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Scribe Training > ED 1 > Flashcards

ED 1 Flashcards

1
Q

Chief Complaint

A

The main reason for patients ED visit

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2
Q

EMR/EHR

A

Electronic medical record / electronic health record

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3
Q

Subjective

A

feeling

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4
Q

Objective

A
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5
Q

Pain

A
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6
Q

Tenderness

A
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7
Q

Acute

A
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8
Q

Chronic

A
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9
Q

Triage

A
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9
Q

History & Physical

A
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10
Q

Differential Diagnosis

A
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11
Q

Orders & Treatment

A
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12
Q

Medical Decision Making

A
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13
Q

Disposition

A

Discharged to home / nursing home /

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14
Q

Medical Chart

A

History of present illness *written in complete sentances.
Review of systems * +/-
History
Vitals
Physical exam
Orders/Results
Course

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15
Q

Heart Disease

A

Coronary Artery Disease

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16
Q

Heart Attack

A

Myocardial Infraction and CAD

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17
Q

Heart Failure

A

Congestive Heart Failure

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18
Q

Irregular Heartbeat

A

Arrhythmia

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19
Q

High Blood Presssure

A

Hypertension

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20
Q

High Cholesterol

A

Hyperlipidemia

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21
Q

Diabetes

A

Diabetes Mellitus

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22
Q

“I only take pills for my diabetes”

A

Non-INsulin Dependant Diabetes Mellitus

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23
Q

“I take shots (insulin) for my diabetes”

A

Insulin Dependant Diabetes Mellitus

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24
Q

Asthma

A

Asthma

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25
Q

Emphysema or Chronic Bronchitis

A

Chronic Obstructive Pulmonary Disease

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26
Q

Blood clot in lung

A

Pulmonary Embolism

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27
Q

Pneumonia

A

Pneumonia (PNA)

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28
Q

Reflux

A

Gastroesophageal Reflux Disease (GERD)

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29
Q

Ulcers

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

30
Q

Pancreatitis

A

Pancreatitis

31
Q

Hepatitis

A

Hepatitis

32
Q

Irritable Bowel

A

Irritable Bowel Syndrom (IBS)

33
Q

Bladder Infection

A

Urinary Tract Infection (UTI)

34
Q

Kidney Infection

A

Pyelonephritis

35
Q

Kidney Stones

A

Renal Calculi

36
Q

“I’m on dialysis”

A

Chronic Kidney Disease (CDK) on dialysis

37
Q

Enlarged Prostate

A

Begnin Prostatic Hyperplaysia (BPH)

38
Q

Gravida

A

Total # of times patient has been pregnant

39
Q

Para

A

Number of pregnancies that resulted in a live birth

40
Q

Abortus

A

Number of miscarriages or elective abortions

41
Q

Stroke

A

Cerebrovascular Accident (CVA)

42
Q

Blockage in the brain

A

Ischemic CVA

43
Q

Brain Bleed

A

Hemorragic CVA

44
Q

“Blood clot in my leg”

A
45
Q

“Mini Stroke”

A
46
Q

“Bulge in my aorta”

A
47
Q

“Bad blood flow in my legs”

A
48
Q

Tonsils removed

A
49
Q

Adenoids Removed

A
50
Q

Ear tubes

A
51
Q

“Balloon in my heart”

A
52
Q

“Stents in my heart”

A
53
Q

Heart bypass

A
54
Q

Breast Removal

A
55
Q

Appendix removed

A
56
Q

Partial lung removal

A
57
Q

Gallbladder removed

A
58
Q

Partial colon removal

A
59
Q

Sleen removed

A
60
Q
A
61
Q

Kidney removed

A
62
Q

Uterus Removed

A
63
Q

Ovary removed

A
64
Q

Ovary and fallopian tube removed

A
65
Q

Prostate removed

A
66
Q

Family Hx

A

Any medical condition present in paitents blood relatives.

67
Q

Social Hx

A

Tabacco use / vapping

68
Q

Alcohol use

A
69
Q

Drug use

A
70
Q

Occupation

A
71
Q

Living circumstances

A
72
Q

Medications & Allergies

A
73
Q

Key things to doccument

A

Reviewing external records
Documenting independant historians
Capturing chronic illnesses

Scribe Training (5 decks)

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