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HUCStudies Diag Exam

HUC Studies diagnostic exam orders

contrast medium Dye or iodine-containing substance that is injected into the body to illuminate inner structures that are hard to see; opaque to x-rays or a substance that will appear solid on xray.
electrode a conductor used to establish electrical contact with a nonmetallic part of a circuit
fluoroscopy a procedure for observing the internal structure of the body
Holter monitor A devise that monitors heart activity throughout the course of the day
invasive Procedure in which a part of the body is entered, such as an incision or cutting
telemetry The process of measuring and transmitting heart activity
ABD abdomen
AP anterior to posterior (front to back)
BaE Barium Enema
BAER Brainstem Auditory Evoked Response
BE Barium Enema
CAT Computed Axial Tomography
CT Computed Tomography
CXR chest x-ray
DSA Digital Subtraction Angiogram
DVI Digital Vascular Imaging
ECG Electrocardiogram
Echo Echocardiogram
EEG Electroencephalogram
EGD Esophagogastroduodenoscopy
GB Gallbladder
GI Gastrointestinal
EKG Electrocardiogram
ERCP Endoscopic Retrograde Cholangiopancreatography
HOH Hard of Hearing
IV Intravenous
IVP Intravenous Pyelogram
KUB Kidneys, Ureters and Bladder
L Left
Lat Lateral (side)
MAR Medication Administration Record
MBO Monitored Bed Orders
MRA Magnetic Resonance Angiography
OCG Oral Cholecystogram
PA Posterior to Anterior (back to front)
Preps Preparation for an Examination
PROCTO Proctopscopy
Sigmoid Sigmoidoscopy
SONO Sonogram
UGI Upper Gastrointestinal
VER Visual Evoked Response
W/C Wheelchair
Processing Diagnostic Exam Orders: HUC must find answers to 5 questions: 1. When is the exam performed? 2. How is the patient prepared? 3. How is the patient transported? 4. Why is the exam ordered? 5. What department performs the exam?
Scheduling Exams - HUC needs to know which exam to schedule before other exams - Some procedures could interfere w/ other procedures, ex. barium enema which has contrast medium could affect another test - most facilities have scheduling policies & procedures @ workstati
Preparation for Exam -may include diet change or meal withheld -also called "prepped" - contrast medium requires prep - some exams require cleaned intestines; laxatives, enemas - procedure form - consent form - scheduling may be affected by preps
Consent Forms - part of preps includes explaining exam to pt - pt to sign consent or procedure form before procedure is started - HUC pulls consent form from a file, completes parts, places it in pt chart
examples of contrast medium -air, barium and iodine dyes -may be swallowed, injected into pt's vein, introduced into the rectum -some may be given before exam; some given during test
Clinical Data -HUC to share data to other dept doing exam: diabetes; allergy; & isolation info, mode of transport, oxygen, IV info, telemetry or other special needs: pt hearing or visually impaired, confused
Transporting Pt to Exam -if pt can sit and stand: wheelchair -if pt can not sit or stand: cart -portable (exam comes to pt room) -important to include if pt uses IV or oxygen so transporting can bring appropriate equipment
Reason for Exam -stating reason for exam gives MDs and techs guidance when performing tests and reading results -to control costs, insurance does not pay for "rule out" exams.
Cardiac cath Cardiac Catherization; consent-yes; prep-yes; invasive proc. long cath is passed into the heart from large vessel in leg/arm to Dx heart disease. Xray to view the catheter as it is inserted. By radiologist or qualified MD.
Echo Echocardiogram; consent-no; prep-no; Noninvasive exam performed by tech using sound frequencies to study the function of the heart
ECG, EKG Electrocardiogram; consent-no; prep-no; noninvasive exam that records electrical impulses of the heart; performed by tech. Often performed with portable at patient's bedside
24-hour Holter Holter monitor; consent-no; prep-no; a device that monitors heart activity thru day. Pt wears electrodes and heart activity is recorded. Pt records physical activity thru day. Nursing staff places electrodes and observes telemetry monitors
Tele; MBOs Telemetry; Monitored bed orders; consent-no; prep-no; Process of measuring and transmitting heart activity during hospitalization. Pt wears electrodes and the heart activity is transmitted to monitors normally kept at nursing workstation
Diagnostic Imaging usually has seven divisions angiography; computer tomography; diagnostic x-ray; magnetic resonance imaging; mammography, nuclear medicine and ultrasound.
Position of Patient the physician may order the pt to be positioned in a specific way during a diagnostic procedure in order to get the best view of the body structure. Important to include position with order when transcribing.
Decubitus a position assumed when lying down
Oblique View a slanting angle
DSA Digital subtraction angiogram; consent-yes; prep-yes; Two xrays taken; 1st before contrast material & 2nd after the contrast. A computer then subtracts the images of bone, tissue and other structures in 1st from 2nd. Result shows only blood vessels
DVI Digital vascular imaging; consent-yes; prep-yes; An exam that allows for the visualization of arteries by a special technique using a flurorscopy and computer enhancements
CT scan of abdomen; CT of abdomen; CAT scan of abdomen Computed tomography of the abdomen; Consent-no; prep-yes
CT scan of head; CT of head; CAT scan of head Computed tomography of the head; Consent-no; prep-no
CT scan of the pelvis; CT of pelvis; CAT scan of pelvis Computed tomography of pelvis; consent-no; prep-yes
CT scan of C1-l5; CT of C1-L5; CAT scan of C1-L5 Computed tomography of the spine; consent-no; prep-no
CT; CAT scan Computed Tomography (computed axial tomography) cross-sectional pictures of the body are made by special xray equipment. Clearly shows shape and exact location of organs, soft tissues and bones. May be ordered w/ or w/out contrast
xray Diagnostic x-rays, also called radiographs.
BaE, BE, lower air contrast BaE GI barium enema; lower gastrointestinal. -single contrast: barium sulfate injected into rectum to view lg intestines. -Double contrast (air contrast) air is inserted into rectum
AP & Lat CXR Chest xray; consent-no; prep-no; Front to back and side view x rays of the chest
X-rays of extremities consent-no; prep-no; xrays of left, right or both arms, hands and wrists; xrays of the left, right or both feet and ankles
GB, OCG Gallbladder, oral cholecystogram; consent-no; prep-yes; xray of the gallbladder (GB) saclike organ stores bile located under liver; involves taking tablets containing dye (contast) which outlines any abnormalities when xrays are taken next day
IVP Intravenous pyelogram; consent-no; prep-yes; contrast medium is injected into vein and kidney, ureters, bladder and urethra are viewed
KUB Kidneys, Ureters, Bladder; consent-no; prep-no; an xray of size and location of kidneys in relation to other organs in the abdominal region
xray of C1-C7; xray of t1-t12, xray of L1-L5; Xray of C1-L5 xray of cervical spine; xray of thoracic spine; xray of lumbar spine; xray of whole spine
UGI Upper gastrointestinal series; consent-no; prep-yes; xray using barium to view the upper digestive tract, including the esophagus, stomach and part of the small intestine.
MRI Magnetic Resonance Imaging: diagnostic technique that produces images of organs and structures. Uses strong magnetic fields, not x-rays, to create images. Provides highly detailed info w/out exposing body to radiation. No metal in pt.
MRI of head; MRI scan of head Magnetic resonance imaging of head; consent=no; prep=no
MRI of abd Magnetic resonance imaging of abdomen; consent-no; prep=no
MRI of L knee Magnetic resonance imaging of left knee; consent-no; prep=no
Mammography x-ray image of the soft tissue of the breast. Used to detect breast cancer at early stages.
Nuclear Medicine very small amts of radioactive material are introduced into the body & are attracted to specific organs. Provide crucial info about particular types of cancer/disease.
Common Nuclear Tests -Brain scan (no consent or prep) -Bone scan (no consent or prep) -Liver/spleen scan (no consent or prep) -Lung scan (no consent or prep) -Thyroid scan (no consent; prep needed)
Ultrasound Also called echo and sono. Uses high-frequency sound to image internal structures.
Digestive Disorders Exams tests or examines related to the digestive system may be ordered from the imaging dept or the GI lab. Orders to the GI lab are invasive procedures.
Colonoscopy Consent-yes; prep-yes; Visualization of the lining of the large intestine using a colonoscope
EGD Esophagogastroduodenoscopy; Consent-yes; prep-yes; Visualization of the inside of the esophagus; stomach and duodenum by a flexible fiber optic tube placed in the mouth
ERCP Endoscopic retrograde cholangiopancreatography; consent-yes; prep-yes; combines the use of xrays and endoscope. Dr. can see the inside of the stomach and duodenum and inject dyes int the ducts in the biliary tree and pancreas so they can be seen on xray
esophaegeal motility consent-yes; prep-yes; Endoscopy-Dr passes fiber optic tube in mouth into stomach for access to lining and muscular activity. xray of esophagus while pt swallows thick liquid visible on xray. Creates picture of lining of esophagus and stomach
Grastroscopy consent-yes; prep-yes; visualization of the inside of the stomach by a gastroscope inserted through the esophagus
procto proctoscopy; consent-yes; prep-yes; visualization of the rectum and lower end of the colon using a proctoscope
Sigmoid Sigmoidoscopy; consent-yes; prep-yes; examination of the rectum and sigmoid colon with the aid of a special instrument called a sigmoidoscope.
Neurology exams examines on the nervous system, especially in respect to its structure, function and abnormalities
BAER Brainstem Auditory evoked response; consent-no; prep-no; evaluates the function of nerve pathways in brain needed to hear. Clicking noises are sent thru earphones to person being tested & each response is recorded from brain waves using electrodes.
EEG Electroencephalogram; consent-no; prep-yes; records electrical activity of the brain. sensors are attached w/ adhesive to head; connected by wires to computer. Records brain electrical activity as wavy lines. Certain abnormalities can be detected.
VER Visual evoked response; consent-no; prep-no; when the eyes are stimulated by looking at a test pattern, the response is called a visual evoked response or potential.