Course 1: ED Flow 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
Benign
A
Normal, nothing of concern
5
Q
Distress
A
The doctor’s judgement of discomfort
6
Q
Febrile
A
The state of having a fever, concerning for infection
7
Q
Acute
A
New onset, likely concerning
8
Q
Chronic
A
Long-standing, not of direct concerm
9
Q
Baseline
A
An individual’s normal state of being
10
Q
Auscultation
A
Listening with a stethoscope
11
Q
Palpation
A
The act of pressing on an area (by the doctor)
12
Q
Inpatient
A
Admitted to the hospital overnight
13
Q
Outpatient
A
Seen and sent home the same day
14
Q
Pain vs. Tenderness
A
Patient’s feeling vs. Physician’s assessment
15
Q
Scribe
A
An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.
16
Q
Charge Nurse
A
Manages the ED patient flow
17
Q
Mid-level provider
A
Nurse practitioner or physician assistant that works under the supervision of a physician to diagnose and treat patients
18
Q
ED Nurse
A
Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures
19
Q
Respiratory therapist
A
Administers breathing treatments and assists with managing a patient’s airway
20
Q
ED Tech
A
Helps the nurse and assists with procedures
21
Q
Unit Secretary
A
Places physician’s orders, answers phone calls, pages other specialists/doctors, organizes the patient’s paperwork
22
Q
ED Flow
A
Check in and chief complaint Physician Assessment Objective orders and results Medical decision making Disposition
23
Q
Level of acuity
A
5 (low) to 1 (high)
24
Q
HR
A
Heart Rate (bpm)
25
BP
Blood Pressure (mmHg)
26
RR
Respiratory Rate
27
T
Temperature
28
SaO2
Oxygen Saturation (%)
29
HPI
History of Present Illness
30
ROS
Review of Systems
31
PMHx
Past Medical History
32
PSHx
Past Surgical History
33
FHx
Family History
34
SHx
Social History
35
PE
Physical Examination
36
Differential Dx
Differential Diagnosis: list of causes for subjective symptoms
37
Physician Orders
Lab studies
Imaging studies
Procedures
Medications
38
Results and ED Course
Patient re-evaluations; consults with specialists
39
Final Dx
Final Diagnosis
40
MDM
Medical Decision Making
41
Disposition
Discharge Home
Admit for further care
Transfer to another facility
42
TEMPLATE
```
(HPI) History of Present Illness
(ROS) Review of Systems
Past History (MPHx, PSHx, SHx, FHx)
(PE) The physician's objective findings
(ED Course) Objective results
(Disposition) Discharge, Admit, Transfer
```
43
Where is a patient complaint documented?
HPI or ROS
44
Where is a patient's past diagnosis or surgery documented?
PH
45
Where is a physician's observation documented?
PE
46
Where is an objective study documented?
Results/ED Course
47
Where is re-evaluation documented?
ED Course
48
Where is a patient's destination documented?
Diagnosis and Disposition
49
Patient says High blood pressure
Hypertension (HTN)
50
Patient says High cholesterol
Hyperlipidemia (HLD)
51
Patient says Thyroid problem
Usually Hypothyroidism, sometimes hyperthyroidism
52
Patient says Diabetes
Diabetes Mellitus (DM)
53
Patient says "i only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
54
Patient says "I take shots for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
55
Patient says Heart disease
Usually Coronary Artery Disease (CAD)
56
Patient says Heart attack
Myocardian Infarction (MI) and CAD
57
Patient says Heart Failure
Congestive Heart Failure (CHF)
58
Patient says Irregular heartbeat
Atrial Fibrillation (A-Fib)
59
Patient Says Heart murmur
Heart Murmur
60
Patient says Episodes of abnormally fast/racing heartbeat
Supraventricular Tachycardia (SVT)
61
Patient says Asthma
Asthma
62
Patient says Emphysema/Chronic Bronchitis
Chronic obstructive pulmonary Disease (COPD)
63
Patient says Blood clot in lung
Pulmonary Embolism (PE)
64
Patient says Pneumonia
Pneumonia (PNA)
65
Patient says Reflux
Gastoesophageal Reflux Disease (GERD)
66
Patient says Ulcer
Gastric Ulcer or Peptic Ulcer Disease
67
Patient says Pancreatitis
Pancreatitis
68
Patient says Hepatitis
Hepatitis A/B/C
69
Patient says Diverticulitus
Diverticulitis
70
Patient says Chron's/UC
Chron's Disease or Ulcerative Colitis
71
Patient says Irritable bowel
Irritable Bowel Syndrome (IBS)
72
Patient says Bladder infection
Urinary Tract Infection (UTI)
73
Patient says Kidney infection
Pyelonephritis (pyelo)
74
Patient says Kidney stones
Renal Calculi
75
Patient says "I'm on dialisis"
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialisis
76
Patient says Enlarged prostate
Benign Prostate Hypertrophy
77
Patient says Stroke
Cerebrovascular Accident (CVA)
78
Patient says Mini-stroke
Transient Ischemic Attack (TIA)
79
Patient says Seizures
Seizure disordery/Epilepsy
80
Patient says Brain bleed
Hemorrhagic CVA
81
Patient says Bipolar
Bipolar disorder
82
Patient says Schiziophrenia
Schizophrenia
83
Patient says "I drink a lot"
ETOH abuse of Alcoholism
84
Patient says "I do drugs"
Substance Abuse
85
Patient says "Blood clog in my leg"
Lower extremity Deep Vein Thrombosis (DVT)
86
Patient says "Bulge in my aorta" or "Triple A"
Abdominal Aortic Aneurysm (AAA)
87
Patient says "bad blood flow to my legs"
Peripheral Vascular Disease (PVD)
88
Patient says "Numbness in my legs"
Peripheral Neuropathy
89
Patient says Low back pain
Chronic low back pain
90
Patient says Bulging/Herniated disc
Degenerative Disc Disease (DDD)
91
Patient says Arthritis
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
92
Patient says Joint pain (chronic)
Degenerative Joint Disease (DJD)
93
Patient says Weak/fragile bones
Often Osteoporosis
94
Patient says Cancer
Cancer or Carcinoma (CA): Brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma
95
Patient says Spread to my...
With metastases to the...
96
Patients Chemo
Chemotherapy
97
Patient says Radiation
Radiation therapy
98
Patient says They cut it out
Status-post surgical resection
99
Patient says It's gone
In remission
100
Patient says Tonsils removed
Tonsillectomy
101
Patient says Adenoids removed
Adenoidextomy
102
Patient says Ear tubes
Pressure Equalizer (P.E.) Tubes
103
Patient says Heart bypass
Coronary Artery Bypass Graft (CABG)
| -> PMHx CAD
104
Ectomy
Removal
105
Patient says Stents
Coronary Stents
| -> PMHx CAD
106
Patient says Heart Cath
Cardiac catheterization
107
Patient says Baloon
Angioplasty
| -> PMHx CAD
108
Patient says Valve surgery
Valve repair or replacement (bovine vs. mechanical)
109
Patient says Pacer
Pacemaker
110
Patient says Defibrillator
Automatic Implanted Cardiac Defibrillator (AICD)
111
Patient says Surgery of Afib
Afib s/p cardiac ablation
112
Patient says Breast removal
mastectomy
113
Patient says Hole in my neck
Tracheostomy ("trach")
114
Patient says Part of my lung removed
Partial lobectomy
115
Patient says Appendix removed
Appendectomy
116
Patient says Gallbladder removed
Cholecystectomy
117
Patient says Hernia repair
Herniorrhaphy
118
Patient says Part of my colon removed
Partial colectomy
119
Patient says Bag to collect stool
Colostomy
120
Patient says Spleen removed
Splenectomy
121
Patient says Stomach stapled
Gastric bypass
122
Patient says Exploratory
Exploratory Laproscopy (ExLap)
123
Patient says Kidney removed
Nephrectomy
124
Patient says Uterus removed
Hysterectomy (partial vs. total)
125
Patient says Ovary removed
Oophorectomy
126
Patient says Overy and fallopian tubes removed
Salpingo-oophorectomy
127
Patient says Tubes tied
Tubal litigation (female) or Vasectomy (male)
128
Patient says C-Section
Cesarean Section
129
Patient says Prostate removed
Prostatechtomy (Trans-Urethral Removal of the Prostate -TURP)
130
Patient says Uterine product removed
Dilation and curettage (D&C)
131
Patient says Neck artery cleaned
Carotid Endarterectomy
132
Patient says Brain surgery
Craniotomy (brain bleed vs. brain CA)
133
Patient says Shunt
Ventriculoperitoneal (VP) shunt
134
Patient says dialysis fistula
AV (arteriovenous) Fistula
135
Patient says Dialysis graft
AV Graft
136
Patient says PICC Line
Peripherally Inserted Central Catheter (PICC)
137
Patient says Port
Port-a-cath or medi-port
138
Patient says Clot filter (lower abdomen)
IVC (inferior vena cava) Filter
139
Patient says Clot filter (leg)
Greenfield Filter
140
Patient says Leg amputated
Above/Below Knee Amputation (A/BKA)
141
Patient says Joint repair
Arthroplasty
142
Patient says Metal Plates/pins
Hardware
143
Patient says Neck fused
Cervical spinal fusion
144
Patient says Back fused
Lumbar spinal fusion
145
Patient says Hip surgery
Open reduction with Internal Fixation (ORIF)
146
Allergy
Rash, itching, swelling, difficulty breathing
147
Age Risk Factor: X
X: Genetic
Y: Environment
148
Social History
```
Tobacco Use
ETOH Use
Illicit Drug Use
Occupation
Living Circumstances
```
149
Smoking status
```
Current (ppd, yrs)
Former (yr quit)
Never
Second-hand
chewing tobacco
```
150
ETOH Use
Never
Occasionally/socially
Daily
Chronic Alcoholic: number/day, type
151
Illicit Drug Use
Which drug
Route of administration
Date of last use
152
Occupation
Employed
Unemployed
On disability
Retired
153
Living Circumstances
```
Lives alone
With family/friends
Nursing home/assisted living
Hospice
Homeless/shelter
```
154
Pediatric SHx
```
Caretaker
Attends daycare
Attends School
Siblings
Second-hand smoke exposure
Immunizations up to date
```
