Course 1 Flashcards
1
Q
Subjective vs. Objective
A
Feeling vs. Fact
2
Q
Chief Complaint
A
The main reason for the patient’s ED visit
3
Q
Medical Decision Making
A
The physician’s thought process
4
Q
Pain vs. Tenderness
A
Patient’s feeling vs. Physicians 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
The physician’s thought process
A
Medical Decision Making
16
Q
The doctor’s judgment of discomfort
A
Distress
17
Q
An individual’s normal state of being
A
Baseline
18
Q
Normal, nothing of concern
A
Benign
19
Q
The state of having a fever, concerning for infection
A
Febrile
20
Q
New onset, likely concerning
A
Acute
21
Q
Long-standing, not of direct concern
A
Chronic
22
Q
Listening with a stethoscope
A
Auscultation
23
Q
The act of pressing on an area (by the doctor)
A
Palpation
24
Q
Admitted to the hospital overnight
A
Inpatient
25
Seen and sent home the same day
Outpatient
26
Manages the ED patient flow.
Charge Nurse
27
Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physician to diagnose and treat patients.
Mid-Level Provider
28
Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures.
ED Nurse
29
Administers "breathing treatments" and assists with managing a patient's airway.
Respiratory Therapist (RT)
30
Helps the nurse and assists with procedures.
ED Tech
31
Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork.
Unit Secretary
32
Documents the patient's visit on behalf of the physician.
Scribe
33
Walk-In -->
Walk-In --> Triage
34
Triage -->
Triage --> Bed Placement
35
Bed Placement -->
Bed Placement --> Nurse Assessment
36
Nurse Assessment -->
Nurse Assessment --> History and Physical (H&P)
37
History and Physical -->
History and Physical --> Physician Orders
38
Differential Dx -->
Differential Dx --> Physician Orders
39
Physician Orders --> (4)
Laboratory Studies, Imaging Studies, Procedures, Medications
40
Lab/Rad/Med -->
Lab/Rad/Med --> Results and ED Course
41
Results and ED Course -->
Results and ED Course --> Final Dx (Dx)
42
Final Dx -->
Final Dx --> Disposition
43
Vital Signs (5)
HR, BP, RR, T, SaO2
44
General Documentation Template (6)
History of Present Illness (HPI), Review of Systems (ROS), Past History, Physical Examination (PE), ED Course, Disposition
45
Subjective parts of template (2)
History of Present Illness (HPI), Review of Systems (ROS)
46
Objective parts of template (2)
Physical Examination (PE), ED Course
47
Chart sections for patient complaint
HPI or ROS
48
Chart section for past diagnosis or surgery
Past History
49
Chart section for physician's observation
Physical Exam
50
Chart section for re-evaluation
ED Course
51
Chart section for where they will go
Diagnosis & Disposition
52
History of Present Illness (HPI)
Subjective story of chief complaint (CC)
53
Review of Systems (ROS)
Subjective head-to-toe list
54
Types of Past History
PMHx (Past Medical), PSHx (Past Surgical), FHx (Family History), SHx (Social History)
55
"High Blood Pressure"
Hypertension (HTN)
56
"High Cholesterol"
Hyperlipidemia (HLD)
57
"Thyroid problem"
usually Hypothyroidism, sometimes Hyperthyroidism
58
"Diabetes"
Diabetes Mellitus (DM)
59
"I only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
60
"I take shots (insulin) for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
61
"Heart disease"
usually Coronary Artery Disease (CAD)
62
"Heart attack"
Myocardial Infarction (MI) and Coronary Artery Disease (CAD)
63
"Heart failure"
Congestive Heart Failure (CHF)
64
"Irregular heartbeat"
Atrial Fibrillation (A-Fib)
65
"Murmur"
Heart murmur
66
"Episodes of abnormally fast/racing heartbeat"
Supraventricular Tachycardia (SVT)
67
"Az-muh"
Asthma
68
"Emphysema -or- Chronic Bronchitis"
Chronic Obstructive Pulmonary Disease (COPD)
69
"Blood clot in lung"
Pulmonary Embolism (PE)
70
"Nuh-mone-yuh"
Pneumonia (PNA)
71
"Reflux"
Gastroesophageal Reflux Disease (GERD)
72
"Ulcer"
Gastric Ulcer -or- Peptic Ulcer Disease (PUD)
73
"pan-cree-uh-tie-tis"
Pancreatitis
74
"Hep-uh-tie-tis"
Hepatitis A, Hepatitis B, or Hepatitis C
75
"Die-ver-tick-you-lie-tis"
Diverticulitis
76
"Crohn's/UC"
Crohn's Disease -or- Ulcerative Colitis
77
"Irritable bowel"
Irritable Bowel Syndrome (IBS)
78
"Bladder infection"
Urinary Tract Infection (UTI)
79
"Kidney infection"
Pyelonephritis (Pyelo)
80
"Kidney stones"
Renal calculi
81
"I'm on dialysis"
Chronic Renal Failure (CRF) on dialysis
82
"Enlarged prostate"
Benign Prostate Hypertrophy (BPH)
83
(G/P/A): G?
G = # pregnancies
84
(G/P/A): P?
P = # live births (viable children)
85
(G/P/A): A?
A = # miscarriages/abortions
86
"Stroke"
Cerebrovascular Accident (CVA)
87
"Mini-stroke"
Transient Ischemic Attack (TIA)
88
"See-jzers"
Seizure disorder / Epilepsy
89
"Brain bleed"
Hemorrhagic CVA
90
"Bipolar"
Bipolar disorder
91
"Skitzo-fren-ee-uh"
Schizophrenia
92
"I drink a lot"
ETOH abuse -or- Alcoholism
93
"Blood clot in my leg"
Lower Extremity DVT
94
"Bulge in my aorta"
Abdominal Aortic Aneurysm (AAA)
95
"Bad blood flow to my legs"
Peripheral Vascular Disease (PVD)
96
"Low back pain"
Chronic Low Back Pain
97
"Bulging/Herniated disc"
Degenerative Disc Disease (DDD)
98
"Arth-rye-tis"
usually Osteoarthritis (OA), sometimes Rheumatoid Arthritis (RA)
99
"Joint pain (chronic)"
Degenerative Joint Disease (DJD)
100
"Weak/fragile bones"
often Osteoporosis
101
"Cancer" and types (10)
Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate, Ovarian, Skin, Bone, Leukemia, Lymphoma
102
"Spread to my . . ."
With metastases to the . . .
103
"Chemo"
Chemotherapy
104
"Radiation"
Radiation therapy
105
"They cut it out"
Status-post surgical resection
106
"It's (cancer) gone"
In remission
107
"ton-suls removed"
Tonsillectomy
108
"Add-in-oids removed"
Adenoidectomy
109
"Ear tubes"
Pressure Equalizer (P.E.) Tubes
110
"Heart bypass"
Coronary Artery Bypass Graft (CABG), CAD (PMHx)
111
"Stents"
Coronary Stents, CAD (PMHx)
112
"Heart Cath"
Cardiac catheterization
113
"Balloon"
Angioplasty, CAD (PMHx)
114
"Valve surgery"
Valve repair or replacement (Bovine vs. Mechanical)
115
"Pacer"
Pacemaker
116
"De-fib-ril-ate-or"
Automatic Implanted Cardiac Defibrillator (AICD)
117
"Surgery for Afib"
Afib s/p cardiac ablation
118
"Breast removal"
Mastectomy
119
"Hole in my neck"
Tracheostomy (commonly called a "trach")
120
"Part of my lung removed"
Partial lobectomy
121
"Uh-pin-dix removed"
Appendectomy
122
"Gallbladder removed"
Cholecystectomy
123
"Hernia repair"
Herniorrhaphy
124
"Part of my colon removed"
Partial colectomy
125
"Bag to collect stool"
Colostomy
126
"Spleen removed"
Splenectomy
127
"Stomach stapled"
Gastric bypass
128
"Kidney removed"
Nephrectomy
129
"Uterus removed"
Hysterectomy (partial vs. total)
130
"Ovary removed"
Oophorectomy
131
"Ovary and fallopian tubes removed"
Salpingo-oophorectomy
132
"Tubes tied"
Tubal ligation (female) -or- Vasectomy (male)
133
"C-Section"
Cesarean Section
134
"Prostate removed"
Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP)
135
"Neck artery cleaned"
Carotid Endarterectomy
136
"Brain surgery"
Craniotomy (brain bleed vs. brain CA)
137
"Shunt"
Ventriculoperitoneal (VP) shunt
138
"Dialysis fist-chew-luh"
AV (arteriovenous) Fistula
139
"Dialysis graft"
AV Graft
140
"PICC Line"
Peripherally Inserted Central Catheter (PICC)
141
"Port"
Port-a-cath -or- Medi-Port
142
"Clot filter (lower abdomen)"
IVC (inferior vena cava) Filter
143
"Clot filter (leg)"
Greenfield Filter
144
"Leg amputated"
Above Knee Amputation (AKA), Below Knee Amputation (BKA)
145
"Joint repair"
Arthroplasty
146
"Metal plates/pins"
Hardware
147
"Neck fused"
Cervical spinal fusion
148
"Back fused"
Lumbar spinal fusion
149
3 common family histories
HTN, DM, CA
150
Age when cardiac disease indicative of FHx
>55 y/o
151
2 common pulmonary family histories
PE, Asthma
152
2 common gastrointestinal family histories
Crohn's, IBS
153
3 common neurological family histories
CVA, Aneurysm, Seizures
154
2 miscellaneous family histories
Sickle Cell Anemia, DVT
155
5 types of Social History (SHx)
Tobacco Use, Alcohol Use, Illicit Drug Use, Occupation, Living Circumstances
156
MDM
Medical Decision Making
157
DDx
Differential Diagnoses
158
HTN
Hypertension
159
HLD
Hyperlipidemia
160
DM
Diabetes Mellitus
161
CAD
Coronary Artery Disease
162
MI
Myocardial Infarction
163
CHF
Congestive Heart Failure
164
A-Fib
Atrial Fibrillation
165
SVT
Supraventricular Tachycardia
166
PE
Pulmonary Embolism
167
PNA
Pneumonia
168
GERD
Gastroesophageal Reflux Disease
169
IBS
Irritable Bowel Syndrome
170
UTI
Urinary Tract Infection
171
Pyelo
Pyelonephritis
172
CRF
Chronic Renal Failure
173
BPH
Benign Prostate Hypertrophy
174
CVA
Cerebrovascular Accident
175
TIA
Transient Ischemic Attack
176
PVD
Peripheral Vascular Disease
177
AAA
Abdominal Aortic Aneurysm
178
DDD
Degenerative Disc Disease
179
OA
Osteoarthritis
180
RA
Rheumatoid Arthritis
181
DJD
Degenerative Joint Disease
182
CA
Cancer, Carcinoma
183
CABG
Coronary Artery Bypass Graft
184
AICD
Automatic Implanted Cardiac Defibrillator
185
TURP
Trans-Urethral Removal of the Prostate
186
VP
Ventriculoperitoneal
187
PICC
Peripherally Inserted Central Catheter
188
AV
Arteriovenous
189
IVC
Inferior vena cava
190
AKA
Above Knee Amputation
191
BKA
Below Knee Amputation
192
3 types of disposition
Discharge home, Admit, Transfer
193
Name of documentation system
Cerner
194
Dialysis
Process of filtering blood
195
"I do drugs"
Substance abuse
196
"Triple A"
Abdominal Aortic Aneurysm (AAA)
197
"Numbness in my legs"
Peripheral Neuropathy
198
PVD and peripheral neuropathy secondary to:
DM
199
"Old age arthritis"
Osteoarthritis (OA)
200
"Autoimmune arthritis"
Rheumatoid Arthritis (RA)
201
Helps prevent ear infections
Pressure Equalizer (P.E.) Tubes
202
"Ex-lap"
Exploratory Laparotomy
203
"Uterine product removed"
Dilation and Curettage (D&C)
204
"Kidney removed"
Nephrectomy
205
Used to treat hydrocephalus
Ventriculoperitoneal (VP) Shunt
206
"Bone fracture surgery"
Open Reduction with Internal Fixation
207
How to document smoking status (3)
Current (#ppd, #yrs), Former (year quit), Never
208
Document this smoking status for pediatrics
Second-hand exposure
209
How to document alcohol use (4)
Never, Occasionally/socially, Daily, Chronic alcoholic
210
Document for chronic alcoholic (2)
drinks/day, type of alcohol
211
Document for illicit drug use (3)
drug type, route of administration, date of last use
212
Document for occupation (4)
Employed, Unemployed, On disability, Retired
213
6 possible components of pediatric SHx
caretaker, attends daycare, attends school, has brothers/sisters, second-hand smoke exposure, immunizations up-to-date
