ED 1 Flashcards
Chief Complaint
The main reason for patients ED visit
EMR/EHR
Electronic medical record / electronic health record
Subjective
feeling
Objective
Pain
Tenderness
Acute
Chronic
Triage
History & Physical
Differential Diagnosis
Orders & Treatment
Medical Decision Making
Disposition
Discharged to home / nursing home /
Medical Chart
History of present illness *written in complete sentances.
Review of systems * +/-
History
Vitals
Physical exam
Orders/Results
Course
Heart Disease
Coronary Artery Disease
Heart Attack
Myocardial Infraction and CAD
Heart Failure
Congestive Heart Failure
Irregular Heartbeat
Arrhythmia
High Blood Presssure
Hypertension
High Cholesterol
Hyperlipidemia
Diabetes
Diabetes Mellitus
“I only take pills for my diabetes”
Non-INsulin Dependant Diabetes Mellitus
“I take shots (insulin) for my diabetes”
Insulin Dependant Diabetes Mellitus
Asthma
Asthma
Emphysema or Chronic Bronchitis
Chronic Obstructive Pulmonary Disease
Blood clot in lung
Pulmonary Embolism
Pneumonia
Pneumonia (PNA)
Reflux
Gastroesophageal Reflux Disease (GERD)
Ulcers
Gastric Ulcer or Peptic Ulcer Disease (PUD)
Pancreatitis
Pancreatitis
Hepatitis
Hepatitis
Irritable Bowel
Irritable Bowel Syndrom (IBS)
Bladder Infection
Urinary Tract Infection (UTI)
Kidney Infection
Pyelonephritis
Kidney Stones
Renal Calculi
“I’m on dialysis”
Chronic Kidney Disease (CDK) on dialysis
Enlarged Prostate
Begnin Prostatic Hyperplaysia (BPH)
Gravida
Total # of times patient has been pregnant
Para
Number of pregnancies that resulted in a live birth
Abortus
Number of miscarriages or elective abortions
Stroke
Cerebrovascular Accident (CVA)
Blockage in the brain
Ischemic CVA
Brain Bleed
Hemorragic CVA
“Blood clot in my leg”
“Mini Stroke”
“Bulge in my aorta”
“Bad blood flow in my legs”
Tonsils removed
Adenoids Removed
Ear tubes
“Balloon in my heart”
“Stents in my heart”
Heart bypass
Breast Removal
Appendix removed
Partial lung removal
Gallbladder removed
Partial colon removal
Sleen removed
Kidney removed
Uterus Removed
Ovary removed
Ovary and fallopian tube removed
Prostate removed
Family Hx
Any medical condition present in paitents blood relatives.
Social Hx
Tabacco use / vapping
Alcohol use
Drug use
Occupation
Living circumstances
Medications & Allergies
Key things to doccument
Reviewing external records
Documenting independant historians
Capturing chronic illnesses