MR260 Medical Transcription II

Week -Chapter 9 “Gastroenterology Practice

& 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.

Gastroenterology Medicine• Answer True or False to the questions below

1. The gastrointestinal tract examination encompasses many organs, including the mouth and pharynx, esophagus, stomach, kidneys, duodenum and liver.

2. GI procedures using an endoscope include gastroscopy, exploratory laparoscopy, colonoscopy, and flexible sigmoidoscopy.

3. Anastomosis is an occlusion of the anal sphincter.

4. Cholecystectomy is the surgical removal of the gallbladder.

5. Meclizine is a generic name for an antinauseant.

ANSWERS

1. The gastrointestinal tract examination encompasses many organs, including the mouth and pharynx, esophagus, stomach, kidneys, duodenum and liver. FALSE Kidneys are not a part of this system.

2. GI procedures using an endoscope include gastroscopy, exploratory laparoscopy, colonoscopy, and flexible sigmoidoscopy. TRUE

3. Anastomosis is an occlusion of the anal sphincter. FALSE it is an opening created by surgery, disease, or trauma between two or more organs or structures.

4. Cholecystectomy is the surgical removal of the gallbladder. TRUE

5. Meclizine is a generic name for an antinauseant. TRUE

Fill in the Blanks

1. Adenomatous pertains to some types of _____________ hyperplasia.

2. Heparin is a generic name for an _________.

3. Decubitus is a ________or horizontal position.

4. Electrolytes are any ________ __________ ________ _________ electricity.

5. Gastritis is the inflammation of the ________, especially the ______________.

6. Hematochezia is the ________ ____ _____

stools.

ANSWERS1. Adenomatous pertains to some types of glandular

hyperplasia.

2. Heparin is a generic name for an anticoagulant.

3. Decubitus is a recumbent or horizontal position.

4. Electrolytes are any solution compound that conducts electricity.

5. Gastritis is the inflammation of the stomach, especially the mucosa.

6. Hematochezia is the passage of bloody

stools.

Gastrointestinal medications

1. Antiemetic medications are used to treat what types of GI disorders?

2. Pepcid , Prilosec and Zantac are medications used by GI doctors to do what?

3. Which of the medications below would NOT be used to treat a GI disorder?1. Tigan, Tenormin, Metamucil.

2. Ritalin, Reglan, Axid.

4. What are the medications below used for? 1. Colace, FiberCon, Imodium, Senokot

ANSWERS1. Antiemetic medications are used to treat what types

of GI disorders? Nausea, vomiting and sometimes motion sickness they include Tigan and Reglan.

2. Pepcid , Prilosec and Zantac are medications used by GI doctors to do what? To control gastric acid production.

3. Which of the medications below would NOT be used to treat a GI disorder?1. Tigan, Tenormin, Metamucil.

2. Ritalin, Reglan, Axid.

4. What are the medications below used for? 1. Colace, FiberCon, Imodium, Senokot

Dealing with problems associated with the patients bowel movements from constipation to diarrhea.

Define the words below

1. Reflux

2. Proctitis

3. Postprandial

4. Odynophagia

5. Occult

6. Colitis

7. Colostomy

8. Dysphagia

9. Hemicolectomy

10. Melena

ANSWERS

1. Reflux: a backward or return flow as in esophageal reflux.

2. Proctitis: inflammation of the rectum.

3. Postprandial: means after a meal.

4. Odynophagia: burning, squeezing pain while swallowing.

5. Occult: hidden from view as occult blood in the feces.

6. Colitis: inflammation of the colon

ANSWERS CONT’

7. Colostomy: the establishment of an artificial opening into the colon.

8. Dysphagia: difficulty in swallowing.

9. Hemicolectomy: the removal of the right or left side of the colon.

10. Melena: darkening of the feces by blood pigments.

ABBREVIATIONS

• Define the abbreviations below:1. GI

2. BUN

3. RBC

4. WBC

5. GB

6. NSAID

7. BM

8. BE

9. EGD

10. RLQ

ANSWERS

1. GI Gastrointestinal

2. BUN blood urea nitrogen

3. RBC red blood cells

4. WBC white blood cells

5. GB gallbladder

6. NSAID nonsteroidal anti-inflammatory drug

7. BM bowel movement

8. BE barium enema

9. EGD esophagogastroduodenoscopy

10. RLQ right lower quadrant

The End• Great job 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!