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Medical Scribe > Course 5 > Flashcards

Course 5 Flashcards

1
Q

Arterial Blood Gas

A

Blood taken from an artery

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2
Q

Serum

A

The clear liquid separated from clotted blood. Serum is also another word for blood

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3
Q

Coagulation

A

The change of blood from liquid to solid

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4
Q

what does POC stand for ?

A

Point of care

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5
Q

What are cultures?

A

The propagation of microorganisms or of living tissue cells in media conducive to their growth

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6
Q

What is Critical care time ?

A

Any Pt. at serious risk for deterioration that may lead to permanent bodily harm or death

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7
Q

Define Hemolyzed Samples

A

The blood cells have broken down due to the incorrect drawing and storing of Blood

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8
Q

What does CBC mean?

A

Complete Blood Count

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9
Q

What does WBC stand for?

A

White blood cells

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10
Q

What does it mean when the blood contains high levels of WBC?

A

-This indicates that there is an infection. A key assoc DDx is Leukocytosis

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11
Q

What does Hgb stand for

A

Hemoglobin

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12
Q

When there are low amounts of hemoglobin in the blood what does this mean?

A

Anemia

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13
Q

What does Hct stand for?

A

Hematocrit

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14
Q

What does it means when there are low levels of hematocrit?

A

anemia

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15
Q

If the doctor puts in a lab work order for H&H what does this mean?

A

Hemoglobin and Hematocrit

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16
Q

What does Plt stand for?

A

Platelets

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17
Q

What does it mean when the platelets count is low?

A

The Pt. is prone to bleeding and might have Thrombocytopenia.

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18
Q

Which DDx has low platelets count is associated with?

A

Thrombocytopenia

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19
Q

Which DDx has high white blood cellc count?

A

Leukocytosis

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20
Q

The physician puts in a lab order for CBC. What does this lab order entail?

A

It entails find the count for:

  • WBC
  • Plts
  • Hgb
  • Hct
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21
Q

What are band cells?

A

Immature Neutrophil

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22
Q

What is another way of saying the Band cells are high?

A

Bandemia

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23
Q

When the band cells are high what does this indicate?

A

A serious infection

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24
Q

What does Seg stand for ?

A

Mature neutrophils also referred to as Segmented Neutrophils

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25
Q

When the levels of segmented neutrophils are high what does this indicate?

A

An acute infection

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26
Q

What does Monos stand for?

A

Monocytes

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27
Q

What does high leves of Monocytes indicate?

A

bacterial infection

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28
Q

What does Lymph stand for?

A

Lymphocytes

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29
Q

What type of infection high levels of Lymphocytes indicate?

A

Viral infection

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30
Q

What does Eos stand for?

A

Eosinophils

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31
Q

What type of infection does high levels of Eosinophils indicate?

A

Parasitic infection

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32
Q

The physician puts in an order for CBC with Differentials what does this mean?

A 
The order is requesting to check the levels of:
-WBC
-Plts
-Hgb
-Hct
in addition to:
-Band cell
-Segs
-Lymphs = viral infection 
-Monos = bacterial infection 
-Eos =parasitic infection
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33
Q

What does BMP stand for?

A

Basic Metabolic Panel

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34
Q

What is the term for low sodium?

A

Hyponatremia

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35
Q

What is the term for high sodium?

A

Hypernatremia

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36
Q

What does it mean when the levels of sodium is too high or low?

A

Dehydration

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37
Q

What is the term for high potassium?

A

Hyperkalemia

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38
Q

What does hyperkalemia indicates?

A

Poor kidney function

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39
Q

What does the term for low potassium mean?

A

Hypokalemia

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40
Q

What does hypokalemia indicate?

A

May cause arrhythmias

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41
Q

Which labs can signify dehydration?

A

Chloride and Sodium

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42
Q

What does BUN stand for?

A

Blood Urea Nitrogen

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43
Q

What do high levels for blood urea nitrogen signify?

A

Renal insufficiency or failure

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44
Q

Where is Creatinine filtered out of the body?

A

Kidneys

So if there are high levels in the blood then the kidneys aren’t working properly

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45
Q

Which labs can signify renal failure or insufficiency?

A

Creatinine and Blood Urea Nitrogen

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46
Q

What does Gluc stand for?

A

Glucose

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47
Q

What is the term for high levels of glucose?

A

Hyperglycemia

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48
Q

What does hyperglycemia signify?

A

High blood sugar

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49
Q

What is the term for low glucose?

A

Hypoglycemia

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50
Q

What does hypoglycemia indicate?

A

Low blood sugar

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51
Q

What does HCO3- stand for?

A

Bicarbonate

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52
Q

What is the term for high HCO3?

A

Hypercarbia

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53
Q

What is the significance of hypercarbia?

A

Possible respiratory disease

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54
Q

What is the term for low HCO3?

A

Hypocarbia

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55
Q

What is the significance of hypocarbia?

A

Hyperventilation (Possible DKA)

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56
Q

What is the term for high chloride?

A

Hyperchloremia

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57
Q

What is the term for low chloride?

A

Hypochloremia

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58
Q

The physician puts in a BMP order. What does this order entail?

A 
-BMP stands for Basic Metabolic Panel 
It entails testing for :
-Na
-Cl-
-BUN
-K
-HCO3-
-Creat
-Gluc
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59
Q

What does LFT’s stand for?

A

Liver Function Test

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60
Q

The LFT’s is apart of which set of tests?

A

CMP

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61
Q

What are the 3 LFTs? What do they assess?

A 
They all test for liver function 
AST (SGOT)
--Aspartate Transaminase 
ALT (SGPT)
--Alanine Transaminase
ALK Phos
--Alkaline Phosphatase
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62
Q

What does AST stand for?

A

Aspartate Transaminase

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63
Q

What does ALT stand for?

A

Alanine Transaminase

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64
Q

What does Alk Phos stand for?

A

Alkaline Phosphatase

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65
Q

What does CMP stand for?

A

Comprehensive Metabolic Panel

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66
Q

What does the CMP include?

A

The 3 LFT’s and
T bili = Total Bilirubin
T Prot/Alb = Total protein/albumin

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67
Q

What does low T Prot/Alb signify?

A

Poor Nutrition

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68
Q

What does high T bili signify?

A

Jaundice/Liver failure

69
Q

What are the labs in the CEP?

A

When these levels are high they indicate heart damage
Trop = Troponin
CK= Creatine Kinase
CK- MB = Creatine Kinase- Muscle Breakdown
CK-RI = Creatine Kinase Relative Index
Myo = Myoglobin

70
Q

Define Rhabdomyolysis

A

s the breakdown of damaged skeletal muscle. Muscle breakdown causes the release of myoglobin into the bloodstream.
A symptom of high Creatine Kinase (CK)

71
Q

What does a troponin diagnose? (be as specific as possible):

A

Non-STEMI Myocardial Infractions

72
Q

What does a D-dimer detect?

A

Helps to detect clots in the body but does not specify the type of location
The amount of D-Dimer circulating in the body

73
Q

What is D-Dimer ?

A

a protein secreted by clots of blood

74
Q

If a D-dimer is possible what is the significance?

A

If the Physician orders a D-Dimer. She is considering PE as a DDx

75
Q

If the D-dimer is positive what must we order to r/o a PE?

A 
CTA chest (with IV contrast)
or a VQ scan
76
Q

If the D-dimer is negative what can be excluded from the DDx?

A

PE

77
Q

What lab is significant for CHF if it is elevated?

A

BNP

B-type Natriuretic Peptide

78
Q

What does the ABG (Arterial Blood Gas) check for?

A

Low pH = Acidosis
High/Low HCO3 = Metabolic problems
High/Low pCO2 (carbon dioxide) = Respiratory problems
Low pO2 = Hypoxia

79
Q

What does the VBG (Venous Blood Gas) check for?

A

1) Low pH = Acidosis

2) High pH = Alkalosis

80
Q

What is the cardiac order set?

A 
CBC
BMP
Troponin 
EKG
CXR
81
Q

A lumbar puncture can diagnose:

A

Hemorrhagic Cerebrovascular Accident
—-If the CSF red blood cells are >0 in tube 4 then its a brain bleed
Meningitis
—If the CSF white blood cells are >3 in tube 4 then it’s possible meningitis

82
Q

Supratherapeutic means:

A

Too much Coumadin

83
Q

Subtherapeutic means:

A

Not enough Coumadin

84
Q

We check INR because:

A

Is used to check the levels of Coumadin in the blood. Coumadin is a blood thinner giving to Pt. with Afib.

85
Q

What does COAGS stand for?

A

Coagulation

86
Q

What is a Normal INR

A

For Pt. that are not on Coumadin, they have an INR of 1.0

87
Q

What does INR stand for?

A

International Normalized Ratio

88
Q

If a provider says: I am going to check the enzymes in your pancreas… what will they order?

A

1) Lip = Lipsae is only found in the Pancreas

2) Amy= Amylase is found in both the pancreas and saliva

89
Q

If a pt had a serum HCG quant that was 500 yesterday, but today it is 300… what do you think is happening?

A

A failed or ectopic pregnancy

90
Q

Nitrites and Leukocyte Esterase are part of what order? What are their significance?

A

Urine Dip. They test for UTIs

91
Q

Name 3 sepsis labs:

A

Blood Cx
Lactate
Complete Blood Count

92
Q

Name the 3 abnormal vitals of septic patients:

A

-Febrile: temp greater than 100.5 degree F or 38.0 degrees Celsius
Tachycardic: HR greater than 100 bpm
Hypotensive : BP less than 90/60

93
Q

A positive Rapid Step Test indicates?

A

Strep Throat

94
Q

A positive Mononucleosis Test indicates?

A

Mononucleosis

95
Q

A positive influenza A + B test indicates ?

A

“The Flu”

96
Q

A positive Respiratory Syncytial Virus test (RSV) indicates?

A

Bronchiolitis

97
Q

High levels of Lipase indicates Pancreatitis while high levels of Amylase indicates the possibility of Pancreatitis. Why?

A

Lipase is only found in the pancreas so high levels of this would indicate Pancreatitis. While Amylase is found in both the saliva and the pancreas so its hard to be confident that high levels of amylase mean pancreatitis

98
Q

What does TSH stand for?

A

Thyroid Stimulating Hormone

99
Q

What is the term for High levels of Thyroid Stimulating Hormone (TSH)? note: think carefully about this one.

A

Hypothyroidism

100
Q

What is the term for low Thyroid Stimulating Hormone (TSH)? note: think carefully about this one.

A

Hyperthyroidism

101
Q

Low levels of T3 (Triiodothronine) signify?

A

Hypothyroidism

102
Q

Low levels of T4 (Thyroxine) signify?

A

Hypothyroidism

103
Q

What are the inflammation labs?

A

CRP : C-Reactive Protein

ESR or Sed Rate: Erythrocyte Sedimentation Rate

104
Q

What does CRP stand for?

A

C-Reactive Protein

105
Q

What does ESR or Sed Rate stand for?

A

Erythrocyte Sedimentation Rate

106
Q

State the significance of a Positive and negative HCG ?

A

Positive HCG in Urine indicates pregnancy

Negative HCG in urine indicates no pregnancy

107
Q

What does T + S/ABORh mean?

A

Type and Screen/Blood Type

108
Q

What does Rh negative of a T + S/ABORh indicates ?

A

Pt. needs RhoGam shot is pregnant

109
Q

What is the purpose of the T + X ?

A

Gets blood ready for transfusion

110
Q

What is the significance of a Wet Prep (Vaginal Wet Mount)?

A

Test for Bacterial Vaginosis (BV)

  • Trichomoniasis (STD)
  • Vaginal Yeast Infection

Wet Prep is done in the ED

111
Q

What 3 labs are known as the rate limiting step?

A

D-Dimer
Troponin
Creatinine

112
Q

What is the significance of Chlamydia Trachomatis?

A

It test for Chlamydia (STD)

Not done in the ED

113
Q

What is the significance of GC (Gonococcus)?

A

Test for Gonorrhea (STD)

Not done in the ED

114
Q

What does positive Gluc in the urine indicates?

A

High Blood Sugar and could mean the Pt. has DM

115
Q

What does Gylcosuria mean?

A

Glucose in Urine

116
Q

What is the significance of hematuria ?

A

Kidney stone Vs. UTI

117
Q

If Epi (Epithelial cells) are found in the urine sample, what does the mean?

A

Contaminated sample

118
Q

What does pyuria mean?

A

Pus in urine

119
Q

If a Pt. is found to have sepsis, what lab test can you anticipate them ordering and why?

A
  • CXR to r/o PNA
  • UA to r/o UTI
  • LP to r/o Meningitis
120
Q

List the 4 types that is typically ordered.

A
  • BCx (Blood Culture)—Sepsis
  • UCx– Urine Culture —UTI
  • Wound Cx–wound culture
  • Stool Cx–Stool Culture
121
Q

What lab checks for toxicity for Aspirin?

A

ASA

Serum Acetysalicylic Acid

122
Q

What lab checks for toxicity for Tylenol?

A

APAP

Serum Acetaminophen

123
Q

What would signify likely DKA?

A

Large amounts of Ketones in the blood (Ketones serum)

124
Q

What lab checks for toxicity for alcohol intoxication?

A

EtOH

Serum EtOH Alcohol

125
Q

What lab checks for toxicity for Drug abuse?

A

Utox

Urine Drug Screen

126
Q

What is a Portable XR?

A

XR that are conducted at the Pt bedside. It is brought to the Pt.

127
Q

List the critical care procedures.

A 
Headache fever- Lumbar Puncture
Joint reduction -Procedural Sedation 
Respiratory failure -Intubation
Sepsis- Central Line Placement 
Pneumothorax- Chest Tube 
Abnormal heart rhythm- Cardioversion 
Cardiac Arrest-CPR
COPD/CHF Exacerbation CPAP/BiPAP
128
Q

What does Low levels of INR mean ?

A

Subthrapeutic; risk of clots

129
Q

What does high levels of coumadin indicate?

A

supratherapeutic risk for toxicity

130
Q

What is the risk of having low levels of Digoxin?

A

risk for having Afib

131
Q

What is the risk of having high levels of Digoxin?

A

risk for toxicity

132
Q

List the four medications that can result in seizure at low levels?

A

-Tegretol
-Keppra
Depakote
-Neurontin

133
Q

What can a CXR diagnose?

A 
PNA
PTX
Widened Mediastinum (dissection)
Pleural effeusion 
CHF
134
Q

What can an AAS/KUB diagnose?

A

Free Air (Rupture)
SBO
Constipation
Large kidney stones

135
Q

What does AAS/KUB stand for ?

A

Acute Abdominal Series/Kidney Ureters Bladder

136
Q

All other X-rays can diagnose?

A

Fracture
Dislocation
Joint effusion

137
Q

X-rays are great for evaluating what?

A

Bones in the body

138
Q

What can a “dry CT” diagnose?

A

CT Head : Ischemic CVA or Hemorrhagic
CT Cervical-spine, Thoracic-spine, lumbar spine
CT Chest: PNA, PTX, Pleural Effusion, Rib fracture
CT A/P: Kidney Stones, Pyelonephritis

139
Q

What does a Dry CT refer to?

A

CT w/o IV contrast

140
Q

What can a CTA w/ IV contrast diagnose?

A

CTA chest: Pulmonary Embolism, Aortic Dissection
CTA Head: Hemorrhagic CVA. Ischemic CVA
CTA Neck: Carotid Dissection, Carotid Occlusion

141
Q

CT A/P with PO contrast: (This requires a 2 hour prep!) this can diagnose what?

A

Appendicitis, SBO, Diverticulitis, Ischemic Gut

142
Q

what is the catch with CT’s with IV contrast? There is a lab that needs to be done…why?

A

Contrast is hazardous to kidney but gives great images.
To ensure that the Pt. is able to do a CTA w/ Iv contrast we check their renal function using the Creatinine test from BMP

143
Q

What does US Doopler LE diagnose?

A

Deep Venous Thrombosis (DVT)

144
Q

What does US RUQ diagnose?

A

Cholelithiasis, Cholecystitis, Bile sludge, Gallbladder wall thickening, Bile duct obstruction

145
Q

What does US Obstetrics/Transvaginal diagnose?

A 
Intrauterine Pregnancy (IUP)
Ectopic Pregnancy
Ovarian Cyst. Ovarian Torsion
146
Q

What does US Scrotum diagnose?

A

Testicular Torsion. Testicular mass

147
Q

Ultrasounds are great for evaluating what?

A

Investigative the flow by providing real time images

148
Q

What procedure would be conducted for a joint injury?

A

Splint Application

149
Q

A dislocation would call for what kind of procedure?

A

Joint reduction

150
Q

A joint effusion would call for what kind of procedure?

A

Arthrocentesis

151
Q

What procedure would be done on a laceration and what information should we document about the laceration?

A
  • Laceration repair would be conducted

- –Key information to record: location, length and depth of the laceration. In addition to what caused the laceration

152
Q

What procedure would be done on an abscess?

A

Incision & drainage

153
Q

What procedure would be done on a meningitis or hemorrhage?

A

Lumbar puncture

-require a sterile environment, betadine prep and local anesthesia with 1% Lido

154
Q

Which Pt. would get bedside US?

A

Trauma, Suspected acute disease or Ultrasound-guided procedure

155
Q

What preparations are required for a conscious sedation procedure?

A

Suction at bedside.

Pt on cardiac monitor and continuous pulse oximetry.

156
Q

Why would a pt. get an endotracheal intubation?

A

If the Pt. experience respiratory failure. Airway control

157
Q

What preparation are need for a endotracheal intubation?

A

Suction at bedside.

Consent precluded by clinical urgency

158
Q

What preparation are needed for a Central Line Placement?

A

Sterile field, chlorhexidine prep, local anesthesia 1% lidocaine

159
Q

Why would a Pt. need a central line placement?

A

For intravenous access for abx or fluid resuscitation

160
Q

Where are the 3 major sites for central line placement?

A

Internal Jugular
Subclavian
Femoral

161
Q

Would would need a chest tube placement?

A

Pt. with PTX or Hemothorax(blood in lungs)

162
Q

Who would need a cardioversion?

A

Pt. with Atrial fib or abnormal rhythm

163
Q

What is the difference between an electronic cardioversion and a pharmacologic cardioversion?

A

electronic cardioversion sends an electrical shock to the heart to adjust the abnormal rhythm
Pharmacologic cardioversion is giving a medication to fix the heart’s abnormal rhythm

164
Q

When would a physician order a 12 lead-EKG?

A

If a Pt. complains of chest pain, SOB or syncope

165
Q

What are the two questions we should ask the provider about critical care time?

A

1) Does this Patient qualify for critical care?

2) How many mins of critical care time were provided?

166
Q

What is the min amount of critical care time given?

A

30 mins

167
Q

What are the reasons for re-evaluations?

A

1) discharged
2) Admitted
3) abnormal vital signs
4) physical exam finding
5) treatment was effective

168
Q

What are the 3 reasons for consultations?

A

1) the Ed doctors needs to admit a pt. to the hospital
2) the ed doctor needs specialist advice regarding a particular disease, treatment or need for follow up
3) the ed doctor calls the patient’s PCP to inform them their pt. was evaluated in the ED

169
Q

What are the critical care procedures?

A 
Intubation---respiratory failure
Central line placement--sepsis
chest tube- PTX
Cardioversion---abnormal heart rhythm
CPR--cardiac arrest
CPAP/BiPAP--COPD/CHF Exacerbation

Medical Scribe (9 decks)

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