Medical Transcription Case Study 2

Front 1

0.5% Marcaine

Back 1

dictated "half percent", brand name for local anesthetic

Front 2

19-French

Back 2

French is a scale used to denote catheter sizes and other tubular instruments, each unit is approximately 0.33 mm in diameter, 19-French indicates a diameter of approximately 602 mm.

Front 3

89% shift

Back 3

"shift" to the left" on CBS differential indicates an increase in the number of band cells or bands; 89% represents the percentage of band cells compared to the total number of white cells counted, this often indicates acute infection

Front 4

anorexia

Back 4

diminished appetite; aversion to food

Front 5

appendicitis

Back 5

infection or inflammation of the vermiform appendix

Front 6

auscultation

Back 6

the act of listening for sounds within the body.

Front 7

benzoin

Back 7

a topical skin protectant

Front 8

Blake drain

Back 8

silicone drain placed in wound to encourage drainage of fluids from wound.

Front 9

cecum

Back 9

any blind pouch, used to describe the closed end of the large intestine.

Front 10

clot

Back 10

a soft mass formed when a liquid (blood or lymph) thickens

Front 11

clubbing

Back 11

a condition of thickening and widening of the fingers and toes with abnormally curved nails.

Front 12

colonoscopy

Back 12

examination by means of a flexible, enlongated scope that permits visual examination of the colon.

Front 13

contrast

Back 13

chemical substances introduced in raiography to increase the difference between defferent tissue types or between abnormal and normal tissues.

Front 14

coronal reconstructions

Back 14

term used in CT scanning to mean three-dimensional view looking at the image from the front of the body.

Front 15

CPT Code A 88304

Back 15

a set of codes that describes medical surgical, and diagnostic services. Code A 88304 is the CPT code for surgical pathology, gross and microscopic examination.

Front 16

cranial nerves

Back 16

referred to by either roman or arabic numerals (2 through 12 or II through XII), the 12 pairs of nerves connected with the brain; cranial nerve 1 or 1 (olfactory) is not always included in the routine physical examination.

Front 17

crystalloid

Back 17

a hydration solution containing only eleoctrolytes.

Front 18

CT scan

Back 18

a procedure in which x-ray images are analyzed and combined by a computer to yield views representing thin slices of the parts examined.

Front 19

cyanosis

Back 19

discoloration of the skin or mucous membrane due to deficient oxygenation fo the blood.

Front 20

degenerative joint disease

Back 20

arthritis characterized by softening and fraying of the cartilage and mainly affecting weightbearing joints.

Front 21

desufflated

Back 21

air or gas removed from a cavity or chamber of the body.

Front 22

dilatation

Back 22

stretching or enlarging an opening of a hollow structure.

Front 23

edema, extremity

Back 23

swelling of the extremity

Front 24

electronically signed

Back 24

a statement that specifies the physican has electronically signed the report; this statement is added to the end of a reprot by a computerized system when the physcian signs the report by pressing a key

Front 25

emesis

Back 25

vomting

Front 26

Endo Catch bag

Back 26

a bag used in laparoscopic surgeries to remove the resected specimen

Front 27

Endo GIA

Back 27

a type of surgical stapler.

Front 28

extraocular motions

Back 28

eye movements; these are examined by having the patient look in all directions without moving the head

Front 29

fibrinous

Back 29

pertaining to or composed of fibrin

Front 30

fistula

Back 30

an abnormal passage between 2 organs in the body or between an organ and the outside of the body

Front 31

fistulogram

Back 31

radiograph after infusion of the fistual with contrast

Front 32

flatus

Back 32

gas or air in the gastrointestinal tract passed through the anus

Front 33

Foley catheter

Back 33

tube that is passed into the bladder through the urethra to collect urine

Front 34

free air

Back 34

air in the abdomen, not trapped within tissues, as a result of perforation of a hollow organ

Front 35

gentamicin

Back 35

antibiotic used to treat many types of infections; sometimes dictated "gent" as medical jargon

Front 36

guarding

Back 36

tensing of muscles in response to touch

Front 37

Hasson trocar

Back 37

a blunt instrument used to enter the abdominal cavity; used for insufflation and introduction of lapraoscope

Front 38

hemicolectomy

Back 38

removal of the right or left side of the colon

Front 39

hemorrhagic

Back 39

relating to or marked by hemorrhage

Front 40

hepatobiliary

Back 40

related to the liver and bile or biliary ducts

Front 41

hepatobiliary

Back 41

related to the liver and bile or biliary ducts

Front 42

illicit

Back 42

unlawful

Front 43

in toto

Back 43

entirely, in the whole

Front 44

inflammatory bowel disease

Back 44

general term for disorders of the small and large intestine

Front 45

integument

Back 45

enveloping membrane of the body, including skin, hair and nails

Front 46

JP drain

Back 46

abbreviation for Jackson-Pratt drain; suction drain with tubing inside the body and bulb reservoir which, when squeezed empy, applies suction and pulls fluid out of the body; used in thoracic or abdominal surgery

Front 47

JVD

Back 47

abbreviation for jugular venous distension or distension fo the neck veins

Front 48

Kelly clamp

Back 48

a curved instrument used for arresting hemorrhage by compression fo the bleeding vessel

Front 49

laparscopic appendectomy

Back 49

removal of vermiform appendix using several scopes placed into the abdomen as opposed to using a right lower quadrant abdominal inscision

Front 50

LFTs

Back 50

abbreviation for liver function tests: a lab study

Front 51

localized

Back 51

restricted or limited to a definite part

Front 52

lymphadenopathy

Back 52

enlargement of lymph nodes, which may indicate infection

Front 53

cervical lymphadenopathy

Back 53

on the back of the neck

Front 54

supraclavicular lymphadenopathy

Back 54

above the collar bones

Front 55

axillary lymphadenopathy

Back 55

in the armpit

Front 56

inguninal lymphadenopathy

Back 56

in the groin

Front 57

McBurney sign

Back 57

tenderness at a point on the abdomen that indicates appendicitis

Front 58

mesoappendix

Back 58

fold of tissue attacing the appendix to the small bowel

Front 59

necrotic

Back 59

dead, as in dead tissue

Front 60

necrotizing

Back 60

causing death of cells

Front 61

normocephalic

Back 61

having a head of medium length

Front 62

obturator sign

Back 62

pain in the lower abdomen or inside of thigh when the hip is flexed and internally rotated; a sign of appendicitis

Front 63

open appendectomy

Back 63

removal of vermiform appendix through a right lower quadrant abdominal incision, going thorugh muscle layers and underlying tissue until reaching the abdominal cavity.

Front 64

OR

Back 64

abbreviation for operating room

Front 65

osseous

Back 65

of the nature or quality of bone; bony

Front 66

p.o.

Back 66

latin abbreviation meaning by mouth (per os)

Front 67

PAR

Back 67

abbreviation for postanesthesia recover, where patients are sent immediately after surgery (the recovery room); each letter is pronounced seperately

Front 68

pedal pulses

Back 68

the 2 arterial pulses able to be felt in the foot; 1 pulse is on the arch of the foot and the other is on the back of the ankle.

Front 69

periappendiceal

Back 69

near the appendix

Front 70

pericecal

Back 70

near the cecum

Front 71

perioperative antibiotics

Back 71

antibiotics given either immediately before or immediately after surgery

Front 72

phlegmon

Back 72

a spreading inflammatory reaction to infection that can form multiple pus pockets

Front 73

piroxicam

Back 73

generic nonsteroidal anti-inflammatory drug (brand name Feldene)

Front 74

pneumoperitoneum

Back 74

within the peritoneal cavity

Front 75

psoas sign

Back 75

flexion of or pain on hyperextension of the hip caused by contact of the psoas muscle plus inflammation; often seen in appendicitis

Front 76

purulent

Back 76

containing, consisting of, or forming pus

Front 77

radiate

Back 77

to spread out in all directions from a center, such as pain radiated from the abdomen

Front 78

rebound

Back 78

when the abdomen is pressed, then released, more pain is felt upon release than when it is applied

Front 79

representative sections

Back 79

in gross pathology, pieces of tissue that represent the overall appearance of the specimen

Front 80

RLQ

Back 80

abbreviation for right lower quadrant (of the abdomen)

Front 81

saturations 96%

Back 81

blood oxygen saturation is measured in percentages with 100% being the most saturated

Front 82

SCDs

Back 82

abbreviation for sequential compression devices (devices that are wrapped around the legs and inflate and deflate to prevent blood clots in the legs)

Front 83

seminal vesicles

Back 83

structures in the male about 2 inches long located behind the bladder. The seminal vesicles contribute fluid to the ejaculate

Front 84

Steri-Strips

Back 84

sterile skin closure strips that are made of a porous, nonwoven backing cated with a pressure-sensitive hypoallergenic adhesive and reinforece with polyester filaments for added strength

Front 85

supine

Back 85

lying face upward

Front 86

terminal ileum

Back 86

the end of the small intestine

Front 87

thrills

Back 87

large areas of sustained outward motion of the chest felt when performing a heart examination

Front 88

thyromegaly

Back 88

enlargement of the thyroid gland

Front 89

TMs

Back 89

abbreviation for tympanic membranes (eardrums)

Front 90

vermiform appendix

Back 90

small, tube-like structure attached to the first part of the large intestine

Front 91

WNL

Back 91

abbreviation for within normal limits