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 documentc. 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.

ANSWERS1. 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 Blanks1. 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, SenokotDealing with problems associated with the patients bowel

movements from constipation to diarrhea.

Define the words below

1. Reflux2. Proctitis3. Postprandial4. Odynophagia5. Occult6. Colitis7. Colostomy8. Dysphagia9. Hemicolectomy10. 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. GI2. BUN3. RBC4. WBC5. GB6. NSAID7. BM8. BE9. EGD10. RLQ

ANSWERS

1. GI Gastrointestinal2. BUN blood urea nitrogen3. RBC red blood cells4. WBC white blood cells5. GB gallbladder6. NSAID nonsteroidal anti-inflammatory

drug7. BM bowel movement8. BE barium enema9. EGD esophagogastroduodenoscopy10. 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!