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scribe america > Day 1: ED Flow/PMHx/PSHx > Flashcards

Day 1: ED Flow/PMHx/PSHx Flashcards

1
Q

Main components of ED flow:

A

Chief complaint (CC), Physician Assessment (H&P), Objective Orders, Results & Medical Decision Making, Disposition

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2
Q

Chief complaint is comprised of:

A

the reason the patient came to the ED

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3
Q

Physician Assessment is comprised of:

A

Initial subjective complaints (HPI, ROS), and objective facts (PE), DDx

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4
Q

Objective orders is comprised of:

A

tests are ordered for each DDx to determine if the disease is present

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5
Q

Results and Medical Decision Making is comprised of :

A

reviewing the lab/test results to rule out unlikely DDx, and arrives at a final diagnosis

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6
Q

Disposition can be:

A

admit, discharge, transfer

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7
Q

Five triage vital signs

A

HR, BP, T, SaO2, RR (respiratory rate)

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8
Q

Covered during nurse assessment

A
  1. confirm chief complaint
  2. review allergies
  3. brief PMHx
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9
Q

Covered during H&P

A

Subjective, Hx, Objective

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10
Q

Covered during subjective

A

HIP, ROS

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11
Q

Covered during Hx

A

PMHx, PSHx, FHx, SHx

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12
Q

Covered during objective:

A

PE

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13
Q

The doctor places orders to ____ each differential diagnosis

A

rule out (r/o)

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14
Q

Types of physician orders

A

labs, imaging, procedures, medications

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15
Q

Charge nurse:

A

manages ED patient flow

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16
Q

LNP, PA:

A

works under supervision of physician

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17
Q

ED Nurse

A

records MHx, symptoms, monitors patient, starts IVs, administers meds, assists w/procedures

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18
Q

Respiratory Therapist (RT)

A

admins breathing treatments, manages patient’s airway

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19
Q

ED tech

A

helps nurse, assists w/procedures

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20
Q

Unit secretary

A

places docs orders, answers phone, pages docs, organizes pt paperwork

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21
Q

Pain vs. tenderness

A

pt’s feeling vs physicians assessment

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22
Q

distress

A

docs judgement of discomfort (none, mild, moderate, severe)

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23
Q

baseline

A

individuals normal state of being

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24
Q

inpatient

A

admitted to the hospital overnight

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25
Q

outpatient

A

seen and sent home same day

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26
Q

Subjective complaints:

A

HPI: story and context of the chief complaint
ROS: head-to-toe list of positives and negatives

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27
Q

Past history (PMSHx,SHx,FHx)

A

past Dz, surgeries, EtOH/tobacco, FHx

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28
Q

Objective Evaluation

A

PE: docs objective findings

ED Course: objective results (labs, XR), re-evals, consults

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29
Q

If the information comes from the pt, it belongs in the:

A

HPI (related to CC), ROS(everything else)

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30
Q

If the info is from the docs observation of the pt, it belongs in the:

A

PE

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31
Q

If the info is from an objective study, it belongs in the:

A

ED course (results)

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32
Q

If the info comes to light after the H&P, it belongs in the:

A

ED course (re-eval, consults, events, etc)

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33
Q

PMHx: high blood pressure

A

HTN

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34
Q

PMHx: high cholesterol

A

hyperlipidemia (HLD)

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35
Q

PMHx: diabetes

A

DM (diabetes mellitus)

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36
Q

PMHx: diabetes, I only take pills

A

NIDDM

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37
Q

PMHx: diabetes, I take shots

A

IDDM

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38
Q

Cardiac PMHx: heart disease

A

CAD

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39
Q

Cardiac PMHx: heart attack

A

MI & CAD

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40
Q

Cardiac PMHx: heart failure

A

CHF

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41
Q

Cardiac PMHx: irregular heartbeat

A

Atrial Fibrillation (A-Fib)

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42
Q

Cardiac PMHx: Murmur

A

Heart Murmer

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43
Q

Cardia PMHx: episodes of abnormally fast/racing heartbeat

A

Supraventricular Tachycardia (SVT)

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44
Q

Pulmonary PMHx: asthma

A

Asthma

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45
Q

Pulmonary PMHx: Emphysema/Chronic bronchitis

A

COPD

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46
Q

Pulmonary PMHx: blood clot in lung

A

PE

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47
Q

Pulmonary PMHx: pneumonia

A

PNA

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48
Q

GI PMHx: reflux

A

Gastroesophageal Reflux Disease (GERD)

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49
Q

GI PMHx: Ulcer

A

Gastric Ulcer or PUD

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50
Q

GI PMHx: pancreatitis

A

pancreatitis

51
Q

GI PMHx: hepatitis

A

Hepatitis A, B, or C

52
Q

GI PMHx: Diverticulitis

A

Diverticulitis

53
Q

GI PMHx: Chrohn’s/UC

A

Chrohn’s Disease or Ulcerative Colitis (UC)

54
Q

GI PMHx: Irritable bowel

A

IBS

55
Q

GU PMHx: bladder infection

A

UTI

56
Q

GU PMHx: kidney infection

A

pyelonephritis (Pyelo)

57
Q

GU PMHx: kidney stones

A

Renal calculi

58
Q

GU PMHx: “I’m on dialysis”

A

Chronic Renal Failure (CRF) on dialysis

59
Q

GU PMHx: enlarged prostate

A

Benign Prostate Hypertrophy (BPH)

60
Q

Neuro PMHx: stroke

A

CVA

61
Q

Neuro PMHx: mini-stroke

A

TIA

62
Q

Neuro PMHx: seizures

A

Sz or epilepsy

63
Q

Neuro PMHx: brain bleed

A

Hemorrhagic CVA (Ischemic CVA from lack of blood)

64
Q

Psych PMHx: bipolar

A

bipolar disorder

65
Q

Psych PMHx: schizophrenia

A

Schizophrenia

66
Q

Psych PMHx: “I drink a lot”

A

ETOH abuse or alcoholism

67
Q

Vascular PMHx: “blood clot in my leg”

A

LE DVT

68
Q

Vascular PMHx: “bulge in my aorta”

A

AAA

69
Q

Vascular PMHx: bad blood flow to my legs

A

Peripheral Vascular Disease (PVD)

70
Q

MS PMHx: low back pain

A

Chronic Low Back pain

71
Q

MS PMHx: bulging/herniated disc

A

Degenerative Disc Disease (DDD)

72
Q

MS PMHx: arthritis

A

Osteoarthritis (OA) or Rheumatoid Arthritis (RA)

73
Q

MS PMHx: joint pain (chronic)

A

Degenerative Joint Disease (DJD)

74
Q

MS PMHx: weak, fragile bones

A

osteoporosis

75
Q

CA PMHx: cancer

A

CA of whereever: brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, lymphoma

76
Q

CA PMHx: spread to my…

A

“with metastases to the …”

77
Q

CA PMHx:chemo

A

chemotherapy

78
Q

CA PMHx: radiation

A

radiation therapy

79
Q

CA PMHx: “they cut it out”

A

s/p surgical resection

80
Q

CA PMHx: “It’s gone”

A

in remission

81
Q

ENT PSHx: tonsils removed

A

Tonsillectomy

82
Q

ENT PSHx: adenoids removed

A

Adenoidectomy

83
Q

ENT PSHx: ear tubes

A

Pressure Equalizer (P.E.) Tubes

84
Q

Cardiac PSHx: heart bypass

A

CABG -> PMHx CAD

85
Q

Cardiac PSHx: stents

A

Coronary Stents -> PMHx CAD

86
Q

Cardiac PSHx: heart cath

A

cardiac catheterization

87
Q

Cardiac PSHx: balloon

A

angioplasty -> PMHx CAD

88
Q

Cardiac PSHx: Valve surgery

A

valve repair or replacement (bovine vs. mechanical)

89
Q

Cardiac PSHx: pacer

A

pacemaker

90
Q

Cardiac PSHx: defibrillator

A

Automatic Implanted Cardiac Defibrillator (AICD)

91
Q

Cardiac PSHx: surgery for Afib

A

A-Fib s/p cardiac ablation

92
Q

Pulmonary PSHx: breast removal

A

mastectomy

93
Q

Pulmonary PSHx: hole in my neck

A

Tracheostomy “trach”

94
Q

Pulmonary PSHx: part of my lung removed

A

Partial lobectomy

95
Q

GI PSHx: appendix removed

A

appendectomy

96
Q

GI PSHx: gallbladder removed

A

cholecystectomy

97
Q

GI PSHx: Hernia repair

A

Herniorrhaphy

98
Q

GI PSHx: part of my colon removed

A

Partial colectomy

99
Q

GI PSHx: bag to collect stool

A

colostomy

100
Q

GI PSHx: Spleen removed

A

splenectomy

101
Q

GI PSHx: stomach stapled

A

Gastric Bypass

102
Q

GU PSHx: uterus removed

A

Hysterectomy (partial or total)

103
Q

GU PSHx: ovary removed

A

oophorectomy

104
Q

GU PSHx: ovary and fallopian tubes removed

A

salpingo-oopherectomy

105
Q

GU PSHx: tubes tied

A

Tubal ligation or vasectomy

106
Q

GU PSHx: C-section

A

cesarean section

107
Q

GU PSHx: prostate removed

A

Prostatectomy (Trans-Urethral Removal of Prostate: TURP)

108
Q

Neuro PSHx; neck artery cleaned

A

Carotid Endarterectomy

109
Q

Neuro PSHx: brain surgery

A

craniotomy

110
Q

Neuro PSHx: shunt

A

ventriculoperitoneal (VP) shunt

111
Q

Vascular PSHx: dialysis fistula

A

AV (arteriovenous) Fistula

112
Q

Vascular PSHx: Dialysis graft

A

AV graft

113
Q

Vascular PSHx: PICC line

A

Peripherally Inserted Central Catheter (PICC)

114
Q

Vascular PSHx: port

A

port-a-cath or Medi-port

115
Q

Vascular PSHx: clot fiter (lower abdomen)

A

IVC (inferior vena cava) filter

116
Q

Vascular PSHx: clot filter (leg)

A

Greenfield Filter

117
Q

Ortho PSHx: leg amputated

A

Above Knee Amputation (AKA)

Below Knee Amputation (BKA)

118
Q

Ortho PSHx: joint repair

A

Arthroplasty

119
Q

Ortho PSHx: metal plates/pins

A

Hardware

120
Q

Ortho PSHx: neck fused

A

Cervical Spine Fusion

121
Q

Ortho PSHx: Back fused

A

Lumbar Spine Fusion

122
Q

Key FHx

A 
General: HTN,DM,CA
Cardiac: CAD/MI < 55 yrs old
Pulmonary: PE, Asthma
Abdominal: cholecystiti
GU: Kidney stones
Neuro: CVA, Aneurysm, Sz
Other: Sickle Cell, DVT
123
Q

Key SHx

A

EtOH: daily, occasionally, never
Tobacco: currend (#ppd, # yrs), former (year quit), never
Illicit Drugs: what drug? how taken? when last use?
Occupation: if doc asks, document it
Living circumstances: at home, w/family, homeless, nursing home, hospice, etc

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