Course 1 Flashcards
Subjective vs. Objective
Feeling vs. Fact
Chief Complaint
The main reason for the patient’s ED visit
Medical Decision Making
The physician’s thought process
Pain vs. Tenderness
Patient’s feeling vs. Physicians assessment
Benign
Normal, nothing of concern
Distress
The doctor’s judgement of discomfort
Febrile
The state of having a fever, concerning for infection
Acute
New onset, likely concerning
Chronic
Long-standing, not of direct concern
Baseline
An individual’s normal state of being
Auscultation
Listening with a stethoscope
Palpation
The act of pressing on an area (by the doctor)
Inpatient
Admitted to the hospital overnight
Outpatient
Seen and sent home the same day
The physician’s thought process
Medical Decision Making
The doctor’s judgment of discomfort
Distress
An individual’s normal state of being
Baseline
Normal, nothing of concern
Benign
The state of having a fever, concerning for infection
Febrile
New onset, likely concerning
Acute
Long-standing, not of direct concern
Chronic
Listening with a stethoscope
Auscultation
The act of pressing on an area (by the doctor)
Palpation
Admitted to the hospital overnight
Inpatient
Seen and sent home the same day
Outpatient
Manages the ED patient flow.
Charge Nurse
Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients.
Mid-Level Provider
Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures.
ED Nurse
Administers “breathing treatments” and assists with managing a patient’s airway.
Respiratory Therapist (RT)
Helps the nurse and assists with procedures.
ED Tech
Places physician’s orders, answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork.
Unit Secretary
Documents the patient’s visit on behalf of the physician.
Scribe
Walk-In –>
Walk-In –> Triage
Triage –>
Triage –> Bed Placement
Bed Placement –>
Bed Placement –> Nurse Assessment
Nurse Assessment –>
Nurse Assessment –> History and Physical (H&P)
History and Physical –>
History and Physical –> Physician Orders
Differential Dx –>
Differential Dx –> Physician Orders
Physician Orders –> (4)
Laboratory Studies, Imaging Studies, Procedures, Medications
Lab/Rad/Med –>
Lab/Rad/Med –> Results and ED Course
Results and ED Course –>
Results and ED Course –> Final Dx (Dx)
Final Dx –>
Final Dx –> Disposition
Vital Signs (5)
HR, BP, RR, T, SaO2
General Documentation Template (6)
History of Present Illness (HPI), Review of Systems (ROS), Past History, Physical Examination (PE), ED Course, Disposition
Subjective parts of template (2)
History of Present Illness (HPI), Review of Systems (ROS)
Objective parts of template (2)
Physical Examination (PE), ED Course
Chart sections for patient complaint
HPI or ROS
Chart section for past diagnosis or surgery
Past History
Chart section for physician’s observation
Physical Exam
Chart section for re-evaluation
ED Course
Chart section for where they will go
Diagnosis & Disposition
History of Present Illness (HPI)
Subjective story of chief complaint (CC)
Review of Systems (ROS)
Subjective head-to-toe list
Types of Past History
PMHx (Past Medical), PSHx (Past Surgical), FHx (Family History), SHx (Social History)
“High Blood Pressure”
Hypertension (HTN)
“High Cholesterol”
Hyperlipidemia (HLD)
“Thyroid problem”
usually Hypothyroidism, sometimes Hyperthyroidism
“Diabetes”
Diabetes Mellitus (DM)
“I only take pills for my diabetes”
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
“I take shots (insulin) for my diabetes”
Insulin Dependent Diabetes Mellitus (IDDM)
“Heart disease”
usually Coronary Artery Disease (CAD)
“Heart attack”
Myocardial Infarction (MI) and Coronary Artery Disease (CAD)
“Heart failure”
Congestive Heart Failure (CHF)
“Irregular heartbeat”
Atrial Fibrillation (A-Fib)
“Murmur”
Heart murmur
“Episodes of abnormally fast/racing heartbeat”
Supraventricular Tachycardia (SVT)
“Az-muh”
Asthma
“Emphysema -or- Chronic Bronchitis”
Chronic Obstructive Pulmonary Disease (COPD)
“Blood clot in lung”
Pulmonary Embolism (PE)
“Nuh-mone-yuh”
Pneumonia (PNA)
“Reflux”
Gastroesophageal Reflux Disease (GERD)
“Ulcer”
Gastric Ulcer -or- Peptic Ulcer Disease (PUD)
“pan-cree-uh-tie-tis”
Pancreatitis
“Hep-uh-tie-tis”
Hepatitis A, Hepatitis B, or Hepatitis C
“Die-ver-tick-you-lie-tis”
Diverticulitis
“Crohn’s/UC”
Crohn’s Disease -or- Ulcerative Colitis
“Irritable bowel”
Irritable Bowel Syndrome (IBS)
“Bladder infection”
Urinary Tract Infection (UTI)
“Kidney infection”
Pyelonephritis (Pyelo)
“Kidney stones”
Renal calculi
“I’m on dialysis”
Chronic Renal Failure (CRF) on dialysis
“Enlarged prostate”
Benign Prostate Hypertrophy (BPH)
(G/P/A): G?
G = # pregnancies
(G/P/A): P?
P = # live births (viable children)
(G/P/A): A?
A = # miscarriages/abortions
