Course 1: ED Flow Flashcards
Subjective vs. Objective
Subjective: feeling (what patient says)
Objective: fact (observations by medical team)
Chief Complaint
The main reason for the patient’s ED visit
Medical Decision Making
(MDM)
-the physician’s thought process
Pain vs. Tenderness
Pain=patient’s feeling (subjective)
Tenderness=physician’s assessment (objective)
Benign
Nothing of concern
Distress
The doctor’s judgement of discomfort
Febrile
The state of having a fever, concerning for infection
Temp greater than 100.4
Acute
New onset, likely concerning
-duration less than 3 months
Chronic
Long-standing, not of direct concern
-duration greater than 3 months
Baseline
An individual’s normal state of being
Auscultation
Listening with a stethoscope
Palpation
Act of pressing an area (by the doctor)
Inpatient
Admitted to the hospital overnight
Outpatient
Seen and sent home the same day
What is a scribe?
Unlicensed person performing documentation and other non-clinical tasks under direction of licensed independent practitioner
Scribes CAN…
- document Hx, PE, results, procedures and physician consults
- access and document lab results and radiology findings
- access and display X-rays for physician review
- locate and obtain PMHx, previous charts, past results, and recent studies
- record physician interpretations of X-rays and ECGs
Scribes CANNOT…
- touch patients
- write orders or prescriptions
- give verbal orders
- partake in any activity that may affect patient health or outcome
- sign or authenticate any chart or record
- handle bodily fluids or specimens
People in the ED
- Mid-Level Provider—> NP or PA that works under the supervision of physician to diagnose and treat patients
- Charge Nurse—> manages the ED patient flow
- ED Nurse—> records medical hx, sx, monitors the patient, starts IVs, administers meds, and assists with procedures
- ED Tech —> helps the Nurse and assists with procedures
- Respiratory Therapist (RT)—>administers breathing treatments and assists with managing a patient’s airway
- HUQ/Unit Secretary —> answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork
- Scribe—> documents the patient’s visit on behalf of the physician
Emergency Department Flow: Overview
Check In and Chief Complaint—> Physician Assessment —> Objective Order and Results—> Medical Decision Making —> Disposition
Triage
- chief complaint
- vital signs
- level of acuity —> 5 (low) to 1 (high)
Vital Signs
- HR=Heart rate—> 60-100bpm
- BP=Blood Pressure—> 90/60-120/80 mm/Hg
- RR=Respiratory Rate—> 12-20
- Temperature—> 98.6
- SaO2=oxygen saturation—> above 96%
Nurse Assessment
- confirm chief complaint
- review allergies
- brief past history
Differential Diagnosis
Based on the H&P the physician generates a list of things that may be causing the patient’s subjective symptoms.
-Then the doctor places orders to “rule out” each differential
Final Dx
By using medical decision making the physician reviews specific results that can rule out differential diagnosis to reach the final diagnosis
History of Present Illness (HPI)
The story and context of the chief complaint
[subjective]
Review of Systems (ROS)
A head-to-toe list of positives and negatives
[subjective complaints]
Past History
- Past Medical History (PMHx)
- Past Surgical History (PSHx)
- Social History (SHx)
- Family History (FHx)
Physical Exam (PE)
The physicians objective findings
[objective evaluation]
ED Course
Objective results (labs, imaging, re-evals, consults, procedures) [objective evaluation]
Disposition
- Discharge Home
- Admit for further care
- Transfer to another facility
High Blood Pressure
[General]
Hypertension (HTN)
High Cholesterol
[General]
Hyperlipidemia (HLD)
Thyroid Problem
[General]
Usually hypothyroidism, sometimes hyperthyroidism
Diabetes
[General] Diabetes Mellitus (DM)
“I only take pills for my diabetes”
[General]
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
“I take shots (insulin) for my diabetes”
[General]
Insulin Dependent Diabetes Mellitus (IDDM)
Heart Disease
[Cardio]
Usually coronary artery disease (CAD)
Heart Attack
[Cardio] Myocardial Infarction (MI)
Heart Failure
[Cardio]
Congestive Heart Failure (CHF)
Irregular Heartbeat
[Cardio]
Arrhythmia, Atrial Fibrillation
Murmur
[Cardio]
Heart murmur
Episodes of abnormally fast/racing heartbeat
[Cardio]
Arrhythmia, supraventricular tachycardia (SVT)
Asthma
[Pulmonary]
Asthma
Emphysema/Chronic Bronchitis
[Pulmonary]
Chronic Obstructive Pulmonary Disease (COPD)
Blood Clot in Lung
[Pulmonary] Pulmonary Embolism (PE)
Pneumonia
[Pulmonary]
Pneumonia (PNA)
Reflux
[GI]
Gastroesophageal Reflux Disease (GERD)
Ulcer
[GI]
Gastric Ulcer or Peptic Ulcer Disease
Pancreatitis
[GI]
Pancreatitis
Hepatitis
[GI]
Hepatitis
Diverticulitis
[GI]
Diverticulitis
Crohn’s/UC
[GI]
Crohn’s Disease or Ulcerative Colitis
Irritable Bowel
[GI]
Irritable Bowel Syndrome (IBS)
Bladder Infection
[GU]
Urinary Tract Infection (UTI)
Kidney Infection
[GU]
Pyelonephritis (Pyelo)
Kidney Stones
[GU] Renal Calculi (Nephrolithiases)
“I’m on dialysis”
[GU]
Chronic Renal Failure (CRF)
or
End Stage Renal Disease (ESRD) on dialysis
G/P/A
Gravida/Para/Abortion
Gravida= total number of times the patient has been pregnant
Para= the number of pregnancies reaching a viable gestational age (23 weeks)
Abortus= the total number of miscarriages or elective abortions
Brain Bleed
[Neuro]
Hemorrhagic Cerebrovascular Accident (CVA)
Stroke
[Neuro]
Ischemic Cerebrovascular Accident (CVA)
Mini-Stroke
[Neuro]
Transient Ischemic Attack (TIA)
Seizures
[Neuro]
History of seizures
Bipolar
[Psych]
Bipolar Disorder
Schizophrenia
[Psych]
Schizophrenia
“I drink a lot”
[Psych]
EtOH Abuse or Alcoholism
“I do drugs”
[Psych]
Substance Abuse
“Blood clot in my leg”
[Vascular]
Lower extremity deep vein thrombosis (DVT)
“Bulge in my aorta”
[Vascular]
Aortic Aneurysm
“Bad blood flow to my legs”
[Vascular]
Peripheral Vascular Disease (PVD)
“Numbness in my legs”
[Vascular]
Peripheral Neuropathy
Low Back Pain
[Musculoskeletal]
Chronic low back pain
Bulging/Herniated Disc
[Musculoskeletal]
Degenerative Disc Disease (DDD)
Arthritis
[Musculoskeletal]
Usually Osteoarthritis (OA)
Sometimes Rheumatoid Arthritis (RA)
Weak/Fragile Bones
[Musculoskeletal]
often osteoporosis
Cancer
[Cancer]
Cancer or carcinoma (CA)
*Brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, lymphoma
Spread tp my…
[Cancer]
With metastasis to the…
Chemo
[Cancer]
Chemotherapy
Radiation
[Cancer]
Radiation Therapy
They cut it out
[Cancer]
Status-post surgical resection
It’s gone
[Cancer]
In remission
-ectomy
Surgical removal
Tonsils Removed
[ENT PSHX]
Tonsillectomy
Adenoids removed
[ENT PSHX]
Adenoidectomy
Ear Tubes
[ENT PSHX]
Myringotomy or Pressure Equalizing (P.E.) Tubes
Heart Cath
[Cardiovascular PSHX]
Cardiac Catheterization
Balloon
[Cardiovascular PSHX]
Angioplasty
* PMHx CAD
Stents
[Cardiovascular PSHX]
Coronary Stents
*PMHx CAD
Heart Bypass
[Cardiovascular PSHX]
Coronary Artery Bypass Graft (CABG)
*PMHx CAD
Valve Surgery
[Cardiovascular PSHX]
Valve-repair or replacement
(Bovine vs. Mechanical)
Pacer
[Cardiovascular PSHX]
Pacemaker
Defibrillator
[Cardiovascular PSHX]
Automatic Implanted Cardiac Defibrillator (AICD)
Surgery for Afib
[Cardiovascular PSHX]
Afib s/p cardiac ablation
Breast Removal
[Pulm/Chest PSHX]
Mastectomy
Hole in my neck
[Pulm/Chest PSHX]
Tracheostomy (commonly called a trach)
Part of my lung removed
[Pulm/Chest PSHX]
Partial lobectomy
Appendix Removed
[GI PSHX]
Appendectomy
Gallbladder Removed
[GI PSHX]
Cholecystectomy
Hernia Repair
[GI PSHX]
Herniorrhaphy
Part of my colon removed
[GI PSHX]
Partial colectomy
Bag to collect stool
[GI PSHX]
Colostomy
Spleen removed
[GI PSHX]
Splenectomy
Spleen removed
[GI PSHX]
Splenectomy
Stomach Stapled
[GI PSHX]
Bariatric surgery
(Gastric sleeve, gastric bands/lap band, gastric bypass, etc)
Exploratory
[GI PSHX] Exploratory Laparaoscopy (ExLap)
Kidney Removed
[GU PSHX]
Nephrectomy
Uterus Removed
[GU PSHX]
Hysterectomy (partial vs. total)
Ovary Removed
[GU PSHX]
Oophorectomy
Ovary and Fallopian Tubes Removed
[GU PSHX]
Salpingo-oophorectomy
Tubes Tied
[GU PSHX]
Tubal Ligation (female)
Vasectomy (male)
C-Section
[GU PSHX]
Cesarean Section
Prostate Removed
[GU PSHX]
Prostatectomy or Prostate Resection
*most often transurethral resection of the prostate TURP
Uterine Product Removed
[GU PSHX]
Dilation & Curettage (D&C)
Neck artery cleaned
[Neuro PSHX]
Carotid endarterectomy
Shunt
[Neuro PSHX]
Cerebral shunt
Brain Surgery
[Neuro PSHX]
Craniotomy (brain bleed vs. brain CA)
Dialysis Fistula
[Vascular PSHX]
Arteriovenous (AV) Fistula
Dialysis Graft
[Vascular PSHX]
Arteriovenous (AV) Graft
PICC Line
[Vascular PSHX]
Peripherally Inserted Central Catheter (PICC)
Port
[Vascular PSHX]
Port-a-Cate or Medi-Port
Clot Filter (Lower Abdomen)
[Vascular PSHX]
IVC (Inferior vena cava) Filter
Leg Amputated
[Ortho PSHX]
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
Joint Repair
[Ortho PSHX]
Arthroplasty
Metal Plates/Pins
[Ortho PSHX]
Hardware
Neck/Back Fused
[Ortho PSHX]
Cervical/Lumbar Spinal Fusion
New Hip
[Ortho PSHX]
Total hip replacement/Open Reduction with Internal Fixation (ORIF)
Genetic Risk vs. Environmental Risk
[FMHx]
- age of onset of dz important
- younger age old onset means higher genetic risk
- older age of onset (55 y/o+) is likely more use to environment than genetics
- genetic risk for the disease is higher if multiple blood-family members suffer from the same disease
Family History (FHx)
- General—> HTN, DM, CA
- Cardiac—> MI/CAD less than 55 y/o [genetic]
- Pulmonary—> PE, Asthma
- Gastrointestinal—> Crohn’s, IBS
- Neurological—> CVA, Aneurysm, Seizures
- Misc.—> Sickle Cell Anemia, DVT
Social History (SHx)
- Tobacco Use
- Alcohol Use (EtOH)
- Illicit Drug Use
- Occupation
- Living Circumstances
Tobacco Use (SHx)
- Smoking status
- current (#ppd, #yrs)
- Former (year quit)
- Never
- Second-hand exposure (pediatrics)
- E-cigs (Nicotine use)
- Chewing tobacco
Alcohol Use (SHx)
- Never
- Occasionally/socially
- Daily
- Chronic alcoholic
- number of drinks/day
- type of alcohol (beer/wine/liquor)
One drink equals:
- 12oz beer (5% alc)
- 8-9 oz of malt liquor (7% alc)
- 5oz of wine (12% alc)
- 1.5oz shot (40% alc, 80-proof)
Illicit Drug Use (SHx)
- Which drug
- heroin
- cocaine
- methamphetamine
- marijuana
- narcotics
- Route of administration
- Oral
- Inhaled
- Injected
- Date of last use
Occupation (SHx)
- Employed
- Unemployed
- On disability
- Retired
*if a physician asks specifically about type of work, be sure to document it
Living Circumstances (SHx)
- Lives alone
- With family/friends
- Nursing home/assisted living
- Hospice
- Homeless/shelter
Pediatrics (SHx)
- caretaker (mother, father, etc.)
- attends daycare
- attends school
- has brothers/sisters
- second hand smoke exposure
- immunizations up to date
What are the 4 types of Hxs?
1) PMHx
2) PSHx
3) FHx
4) SHx
The HPI and ROS are what type of info, subjective or objective?
Subjective
The Physical Exam is what type of info, subjective or objective?
Objective
While evaluating a patient complaining of CP your physician tells you heart sounds are normal, would you document this in HPI, ROS or PE?
PE
Would you be contradicting yourself if you wrote “the patient has abdominal Pain” in HPI but then later wrote in PE “the abd is nontender”?
No
- Pain=subjective and patient reported
- Tenderness=objective assessment of pain
What does disposition mean?
Patient’s destination after they leave the ED
What subcategories are included in the Past Hx section of the template?
PMHx—> HTN, DM, CAD, MI
PSHx—> appendectomy, cholecystectomy, CABG
FHx—> Hx of CAD <55yo
SHx—> EtOH, smoking, drug abuse, occupation
Abbreviation Heart Attack
MI—> Myocardial Infarction
Abbreviation Hypertension
HTN
Medical Term for Acid Reflex
GERD—> Gastroesophageal Reflux Disease
Medical Term for Stroke
Cerebrovascular Accident—>CVA
Term for Gallbladder Removal
Cholecystectomy
NKDA
No Known Drug Allergies
Medical term for Redness
Erythema
Medical Term for Bruising
Ecchymosis
