Course 1 Flashcards
1
Q
Subjective vs objective
A
Feeling vs Fact
2
Q
Cheif complaint
A
the main reason for the patient’s ED visit
3
Q
Medical Decision Making
A
Physician’s thought process
4
Q
Pain vs tenderness
A
Patient’s feeling vs. physician’s assessment
5
Q
benign
A
normal, nothing of concern
6
Q
Distress
A
the doctor’s judgement of discomfort
7
Q
febrile
A
the state of having a fever, concerning for infection
8
Q
acute
A
new onset, likely concerning
9
Q
chronic
A
long-standing, not of direct concern
10
Q
baseline
A
an individual’s normal state of being
11
Q
auscultation
A
listening with a stethoscope
12
Q
palpation
A
the act of pressing on an area (by the doctor)
13
Q
inpatient
A
admitted to the hospital overnight
14
Q
outpatient
A
seen and sent home the same day
15
Q
What is a scribe (specifically Emergency physician scribe?
A
An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.
16
Q
Scribes can document..
A
history, PE, results, procedures, and physician consults.
17
Q
scribes can access and document…
A
laboratory results and radiology findings
18
Q
scribes can access and display
A
X-rays for the physician to review
19
Q
Scribes can locate and obtain..
A
PMHx, previous charts, past results, and recent studies
20
Q
Scribes can record…
A
physician interpretations of X-Rays and ECGs
21
Q
Scribes can’t…
A
touch patients, write orders or prescriptions, give verbal orders, partake in anything that may affect patient health or outcome, sign/authenticate any chart or record, handle bodily fluids or specimens.
22
Q
charge nurse
A
Manages the ED patient flow
23
Q
Mid-level provider
A
Nurse practitioner (LNP) or Physician assistant (PA) that works under the supervision of a physician to diagnose and treat patients
24
Q
ED nurse
A
records medical histories, symptoms, monitors the patient, starts IVs, administer medication, and assists with procedures.
25
Respiratory therapist (RT)
Administers "breathing treatments" and assists with managing a patient's airway.
26
ED tech
helps the nurse and assists with procedures.
27
Unit secretary
places physician's orders, answer phone calls, pages other specialists/doctors, and organizes the patient's paperwork.
28
Scribe
documents the patient's visit on behalf of the physician.
29
Job of emergency physician is?
to use a patient’s subjective complaints as a guide for obtaining objective facts that lead to an accurate diagnosis.
30
ED flow overview
check in and chief complaint-physician assessment- objective orders and results- medical decision making- disposition
31
ED flow before orders
Walk-in/EMS - triage - bed placement- nurse assessment - H & P - physician orders
32
ED flow after orders
physician orders- ruling out differentials - results and ED course- Final Dx- disposition
33
walk-in/EMS
waiting room/ambulance bay
34
triage
chief complaint, vital signs, Level of acuity
35
Vital signs
HR, BP, RR, T, SaO2
36
Nurse assessment
confirm chief complaint, review allergies, brief past medical history
37
History and physical (H& P)
subjective (HPI, ROS), past history (PMHx, PSHx, FHx, SHx), objective (PE)
38
Differential Dx
Based on the H&P, the physician generates a list of things that may be causing the pt’s subjective symptoms. Then the doctor places orders to “rule out” each differential.
39
physician orders
Laboratory studies, imaging, procedures, medications
40
Results and ED course
Patient re-evaluations. Consults with specialists
41
Final Dx
By using Medical Decision Making (MDM) the physician reviews specific
results that can rule out Differential Diagnoses (DDx) to reach the Final Diagnosis (Dx)
42
MDM
Medical decision making
43
DDx
differential diagnosis
44
HPI (history of present illness)
The story and context of the Chief Complaint
45
review of systems (ROS)
A head-to-toe list of positives and negatives
46
Past History
PMHx, PSHx, SHx, FHx
47
Physical Exam (PE)
The physician’s objective findings
48
ED Course
Objective results (Labs, Imaging, Re-Evals, Consults, Procedures)
49
Disposition
Discharge, Admit, Transfer
50
ED chart layout
Subjective complaints(HPI and ROS), Past history, Objective Evaluation (PE and ED course), Dx and disposition
51
What is the name of your hospital's documentation system?
Epic
52
Vital signs (scribes part)
obtained in nurse triage, but documentation in chart is your job, and doc of changes
53
high blood pressure
Hypertension (HTN)
54
High cholesterol
Hyperlipidemia (HLD)
55
Thyroid problem
Usually hypothyroidism, sometimes hyperthyroidism
56
diabetes
DM
57
I take pills for Diabetes
NIDDM
58
I take shots of insulin for diabetes
IDDM
59
Heart disease
CAD (coronary artery disease)
60
heart failure
congestive heart failure (CHF)
61
irregular heart beat
A- fib
62
Murmur
hear murmur
63
Episodes of abnormally fast/ racing heartbeat
Supraventricular Tachycardia (SVT)
64
asthma
asthma
65
Emphysema/ Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
66
blood clot in lung
Pulmonary embolism (PE)
67
Pneumonia
PNA
68
reflux
Gastroesophageal Reflux Disease (GERD)
69
pancreatitis
pancreatitis
70
Hepatitis
A, B, Or C
71
Diverticulitis
diverticulitis
72
Crohn's/UC
Crohn’s Disease or Ulcerative Colitis
73
irratable bowel
Irritable Bowel Syndrome (IBS)
74
bladder infection
UTI
75
kidney infection
pyelonephritis (pyelo)
76
kidney stones
Renal calculi
77
I'm on dialysis
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis
78
enlarged prostate
Benign Prostate Hypertrophy (BPH)
79
Chronic renal failure
CRF
80
End stage renal disease
ESRD
81
benign prostate hypertrophy
BPH
82
Gynecological PMHx
G/P/A
83
G: gravida
is the total number of times the patient has been pregnant
84
P: para
is the number of lives births (viable children) that the pt has had
85
Abortion A:
is the total number of miscarriages or elective abortions
86
stroke
CVA cerebrovacular accident
87
mini-stroke
Transient Ischemic Attack (TIA)
88
seizures
Seizure disorder/Epilepsy
89
brain bleed
Hemorrhagic CVA
90
bipolar
bipolar disorder
91
schizophrenia
schizophrenia
92
i drink a lot
ETOH abuse or Alcoholism
93
“I do drugs”
substance abuse
94
blood clot in my leg
Lower Extremity Deep Vein Thrombosis (DVT)
95
“Bulge in my aorta” or “Triple A”
Abdominal Aortic Aneurysm (AAA)
96
“Bad blood flow to my legs
Peripheral Vascular Disease (PVD)
97
“Numbness in my legs”
Peripheral Neuropathy
98
low back pain
chronic low back pain
99
bulging/heriniated disc
Degenerative Disc Disease (DDD)
100
arthritis
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
101
Joint pain (chronic)
Degenerative Joint Disease (DJD)
102
Weak/fragile bones
often osteoporosis
103
Cancer
Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate, Ovarian, Skin, Bone, Leukemia, or Lymphoma
104
spread to my...
with metastases to the
105
chemo
chemotherapy
106
radiation
radiation therapy
107
they cut it out
Status-post surgical resection
108
it's gone
in remission
109
Tonsils removed
Tonsillectomy
110
Adenoids removed
Adenoidectomy
111
Ear tubes
Pressure Equalizer (P.E.) Tubes
112
Heart Bypass
CABG - PMHx CAD
113
stents
Coronary stents- PMHx CAD
114
Heart Cath
Cardiac Catherization
115
Balloon
Angioplasty- PMHx CAD
116
Valve surgery
valve repair or replacement (Bovine vs. Mechanical)
117
Pacer
PAcemaker
118
Defibrillator
Automatic Implanted Cardiac Defibrillator (AICD)
119
Surgery for AFib
Afib s/p cardiac ablation
120
breast removal
mastectomy
121
hole in my neck
tracheostomy (trach)
122
part of my lung removed
Partial lobectomy
123
Appendix removed
appendectomy
124
gallbladder removed
cholecystectomy
125
hernia repair
herniorrhaphy
126
part of my colon removed
partial colectomy
127
bag to collect stool
colostomy
128
spleen removed
splenectomy
129
stomach stapled
gastric bypass
130
exploratory
exploratory Laproscopy (ExLap)
131
kidney removed
nephrectomy
132
uterus removed
hysterectomy (partial vs. total)
133
ovary removed
oophorectomy
134
ovary and fallopian tubes removed
salpingo-oophorectomy
135
tubes tied
tubal ligation (female) or Vasectomy (male)
136
C-section
cesarean section
137
prostate removed
prostatectomy (most often trans-urethral removal of the prostate, or TURP)
138
Uterine product removed
Dilation and curettage (D&C)
139
Neck artery cleaned
Carotid Endarterectomy
140
Brain surgery
craniotomy (brain bleed vs. brain CA)
141
Shunt
Ventriculoperitoneol (VP) shunt
142
Dialysis fistula
AV (arteriovenous fistula)
143
Dialysis graft
AV graft
144
PICC line
Peripherally inserted central catheter (PICC)
145
Port
Port-a-cath or Medi-Port
146
Clot filter (Lower abdomen)
IVC (inferior vena cava) Filter
147
Clot filter (leg)
greenfield filter
148
leg amuptated
Above Knee Amputation (AKA) Below Knee Amputation (BKA)
149
joint repair
arthroplasty
150
Metal plates/pins
Hardware
151
Neck fused
cervical spinal fusion
152
Back fused
Lumbar spinal fusion
153
Hip surgery
Open Reduction with Internal Fixation (ORIF)
154
Home medications and Allergies
Physician will almost always ask pt their home meds and allergies. Home meds entered by nurse, but may be asked to update med list in PMHx. Pay attentions to allergies reviewed.
155
True allergies
causes rash, itching swelling, or difficulty reaction
156
not an allergy
adverse reaction
157
FHx (Family History)
Younger age means higher genetic risk. Older (50+) more due to the environment than genetics. Genetic risk is higher if high frequency of disease in family.
158
FHx General
HTN, DM, CA
159
FHx Cardiac
MI/CAD less than 55 years old
160
FHx Pulmonary
PE, Asthma
161
Gastronintestinal FHx
Crohn's, IBS
162
Neurological FHx
CVA, ANeurysm, Seizures
163
Misc. FHx
Sickle cell Anemia, DVT
164
Social history (SHx)
Tobacco use, Alcohol Use, Illicit Drug Use, Occupation, Living circumstances,
165
Tobacco use SHX
* Smoking status
* Former (year quit)
* Never
* Current (#ppd, #yrs)
* Second-hand exposure (pediatrics)
* Chewing tobacco
166
Alcohol Use (ETOH) SHx
* Never
* Occasionally/socially
* Daily
* Chronic alcoholic
* Number of drinks/day
* Type of alcohol (beer/wine/liquor)
167
Illicit Drug Use SHx
```
• Which drug
• Heroin
• Cocaine
• Methamphetamine • THC
• Narcotics
• Route of administration Oral
Inhaled Injected
• Date of last use
```
168
Occupation SHx
* Employed
* Unemployed
* On disability
* Retired
* If physician asks specifically about type of work, be sure to document it
169
SHx living circumstances
* Lives alone
* With family/friends
* Nursing home/assisted living
* Hospice
* Homeless/shelter
170
SHx Pediatrics
```
• Caretaker (mother, father, etc.)
• Attends daycare
• Attends school
• Has brothers/sisters
• Second-hand smoke exposure
• Immunizations up to date
*unique, kids can't talk
```
