx)

A

Pulmonary embolism
-blood clot in the lung

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23
Q

PNA

A

Pneumonia
pneumonia or lung infection

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24
Q

GERD

A

gastroesophageal reflux disease

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25
Q

PUD

A

gastric ulcers or peptic ulcer disease

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26
Q

IBS

A

irritable bowel syndrome

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27
Q

UTI

A

urinary tract infection

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28
Q

Pyelonephritis

A

kidney infection

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29
Q

CKD on dialysis

A

Chronic kidney disease on dialysis

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30
Q

BPH

A

Benign prostatic hyperplasia
enlarged prostate

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31
Q

CVA

A

Cerebrovascular accident’
stroke

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32
Q

Ischemic CVA

A

blood clot in the brain

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33
Q

Hemorrhagic CVA

A

brain bleed

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34
Q

TIA

A

Transient ischemic attack
mini stroke

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35
Q

DVT

A

deep vein thrombosis

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36
Q

Aortic Aneurysm

A

bulge in the aorta

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37
Q

PVD

A

peripheral vascular disease

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38
Q

CA

A

cancer or carcinoma

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39
Q

“With metastasis to the…”

A

cancer spread

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40
Q

status-post surgical resection

A

“they cut it out” or “cancer removal”

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41
Q

Tonsil removal

A

tonsillectomy

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42
Q

Adenoids removed

A

adenoidectomy

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43
Q

Carotid endarterectomy

A

surgery to treat carotid artery disease

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44
Q

AKA

A

above knee amputation

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45
Q

BKA

A

below knee amputation

46
Q

Arthroplasty

A

joint repair

47
Q

Mastectomy

A

breast removal

48
Q

Partial lobectomy

A

part of the lung is removed

49
Q

Cholecystectomy

A

gallbladder removed

50
Q

Appendectomy

A

appendix removed

51
Q

Partial colectomy

A

part of the colon removed

52
Q

Splenectomy

A

spleen removed

53
Q

Nephrectomy

A

kidney removed

54
Q

Hysterectomy

A

uterus removed

55
Q

Oophorectomy

A

ovary removal

56
Q

A younger age of — onset means higher genetic risk

A

under 55

57
Q

What is listed under SHx

A

Alcohol use
tobacco/vaping
drug use
occupation
living circumstances

58
Q

Chronic disease

A

An illness that lasts longer than 3 months

59
Q

Comorbidity

A

The simultaneous presence of two chronic diseases or conditions in a patient

60
Q

Having a comorbidity will increase a patient’s —

A

complexity and health risk

61
Q

How is HTN diagnosed?

A

BP reading. usually takes several high readings to confirm HTN

62
Q

Systolic blood pressure

A

measures the pressure in the arteries when the heart contracts (beats)

63
Q

Diastolic blood pressure

A

measures the pressure in the arteries when relaxed (between heart beats)

64
Q

HTN can lead to other chronic illnesses:

A

Impaired vision
renal failure
CVA
CAD/MI
CHF

65
Q

Ace inhibitors HTN

A

Lisinopril (zestril)
Lotensin (benazepril)

66
Q

CA Channel blockers HTN

A

Norvasc (amlodipine)
Cardizem (diltiazem)

67
Q

Diuretics HTN

A

Hydrochlorothiazide (HCTZ)

68
Q

ARBs HTN

A

Cozaar (losartan)
Benicar (Olmesartan)

69
Q

Type 1 DM

A

Insulin insufficiency
-pancreas is unable to produce insulin which moves glucose from the blood into cells
-always treated with insulin
-Dx early in life with strong FHx component

70
Q

Type 2 DM

A

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

71
Q

How is DM 2 diagnosed?

A

fasting blood glucose/hemoglobin A1c

72
Q

DM can lead to chronic illnesses:

A

-diabetic retinopathy
-renal failure
cardiac disease
PVD
neuropathy

73
Q

Injected medications for DM

A

Humalog
Lantus
Sliding scale

74
Q

Oral medications for DM

A

metformin
glyburide

75
Q

How to diagnosis HLD

A

bloodwork (lipid panel) measuring cholesterol and triglyceride levels - elevated LDL

76
Q

LDL

A

low density lipoprotein

77
Q

“bad cholesterol”

A

low density lipoprotein
transports cholesterol to arterial walls and aides the formation of plaques

78
Q

“good cholesterol”

A

high density lipoprotein
HDL is able to remove cholesterol from artery plaques and recycle it back to the liver

79
Q

HDL

A

high density lipoprotein

80
Q

HLD can lead to:

A

pancreatitis
CVA
arterial atherosclerosis
CAD/MI

81
Q

Any medication ending in ___ is used to treat HLD

A

statin
-atorvastatin
rosuvastatin
simvastatin

82
Q

How is CAD diagnoses?

A

cardiac catheterization by cardiologist

83
Q

What is the biggest factor for an MI?

A

CAD

84
Q

Acetylsalicylic Acid (ASA)

A

Aspirin
81 mg daily
prevents clotting

85
Q

Nitroglycerin (NTG)

A

can be used to prevent angina or relieve an angina attack that is already occuring

86
Q

Patient problem list

A

a section of the chart that helps organize the patients history and allows the doctor to identify a patients active issues quickly

87
Q

Problem lists include:

A

-chronic illnesses
surgeries/procedures
injuries suffered by the patient
any symptom or disease that has affected the patient

88
Q

Active problem

A

a problem/dx that the patient still has. chronic illness will always be an active problem

89
Q

resolved problem

A

a problem/dx that a patient had at one point but it not an active problem

90
Q

What info is considered subjective?

A

CC/HPI/ROS

91
Q

Chief complaint

A

main reason for the visit

92
Q

What are the 8 elements of the HPI?

A

Onset
timing
location
quality
severity
modifying factors
associated Sx
context

93
Q

Onset

A

when did the complaint begin?

94
Q

Timing HPI

A

has it been constant, intermittent, or waxing and waning

95
Q

Location HPI

A

where is the discomfort?

96
Q

Quality HPI

A

does it feel sharp, dull, aching, cramping…

97
Q

Severity HPI

A

how bad is it?
mild, moderate, severe or 0-10

98
Q

Modifying factors HPI

A

what makes it better? what makes it worse?

99
Q

Associated Sx HPI

A

do any other symptoms accompany the complaint?

100
Q

Context HPI

A

is there anything else that is relevant?

101
Q

Single complaint formula HPI

A

the most commonly used HPI structure
best for patients with 1-2 new complaints

102
Q

Multiple complaint formula HPI

A

most commonly used in primary care since PCPs typically discuss every complaint or disease in detail with patient

103
Q

The chronological structure is best for:

A

complex stories
-multiple comorbidities
-chronic illness

104
Q

Objective information

A

factual and comes from a healthcare providers observations or diagnostic tests

105
Q

Carotid pulse location

A

neck

106
Q

radial pulse location

A

wrist

107
Q

femoral pulse location

A

groin

108
Q

dorsalis pedis pulse location

A

top of the foot

109
Q

posterior tibial pulse

A

back of the ankle

110
Q

Positive/negative McBurney’s point tenderness involves the…

A

appendix

111
Q

positive/negative murphy’s signs involve the…

A

gallbladder

112
Q
A

Scribe America (4 decks)

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