MR260 Medical Transcription II

Week 6-Chapter 8 “Pulmonary Medicine

& Critical Thinking”

Essentials of Medical Transcription

Instructor: Kathleen A. Bishop, M.B.A., Ph.D.

What You need for this class…

• Both textbooks:Essentials of Medical Transcription, A

Modular Approach, Destafano & Federman, Second Edition

AAMT Book of Style for Medical Transcription

Any other resource books you may have available such as medical dictionary, PDR, Merck Manual, etc.

How the class will work…

• This is an open book Seminar.

• Be prepared to respond to the questions on each slide, where indicted.

• Be prepared to share your thoughts with the other class participants.

• After the questions slide you will see an answer slide so you can check to see how you did.

Is everyone ready?

4 Steps to Critical Thinking

1. Identify the elements of your documenta. Body system and/or specialty

b. type of document

c. report headings, paragraph content, and the other sentences in the paragraph that you have already transcribed

d. Find the diagnosis or procedure.

e. Use any other information you may have on hand, such as the medical record or previous reports.

4 Steps to Critical Thinking

2. Evaluate your assumptions about those elementsa. Does this word, test, etc. belong in

or with this body system, procedure, operation, diagnosis?

3. Judge your choices probability or acceptability of being right.

4 Steps to Critical Thinking Cont.

4. Evaluate your choices by asking: “With what I already know, which is the most probable or likely to be correct, and why?”

Now here are some opportunities to use what you

just reviewed.

Exercise

• The next few slides have questions to answer.

• Answer the questions using the Critical Thinking Model we just reviewed.

Pulmonary Medicine1. Choose the correct word for the sentences below.

1. “The pulmonologist assesses abnormalities that decrease the amount of air entry, cause restrictive breathing, and affect lung paresthesia/parenchyma/paronychia.”

2. “The chest x-ray showed epiphysis/atelectasis/calculus in the right upper lobe.”

3. “The chest is clear to auscultation/apophysis/aspirate and percussion.”

4. “The emesis/diaphoresis/dyspnea is worse on exertion, especially when climbing stairs and doing his job as a janitor.”

ANSWERS

1. “The pulmonologist asses abnormalities that decrease the amount of air entry, cause restrictive breathing, and affect lung parenchyma.”

2. “The chest x-ray showed atelectasis in the right upper lobe.’

3. ‘The chest is clear to auscultation and percussion.”

4. “The dyspnea is worse on exertion, especially when climbing stairs and doing his job as a janitor.”

Pulmonary Medicine Cont’

• What are these medications used for? 1. Proventil

2. Slo-bid

3. Vanceril

4. Atrovent

• Define the tests and procedures below associated with pulmonary medicine:1. Bronchoscopy

2. Thoracentesis

3. MUGA Scan

4. Ventilation perfusion scan

Answers• What are these medications associated with the

pulmonary diagnosis used for? 1. Proventil: trade name for a bronchodilator,

metered-dose inhaler; aka Ventolin and the generic name is Albuterol, common use: acute exacerbations of asthma and COPD

2. Slo-bid: trade name for an extended-release bronchodilator; aka Theo-Dur, Elixophyllin and the generic name is theophylline is used for the relief and/or prevention of symptoms of asthma and reversible bronchospasm associated with chronic bronchitis and emphysema.

Answers

3. Vanceril: trade name for a corticosteroid; aka Beclovent, Vancenase, and the generic name is beclomethasone, inhaled corticosteroid, common use: asthma and COPD

4. Atrovent: trade name for a nasal spray, bronchodilator; aka generic name Ipratropium

Antiasthmatic: blocks parasympathetic receptors in lungs, common uses: asthma and COPD

ANSWERS

• Define the tests and procedures below associated with pulmonary medicine:1. Bronchoscopy: visual examination of the bronchi

2. Thoracentesis: aspiration of fluid from the chest cavity; surgical puncture and drainage of the thoracic cavity.

3. MUGA Scan: multiple-gated acquisition scan, nuclear medicine imaging

4. Ventilation perfusion scan: a nuclear medicine procedure used to diagnose pulmonary embolism and other conditions (also called a lung scan).

More Questions

• Define the words below:1. Pneumonectomy

2. Pulmonary toilet

3. Rale

4. Rhonchus

5. Bruit

6. Dyspnea

ANSWERS

1. Pneumonectomy: surgical removal of all or a segment of the lung

2. Pulmonary toilet: the cleansing of the trachea and bronchial tree

3. Rale: an abnormal crackle sound heard on chest auscultation

4. Rhonchus: an abnormal sound heard on chest auscultation due to an obstructed airway.

5. Bruit: a sound or murmur heard on auscultation

6. Dyspnea: labored or difficult breathing

More Questions

• Define the abbreviations below:1. A&P

2. COPD

3. ARD

4. DOE

5. CPR

6. P&A

7. SOB

ANSWERS

1. A&P: auscultation and percussion

2. COPD: chronic obstructive pulmonary disease

3. ARD: acute respiratory distress

4. DOE: dyspnea on exertion

5. CPR: cardiopulmonary resuscitation

6. P&A: percussion and auscultation

7. SOB: shortness of breath

Exercise

• Now, use these new abbreviations in a sentence, either in their abbreviated form or in their spelled out form.

Proofreading Exercise

• Correct the sentences below:1. Mr. Rabai is a 62 year old white male with a

past history of smoking.

2. On physical examination the patients temperature was ninety-nine.

3. His neck showed no mass or adenpathy.

4. Cardiovascular exam shows S1 SII within normal limits and grade 1 over 6 systolic injection murmur at the lower left sternal border.

5. His blood pressure is 120 over 70 pluse seventy respirations 12 per minute.

ANSWERS

1. Mr. Rabai is a 62-year-old white male with a past history of smoking.

2. On physical examination, the patient’s temperature was 99.

3. His neck showed no mass or adenopathy.

4. Cardiovascular exam shows S1, S2 within normal limits and grade 1/6 systolic injection murmur at the lower left sternal border.

5. His blood pressure is 120/70 pulse 70, respirations 12/min.

The End• Well that’s all for tonight! Next week we’ll

do some more metacognating!!

• Thanks for joining us. I hope you learned something to help you in your transcription career.

• See you next week! Same time—same place!

• Bye for now!