ScribeAmerica Final Exam > Course 1: ED Flow > Flashcards

Course 1: ED Flow Flashcards

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1
Q

Diagnosis & Disposition

A
  1. discharge, admit, transfer
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2
Q

seizures

(​Patient)

A

history of seizures

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3
Q

crohns/UC

(​Patient)

A

crohn’s disease / ulcerative colitis

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4
Q

ED Course

A
  1. objective results
  2. labs, imaging, re-evals, consults, procedures
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5
Q

ischemic stroke

(​Patient)

A

ischemic cerebrovascular accident (CVA)

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6
Q

acid reflux

(​Patient)

A
  1. gastroesophageal reflux disease
  2. GERD
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7
Q

high cholesterol

(​Patient)

A
  1. hyperlipidemia
  2. HLD
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8
Q

murmur

(​Patient)

A

heart murmur

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9
Q

Physical Examination

A
  1. PE
  2. physician objective findings
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10
Q

Bipolar

(​Patient)

A

Bipolar disorder

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11
Q

ulcer

(​Patient)

A
  1. gastric ulcer
  2. peptic ulcer disease
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12
Q

mini-stroke

(​Patient)

A

transient ischemic attack (TIA)

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13
Q

diabetes

(​Patient)

A
  1. diabetes mellitus
  2. DM
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14
Q

pancreatitis

(​Patient)

A

pancreatitis—»inflammation of the pancreas

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15
Q

heart failure

(​Patient)

A
  1. congestive heart failure
  2. CHF
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16
Q

WHERE TO DOCUMENT

a) patient complaint
b) past diagnosis/surgery
c) physician’s observation
d) objective study
e) re-evaluation
f) where pc will go

A

a) HPI/ROS
b) past history
c) physical exam
d) results/ED course
e) ED course
f) diagnosis & disposition

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17
Q

PSHx

A
  1. Past surgical history
  2. Ex —» appendectomy, cholecystectomy, CABG, etc.
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18
Q

heart attack

(​Patient)

A
  1. myocardial infarction
  2. MI
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19
Q

blood clot in lung

(​Patient)

A
  1. pulmonary embolism
  2. PE
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20
Q

episodes of abnormally fast/racing heartbeat

(​Patient)

A

arrhythmia or supraventricular tachycardia (SVT)

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21
Q

kidney infection

(​Patient)

A
  1. pyelonephritis
  2. Pyelo
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22
Q

“i only take pills for my diabetes”

(​Patient)

A
  1. non-insulin dependent diabetes mellitus
  2. NIDDM
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23
Q

ROS

A
  1. review of systems
  2. full body evaluation
  3. subjective complaints
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24
Q

high blood pressure

(​Patient)

A
  1. hypertension
  2. HTN
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25
irritable bowel | (​**Patient**)
1. irritable bowel syndrome 2. IBS
26
pneumonia | (​**Patient**)
1. pneumonia 2. PNA
27
heart disease | (​**Patient**)
1. coronary artery disease 2. CAD
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irregular heartbeat | (​**Patient**)
1. arrhythmia, atrial fibrillation
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Schizophrenia ## Footnote **(​Patient)**
Schizophrenia
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bladder infection | (​**Patient**)
1. urinary tract infection 2. UTI
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hepatitis | (​**Patient**)
hepatitis—»inflammation of the liver
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thyroid problem | (​**Patient**)
1. hyperthyroidism or hypothyroidism
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PMHx
1. past medical history 2. Ex: HTN, DM, HLD, CAD, MI, etc.
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brain bleed | (​**Patient**)
1. hemorrhagic cerebrovascular accident 2. CVA
35
SHx
1. Social History 1. tobacco/illicit drug/alcohol usage 2. occupation 3. living circumstances 2. will vary depending on pc age (i.e. child vs. geriatric patient)
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"i'm on dialysis" | (​**Patient**)
1. chronic renal failure (CRF) 2. end stage renal disease (ESRD) on dialysis
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kidney stones | (​**Patient**)
renal calculi
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diverticulitis | (​**Patient**)
diverticulitis–»inflammation/scarring of diverticula in colon
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asthma | (​**Patient**)
asthma—»bronchoconstriction, tightened smooth muscles of bronchial tube, mucus buildup
40
emphysema/chronic bronchitis | (​**Patient**)
1. chronic obstructive pulmonary disease 2. COPD
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"i take shots of insulin for my diabetes" (​**Patient**)
1. insulin dependent diabetes mellitus 2. (IDDM)
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enlarged prostate | (​**Patient**)
1. benign prostatic hypertrophy 2. BPH
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HPI
1. History of Present Illness 2. pc story and chief complaint 3. _subjective_ complaints
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GPA
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FHx
1. Family History 2. onset of each familial disease is important b/c it helps determine genetic risks —» **older age of onset (55+ y/o) is likely more due to environment than genetics** 3. genetic risk for disease inc. if mult. blood-family members suffer from same disease 4. Ex: Hx of CAD \<55 y/o...
46
"i drink alot" ## Footnote **(​Patient)**
ETOH abuse / Alcoholism
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"i do drugs" ## Footnote **(​Patient)**
Substance Abuse
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"blood clot in my leg" | (​Patient)
1. Lower Extremity Deep Vein Thrombosis 2. DVT
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"buldge in my aorta" | (​Patient)
Aortic Aneurysm
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"bad blood flow to my legs" | (​Patient)
1. Peripheral Vascular Disease 2. PVD
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"numbness in my legs" | (​Patient)
Peripheral Neuropathy
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Low back pain | (​Patient)
Chronic Low Back Pain
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Buldging/Herniated disc
1. Degenerative Disc Disease 2. **DDD**
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Arthritis | (​Patient)
1. Osteoarthritis (OA) 2. Rheumatoid Arthritis (RA)
55
weak/fragile bones
1. Osteoporosis (most often)
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Cancer | (​Patient)
1. Cancer or Carcinoma: brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma 2. **CA**
57
Cancer "spread to my..." (​Patient)
with metastases to the ...
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Chemo | (​Patient)
Chemotherapy
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Radiation | (​Patient)
Radiation Therapy
60
"they cut it out..." [cancer] | (​Patient)
Status-post surgical resection
61
"its gone" [cancer] (​Patient)
in remission
62
tonsils removed (​Patient)
Tonsillectomy
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Adenoids removed | (​Patient)
Adenoidectomy
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Ear Tubes (PSHX) | (​Patient)
Myringotomy / Pressure Equalizing **(P.E.)** Tubes
65
Heart Cath (​Patient)
Cardiac catheterization
66
Balloon (​Patient)
Angioplasty—»PMHx CAD
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Stents (​Patient)
Coronary Stents —» PMHx CAD
68
Heart bypass | (​Patient)
Coronary Atery Bypass Graft **(CABG)** —» PMHx CAD
69
Valve surgery | (​Patient)
Valve repair or replacement (Bovine vs. Mechanical)
70
Pacer | (​Patient)
Pacemaker
71
defibrillator | (​Patient)
1. Automatic Implanted Cardiac Defilbrillator 2. **AICD**
72
Surgery for Afib | (​Patient)
Afib s/p cardiac ablation
73
breast removal | (​Patient)
Mastectomy
74
hole in my neck | (​Patient)
Tracheostomy (commonly called a _trach_)
75
Part of my lung removed
Partial lobectomy
76
appendix removed | (​Patient)
Appendectomy
77
gallbladder removed
Cholecystectomy
78
hernia repair | (​Patient)
Herniorrhaphy
79
part of my colon removed | (​Patient)
Partial colectomy
80
bag to collect stool | (​Patient)
Colostomy
81
spleen removed | (​Patient)
Splenectomy
82
Stomach stapled | (​Patient)
Bariatric Surgery (i.e. gastric sleeve, gastric band/lap band, gastric bypass, etc.)
83
Exploratory | (​Patient)
1. Exploratory Laparoscopy 2. **(ExLap)**
84
kidney removed | (​Patient)
Nephrectomy
85
uterus removed | (​Patient)
Hysterectomy (partial vs. total)
86
Ovary and fallopian tubes removed | (​Patient)
Salpingo-oophorectomy
87
tubes tied (Male vs. Female) (​Patient)
1. Male —» Vasectomy 2. Female —» Tubal ligation
88
C-section (​Patient)
Cesarean Section
89
prostate removed (​Patient)
1. Prostatectomy or Prostate resection 2. most often—» Transurethral Resection of the Prostate **(TURP)**
90
uterine product removed (​Patient)
1. Dilation and Curettage 2. **D&C**
91
neck artery cleaned (​Patient)
Carotid Endarterectomy
92
shunt (​Patient)
Cerebral Shunt
93
Brain Surgery (​Patient)
Craniotomy (brain bleed vs. brain CA)
94
dialysis fistula (​Patient)
AV (arteriovenous) Fistula
95
dialysis graft (​Patient)
AV Graft
96
PICC line (​Patient)
1. Peripherally Inserted Central Catheter 2. **PICC**
97
Port (​Patient)
Port-a-cath / Medi-Port
98
Clot filter (lower abdomen) (​Patient)
IVC (inferior vena cava) Filter
99
leg amputated (​Patient)
1. Above Knee Amputation (**AKA**) 2. Below Knee Amputation (**BKA**)
100
joint repair (Patient)
Arthroplasty
101
metal plates/pins (Patient)
Hardware
102
Neck/Back fused (Patient)
Cervical/Lumbar Spinal Fusion
103
new hip (Patient)
1. Total hip replacement / Open Reduction with Internal Fixation (**ORIF**)
104
HIPPA
1. Health Insurance Portability and Accountability Act 2. body of laws designed to protect the private health information of patients across the country.
105
PHI
1. Protected Health Information —» any info that can be directly or indirectly tied to a particular patient or visit
106
HITECH
1. Health Information Technology for Economic and Clinical Health Act (HITECH) 2. specifically address the privacy and security issues related to electronic transmission of health information —» states that PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption
107
ED Flow
1. walk-in 2. triage 3. bed 4. PE (physical exam) 5. labs/rad/meds 6. results 7. MDM 8. diagnosis 9. consults 10. Disposition: (A) discharge (B) admit (C) transfer
108
what are the 4 types of medical histories?
1. Medical Hx (PMHx) 2. Surgical Hx (PSHx) 3. Family Hx (FHx) 4. Social Hx (SHx)
109
Would you be contradicting yourself if you wrote “The patient has abdominal pain” in the HPI, but then later in the physical exam documented “The abdomen is nontender.” Why or why not?
* No —» the patient stating they have abdominal pain is a subjective complaint. * A non-tender abdomen is an objective finding.
110
What does disposition (dispo) mean?
The patient’s destination after they leave the Emergency Department.
111
no known drug allergies | (Patient)
**NKDA** [No Known Drug Allergies]
112
medical term for redness
Erythema
113
medical term for bruising
Ecchymosis
114
If the doctor says the exam was “benign”, what does that mean?
Normal —» Nothing of concern
115
Jugular Vein Distention | (Patient)
**JVD**
116
Tachycardia
Increased HR
117
Ronchi
sound that results from mucus and fluid buildup in pc w/pnemonia (PNA)
118
Cephalgia
A distinctive syndrome of headaches, also known as cluster headache or migrainous neuralgia
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133
Arrange the following steps in order from first to last for a typical patient’s flow through the ED. (Top to bottom). Bed placement, triage, labs/radiology/medications, disposition, MDM, history and physical (H&P)
134

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