Course 1 Flashcards
distress
the doctor’s judgment of discomfort
medical decision-making
the physician’s thought of process
subjective
feelings
objective
facts
H&P
history and physical
PMHx
past medical history
PSHx
past surgical history
FHx
family history
SHx
social history
ED flow
- check-in and chief complaint
- physician assessments
- objective orders and results
- medical decision making (dr. determines what he wants to do base on the results and etc.)
- disposition
DDx
differential diagnosis - based on H&P, dr generates a list of things that could be causing the pt’s subjective symptoms and orders tests to r/o each differential
documentation template
- HPI - the story and context of the chief of complaint
- ROS - a head-to-toe list of positives and negatives
- Past history - PMHx, PSHx, SHx, FHx
- Physical examination - physician’s objective findings
- ED course - objective results (lab, imaging, re-evils, consults, procedures)
- disposition - discharge, admit, transfer…
“high cholesterol”
= hyper-lipid-emia (HLD)
“I only take pills for my diabetes”
= type II - NIDDM
“i take shots (insulin) for my diabetes”
= type I - IDDM
“irregular heartbeat”
= A-fib
“episodes of abnormally fast/racing HR”
= supraventricular tachycardia (SVT)
SVT
supraventricular tachycardia
“emphysema/chronic bron”
COPD
PNA
pneumonia
“reflux”
= gastroesophageal reflux disease (GERD)
“ulcer”
= gastric ulcer or peptic ulcer disease
IBS
irritable bowel syndrome
“kidney infection”
= pyelonephritis
