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Scribe America > Course 1 ED Flow > Flashcards

Course 1 ED Flow Flashcards

1
Q

ROS

Template

A

Review of Systems
A head to toe list of positive and negatives
Subjective

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2
Q

Past history

template

A

PMHx PSHx SHx FHx

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3
Q

PE

Template

A

Physical Examination

Physicians objective findings

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4
Q

ED course

Template

A

Objective results (labeling, imaging, re-Evans, consults, procedures)

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5
Q

Disposition

Template

A

Discharge, Admit, Transfer

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6
Q

Pulmonary PMHX
Pt says: Emphysema/Chronic Bronchitis
Scribe Writes:

A

COPD

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7
Q

Pulmonary PMHX
Pt says: blood clot in lung
Scribe Writes:

A

PE

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8
Q

Pulmonary PMHX
Pt says: Pneumonia
Scribe Writes: (short hand)

A

Pneumonia (PNA)

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9
Q

Gastrointestinal PMHX
Pt says: reflux
Scribe Writes:

A

Gastrophageal Reflux Disease (GERD)

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10
Q

Gastrointestinal PMHX
Pt says: Ulcer
Scribe Writes:

A

Gastric Ulcer or Ulcer Disease

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11
Q

Gastrointestinal PMHX
Pt says: hepatitis
Scribe Writes:

A

“A “B or “C

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12
Q

Gastrointestinal PMHX
Pt says: crohn’s/ UC
Scribe Writes:

A

Crohn’s Disease or Ulcerative Colitis

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13
Q

Gastrointestinal PMHX
Pt says: irritable bowel
Scribe Writes:

A

Irritable Bowel Syndrome (IBS)

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14
Q

Genitourinary PMHX
Pt says: bladder infection
Scribe Writes:

A

Urinary Tract Infection (UTI)

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15
Q

Genitourinary PMHX
Pt says: kidney infection
Scribe Writes:

A

Pyelonephritis (Pyelo)

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16
Q

Genitourinary PMHX
Pt says: kidney stones
Scribe Writes:

A

Renal calculi

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17
Q

Genitourinary PMHX
Pt says: I’m on dialysis
Scribe Writes:

A

Chronic Renal Failure (CRF) on dialysis or End stage renal disease

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18
Q

Genitourinary PMHX
Pt says: enlarged prostate
Scribe Writes:

A

Benign Prostate Hypertrophy (BPH)

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19
Q

Gynecological PMHx
G
P
A

A

G: total number of times pt has been pregnant P: number of live births pt had A: number of miscarriages or elective abortions

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20
Q

Neurological PMHX
Pt says: stroke
scribe writes:

A

CVA

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21
Q

Neurological PMHX
Pt says: mini stroke
scribe writes:

A

TIA

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22
Q

Neurological PMHX
Pt says: seizures
scribe writes:

A

Seizures disorder/ epilepsy

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23
Q

Neurological PMHX
Pt says: brain bleed
scribe writes:

A

Hemorrhagic CVA

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24
Q

Psychological PMHX
Pt says: bipolar
scribe writes:

A

Bipolar disorder

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25
Q

Psychological PMHX
Pt says: drink a lot
scribe writes:

A

ETOH or alcoholism

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26
Q

Vascular PMHX
Pt says: blood clot in my leg
scribe writes:

A

Lower extremity DVT

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27
Q

Vascular PMHX
Pt says: blood clot in my aorta
scribe writes:

A

Abdominal Aortic Aneurysm (AAA)

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28
Q

Vascular PMHX
Pt says: bad blood flow to my legs
scribe writes:

A

Peripheral Vascular Disease (PVD)

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29
Q

Musculoskeletal PMHX
Pt says: lower back pain
scribe writes:

A

Chronic lower back pain

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30
Q

Musculoskeletal PMHX
Pt says: bulging/herniated disk
scribe writes:

A

Degenerative Disk Disease (DDD)

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31
Q

Musculoskeletal PMHX
Pt says: arthritis
scribe writes:

A

Osteoarthritis or Rheumatoid Arthritis

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32
Q

Musculoskeletal PMHX
Pt says: joint pain
scribe writes:

A

Degenerative Joint Disease (DJD)

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33
Q

Musculoskeletal PMHX
Pt says: weak/fragile bones
scribe writes:

A

Osteoporosis

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34
Q

Cancer PMHX
Pt says: cancer
scribe writes:

A

Cancer or carcinoma (CA): Brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, lymphoid

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35
Q

Cancer PMHX
Pt says: spread to my…
scribe writes:

A

With metastases

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36
Q

Cancer PMHX
Pt says: chemo
scribe writes:

A

Chemotherapy

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37
Q

Cancer PMHX
Pt says: radiation
scribe writes:

A

Radiation therapy

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38
Q

Cancer PMHX
Pt says: they cut it out
scribe writes:

A

Status-post surgical resection

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39
Q

Cancer PMHX
Pt says: it’s gone
scribe writes:

A

In remission

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40
Q

Ears Nose Throat PSHX
Pt says: tonsils removed
scribe writes:

A

Tonsillectomy

41
Q

Ears Nose Throat PSHX
Pt says: adenoids removed
scribe writes:

A

Adenoidectomy

42
Q

Ears Nose Throat PSHX
Pt says: ear tubes
scribe writes:

A

Pressure equalizer (P.E.) tubes

43
Q

Cardiovascular PSHX
Pt says: heart bypass
scribe writes:

A

CABG -> PMHx CAD

44
Q

Cardiovascular PSHX
Pt says: stents
scribe writes:

A

Coronary stints -> PMHx CAD

45
Q

Cardiovascular PSHX
Pt says: health cath
scribe writes:

A

Cardiac catheterization

46
Q

Cardiovascular PSHX
Pt says: balloon
scribe writes:

A

Angioplasty -> PMHx CAD

47
Q

Cardiovascular PSHX
Pt says: Valve surgery
scribe writes:

A

Valve repair or replacement (bovine vs. mechanical)

48
Q

Cardiovascular PSHX
Pt says: pacer
scribe writes:

A

Pace maker

49
Q

Cardiovascular PSHX
Pt says: defibrillator
scribe writes:

A

Automatic Implanted Cardiac Defibrillator (AICD)

50
Q

Cardiovascular PSHX
Pt says: surgery for afib
scribe writes:

A

Afib s/p cardiac ablation

51
Q

Pulmonary/chest PSHX
Pt says: breast removal
scribe writes:

A

Mastectomy

52
Q

Pulmonary/chest PSHX
Pt says: hole in my neck
scribe writes:

A

Tracheostomy

53
Q

Pulmonary/chest PSHX
Pt says: part of my lung removed
scribe writes:

A

Partial lobectomy

54
Q

Gastrointestinal PSHX
Pt says: appendix removed
scribe writes:

A

Appendectomy

55
Q

Gastrointestinal PSHX
Pt says: gallbladder removed
scribe writes:

A

Cholecystectomy

56
Q

Gastrointestinal PSHX
Pt says: hernia repair
scribe writes:

A

Herniorrhaphy

57
Q

Gastrointestinal PSHX
Pt says: part of my colon removed
scribe writes:

A

Partial cholectomy

58
Q

Gastrointestinal PSHX
Pt says: bag to collect stool
scribe writes:

A

Colostomy

59
Q

Gastrointestinal PSHX
Pt says: spleen removed
scribe writes:

A

Splenectomy

60
Q

Gastrointestinal PSHX
Pt says: stomach stapled
scribe writes:

A

Gastric bypass

61
Q

Gastrointestinal PSHX
Pt says: kidney removed
scribe writes:

A

Nephrectomy

62
Q

Genitourinary PSHX
Pt says: uterus removed
scribe writes:

A

Hysterectomy (partial vs. total)

63
Q

Genitourinary PSHX
Pt says: ovary removed
scribe writes:

A

Oophorectomy

64
Q

Genitourinary PSHX
Pt says: ovary and Fallopian tubes removed
scribe writes:

A

Saplingo-oophorectomy

65
Q

Genitourinary PSHX
Pt says: tubes tied
scribe writes:

A

Tubal ligation or vasectomy

66
Q

Genitourinary PSHX
Pt says: c-section
scribe writes:

A

Cesarean section

67
Q

Genitourinary PSHX
Pt says: prostate removed
scribe writes:

A

Prostatectomy (most often trans-urethral removal of the prostate, or TURP)

68
Q

Neurological PSHX
Pt says: neck and artery cleaned
scribe writes:

A

Carotid endarterectomy

69
Q

Neurological PSHX
Pt says: brain surgery
scribe writes:

A

Craniotomy (brain bleed vs. CA)

70
Q

Neurological PSHX
Pt says: shunt
scribe writes:

A

Ventriculoperitoneal (VP) Shunt

To drain brain into Abd

71
Q

Vascular PSHX
Pt says: dialysis fistula
scribe writes:

A

AV (arteriovenous) fistula

72
Q

Vascular PSHX
Pt says: dialysis graft
scribe writes:

A

AV Graft

73
Q

Vascular PSHX
Pt says: PICC Line
scribe writes:

A

Peripherally Inserted Central Catheter

74
Q

Vascular PSHX
Pt says: port
scribe writes:

A

Port-a-cath or medi-port

75
Q

Vascular PSHX
Pt says: clot filter (lower abdomen)
scribe writes:

A

IVC (inferior vena cava) filter

76
Q

Vascular PSHX
Pt says: clot filter (leg)
scribe writes:

A

Greenfield filter

77
Q

Orthopedic PSHX
Pt says: leg amputated
scribe writes:

A

Above knee amputation (AKA) Below knee amputation (BKA)

78
Q

Orthopedic PSHX
Pt says: joint repair
scribe writes:

A

Arthroplasty

79
Q

Orthopedic PSHX
Pt says: metal plates/pins
scribe writes:

A

Hardware

80
Q

Orthopedic PSHX
Pt says: neck fused
scribe writes:

A

Cervical spinal fusion

81
Q

Orthopedic PSHX
Pt says: back fused
scribe writes:

A

Lumbar spinal fusion

82
Q

HPI

Template

A

History of present illness
The story and context of the Chief Complaint
Subjective

83
Q

ED Flow Chart

A

Walk-in -> triage -> bed -> physician assessment -> lab/rad/Meds -> results -> MDM -> Diagnosis -> consults -> disposition

84
Q

5 Vital Signs

A 
Blood pressure 
Heart Rate
Respiratory Rate 
Temperature 
Oxygen Saturation
85
Q

Cardiovascular PMHX
Pt says: heart disease
Scribe Writes:

A

coronary artery disease (CAD)

86
Q

Cardiovascular PMHX
Pt says: heart attack
Scribe Writes:

A

Myocardial infarction (MI) and CAD

87
Q

Cardiovascular PMHX
Pt says: heart failure
Scribe Writes:

A

Congestive heart failure (CHF)

88
Q

Cardiovascular PMHX
Pt says: irregular heartbeat
Scribe Writes:

A

Atrial fibrillation (A-fib)

89
Q

Cardiovascular PMHX
Pt says: murmur
Scribe Writes:

A

Heart murmur

90
Q

General Past Medical History
Pt says: high blood pressure
Scribe Writes:

A

Hypertension (HTN)

91
Q

General Past Medical History
Pt says: high cholesterol
Scribe Writes:

A

Hyperlipidemia

92
Q

General Past Medical History
Pt says: thyroid problem
Scribe Writes:

A

Hypothyroidism or hyperthyroidism

93
Q

General Past Medical History
Pt says: diabetes
Scribe Writes:

A

Diabetes mellitus (DM)

94
Q

General Past Medical History
Pt says: only take pills for my diabetes
Scribe Writes:

A

Non-insulin dependent diabetes mellitus (NIDDM)

95
Q

General Past Medical History
Pt says: only take shots for my diabetes
Scribe Writes:

A

Insulin dependent diabetes mellitus (IDDM)

96
Q 
family histories physician may ask about
General
Cardiac
Pulmonary
Gastrointestinal 
Neurological
Misc.
A

General: HYN DM CA, cardiac: MI/CD >55, pulmonary: PE Asthma, gastrointestinal:Crohn’s IBS, neurological: CVA Aneurism Seizures, misc.: sickle cell anemia DVT

97
Q

Social Hx physician may ask about

A

Tobacco use, ETOH use, illicit drug use, occupation, living conditions, pediatrics

98
Q

Three most common routs of administration of illicit drugs

A

Oral, inhalation, injection

Scribe America (5 decks)

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