Emergency Department Flow Flashcards by Ashlee Smalley

Subjective vs. Objective

Feeling (pt) vs Fact (MD)

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Chief Complaint

Main reason for pt visit

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Medical Decision Making

The physician’s thought process

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Pain vs. Tenderness

pt feeling vs. Physician’s assessment

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Auscultation

Listening with a stethoscope

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Palpation

Act of pressing on an area (by dr)

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Scribes CAN NOT

Touch pt
Write orders or prescriptions
Give verbal orders
Partake in any activity that may affect pt outcome
Sign/authenticate charts/records
Handle bodily fluids/specimens

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Flow Overview

Check in/chief complaint -> Dr Assessment -> objective orders and results -> Medical decision making -> disposition

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Documentation Template

HPI (sub) and ROS (sub) -> Past History -> PE (obj), ED Course (obj), and Disposition

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HPI

History of Present Illness: Story and context of chief complaint

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ROS

A head-to-toe list of positives and negatives

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Past History

PMHx, PSHx, SHx, FHx

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Physical Examination: Physician’s objective findings

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ED Course

Objective results: Labs, imaging, re-evals, consults, procedures

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Disposition

Discharged home, admitted for further care, transfer to another facility, or death

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Epic

Pres’s documentation system

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I have high blood pressure

HTN: Hypertension

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I have high cholesterol

HLD: Hyperlipidemia

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I have thyroid problems

Usually Hypothyroidism, sometimes hyperthyroidism

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I have diabetes

DM: Diabetes Mellitus

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I only take pills for my diabetes

NIDDM

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I take shots (insulin) for my diabetes

IDDM

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I have heart disease

CAD

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I’ve had a heart attack

MI and CAD

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I've had heart failure

CHF

I have an irregular heart beat

A-Fib

I have a heart murmur

Heart murmur

I have episodes of racing heartbeats

SVT: Supraventricular Tachycardia

I have asthma

Asthma

I have emphysema/chronic bronchitis

COPD

I have a blood clot in my lung

I've had pneumonia

PNA

I have acid reflux

GERD

I have an ulcer

Gastric Ulcer or Peptic Ulcer Disease

I have pancreatitis

Pancreatitis

I have hepatitis

Hepatitis A, B, or C

I have diverticulitis

Diverticulitis

I have Crohn's/UC

Crohn's Disease or Ulcerative Colitis

I have irritable bowels

IBS

I have a bladder infection

UTi

I have a kidney infection

Pyelonephritis (Pyelo)

I have kidney stones

Renal calculi

I'm on dialysis

CRF: Chronic renal failure ESRD: End stage renal disease (dialysis, freq, last Tx)

I have an enlarged prostate

BPH: Benign Prostate Hypertrophy

G/P/A

Gravida: Total # times pregnant Para: # live births Abortion: # miscarriages or elective abortions

I've had a stroke

CVA: Cerebrovascular Accident

I've had a mini-stroke

TIA: Transient Ischemic Attack

I've had seizures

Seizure disorder/epilepsy

I've had a brain bleed

Hemmorrhagic CVA

I'm bipolar

Bipolar disorder

I'm schizophrenic

Schizophrenia

I drink a lot

EtOH abuse/Alcoholism

I do drugs

Substance Abuse

I've had a blood clot in my leg

Lower Extremity DVT

I have a bulge in my aorta

AAA: Abdominal Aortic Aneurysm

I have bad blood flow to my legs

PVD: Peripheral Vascular Disease

I have numbness in my legs

Peripheral Neuropathy

I have Cancer

CA + Type

My cancer has spread

With metastases

I'm in chemo

Chemotherapy

I'm in radiation

Radiation therapy

They cut my cancer out

Status-post surgical resection

My cancer is gone

In remission

I have low back pain

Chronic low back pain

I have a bulging/herniated disc

DDD: Degenerative Disc Disease

I have arthritis

OA: Osteoarthritis (usually) RA: Rheumatoid Arthritis

I have joint pain (chronic)

DJD: Degenerative Joint Disease

I have weak/fragile bones

Osteoperosis (usually)

I've had my tonsils removed

Tonsillectomy

I've had my adenoids removed

Adenoidectomy

I have ear tubes

P.E.: Pressure Equalizer Tubes

I've had a heart bypass

CABG -> PMHx CAD

I've had stents inserted

Coronary stents -> PMHx CAD

I have a heart cath

Cardiac catheterization

I've had a balloon in my heart

Angioplasty -> PMHx CAD

I've had valve surgery

Valve repair or replacement (bovine vs mechanical)

I have a pacer

Pacemaker

I have a defibrillator

AICD: Automatic Implanted Cardiac Dibibrillator

I've had surgery for Afib

Afib s/p cardiac ablation

I've had my breast removed

Mastectomy

I have a hole in my neck

Tracheostomy or trach

I've had part of my lung removed

Partial lobectomy

I've had my appendix removed

Appendectomy

I've had my gallbladder removed

Cholecystectomy

I've had a hernia repaired

Herniorrhalphy

I've had part of my colon removed

Partial colectomy

I have a bag to collect stool

Colostomy bag

I've had my spleen removed

Splenectomy

I've had my stomach stapled

Gastric bypass

I've had exploratory surgery

Exploratory Laproscopy (ExLap)

I've had my kidney removed

Nephrectomy

I've had my uterus removed

Hysterectomy (partial vs total)

I've had an ovary removed

Oophorectomy

I've had my ovary and fallopian tubes removed

Salpingo-oophorectomy

I've had my tubes tied

Tubal ligation (female) or Vasectomy (male)

I've had a C-Section

Ceasarean section

I've had my prostate removed

Prostatectomy (most often TURP: Trans-Urethral Removal of the Prostate)

I've had a uterine product removed

D&C: Dilation and Curettage

I've had my neck artery cleaned

Carotid Endarterectomy

I've had brain surgery

Craniotomy (brain bleed vs CA)

I have a shunt

VP Shunt (Ventriculoperitoneal)

I have a dialysis fistula

AV (arteriovenous) fistula

I have a dialysis graft

AV graft

I have a PICC line

PICC: Peripherally inserted central catheter

I have a port

Port-a-cath or Medi-Port

I have a clot filter (lower abdomen)

IVC (inferior vena cava) Filter

I have a clot filter (leg)

Greenfield filter

I've had my leg amputated

AKA: Above knee amputation BKA: Below knee amputation

I've had joint repaired

Arthroplasty

I have metal plates/pin

Hardware

My neck is fused

Cervical spine fusion

My back is fused

Lumbar spinal fusion

I've had hip surgery

ORIF: Open Reduction with Internal Fixation

Medical Allergy vs Adverse Reaction

Only a medication causing rash, itching, swelling, or difficulty breathing is a true allergy.

FHx (Family History Topics)

``` General: HTN, DM, CA Cardiac: MI/CAD less than 55 y/o Pulmonary: PE, Asthma GI: Crohn's, IBS Neuro: CVA, Seizures, Aneurysm Misc: Sickle cell, DVT ```

Sx (Social History)

Tobacco, EtOH, Illicit Drugs, Occupation, Living circumstances

Smoking Use

``` Current (#ppd, #yrs) Former (years quit) Never Second-hand exposure Chewing tobacco ```

EtOH Use

Never Occasionally/socially Daily Chronic (#dpd, type)

Illicit Drug Use

Which drug Route of administration Date of last use

Occupation

Employed Unemployed On disability Retired

Living Circumstances

``` Lives alone With family/friends Nursing home/assisted living Hospice Homeless/shelter ```

Pediatric Sx

``` Caretaker Attends daycare Attends school Has siblings Second-hand smoke exposure Immunizations UTD ```