Lectures Flashcards
1
Q
The main reason for the patient’s ED visit
A
Chief Complaint
2
Q
The physician’s thought process
A
Medical Decision Making
3
Q
Normal, nothing of concern
A
Benign
4
Q
The doctor’s judgment of discomfort
A
Distress
5
Q
The state of having a fever, concerning for infection
A
Febrile
6
Q
New onset, likely concerning
A
Acute
7
Q
Long-standing, not of direct concern
A
Chronic
8
Q
An individual’s normal state of being
A
Baseline
9
Q
Listening with a stethoscope
A
Auscultation
10
Q
The act of pressing on an area (by the doctor)
A
Palpation
11
Q
Admitted to the hospital overnight
A
Inpatient
12
Q
Seen and sent home the same day
A
Outpatient
13
Q
Subjective vs. Objective
A
Feeling vs. Fact
14
Q
Chief Complaint
A
The main reason for the patient’s ED visit
15
Q
Medical Decision Making
A
The physician’s thought process
16
Q
Pain vs. Tenderness
A
Patient’s feeling vs. Physician’s assessment
17
Q
Benign
A
Normal, nothing of concern
18
Q
Distress
A
The doctor’s judgment of discomfort
19
Q
Acute
A
New onset, likely concerning
20
Q
Chronic
A
Long-standing, not of direct concern
21
Q
Baseline
A
An individual’s normal state of being
22
Q
Auscultation
A
Listening with a stethoscope
23
Q
Palpation
A
The act of pressing on an area (by the doctor)
24
Q
Inpatient
A
Admitted to the hospital overnight
25
Outpatient
Seen and sent home the same day
26
5 vital signs
HR, BP, RR, T, SaO2
27
HPI
History of Present Illness
28
ROS
Review of Systems
29
H&P
History and Physical
30
Hx
Past History
31
PMHx
Past Medical History
32
PSHx
Past Surgical History
33
FHx
Family History
34
SHx
Social History
35
2 Parts of Subjective Exam
HPI, ROS
36
MDM
Medical Decision Making
37
DDx
Differential Diagnoses
38
2 Parts of Objective Exam
PE, ED Course
39
6 parts of template
HPI, ROS, Hx, PE, ED Course, Dx/Dispo
40
Name of hospital documentation system
Cerner
41
"High blood pressure"
Hypertension (HTN)
42
"High cholesterol"
Hyperlipidemia (HLD)
43
"Thyroid problem"
Hypothyroidism (or Hyper)
44
"Diabetes"
Diabetes Mellitus (DM)
45
"Take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus
46
"Take shots for my diabetes"
Insulin Dependent Diabetes Mellitus
47
"Heart disease"
Coronary Artery Disease (CAD)
48
"Heart attack"
Myocardial Infarction (MI) and Coronary Artery Disease (CAD)
49
"Heart failure"
Congestive Heart Failure (CHF)
50
"Irregular heartbeat"
Atrial Fibrillation (A Fib)
51
"Murmur"
Heart murmur
52
"Episodes of abnormally fast/racing heartbeat"
Supraventricular Tachycardia (SVT)
53
"Emphysema/Chronic Bronchitis"
Chronic Obstructive Pulmonary Disease (COPD)
54
"Blood clot in lung"
Pulmonary Embolism (PE)
55
"Reflux"
Gastroesophageal Reflux Disease (GERD)
56
"Ulcer" (2)
Gastric Ulcer, Peptic Ulcer Disease (PUD)
57
"Krones/UC"
Crohn's Disease, Ulcerative Colitis
58
"Bladder infection"
Urinary Tract Infection (UTI)
59
"Kidney infection"
Pyelonephritis (Pyelo)
60
"Kidney stones"
Renal calculi
61
"I'm on dialysis" (2)
Chronic Renal Failure (CRF), End Stage Renal Disease (ESRD) on dialysis
62
"Enlarged prostate"
Benign Prostate Hypertrophy (BPH)
63
GPA: G?
G = total number of times pt has been pregnant
64
GPA: P?
P = Number of live births (viable children)
65
GPA: A?
A = number of miscarriages or elective abortions
66
"Stroke"
Cerebrovascular Accident (CVA)
67
"Mini-stroke"
Transient Ischemic Attack (TIA)
68
"See-jzers" (2)
Seizure disorder, Epilepsy
69
"Brain bleed"
Hemorrhagic CVA
70
"Bipolar"
Bipolar disorder
71
"Skit-zoe-fren-ee-uh"
Schizophrenia
72
"I drink a lot" (2)
EtOH abuse, Alcoholism
73
"I do drugs"
Substance Abuse
74
"Blood clot in my leg"
Lower Extremity Deep Vein Thrombosis (DVT)
75
"Bulge in my aorta"
Abdominal Aortic Aneurysm (AAA)
76
"Bad blood flow to my legs"
Peripheral Vascular Disease (PVD)
77
"Numbness in my legs"
Peripheral Neuropathy
78
"Low back pain"
Chronic Low Back Pain
79
"Bulging/Herniated disc"
Degenerative Disc Disease (DDD)
80
"Arthritis" (2)
Osteoarthritis (OA), Rheumatoid Arthritis (RA)
81
"Joint pain (chronic)"
Degenerative Joint Disease (DJD)
82
"Weak/fragile bones"
Osteoporosis
83
"Spread to my..."
With metastases to the...
84
"Chemo"
Chemotherapy
85
"Radiation"
Radiation therapy
86
"They cut it out"
s/p surgical resection
87
"It's (the cancer) gone"
In remission
88
"Tonsils" removed"
Tonsillectomy
89
"Adenoids removed"
Adenoidectomy
90
"Ear tubes"
Pressure Equalizer (P.E.) Tubes
91
"Heart bypass"
Coronary Artery Bypass Graft (CABG), PMHx CAD
92
"Stents"
Coronary Stents, PMHx CAD
93
"Heart Cath"
Cardiac catheterization
94
"Balloon"
Angioplasty, PMHx CAD
95
"Valve surgery"
Valve repair/replacement (Bovine vs. Mechanical)
96
"Pacer"
Pacemaker
97
"Defibrillator"
Automatic Implanted Cardiac Defibrillator (AICD)
98
"Surgery for Afib"
Afib s/p cardiac ablation
99
"Breast removal"
Mastectomy
100
"Hole in my neck"
Tracheostomy
101
"Part of my lung removed"
Partial lobectomy
102
"Appendix removed"
Appendectomy
103
"Gallbladder removed"
Cholecystectomy
104
"Hernia repair"
Herniorrhaphy
105
"Part of my colon removed"
Partial colectomy
106
"Bag to collect stool"
Colostomy
107
"Spleen removed"
Splenectomy
108
"Stomach stapled"
Gastric bypass
109
"Exploratory"
Exploratory Laproscopy
110
"Kidney removed"
Nephrectromy
111
"Uterus removed"
Hysterectomy (partial vs. total)
112
"Ovary removed"
Oophorectomy
113
"Ovary and fallopian tubes removed"
Salpingo-oophorectomy
114
"Tubes tied" (female)
Tubal ligation
115
"Tubes tied" (male)
Vasectomy
116
"C-Section"
Caesarean Section
117
"Prostate removed"
Prostatectomy (often Trans-Urethral Removal of the Prostate, or TURP)
118
"Uterine product removed"
Dilation and Curettage (D&C)
119
"Neck artery cleaned"
Carotid Endarterectomy
120
"Brain surgery"
Craniotomy (brain bleed vs. brain CA)
121
"Shunt"
Ventriculoperitoneal (VP) Shunt
122
"Dialysis fistula"
AV (arteriovenous) Fistula
123
"Dialysis graft"
AV (arteriovenous) Graft
124
"PICC Line"
Peripherally Inserted Central Catheter (PICC)
125
"Port" (2)
Port-a-cath or Medi-port
126
"Clot filter (lower abdomen)"
IVC (inferior vena cava) Filter
127
"Clot filter (leg)"
Greenfield Filter
128
"Leg amputated" (2)
Above Knee Amputation (AKA), Below Knee Amputation (BKA)
129
"Joint repair"
Arthroplasty
130
"Metal plates/pins"
Hardware
131
"Neck fused"
Cervical spinal fusion
132
"Back fused"
Lumbar spinal fusion
133
"Hip surgery"
Open Reduction with Internal Fixation (ORIF)
134
HTN
Hypertension
135
HLD
Hyperlipidemia
136
DM
Diabetes Mellitus
137
NIDDM
Non-Insulin Dependent Diabetes Mellitus
138
CAD
Coronary Artery Disease
139
MI
Myocardial Infarction
140
CHF
Congestive Heart Failure
141
A-Fib
Atrial Fibrillation
142
SVT
Supraventricular Tachycardia
143
COPD
Chronic Obstructive Pulmonary Disease
144
PE
Pulmonary Embolism
145
PNA
Pneumonia
146
GERD
Gastroesophageal Reflux Disease
147
PUD
Peptic Ulcer Disease
148
IBS
Irritable Bowel Syndrome
149
UTI
Urinary Tract Infection
150
Pyelo
Pyelonephritis
151
CRF
Chronic Renal Failure
152
ESRD
End Stage Renal Disease
153
BPH
Benign Prostate Hypertrophy
154
CVA
Cerebrovascular Accident
155
TIA
Transient Ischemic Attack
156
"Skit-zoe-fren-ee-uh"
Schizophrenia
157
DVT
Deep Vein Thrombosis
158
AAA
Abdominal Aortic Aneurysm
159
PVD
Peripheral Vascular Disease
160
DDD
Degenerative Disc Disease
161
OA
Osteoarthritis
162
RA
Rheumatoid Arthritis
163
DJD
Degeneratie Joint Disease
164
"Ton-sals"
Tonsils
165
"Add-uh-noids"
Adenoids
166
P.E. Tubes
Pressure Equalizer Tubes
167
Trach
Tracheostomy
168
"Uh-pin-dics"
Appendix
169
ExLap
Exploratory Laproscopy
170
TURP
Trans-Urethral Removal of the Prostate
171
D&C
Dilation and Curettage
172
VP
Ventriculoperitoneal
173
AV
Arteriovenous
174
PICC
Peripherally Inserted Central Catheter
175
IVC
Inferior Vena Cava
176
AKA
Above Knee Amputation
177
BKA
Below Knee Amputation
178
ORIF
Open Reduction with Internal Fixation
179
Diagnosed by: MI (STEMI)
EKG
180
Diagnosed by: MI (non-STEMI)
elevated Troponin
181
Diagnosed by: AFIB
EKG
182
Diagnosed by: CHF
CXR, elevated BNP
183
Diagnosed by: CAD
Positive cardiac catheterization (not in ED)
184
Diagnosed by: Angina
Exertional CP with Hx of CAD
185
Diagnosed by: PE
CTA Chest
186
Diagnosed by: PTX
CXR
187
Diagnosed by: PNA
CXR
188
Diagnosed by: COPD
CXR with Hx of Smoking
189
Diagnosed by: Asthma/Reactive Airway Disease (RAD)
Clinically
190
Diagnosed by: Ischemic CVA
Clinically
191
Diagnosed by: Hemorrhagic CVA ("brain bleed")
CT Head, LP
192
Diagnosed by: TIA
Clinically
193
Diagnosed by: Meningitis
LP
194
Diagnosed by: Spinal Cord Injury
CT Cervical/Thoracic/Lumbar Spine
195
Cervical Spine
Neck
196
Thoracic Spine
Upper back
197
Lumbar Spine
Lower back
198
Diagnosed by: Bells Palsy
Clinically
199
Medical term for HA
Cephalgia
200
Condition when eye makes repetitive, uncontrolled eye movements
Nystagmus
201
Associated Diseases: Epigastric
GERD, MI
202
Associated Diseases: RUQ
Cholecystitis
203
Associated Diseases: LUQ
Pancreatitis
204
Associated Diseases: Periumbillical
SBO
205
Associated Diseases: RLQ
Appendicitis
206
Associated Diseases: LLQ
Diverticulitis
207
Associated Diseases: Suprapubic
Ovarian Torsion, Ovarian Cyst, UTI
208
Associated Diseases: Flanks
Pyelonephritis, Renal Calculi
209
Abdominal Region: Appendicitis
RLQ
210
Abdominal Region: SBO
Periumbillical
211
Abdominal Region: Cholecystitis
RUQ
212
Abdominal Region: GI Bleed
Any
213
Abdominal Region: Diverticulitis
LLQ
214
Abdominal Region: Pancreatitis (2)
Epigastric, LUQ
215
Abdominal Region: GERD
Epigastric
216
Diagnosed by: Appendicitis
CT A/P with PO
217
Diagnosed by: SBO (2)
CT A/P with PO, Acute Abdominal Series (AAS)
218
Diagnosed by: Cholecystitis
US RUQ
219
Diagnosed by: GI Bleed
Guaiac (Heme) Positive
220
Diagnosed by: Diverticulitis
CT A/P with PO
221
Diagnosed by: Pancreatitis
Elevated Lipase
222
Diagnosed by: GERD
Endoscopy (not in ED)
223
Diagnosed by: UTI
Urinalysis (WBC, Nitrite, or Bacteria)
224
Diagnosed by: Pyelo (2)
CT A/P, UTI with CVA tenderness on exam
225
Diagnosed by: Kidney Stone (and clue)
CT A/P, RBC in UA may be a clue
226
Diagnosed by: Ectopic Pregnancy
US Pelvis
227
Diagnosed by: Ovarian Torsion
US Pelvis
228
Diagnosed by: Testicular Torsion
US Scrotum
229
Diagnosed by: Upper Respiratory Infection (URI)
Clinically
230
Diagnosed by: Otitis Media
Clinically
231
Diagnosed by: Streptococcal Pharyngitis
Rapid Strep
232
Diagnosed by: Conjunctivitis
Clinically
233
Diagnosed by: Epistaxis
Clinically
234
Diagnosed by: Abdominal Aortic Aneurysm (AAA)
CTA A/P
235
Diagnosed by: Aortic Dissection
CTA Chest
236
Diagnosed by: Deep Vein Thrombosis (DVT)
US/Doppler of the extremity
237
Diagnosed by: Cellulitis
Clinically
238
Diagnosed by: Abscess
Clinically
239
Diagnosed by: Rash
Clinically
240
Diagnosed by: Allergic Reaction
Clinically
241
Diagnosed by: Diabetic Ketoacidosis (DKA) (2)
Arterial Blood Gas (ABG) showing low pH (acidosis), Positive Serum ketones
242
Diagnosed by: Trauma (2)
CT, XR
243
CAD
Coronary Artery Disease
244
ASA
Aspirin
245
NTG
Nitroglycerin
246
CHF
Congestive Heart Failure
247
PND
Paroxysmal Nocturnal Dyspnea
248
DOE
Dyspnea on Exertion
249
JVD
Jugular Vein Distention
250
BNP
B-type Natriuretic Peptide
251
AFIB
Atrial Fibrillation
252
RVR
Rapid Ventricular Response
253
NSR
Normal Sinus Rhythm
254
CP
Chest Pain
255
SOB
Shortness of Breath
256
BCP
Birth Control Pills
257
PNA
Pneumonia
258
CAP
Community Acquired Pneumonia
259
Abx
Antibiotics
260
PTX
Pneumothorax
261
RAD
Reactive Airway Disease
262
LP
Lumbar Puncture
263
TIA
Transient Ischemic Attack
264
Sz
Seizure
265
HA
Headache
266
FND
Focal Neurological Deficits
267
AMS
Altered Mental Status
268
APPY
Appendicitis
269
SBO
Small Bowel Obstruction
270
AAS
Acute Abdominal Series
271
BM
Bowel Movement
272
N/V/D
Nausea/Vomiting/Diarrhea
273
US
Ultrasound
274
GERD
Gastroesophageal Reflux Disease
275
CVA
Costovertebral Angle
276
RBC
Red Blood Cells
277
A/P
Abdomen/Pelvis
278
UA
Urinalysis
279
URI
Upper Respiratory Infection
280
TM
Tympanic Membrane
281
PTA (not prior to arrival)
Peri-Tonsillar Abscess
282
SLR
Straight Leg Raise
283
CSMT
Circulation, Sensory, Motor, Tendon
284
ROM
Range of Motion
285
I&D
Incision and Drainage
286
DM
Diabetes Mellitus
287
DKA
Diabetic Ketoacidosis
288
ABG
Arterial Blood Gas
289
SI
Suicidal Ideation
290
HI
Homicidal Ideation
291
GCS
Glasgow Coma Scale
292
MVA
Motor Vehicle Accident
293
GSW
Gun Shot Wound
294
MOI
Mechanism of Injury
295
Congestive Heart Failure
Fluid traffic jam
296
Sudden attack or increase in symptoms
Paroxysmal
297
Paroxysmal
Sudden attack or increase in symptoms
298
Inflammation of sac surrounding the heart causing CP
Pericarditis
299
Inflammation of the sac surrounding the lungs causing CP
Pleurisy
300
Irritation of the ribs causing CP worsened by pressing on the sternum
Costochondritis
301
Irritation of the chest wall causing pain with palpation of the chest
Chest Wall Pain
302
Fluid collecting around the lungs causing SOB or CP
Pleural Effusion
303
"lung infection and inflammation"
Pneumonia (PNA)
304
"collapsed lung"
Pneumothorax (PNA)
305
"damage to alveoli"
Emphysema
306
"long term lung inflammation and mucus production"
chronic bronchitis
307
"constricting of airway and muscular contraction in lungs"
bronchospasm
308
"nebulizer breathing treatment for RAD"
bronchodilators
309
"weakness of half of the body"
Hemiparesis
310
"one-sided numbness"
Unilateral Paresthesias
311
"cannot generate or understand language"
Aphasia
312
"stiff neck"
Nuchal rigidity
313
"cannot control urination"
Incontinence
314
"inflammation or viral infection of facial nerve causing one-sided weakness"
Bells Palsy
315
"about to pass out"
near-syncope
316
"relating to sudden drop in blood pressure"
Vasovagal
317
"feeling off balance"
Disequilibrium
318
"ringing in ears"
Tinnitus
319
"production of gallstones"
Cholelithiasis
320
"inflammation of the gallbladder"
Cholecystitis
321
GI
Gastrointestinal
322
"vomiting blood"
Hematemesis
323
"bright red blood in stool"
Hematochezia
324
"black tarry stool"
Melena
325
"abdominal pockets of the large intestine"
Diverticuli
326
"immune disorder causing diarrhea and abdominal pain"
Crohn's Disease
327
"GI Bug"
Gastroenteritis
328
"Stomach ache with vomiting"
Gastritis
329
"painful urination"
Dysuria
330
"spread from a UTI"
Pyelonephritis
331
"kidney stones"
Renal Calculi
332
"kidney stone in kidney"
Nephrolithiasis
333
"kidney stone in ureter"
Urolithiasis
334
"tubal pregnancy"
Ectopic pregnancy
335
"twisting of ovarian artery"
Ovarian Torsion
336
"twisting of spermatic cord"
Testicular Torsion
337
"middle ear infection"
Otitis Media
338
"red throat"
Pharyngeal Erythema
339
"enlargement"
hypertrophy
340
"pus"
exudates
341
"back pain that radiates down legs"
Sciatica
342
"separation of muscular wall from membrane of artery"
Aortic Dissection
343
"widened and weakened arterial wall"
Abdominal Aortic Aneurysm
344
"skin system"
Integumentary System
345
"infection of skin cells"
Cellulitis
346
"skin infection with collection of pus"
Abscess
347
"pus-pocket"
Fluctuance
348
"skin hardening"
Induration
349
"pus-like"
Purulent
350
"itchy"
Pruritic
351
"hives or wheals"
Urticaria
352
"flat rash"
Macules
353
"rash with raised bumps"
Papules
354
"small blisters"
Vesicles
355
"face swelling"
Facial Angioedema
356
3 symptoms from allergic reaction
Rash, Itching, Swelling
357
"dry mouth"
Dry Mucous Membranes
358
"increased thirst"
Polydipsia
359
"increased urination"
Polyuria
360
"low blood pH"
acidosis
361
A short list of diseases the doctor considers when diagnosing a patient
Differential Diagnosis
362
Specific symptoms that raise the physician's concern for that particular disease
Pertinent Positives
363
Specific symptoms that are not present which cause the physician to doubt certain diagnoses
Pertinent Negatives
364
"Red flags" that would put a patient at risk for that particular disease
Risk Factors
365
The study of the causes of diseases
Etiology
366
Membrane lining the thoracic cavity
Parietal Pleura
367
Membrane covering the lungs
Visceral Pleura
368
Differential Diagnosis
A short list of diseases the doctor considers when diagnosing a patient
369
Pertinent Positives
Specific symptoms that raise the physician's concern for that particular disease
370
Pertinent Negatives
Specific symptoms that are not present which cause the physician to doubt certain diagnoses
371
Risk Factors
"Red flags" that would put a patient at risk for that particular disease
372
Etiology
The study of the causes of diseases
373
Parietal Pleura
Membrane lining the thoracic cavity
374
Visceral Pleura
Membrane covering the lungs
375
Description: Onset
When did the complaint begin?
376
Description: Timing
Has it been constant, intermittent, or waxing and waning?
377
Description: Location
Where is the discomfort?
378
Description: Quality
Does it feel sharp, dull, aching, cramping... ?
379
Description: Severity
How bad is it? Mild, mod, sever, or 0-10
380
Description: Modifying Factors
What makes it better? What makes it worse?
381
Description: Associated Sx
Do any other symptoms accompany the complaint?
382
Description: Context
Is there anything else that's important?
383
HPI Element: When did the complaint begin?
Onset
384
HPI Element: Has it been constant, intermittent, or waxing and waning?
Timing
385
HPI Element: Where is the discomfort?
Location
386
HPI Element: Does it feel sharp, dull, aching, cramping... ?
Quality
387
HPI Element: How bad is it? Mild, mod, severe, or 1-10?
Severity
388
HPI Element: What makes it better? What makes it worse?
Modifying Factors
389
HPI Element: Do any other symptoms accompany the complaint?
Associated Sx
390
HPI Element: Is there anything else that's important?
Context
391
Body System: Fever, weight loss, sweats
Constitutional
392
Body System: Change in vision, Eye pain, Double vision
Eyes
393
Body System: Ear ache, Nose bleed, Congestion, Sore throat
Ear/Nose/Throat
394
Body System: Chest pain, Palpitations, Leg swelling
Cardiovascular
395
Body System: SOB, Cough, Sputum, Wheezing
Respiratory
396
Body System: Abdominal pain, N/V/D, Black or bloody stools
Gastrointestinal
397
Body System: Dysuria, Frequency, Urgency, Hematuria
Genitourinary
398
Body System: Joint pain, Muscle pain
Musculoskeletal
399
Body System: Rash, Itching, Abrasion, Laceration
Integumentary/Skin
400
Body System: Headache, Syncope, Seizure, Numbness, Focal weakness
Neurological
401
Body System: Depression, Anxiety
Psychiatric
402
Body System: Polyuria, Polydipsia
Endocrine
403
Body System: Bleeding gums, easy bruising, swollen lymph nodes
Hematologic/Lymph
404
Body System: HIV/AIDS, Splenectomy
Immunologic
405
Based on the patient's feeling (HPI, ROS)
Subjective
406
Factual information from the provider (PE)
Objective
407
The story of the patient's chief complaint
History of Present Illness
408
Head-to-toe checklist of patient's symptoms
Review of Systems
409
"Comes and goes"
Intermittent
410
Always present but changing in intensity
Waxing and waning
411
Something that makes a symptom better or worse
Modifying factor
412
To make worse
Exacerbate
413
Review of Systems
Head-to-toe checklist of patient's symptoms
414
Waxing and waning
Always present but changing in intensity
415
Modifying factor
Something that makes a symptom better or worse
416
AT/NC
Atraumatic/Normocephalic
417
"drowsy"
Somnolent
418
"deadened"
Obtunded
419
PERRL
Pupils are Equal, Round, and Reactive to Light
420
EOMI
Extra Ocular Movements Intact
421
"sclera are white"
Sclera are anicteric
422
"yellowing of sclera"
Scleral icterus
423
"redness of eye"
Conjunctival injection
424
"swelling behind eye"
Papilledema
425
"blood behind front lens"
Hyphema
426
Internal Eye Exam
Fundoscopic Exam
427
Instrument for Fundoscopic Exam
Ophthalmoscope
428
Used for external eye exam (2)
Wood's lamp, Fluorescein
429
"earwax"
Cerumen
430
"Nostrils"
Nares
431
"Nostril"
Naris
432
"nose swelling due to trauma"
Septal Hematoma
433
"runny nose"
Rhinorrhea
434
"nose bleed"
Epistaxis
435
"swollen inner nose"
Boggy turbinates
436
DMM
Dry Mucous Membranes
437
OP
Oropharynx
438
"cavities"
Dental Caries
439
"missing teeth"
Edentulous
440
"white plaque on back of tonsils"
Tonsillar Exudate
441
"swooshing sound in neck artery"
Carotid Bruit
442
2 types of spine tenderness
Vertebral Point, Paraspinal
443
"enlargement of thyroid"
Thyromegaly
444
Description of AFIB
Irregularly Irregular Rhythm
445
"extra beats"
Extra systoles
446
5 pulse types
Radial, Carotid, Femoral, Dorsalis Pedis (DP), Posterior Tibialis (PT)
447
DP
Dorsalis Pedis
448
PT (not physical therapy)
Posterior Tibialis
449
CTAB
Clear to auscultation bilaterally
450
"signs of a surgical abdomen"
Peritoneal Signs
451
3 Peritoneal Signs
Voluntary Guarding, Rebound Tenderness, Rigidity
452
TTP
Tender To Palpation
453
S, NT
Soft and Non-tender
454
"enlarged organ"
Organomegaly
455
"enlarged liver"
Hepatomegaly
456
"enlarged spleen"
Splenomegaly
457
HSM
Hepatosplenomegaly
458
Appendicitis Sign
McBurney's point tenderness
459
Cholecystitis Sign
Murphy's sign
460
CMT
Cervical Motion Tenderness
461
FROM
Full Range of Motion
462
"tender raised area of tissue"
Contusion
463
"blue"
Cyanotic
464
"yellow"
Jaundice
465
"sweaty or clammy"
Diaphoretic
466
"increased warmth"
Calor
467
Skin trauma seen in elderly
Skin Tear
468
"flap of skin"
Avulsion
469
"difficulty speaking"
Dysarthria
470
"decreased sensation"
Hypoesthesia
471
"absent sensation"
Numbness
472
"off balance walking"
Ataxia
473
"painful walking"
Antalgic
474
A frame of reference used to describe anatomy and movement
Anatomical Position
475
Pain felt on palpation
Tenderness
476
Without trauma
Atraumatic
477
Yellowing, also known as jaundice
Icterus
478
Pus-like
Purulent
479
Redness
Erythema
480
Organ enlargement
Organomegaly
481
The flow of blood through the body's blood vessels
Perfusion
482
Feeling and emotion
Affect
483
Able to be comforted
Consolable
484
Used to access level of consciousness in trauma patients
GCS
485
Anatomical Position
A frame of reference used to describe anatomy and movement
486
Icterus
Yellowing, also known as jaundice
487
Perfusion
The flow of blood through the body's blood vessels
488
Affect
Feeling and emotion
489
Consolable
Able to be comforted
490
CBC
Complete Blood Count
491
WBC
White Blood Cells
492
BMP
Basic Metabolic Panel
493
CMP
Comprehensive Metabolic Panel
494
LFT
Liver function test
495
BUN
Blood Urea Nitrogen
496
CK
Creatine Kinase
497
CEP
Cardiac Enzyme Panel
498
CK-MB
Creatine Kinase - Muscle Breakdown
499
CK-RI
Creatine Kinase - Relative Index
500
BNP
B-type Natriuretic Peptide
501
ABG
Arterial Blood Gas
502
VBG
Venous Blood Gas
503
CSF
Cerebrospinal Fluid
504
2 tests for coagulation studies
PT/INR
505
NSR
Normal Sinus Rhythm
506
SB
Sinus Bradycardia
507
ST
Sinus Tachycardia
508
A fib
Atrial Fibrillation
509
A flutter
Atrial Flutter
510
Paced
Pacemaker is functioning
511
SVT
Supraventricular Tachycardia
512
PVC
Premature Ventricular Contraction
513
PAC
Premature Atrial Contraction
514
LAD
Left Axis Deviation
515
RAD (ekg interpretation)
Right Axis Deviation
516
LAFB
Left anterior fascicular block
517
LBBB
Left Bundle Branch Block
518
RBBB
Right Bundle Branch Block
519
1° AVB
First Degree AV Block
520
LVH
Left Ventricular Hypertrophy
521
PRWP
Poor R wave Progression
522
ST ↑
Acute ST Elevation
523
ST ↓
Acute ST Depression
524
NSSTΔ's
Non-specific ST/T changes
525
Inferior leads
II, III, aVF
526
Lateral leads
I, aVL, V5, V6
527
Anterior leads
V3, V4
528
Septal leads
V1, V2
529
CCT
Critical Care Time
530
ACS
Acute Coronary Syndrome
531
Blood taken from an artery
Arterial Blood Gas
532
The clear liquid separated from clotted blood
Serum
533
The change of blood from liquid to solid
Coagulation
534
Medication that suppresses the central nervous system that results in unconsciousness and lack of sensation
Anesthesia
535
The propagation of microorganisms or of living tissue cells in media conductive to their growth
Cultures
536
Care provided to any patient that is at serious risk for deterioration that may lead to permanent bodily harm or death
Critical Care Time
537
Serum
The clear liquid separated from clotted blood
538
Coagulation
The change of blood from liquid to solid
539
Anesthesia
Medication that suppresses the CNS that results in unconsciousness and lack of sensation
540
POC
Point of Care
541
elements for level 5 HPI
4
542
elements for level 5 ROS
10, 2 + "All systems negative"
543
elements for level 5 PMH/SH/FH
2
544
elements for level 5 PE
8
545
8 elements of HPI
Location, Quality, Timing, Severity, Duration, Associated Symptoms, Modifying Factors, Context
546
14 elements of ROS or PE
Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurological, Integumentary, Hematological, Lymphatic, Immunological, Psychological
547
3 elements of PMHx
PMHx/PSHx, SHx, FHx
548
RA (not arthritis)
Room Air
549
NC
Nasal Cannula
550
FM
Facial Mask
551
NRM
Non-Rebreather Mask
552
CPAP
Continuous Positive Airway Pressure
553
BiPAP
Biphasic Positive Airway Pressure
554
BVM
Bag-valve-mask
555
ETT
Endotracheal Tube
556
R/B/A
Risks/Benefits/Alternatives
557
HIPAA
Health Insurance Portability and Accountability Act
558
HITECH
Health Information for Economic and Clinical Health Act
559
PHI
Protected Health Information
560
Disposition
The patient's destination after they leave the ED
561
Diagnosis
The process of determining which disease or condition explains a person's symptoms and signs
562
HIPPA definition
A body of laws designed to protect private health information of patients
563
HITECH definition
Privacy laws related to electronic transmission of health information
564
Protected Health Information
Any information that can be tied to a particular patient
