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ScribeAmerica: ER > Course 1: ED Flow > Flashcards

Course 1: ED Flow Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Subjective vs. Objective

A

Subjective: feeling (what patient says)
Objective: fact (observations by medical team)

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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

(MDM)

-the physician’s thought process

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4
Q

Pain vs. Tenderness

A

Pain=patient’s feeling (subjective)

Tenderness=physician’s assessment (objective)

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5
Q

Benign

A

Nothing of concern

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6
Q

Distress

A

The doctor’s judgement of discomfort

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7
Q

Febrile

A

The state of having a fever, concerning for infection

Temp greater than 100.4

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8
Q

Acute

A

New onset, likely concerning

-duration less than 3 months

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9
Q

Chronic

A

Long-standing, not of direct concern

-duration greater than 3 months

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10
Q

Baseline

A

An individual’s normal state of being

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11
Q

Auscultation

A

Listening with a stethoscope

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12
Q

Palpation

A

Act of pressing an area (by the doctor)

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13
Q

Inpatient

A

Admitted to the hospital overnight

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14
Q

Outpatient

A

Seen and sent home the same day

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15
Q

What is a scribe?

A

Unlicensed person performing documentation and other non-clinical tasks under direction of licensed independent practitioner

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16
Q

Scribes CAN…

A
  • 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
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17
Q

Scribes CANNOT…

A
  • 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
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18
Q

People in the ED

A
  • 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
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19
Q

Emergency Department Flow: Overview

A

Check In and Chief Complaint—> Physician Assessment —> Objective Order and Results—> Medical Decision Making —> Disposition

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20
Q

Triage

A
  • chief complaint
  • vital signs
  • level of acuity —> 5 (low) to 1 (high)
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21
Q

Vital Signs

A
  • 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%
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22
Q

Nurse Assessment

A
  • confirm chief complaint
  • review allergies
  • brief past history
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23
Q

Differential Diagnosis

A

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

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24
Q

Final Dx

A

By using medical decision making the physician reviews specific results that can rule out differential diagnosis to reach the final diagnosis

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25
Q

History of Present Illness (HPI)

A

The story and context of the chief complaint

[subjective]

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26
Q

Review of Systems (ROS)

A

A head-to-toe list of positives and negatives

[subjective complaints]

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27
Q

Past History

A
  • Past Medical History (PMHx)
  • Past Surgical History (PSHx)
  • Social History (SHx)
  • Family History (FHx)
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28
Q

Physical Exam (PE)

A

The physicians objective findings

[objective evaluation]

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29
Q

ED Course

A 
Objective results (labs, imaging, re-evals, consults, procedures)
[objective evaluation]
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30
Q

Disposition

A
  • Discharge Home
  • Admit for further care
  • Transfer to another facility
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31
Q

High Blood Pressure

A

[General]

Hypertension (HTN)

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32
Q

High Cholesterol

A

[General]

Hyperlipidemia (HLD)

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33
Q

Thyroid Problem

A

[General]

Usually hypothyroidism, sometimes hyperthyroidism

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34
Q

Diabetes

A 
[General]
Diabetes Mellitus (DM)
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35
Q

“I only take pills for my diabetes”

A

[General]

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

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36
Q

“I take shots (insulin) for my diabetes”

A

[General]

Insulin Dependent Diabetes Mellitus (IDDM)

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37
Q

Heart Disease

A

[Cardio]

Usually coronary artery disease (CAD)

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38
Q

Heart Attack

A 
[Cardio]
Myocardial Infarction (MI)
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39
Q

Heart Failure

A

[Cardio]

Congestive Heart Failure (CHF)

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40
Q

Irregular Heartbeat

A

[Cardio]

Arrhythmia, Atrial Fibrillation

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41
Q

Murmur

A

[Cardio]

Heart murmur

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42
Q

Episodes of abnormally fast/racing heartbeat

A

[Cardio]

Arrhythmia, supraventricular tachycardia (SVT)

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43
Q

Asthma

A

[Pulmonary]

Asthma

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44
Q

Emphysema/Chronic Bronchitis

A

[Pulmonary]

Chronic Obstructive Pulmonary Disease (COPD)

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45
Q

Blood Clot in Lung

A 
[Pulmonary]
Pulmonary Embolism (PE)
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46
Q

Pneumonia

A

[Pulmonary]

Pneumonia (PNA)

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47
Q

Reflux

A

[GI]

Gastroesophageal Reflux Disease (GERD)

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48
Q

Ulcer

A

[GI]

Gastric Ulcer or Peptic Ulcer Disease

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49
Q

Pancreatitis

A

[GI]

Pancreatitis

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50
Q

Hepatitis

A

[GI]

Hepatitis

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51
Q

Diverticulitis

A

[GI]

Diverticulitis

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52
Q

Crohn’s/UC

A

[GI]

Crohn’s Disease or Ulcerative Colitis

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53
Q

Irritable Bowel

A

[GI]

Irritable Bowel Syndrome (IBS)

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54
Q

Bladder Infection

A

[GU]

Urinary Tract Infection (UTI)

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55
Q

Kidney Infection

A

[GU]

Pyelonephritis (Pyelo)

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56
Q

Kidney Stones

A 
[GU]
Renal Calculi (Nephrolithiases)
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57
Q

“I’m on dialysis”

A

[GU]
Chronic Renal Failure (CRF)
or
End Stage Renal Disease (ESRD) on dialysis

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58
Q

G/P/A

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

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59
Q

Brain Bleed

A

[Neuro]

Hemorrhagic Cerebrovascular Accident (CVA)

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60
Q

Stroke

A

[Neuro]

Ischemic Cerebrovascular Accident (CVA)

61
Q

Mini-Stroke

A

[Neuro]

Transient Ischemic Attack (TIA)

62
Q

Seizures

A

[Neuro]

History of seizures

63
Q

Bipolar

A

[Psych]

Bipolar Disorder

64
Q

Schizophrenia

A

[Psych]

Schizophrenia

65
Q

“I drink a lot”

A

[Psych]

EtOH Abuse or Alcoholism

66
Q

“I do drugs”

A

[Psych]

Substance Abuse

67
Q

“Blood clot in my leg”

A

[Vascular]

Lower extremity deep vein thrombosis (DVT)

68
Q

“Bulge in my aorta”

A

[Vascular]

Aortic Aneurysm

69
Q

“Bad blood flow to my legs”

A

[Vascular]

Peripheral Vascular Disease (PVD)

70
Q

“Numbness in my legs”

A

[Vascular]

Peripheral Neuropathy

71
Q

Low Back Pain

A

[Musculoskeletal]

Chronic low back pain

72
Q

Bulging/Herniated Disc

A

[Musculoskeletal]

Degenerative Disc Disease (DDD)

73
Q

Arthritis

A

[Musculoskeletal]
Usually Osteoarthritis (OA)
Sometimes Rheumatoid Arthritis (RA)

74
Q

Weak/Fragile Bones

A

[Musculoskeletal]

often osteoporosis

75
Q

Cancer

A

[Cancer]
Cancer or carcinoma (CA)
*Brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, lymphoma

76
Q

Spread tp my…

A

[Cancer]

With metastasis to the…

77
Q

Chemo

A

[Cancer]

Chemotherapy

78
Q

Radiation

A

[Cancer]

Radiation Therapy

79
Q

They cut it out

A

[Cancer]

Status-post surgical resection

80
Q

It’s gone

A

[Cancer]

In remission

81
Q

-ectomy

A

Surgical removal

82
Q

Tonsils Removed

A

[ENT PSHX]

Tonsillectomy

83
Q

Adenoids removed

A

[ENT PSHX]

Adenoidectomy

84
Q

Ear Tubes

A

[ENT PSHX]

Myringotomy or Pressure Equalizing (P.E.) Tubes

85
Q

Heart Cath

A

[Cardiovascular PSHX]

Cardiac Catheterization

86
Q

Balloon

A

[Cardiovascular PSHX]
Angioplasty
* PMHx CAD

87
Q

Stents

A

[Cardiovascular PSHX]
Coronary Stents
*PMHx CAD

88
Q

Heart Bypass

A

[Cardiovascular PSHX]
Coronary Artery Bypass Graft (CABG)
*PMHx CAD

89
Q

Valve Surgery

A

[Cardiovascular PSHX]
Valve-repair or replacement
(Bovine vs. Mechanical)

90
Q

Pacer

A

[Cardiovascular PSHX]

Pacemaker

91
Q

Defibrillator

A

[Cardiovascular PSHX]

Automatic Implanted Cardiac Defibrillator (AICD)

92
Q

Surgery for Afib

A

[Cardiovascular PSHX]

Afib s/p cardiac ablation

93
Q

Breast Removal

A

[Pulm/Chest PSHX]

Mastectomy

94
Q

Hole in my neck

A

[Pulm/Chest PSHX]

Tracheostomy (commonly called a trach)

95
Q

Part of my lung removed

A

[Pulm/Chest PSHX]

Partial lobectomy

96
Q

Appendix Removed

A

[GI PSHX]

Appendectomy

97
Q

Gallbladder Removed

A

[GI PSHX]

Cholecystectomy

98
Q

Hernia Repair

A

[GI PSHX]

Herniorrhaphy

99
Q

Part of my colon removed

A

[GI PSHX]

Partial colectomy

100
Q

Bag to collect stool

A

[GI PSHX]

Colostomy

101
Q

Spleen removed

A

[GI PSHX]

Splenectomy

102
Q

Spleen removed

A

[GI PSHX]

Splenectomy

103
Q

Stomach Stapled

A

[GI PSHX]
Bariatric surgery
(Gastric sleeve, gastric bands/lap band, gastric bypass, etc)

104
Q

Exploratory

A 
[GI PSHX]
Exploratory Laparaoscopy (ExLap)
105
Q

Kidney Removed

A

[GU PSHX]

Nephrectomy

106
Q

Uterus Removed

A

[GU PSHX]

Hysterectomy (partial vs. total)

107
Q

Ovary Removed

A

[GU PSHX]

Oophorectomy

108
Q

Ovary and Fallopian Tubes Removed

A

[GU PSHX]

Salpingo-oophorectomy

109
Q

Tubes Tied

A

[GU PSHX]
Tubal Ligation (female)
Vasectomy (male)

110
Q

C-Section

A

[GU PSHX]

Cesarean Section

111
Q

Prostate Removed

A

[GU PSHX]
Prostatectomy or Prostate Resection
*most often transurethral resection of the prostate TURP

112
Q

Uterine Product Removed

A

[GU PSHX]

Dilation & Curettage (D&C)

113
Q

Neck artery cleaned

A

[Neuro PSHX]

Carotid endarterectomy

114
Q

Shunt

A

[Neuro PSHX]

Cerebral shunt

115
Q

Brain Surgery

A

[Neuro PSHX]

Craniotomy (brain bleed vs. brain CA)

116
Q

Dialysis Fistula

A

[Vascular PSHX]

Arteriovenous (AV) Fistula

117
Q

Dialysis Graft

A

[Vascular PSHX]

Arteriovenous (AV) Graft

118
Q

PICC Line

A

[Vascular PSHX]

Peripherally Inserted Central Catheter (PICC)

119
Q

Port

A

[Vascular PSHX]

Port-a-Cate or Medi-Port

120
Q

Clot Filter (Lower Abdomen)

A

[Vascular PSHX]

IVC (Inferior vena cava) Filter

121
Q

Leg Amputated

A

[Ortho PSHX]
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)

122
Q

Joint Repair

A

[Ortho PSHX]

Arthroplasty

123
Q

Metal Plates/Pins

A

[Ortho PSHX]

Hardware

124
Q

Neck/Back Fused

A

[Ortho PSHX]

Cervical/Lumbar Spinal Fusion

125
Q

New Hip

A

[Ortho PSHX]

Total hip replacement/Open Reduction with Internal Fixation (ORIF)

126
Q

Genetic Risk vs. Environmental Risk

A

[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
127
Q

Family History (FHx)

A
  • 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
128
Q

Social History (SHx)

A
  • Tobacco Use
  • Alcohol Use (EtOH)
  • Illicit Drug Use
  • Occupation
  • Living Circumstances
129
Q

Tobacco Use (SHx)

A
  • Smoking status
  • current (#ppd, #yrs)
  • Former (year quit)
  • Never
  • Second-hand exposure (pediatrics)
  • E-cigs (Nicotine use)
  • Chewing tobacco
130
Q

Alcohol Use (SHx)

A
  • 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)
131
Q

Illicit Drug Use (SHx)

A
  • Which drug
  • heroin
  • cocaine
  • methamphetamine
  • marijuana
  • narcotics
  • Route of administration
  • Oral
  • Inhaled
  • Injected
  • Date of last use
132
Q

Occupation (SHx)

A
  • Employed
  • Unemployed
  • On disability
  • Retired

*if a physician asks specifically about type of work, be sure to document it

133
Q

Living Circumstances (SHx)

A
  • Lives alone
  • With family/friends
  • Nursing home/assisted living
  • Hospice
  • Homeless/shelter
134
Q

Pediatrics (SHx)

A
  • caretaker (mother, father, etc.)
  • attends daycare
  • attends school
  • has brothers/sisters
  • second hand smoke exposure
  • immunizations up to date
135
Q

What are the 4 types of Hxs?

A

1) PMHx
2) PSHx
3) FHx
4) SHx

136
Q

The HPI and ROS are what type of info, subjective or objective?

A

Subjective

137
Q

The Physical Exam is what type of info, subjective or objective?

A

Objective

138
Q

While evaluating a patient complaining of CP your physician tells you heart sounds are normal, would you document this in HPI, ROS or PE?

A

PE

139
Q

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”?

A

No

  • Pain=subjective and patient reported
  • Tenderness=objective assessment of pain
140
Q

What does disposition mean?

A

Patient’s destination after they leave the ED

141
Q

What subcategories are included in the Past Hx section of the template?

A

PMHx—> HTN, DM, CAD, MI
PSHx—> appendectomy, cholecystectomy, CABG
FHx—> Hx of CAD <55yo
SHx—> EtOH, smoking, drug abuse, occupation

142
Q

Abbreviation Heart Attack

A

MI—> Myocardial Infarction

143
Q

Abbreviation Hypertension

A

HTN

144
Q

Medical Term for Acid Reflex

A

GERD—> Gastroesophageal Reflux Disease

145
Q

Medical Term for Stroke

A

Cerebrovascular Accident—>CVA

146
Q

Term for Gallbladder Removal

A

Cholecystectomy

147
Q

NKDA

A

No Known Drug Allergies

148
Q

Medical term for Redness

A

Erythema

149
Q

Medical Term for Bruising

A

Ecchymosis

ScribeAmerica: ER (9 decks)

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