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ScribeAmerica VCRT > Course 1: ED Flow > Flashcards

Course 1: ED Flow Flashcards

1
Q

Subjective vs. Objective

A

Feeling vs. Fact

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2
Q

Chief Complaint

A

The main reason for the patient’s ED visit

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3
Q

Medical Decision Making

A

The physician’s thought process

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4
Q

Benign

A

Normal, nothing of concern

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5
Q

Distress

A

The doctor’s judgement of discomfort

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6
Q

Febrile

A

The state of having a fever, concerning for infection

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7
Q

Acute

A

New onset, likely concerning

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8
Q

Chronic

A

Long-standing, not of direct concerm

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9
Q

Baseline

A

An individual’s normal state of being

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10
Q

Auscultation

A

Listening with a stethoscope

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11
Q

Palpation

A

The act of pressing on an area (by the doctor)

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12
Q

Inpatient

A

Admitted to the hospital overnight

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13
Q

Outpatient

A

Seen and sent home the same day

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14
Q

Pain vs. Tenderness

A

Patient’s feeling vs. Physician’s assessment

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15
Q

Scribe

A

An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.

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16
Q

Charge Nurse

A

Manages the ED patient flow

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17
Q

Mid-level provider

A

Nurse practitioner or physician assistant that works under the supervision of a physician to diagnose and treat patients

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18
Q

ED Nurse

A

Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures

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19
Q

Respiratory therapist

A

Administers breathing treatments and assists with managing a patient’s airway

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20
Q

ED Tech

A

Helps the nurse and assists with procedures

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21
Q

Unit Secretary

A

Places physician’s orders, answers phone calls, pages other specialists/doctors, organizes the patient’s paperwork

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22
Q

ED Flow

A 
Check in and chief complaint
Physician Assessment
Objective orders and results
Medical decision making
Disposition
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23
Q

Level of acuity

A

5 (low) to 1 (high)

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24
Q

HR

A

Heart Rate (bpm)

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25
Q

BP

A

Blood Pressure (mmHg)

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26
Q

RR

A

Respiratory Rate

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27
Q

T

A

Temperature

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28
Q

SaO2

A

Oxygen Saturation (%)

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29
Q

HPI

A

History of Present Illness

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30
Q

ROS

A

Review of Systems

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31
Q

PMHx

A

Past Medical History

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32
Q

PSHx

A

Past Surgical History

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33
Q

FHx

A

Family History

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34
Q

SHx

A

Social History

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35
Q

PE

A

Physical Examination

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36
Q

Differential Dx

A

Differential Diagnosis: list of causes for subjective symptoms

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37
Q

Physician Orders

A

Lab studies
Imaging studies
Procedures
Medications

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38
Q

Results and ED Course

A

Patient re-evaluations; consults with specialists

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39
Q

Final Dx

A

Final Diagnosis

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40
Q

MDM

A

Medical Decision Making

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41
Q

Disposition

A

Discharge Home
Admit for further care
Transfer to another facility

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42
Q

TEMPLATE

A 
(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
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43
Q

Where is a patient complaint documented?

A

HPI or ROS

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44
Q

Where is a patient’s past diagnosis or surgery documented?

A

PH

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45
Q

Where is a physician’s observation documented?

A

PE

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46
Q

Where is an objective study documented?

A

Results/ED Course

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47
Q

Where is re-evaluation documented?

A

ED Course

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48
Q

Where is a patient’s destination documented?

A

Diagnosis and Disposition

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49
Q

Patient says High blood pressure

A

Hypertension (HTN)

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50
Q

Patient says High cholesterol

A

Hyperlipidemia (HLD)

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51
Q

Patient says Thyroid problem

A

Usually Hypothyroidism, sometimes hyperthyroidism

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52
Q

Patient says Diabetes

A

Diabetes Mellitus (DM)

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53
Q

Patient says “i only take pills for my diabetes”

A

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

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54
Q

Patient says “I take shots for my diabetes”

A

Insulin Dependent Diabetes Mellitus (IDDM)

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55
Q

Patient says Heart disease

A

Usually Coronary Artery Disease (CAD)

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56
Q

Patient says Heart attack

A

Myocardian Infarction (MI) and CAD

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57
Q

Patient says Heart Failure

A

Congestive Heart Failure (CHF)

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58
Q

Patient says Irregular heartbeat

A

Atrial Fibrillation (A-Fib)

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59
Q

Patient Says Heart murmur

A

Heart Murmur

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60
Q

Patient says Episodes of abnormally fast/racing heartbeat

A

Supraventricular Tachycardia (SVT)

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61
Q

Patient says Asthma

A

Asthma

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62
Q

Patient says Emphysema/Chronic Bronchitis

A

Chronic obstructive pulmonary Disease (COPD)

63
Q

Patient says Blood clot in lung

A

Pulmonary Embolism (PE)

64
Q

Patient says Pneumonia

A

Pneumonia (PNA)

65
Q

Patient says Reflux

A

Gastoesophageal Reflux Disease (GERD)

66
Q

Patient says Ulcer

A

Gastric Ulcer or Peptic Ulcer Disease

67
Q

Patient says Pancreatitis

A

Pancreatitis

68
Q

Patient says Hepatitis

A

Hepatitis A/B/C

69
Q

Patient says Diverticulitus

A

Diverticulitis

70
Q

Patient says Chron’s/UC

A

Chron’s Disease or Ulcerative Colitis

71
Q

Patient says Irritable bowel

A

Irritable Bowel Syndrome (IBS)

72
Q

Patient says Bladder infection

A

Urinary Tract Infection (UTI)

73
Q

Patient says Kidney infection

A

Pyelonephritis (pyelo)

74
Q

Patient says Kidney stones

A

Renal Calculi

75
Q

Patient says “I’m on dialisis”

A

Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialisis

76
Q

Patient says Enlarged prostate

A

Benign Prostate Hypertrophy

77
Q

Patient says Stroke

A

Cerebrovascular Accident (CVA)

78
Q

Patient says Mini-stroke

A

Transient Ischemic Attack (TIA)

79
Q

Patient says Seizures

A

Seizure disordery/Epilepsy

80
Q

Patient says Brain bleed

A

Hemorrhagic CVA

81
Q

Patient says Bipolar

A

Bipolar disorder

82
Q

Patient says Schiziophrenia

A

Schizophrenia

83
Q

Patient says “I drink a lot”

A

ETOH abuse of Alcoholism

84
Q

Patient says “I do drugs”

A

Substance Abuse

85
Q

Patient says “Blood clog in my leg”

A

Lower extremity Deep Vein Thrombosis (DVT)

86
Q

Patient says “Bulge in my aorta” or “Triple A”

A

Abdominal Aortic Aneurysm (AAA)

87
Q

Patient says “bad blood flow to my legs”

A

Peripheral Vascular Disease (PVD)

88
Q

Patient says “Numbness in my legs”

A

Peripheral Neuropathy

89
Q

Patient says Low back pain

A

Chronic low back pain

90
Q

Patient says Bulging/Herniated disc

A

Degenerative Disc Disease (DDD)

91
Q

Patient says Arthritis

A

Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)

92
Q

Patient says Joint pain (chronic)

A

Degenerative Joint Disease (DJD)

93
Q

Patient says Weak/fragile bones

A

Often Osteoporosis

94
Q

Patient says Cancer

A

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

95
Q

Patient says Spread to my…

A

With metastases to the…

96
Q

Patients Chemo

A

Chemotherapy

97
Q

Patient says Radiation

A

Radiation therapy

98
Q

Patient says They cut it out

A

Status-post surgical resection

99
Q

Patient says It’s gone

A

In remission

100
Q

Patient says Tonsils removed

A

Tonsillectomy

101
Q

Patient says Adenoids removed

A

Adenoidextomy

102
Q

Patient says Ear tubes

A

Pressure Equalizer (P.E.) Tubes

103
Q

Patient says Heart bypass

A

Coronary Artery Bypass Graft (CABG)

-> PMHx CAD

104
Q

Ectomy

A

Removal

105
Q

Patient says Stents

A

Coronary Stents

-> PMHx CAD

106
Q

Patient says Heart Cath

A

Cardiac catheterization

107
Q

Patient says Baloon

A

Angioplasty

-> PMHx CAD

108
Q

Patient says Valve surgery

A

Valve repair or replacement (bovine vs. mechanical)

109
Q

Patient says Pacer

A

Pacemaker

110
Q

Patient says Defibrillator

A

Automatic Implanted Cardiac Defibrillator (AICD)

111
Q

Patient says Surgery of Afib

A

Afib s/p cardiac ablation

112
Q

Patient says Breast removal

A

mastectomy

113
Q

Patient says Hole in my neck

A

Tracheostomy (“trach”)

114
Q

Patient says Part of my lung removed

A

Partial lobectomy

115
Q

Patient says Appendix removed

A

Appendectomy

116
Q

Patient says Gallbladder removed

A

Cholecystectomy

117
Q

Patient says Hernia repair

A

Herniorrhaphy

118
Q

Patient says Part of my colon removed

A

Partial colectomy

119
Q

Patient says Bag to collect stool

A

Colostomy

120
Q

Patient says Spleen removed

A

Splenectomy

121
Q

Patient says Stomach stapled

A

Gastric bypass

122
Q

Patient says Exploratory

A

Exploratory Laproscopy (ExLap)

123
Q

Patient says Kidney removed

A

Nephrectomy

124
Q

Patient says Uterus removed

A

Hysterectomy (partial vs. total)

125
Q

Patient says Ovary removed

A

Oophorectomy

126
Q

Patient says Overy and fallopian tubes removed

A

Salpingo-oophorectomy

127
Q

Patient says Tubes tied

A

Tubal litigation (female) or Vasectomy (male)

128
Q

Patient says C-Section

A

Cesarean Section

129
Q

Patient says Prostate removed

A

Prostatechtomy (Trans-Urethral Removal of the Prostate -TURP)

130
Q

Patient says Uterine product removed

A

Dilation and curettage (D&C)

131
Q

Patient says Neck artery cleaned

A

Carotid Endarterectomy

132
Q

Patient says Brain surgery

A

Craniotomy (brain bleed vs. brain CA)

133
Q

Patient says Shunt

A

Ventriculoperitoneal (VP) shunt

134
Q

Patient says dialysis fistula

A

AV (arteriovenous) Fistula

135
Q

Patient says Dialysis graft

A

AV Graft

136
Q

Patient says PICC Line

A

Peripherally Inserted Central Catheter (PICC)

137
Q

Patient says Port

A

Port-a-cath or medi-port

138
Q

Patient says Clot filter (lower abdomen)

A

IVC (inferior vena cava) Filter

139
Q

Patient says Clot filter (leg)

A

Greenfield Filter

140
Q

Patient says Leg amputated

A

Above/Below Knee Amputation (A/BKA)

141
Q

Patient says Joint repair

A

Arthroplasty

142
Q

Patient says Metal Plates/pins

A

Hardware

143
Q

Patient says Neck fused

A

Cervical spinal fusion

144
Q

Patient says Back fused

A

Lumbar spinal fusion

145
Q

Patient says Hip surgery

A

Open reduction with Internal Fixation (ORIF)

146
Q

Allergy

A

Rash, itching, swelling, difficulty breathing

147
Q

Age Risk Factor: X

A

X: Genetic
Y: Environment

148
Q

Social History

A 
Tobacco Use
ETOH Use
Illicit Drug Use
Occupation
Living Circumstances
149
Q

Smoking status

A 
Current (ppd, yrs)
Former (yr quit)
Never
Second-hand
chewing tobacco
150
Q

ETOH Use

A

Never
Occasionally/socially
Daily
Chronic Alcoholic: number/day, type

151
Q

Illicit Drug Use

A

Which drug
Route of administration
Date of last use

152
Q

Occupation

A

Employed
Unemployed
On disability
Retired

153
Q

Living Circumstances

A 
Lives alone
With family/friends
Nursing home/assisted living
Hospice
Homeless/shelter
154
Q

Pediatric SHx

A 
Caretaker
Attends daycare
Attends School
Siblings
Second-hand smoke exposure
Immunizations up to date

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