LESSON 7: THE RESPIRATORY
SYSTEM
Common Terms Related to Respiratory
System
✓ Aphonia: Absence of voice
✓ Apnea: Absence of breathing
✓ Dysphonia: Difficulty in speaking
✓ Dyspnea: Difficulty breathing
✓ Eupnea: Normal breathing
✓ Hemoptysis: Coughing up blood from
the lung
✓ Hyperventilation: Ventilation of lungs
beyond normal body needs
✓ Hypoxemia: Deficient oxygen content
in blood
✓ Mucous: Pertaining to mucus
✓ Mucus: Secretion (slime) from the
mucous membranes
✓ Nasopharyngeal: Referring to the nose
and throat
✓ Rhinorrhea: Discharge from the nose
✓ Adenoids: A collection of lymph tissue
in the nasopharynx
✓ Alveolus: An air sac in the lung
Respiratory Diseases and Pathology
Adult respiratory distress syndrome
(ARDS) is respiratory failure in an adult as a
result of disease or injury.
Bronchogenic carcinoma is a cancerous
tumor arising from the bronchus. This tumor
can metastasize (spread) to brain, liver, and
other organs.
Chronic obstructive pulmonary disease
(COPD) refers to any persistent lung disease
that obstructs the bronchial airflow
Pulmonary edema means fluid
accumulation in the alveoli and bronchioles.
Pulmonary embolism is a blood clot, fat
clot, or air carried in blood circulation to
pulmonary artery where it blocks the artery.
Respiratory and Diagnostic Tests
Chest x-ray (CXR): Radiograph of chest to
evaluate heart and lungs.
Endotracheal intubation is when a tube is
placed through the mouth, into the trachea,
to establish an airway.
Lung biopsy: Lung tissue is obtained by
forceps or brush (bronchial brushing). Can
also be accomplished through a catheter
inserted under x-ray guidance.
Lung scan: Radioactive material is injected
or inhaled and images are recorded of its
distribution into lung tissue.
Pulmonary angiography: X-ray image of
the blood vessels of the lungs after injection
of contrast material.
Pulmonary function tests evaluate
ventilation capacity of the lung. A
spirometer measures the air taken in and out
of the lungs.
Thoracentesis: Chest wall is punctured with
a needle to obtain fluid from the pleural
cavity for diagnostic studies or to relieve
pressure in the lung.
LESSON 8: GASTROINTESTINAL
SYSTEM
The gastrointestinal system, also called the
alimentary or digestive tract, provides a
tubelike passage through a maze of
organs and body cavities, beginning at the
mouth, the food entrance into the body,
and ending at the anus, where solid waste
material exits the body.
This system and its organs perform three
primary functions:
✓ Carrying food for digestion
✓ Preparing it for absorption
✓ Transporting waste products for
elimination
Common Gastrointestinal Terms
✓ Aphthous stomatitis: Canker sores in
mouth
✓ Bruxism: Grinding teeth involuntarily,
often while sleeping
✓ Dysphasia: Difficulty speaking
✓ Edentulous: Without teeth
✓ Gingivitis: Inflammation of gums
✓ Halitosis: Bad breath
✓ Herpes simplex: Cold sore or fever
blister on lip or nose due to herpes virus
✓ Sublingual: Under the tongue
✓ Aphagia: Inability to swallow
✓ Dysphagia: Difficulty swallowing
✓ Esophagitis: Inflammation of the
esophagus
✓ Heartburn: Burning sensation caused
by reflux or flowing back of acid from the
stomach into esophagus
✓ Dyspepsia: Difficult digestion
✓ Emesis (vomiting): Stomach contents
expelled through the mouth
✓ Gastric ulcer: Lesion on wall of
stomach; also known as peptic ulcer
✓ Gastritis: Inflammation of the stomach
✓ Hematemesis: Vomiting of blood
✓ Hiatal hernia: Protrusion of part of the
stomach through the esophageal opening
into diaphragm
✓ Hyperemesis: Excessive vomiting
✓ Nausea: Urge to vomit
✓ Regurgitation: Return of solids and
fluids to mouth from stomach
✓ Ulcer: Sore or lesion of mucous
membrane or skin
✓ Gallstones: Hard collections of bile
that form in gallbladder and bile ducts
✓ Hepatomegaly: Enlargement of liver
✓ Hepatoma: Tumor of liver
✓ Aphagia: Inability to swallow
✓ Dysphagia: Difficulty swallowing
✓ Esophagitis: Inflammation of the
esophagus
✓ Heartburn: Burning sensation caused
by reflux or flowing back of acid from the
stomach into esophagus
✓ Dyspepsia: Difficult digestion
✓ Emesis (vomiting): Stomach contents
expelled through the mouth
✓ Gastric ulcer: Lesion on wall of
stomach; also known as peptic ulcer
✓ Gastritis: Inflammation of the stomach
LESSON 11: INTRODUCTION TO
MEDICAL TRANSCRIPTION
Medical Transcription is a process of
converting physician dictated audio into text
format. Physician dictation would include
any type of medical treatment, procedure,
diagnosis etc. These documents should be
recorded into patient’s permanent medical
record.
Medical Transcriptionist
What They Do: Medical transcriptionists provide proper care for the patient; however,
listen to voice recordings that physicians and the admitting/attend- ing physician is in
other healthcare workers make and convert charge and maintains continuity of care at all
them into written reports. times.
Work Environment: Most medical Discharge Summary
transcriptionists work for hospitals,
A discharge summary (also called a clinical
physicians' offices, and third-party
résumé or final progress note) is required for
transcription service companies that provide
each patient who is discharged from the
transcription services to healthcare
hospital. It contains some of the same
establishments. Others are self-employed.
information that is included in the patient’s
How to Become One: Medical admission history and physical examination.
transcriptionists typically need I
postsecondary education. Prospective
Death Summary
medical transcriptionists must have an
understanding of medical terminology, A death summary is a standard medical
anatomy and physiology, grammar, and report exactly like a discharge summary but
word-processing software. with some important, obvious differences.
Medical Transcription and Autopsy Reports
Documentation
History and Physical Examination (H&P)
When a patient is admitted to the hospital
for evaluation and treatment, the
admitting/attending physician prepares a
medical history detailing the specific
complaint/illness that prompted admission to
the hospital. Information about the patient’s
past medical history, surgery, allergies, and
family and social histories, as well as
psychiatric information, may be included in
this report.
Diagnostic Imaging or Radiology Report
The radiology report is a description of the
findings and the interpretation of
radiographs and other studies done by a
radiologist.
Operative Report (OP)
Immediately after completion of a surgical
procedure, a record of the procedure must be
dictated by the physician, transcribed, and
placed in the patient’s file. This information
is necessary for other physicians and allied
health professionals who may be attending
the patient. Preoperative and postoperative
diagnoses are included.
Pathology Report (Path)
Pathology is that branch of medicine dealing
with the study of disease. It is divided into
anatomic pathology and clinical pathology.
Consultation (Consult)
Consults from physicians specializing in
different fields of medicine are necessary to