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1
Abortus
total number of miscarriages or elective abortions
2
ACE inhibitor
Zestril (lisinopril)
Lotensin (benazepril)
3
active problem
A problem/diagnosis a patient still has.
4
ARBs
Benicar (olmesartan)
Cozaar (losartan)
5
Assessment structures
simple statement, brief summary, comprehensive summary
6
Associated Sx
Do any other Sx accompany the complaint?
7
Asthma assessing severity
1. Do you have a
home nebulizer?

2. Have you been
prescribed
steroids
recently?

3. Have you
previously been
hospitalized for
asthma?

4. Have you
previously been
intubated?
(Breathing tube)
8
Asthma CC
shortness of breath, wheezing (improved with nebulizer treatments)
9
Asthma Etiology
constriction of the airway due to inflammation and muscular contraction of the bronchioles, known as "bronchospasm"
10
asthma inhaler
Pressurized device that releases a "puff" of medication for inhalation, one dose at a time
11
Asthma Nebulizer
Machine that delivers continuous aerosol mist
Treatment is delivered over a period of time
12
Asthma PE
Wheezes (inspiratory or expiratory)
13
Asthma pharmacological management
- Inhaled:

* Bronchodilators
- Advair
- Albuterol (Ventolin)
- Xopenex (Levalbuterol)
- Atrovent (Ipratropium)

*Steroids
- Pulmicort
- Flovent
- Symbicort

- Oral:

* Steroids
- Prednisone
- Decadron
14
Asthma risk factors
FHx of asthma, obesity, allergic rhinitis
15
AT/NC
atraumatic/normocephalic
16
Beta Blockers
Toprol (metoprolol)
Tenormin (atenolol)
Lopressor (metoprolol)
17
Brief Summary Structure
A&S, Relevant PMHx, Relevant PE findings, New and relevant results, diagnoses, differential + prognosis if no diagnosis
18
Cachectic
emaciated, malnourished
19
CAD associated medications
ASA, NTG (anticoagulants - blood thinning medications)
20
CAD CC
chest pain or pressure, worse with exertion, improved with rest or nitroglycerin (NTG)
21
CAD Dx by
Cardiac catheterization by cardiologist
22
CAD etiology
narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia
23
CAD non-pharmacological management
control risk factors, weight loss, manage stress and depression, smoking cessation, exercise
24
CAD pharmacological management
ASA (aspirin)
NTG (nitroglycerin)
25
CAD risk factors
HTN, HLD, DM, smoking, FHx <55 y/o
26
CAD surgical management
cardiac cath, angioplasty, stent, CABG
27
Calcium Cannel Blockers
Cardizem (diltiazem)
Norvasc (amlodipine)
28
Chronologic Structure
best for complex stories: Patients with multiple comorbidities, patients who have had significant workup in the past, established patients here for a follow-up of a chronic illness.
29
Clinic Flow
1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
30
CMS
Centers for Medicare and Medicaid Services

largest payer for healthcare in the U.S.

sets the stage for how all doctors are paid for their services
31
Comprehensive summary structure
A&S, Summary of PMHx, Summary of HPI, Summary of PE, Summary of results, diagnosis, differential/prognosis if applicable
32
context
Is there anything else that's important?
33
DDx
differential diagnosis
34
Diagnostic visit
New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment
35
Diastolic Blood Pressure
measures the pressure in the arteries when relax (between heart beats)
36
Diseases cause by HLD
arterial atherosclerosis, CAD/MI, CVA/TIA, pancreatitis
37
Diseases caused by DM
Peripheral Neuropathy, PVD, Diabetic Retinopathy, Renal Failure, Cardiac Disease
38
Diseases caused by HTN
MI/CAD, CHF, CVA, Renal Failure, Impaired Vision
39
Diuretics
reduce the volume of fluid in the blood vessels by urinating excess fluid
40
DM CC
unusual weight loss or gain, polyuria, polydipsia, blurred vision, fatigue, N/V
41
DM Dx by
fasting blood glucose/hemoglobin A1c
42
DM non-pharmacological management
blood glucose log, weight loss, low-carb diet, exercise
43
DM PE
distal paresthesias, pedal edema, weight change since last visit
44
DM pharmacological management
Injected: Humalog, Lantus, and Sliding Scale
Oral: Metformin, Glyburide
45
DM risk factors
obesity, high carb diet, lack of exercise, HTN, HLD, FHx
46
Drug administration routes
Oral, Inhaled, Injected
47
Dx by
peak flow testing
48
E&M level codes established patient
9921(#oflevel)
49
E&M level codes new patient
9920(#oflevel)
50
established patient
Previous records available from last 3 years, shorter visit, concise chart
51
Gravida
Total number of time the patient has been pregnant
52
HCTZ
Hydrochlorothiazide
(Diuretic)
53
HDL cholesterol
good cholesterol
54
health management
check up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems
55
HLD CC
asymptomatic, typically diagnosed during routine bloodwork
56
HLD Dx by
Bloodwork measuring cholesterol and triglyceride levels - elevated LDL
57
HLD etiology
An elevated level of lipid in the blood causes plaque build-up along arterial walls
58
HLD non-pharmacological management
Decrease ETOH intake, lose weight, close follow-up, exercise, change diet
59
HLD pharmacological management
statin (lipitor, crestor, zocor)
60
HLD risk factors
obesity, high lipid diet, physical inactivity, FHx, DM, ETOH use
61
how do you document a neck pulse?
Right carotid pulse 2+
62
How do you document a normal radial pulse?
Right radial pulse 2+
63
How do you document a pulse on the heal?
Posterior Tibialis Pulse 2+
64
How do you document a pulse on top of the foot?
Dorsal pedis pulse 2+
65
How is the plan written?
1) Each item should appear on a separate line
2) Bulleted or numbered list
3) At least one bullet to address each diagnosis
4) Last bullet should always be timeline for follow-up in the office
66
HPI Elements
Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Sx, Context
67
HTN CC
often asymptomatic, headache, chest pain, palpitations, blurred vision, epistaxis
68
HTN Dx by
BP check and monitoring with sphygmomanometer
69
HTN etiology
an increase in blood pressure causes excess force against the arterial walls
70
HTN non-pharmacological management
BP log, decreased ETOH intake, low-sodium diet, smoking cessation, exercise
71
HTN PE
lower extremity edema, carotid bruit, JVD, abnormal heart sounds
72
HTN risk factors
FHx of HTN, obesity, DM, high sodium diet, smoking, ETOH
73
Hypertensive
greater than 140/90
74
Hypotensive
less than 90/60
75
LDL cholesterol
bad cholesterol
76
Level 4 Assessment
new: 1
estab: 2
77
Level 4 HPI elements
new: 4
estab: 2
78
Level 4 PE systems
new: 9
estab: 2
79
Level 4 PHx
new: 3
estab: 1
80
Level 4 ROS elements
new: 10
estab: 2
81
Location
where is the discomfort?
82
MACRA
a payment model for physicians and is run by CMS
83
MIPS
Merit-based Incentive Payment System

Doctors who prove high quality and better outcomes can receive large bonus payments from CMS. Those with poor quality are penalized financially.
84
Modifying Factors
What makes it better? What makes it worse?
85
multiple complaint formula
effective for patients who have multiple complaints, routine follow-up for chronic illnesses, and different treatment plans for different complaints.
86
New Patient
No previous records, longer visit, detailed chart
87
Normal
90/60 to 120/80
88
onset
When did the complaint begin?
89
Para
number of pregnancies reaching viable gestational age (23 weeks) that the patient has had
90
patient problem list
helps organize the patient's
PMHx and allows the doctor to identify a patient's active issues quickly.
91
Patient says "I only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
92
Patient says "I take shots for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
93
Patient says adenoids removed
Adenoidectomy
94
Patient says appendix removed
appendectomy
95
Patient says arthritis
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
96
Patient says asthma
asthma
97
Patient says back fused
spinal fusion
98
Patient says bad flow to my legs
peripheral vascular disease (PVD)
99
Patient says bag to collect stool
colostomy
100
Patient says balloon
Angioplasty --> PMHx CAD
101
Patient says bipolar
bipolar disorder
102
Patient says bladder infection
Urinary Tract Infection (UTI)
103
Patient says blood clot in lung
Pulmonary Embolism (PE)
104
Patient says Blood clot in my leg
Lower Extremity Deep Vein Thrombosis (DVT)
105
patient says brain bleed (stroke)
Hemorrhagic CVA
106
Patient says brain surgery
Craniotomy (brain bleed vs. brain CA)
107
Patient says breast removal
mastectomy
108
Patient says breast removal
mastectomy
109
Patient says Bulge in my aorta
aortic aneurysm
110
Patient says bulging/herniated disc
Degenerative Disc Disease (DDD)
111
Patient says C-section
cesarean section
112
Patient says cancer
Cancer or carcinoma (CA) (attached to the type of cancer)
113
Patient says chemo
chemotherapy
114
Patient says clot filter (lower abdomen)
IVC (inferior vena cava) filter
115
Patient says Crohn's/UC
Crohn's Disease or Ulcerative Colitis
116
Patient says defibrillator
Automatic Implanted Cardiac Defibrillator (AICD)
117
Patient says diabetes
Diabetes Mellitus (DM)
118
Patient says dialysis fistula
AV (arteriovenous) Fistula
119
Patient says dialysis graft
AV graft
120
Patient says diverticulitis
Diverticulitis
121
Patient says ear tubes
myringotomy or Pressure equalizing (P.E) tubes
122
Patient says Emphysema/Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
123
Patient says enlarged prostate
Benign Prostate Hypertrophy (BPH)
124
Patient says episodes of abnormally fastacing heartbeat
supraventricular tachycardia (SVT)
125
Patient says exploratory
Exploratory Laparoscopy (Ex Lap)
126
Patient says Gallbladder removed
cholecystectomy
127
Patient says heart attack
Myocardial Infarction (MI) and CAD
128
Patient says heart bypass
Coronary Artery Bypass Graft (CABG) --> PMHx CAD
129
Patient says heart cath
cardiac catheterization
130
Patient says heart disease
Coronary Artery Disease (CAD)
131
Patient says heart failure
Congestive Heart Failure (CHF)
132
Patient says hepatitis
Hepatitis A, B, or C
133
Patient says hernia repair
Herniorrhaphy
134
Patient says high blood pressure
Hypertension (HTN)
135
Patient says high cholesterol
Hyperlipidemia (HLD)
136
Patient says hole in my neck
tracheostomy (trach)
137
Patient says I do drugs
substance abuse
138
Patient says I drink a lot
ETOH abuse or alcoholism
139
Patient says I'm on dialysis
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis
140
Patient says Irregular heartbeat
arrhythmia
141
Patient says irritable bowel
Irritable Bowel Syndrome (IBS)
142
Patient says its gone
In remission
143
Patient says joint repair
arthroplasty
144
Patient says kidney infection
Pyelonephritis (Pyelo)
145
Patient says kidney removed
nephrectomy
146
Patient says kidney stones
renal calculi
147
Patient says leg amputated
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
148
Patient says low back pain
Chronic Low Back Pain
149
Patient says metal plates/pins
hardware
150
Patient says mini-stroke
Transient Ischemic Attack (TIA)
151
Patient says murmur
heart murmur
152
Patient says neck artery cleaned
carotid endarterectomy
153
Patient says neck fused
Cervical spinal fusion
154
Patient says new hip
total hip replacement
155
Patient says ovary and fallopian tubes removed
Salpingo-oophorectomy
156
Patient says ovary removed
oophorectomy
157
Patient says pacer
pacemaker
158
Patient says pancreatitis
pancreatitis
159
Patient says part of my colon removed
Partial colectomy
160
Patient says part of my lung removed
Partial lobectomy
161
Patient says PICC line
Peripherally Inserted Central Catheter (PICC)
162
Patient says pneumonia
Pneumonia (PNA)
163
Patient says Port
Port-a-cath or Medi-Port
164
Patient says prostate removed
Prostatectomy or prostate resection (most often Trans-Urethral Resection of the Prostate, or TURP)
165
Patient says radiation
radiation therapy
166
Patient says reflux
Gastroesophageal Reflux Disease (GERD)
167
Patient says schizophrenia
schizophrenia
168
Patient says seizures
Seizure disorder/Epilepsy
169
Patient says shunt
cerebral shunt
170
Patient says spleen removed
splenectomy
171
Patient says spread to my
With metastases to the...
172
Patient says stents
Coronary Stents --> PMHx CAD
173
Patient says stomach stapled
bariatric surgery
174
Patient says stroke
Cerebrovascular Accident (CVA)
175
Patient says surgery for afib
Afib s/p cardiac ablation
176
Patient says they cut it out
s/p surgical resection
177
Patient says thyroid problem
Usually Hypothyroidism, sometimes Hyperthyroidism
178
Patient says tonsils removed
tonsillectomy
179
Patient says tubes tied
Tubal ligation (female) or Vasectomy (male)
180
Patient says ulcer
Gastric Ulcer or Peptic Ulcer Disease (PUD)
181
Patient says uterine product removed
Dilation and Curettage (D&C)
182
Patient says uterus removed
Hysterectomy (partial vs. total)
183
Patient says valve surgery
Valve repair or replacement (Bovine vs. Mechanical)
184
Patient says weak/fragile bones
Often Osteoporosis
185
Patient says: Numbness in my legs
peripheral neuropathy
186
Peak flow measurement
liters/minute
187
PHI
Protected Health Information

First or last name
Date of birth
Medical record number
Even the fact that the patient was seen in your clinic
188
Prehypertensive
121/81 to 140/90
189
quality
Does it feel sharp, dull, aching, cramping...?
190
Quality Measures
chief complaint
vital signs
height, weight, BMI
Smoking Status
191
Quality Measures
physicians receive their payment adjustments by reporting on a number of __________ that must be recorded in a specific location in the EMR.
192
resolved problem
a problem/diagnosis that patient had at point, but it is not actively a problem.
193
Scribes CAN
1. Document the history, physical exam, results, procedures, and physician consults
2. Access and document laboratory results and radiology findings
3. Access and display X-Rays for the physician to review
4. Locate and obtain PMHx, previous charts, past results, and recent studies
5. Record physician interpretations of X-Rays and ECG's
194
Scribes CANNOT
1. touch patients
2. partake in any activity that may affect patient health
3. handle bodily fluids or specimens
4. sign or authenticate any chart or record
5. give verbal orders or submit electronic orders
195
severity
How bad is it? Mild, moderate, severe or 0-10
196
Simple Statement Structure
A&S, Relevant PMHx, Diagnosis
197
Single Complaint Formula
Formula best for patients with only 1-2 complaints that have not been previously evaluated.
198
Social History
Tobacco use, alcohol use (ETOH), illicit drug use, occupation, living circumstances
199
subjective
information from the patient

includes:
CC
HPI
ROS
200
Superbill
A bill, submitted to the insurance company, that reflects the services provided to the patient
201
systolic blood pressure
measure the pressure in the arteries when the heart contracts (beats)
202
Timing
Has it been constant, intermittent, or waxing and waning?
203
True allergy symptoms
rash, itching, swelling, difficulty breathing
204
type 2 diabetes etiology
The inadequacy of insulin in controlling the blood glucose level (insulin resistance)
205
What does a beta blocker do?
slow the heart rate and reduce the heart's workload
206
What does a ca channel blocker do?
Dilate the arteries and reduce the force of the heart's contractions
207
What does an ACE inhibitor do?
relax arteries and block reabsorption of water by kidneys
208
What does an ARB do?
Dilate the arteries
209
What does the plan include?
Recommended Txs for each diagnosis
Prescriptions ordered today
Studies or tests ordered today
Follow-up with other healthcare professionals
Follow-up here: when should pt return?
210
What goes in the History and Physical (H&P)
HPI, ROS, PE
211
What organs are in the LLQ
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
212
What organs are in the LUQ?
Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal gland
Splenic flexure of colon
Part of transverse and descending colon
213
What organs are in the RLQ
colon, cecum, appendix, small intestine, large intestine, right ovary and cord
right ureter
right spermatic cord
214
What organs are in the RUQ
liver
gallbladder
duodenum
head of pancreas
R kidney and adrenal
hepatic flexure of colon
part of ascending and transverse colon
215
What Sx go into constitutional
Fever, weight loss, sweats
216
What Sx goes into cardiovascular
Chest pain, palpitations, leg swelling
217
What Sx goes into endocrine
polyuria, polydipsia
218
What Sx goes into ENT
Earache, nosebleed, congestion, sore throat
219
What Sx goes into Eyes
Change in vision, Eye pain, double vision
220
What Sx goes into gastrointestinal
Abdominal pain, N/V/D, Black or blood stools
221
What Sx goes into genitourinary
dysuria, frequency, urgency, hematuria
222
What Sx goes into hematologic/lymph
bleeding gums, easy bruising, swollen lymph nodes
223
What Sx goes into immunologic
HIV/AIDS
224
What Sx goes into integumentary/skin
rash, itching, abrasion, laceration
225
What Sx goes into musculoskeletal
joint pain, muscle pain
226
What Sx goes into neurological
headache, syncope, seizure, numbness, focal weakness
227
What Sx goes into psychiatric
depression, anxiety
228
What Sx goes into respiratory
SOB, cough, sputum, wheezing
229
When should you delete problems from the problem list?
Only delete problems when they were entered incorrectly. (DO NOT MARK AS RESOLVED)
230
Why are patients with comorbidities complex?
1. Tx for different diseases can contradict
2. Adverse drug interactions
3. Compounding Sx can affect compliance
4. Multiple illnesses affect a single organ and increase risk of organ failure
231
You should only store PHI within the
EHR
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