Entrance Exam Flashcards
What is the fundamental purpose of healthcare?
To enhance quality of life [in the population] by enhancing overall health [of the population
What is healthcare?
The organized provision of medical care to individuals or a community
What is a healthcare setting?
any location where someone may receive health care
What are examples of a healthcare setting?
Hospital Clinic Urgent Care Rehab Facility Home (Home Healthcare)
What are the four principles of healthcare?
Autonomy
Justice
Benefice
Non-maleficence
What does autonomy refer to?
The right of a patient to make decisions about their medical care without their health care provider trying to influence the decision
What does justice refer to?
The principle that there should be an element of fairness in all medical decisions.
- Fairness in decisions that burden and benefit society
- Equal distribution of scare resources and new treatments
- Medical practitioners are required to uphold applicable laws and legislation when making decisions
What does patient autonomy allow for health providers to do?
To educate the patient, but does not allow the health care provider to make the decision for them. The decision-making process must be free of coercion or coaxing. In order for a patient to make a fully informed decision, she/he must understand all risks and benefits and the likelihood of success.
What does beneficence refer to?
The act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation. All professionals have the foundational moral imperative of doing right.
What does beneficence, as a principle, demand that health care providers do?
Develop and maintain their skills and knowledge. To continually update their training, consider individual circumstances of all patients, and strive for net benefit.
What does Non-maleficence refer to?
Not harming or inflicting the least harm possible to reach a beneficial outcome.
What principle is is sometimes difficult for a healthcare provider to successfully apply?
In some cases, it is difficult for healthcare providers to successfully apply the do no harm principle (Non-maleficence).
What is a medical scribe?
A healthcare worker who assists providers in documenting all aspects of patient encounters, from initial examination to the end of the visit. The scribe will follow the provider into patient rooms and document the entire patient encounter in real-time directly into the EHR in a structured manner.
What is a medical scribe’s number one priority?
Proper documentation of the provider’s encounter with each patient.
What does a medical scribe document through the entirety of a patient’s stay?
Re-evaluations, procedures, orders, results, and calls/consults
What is within the scope of a medical scribe’s role?
What are they allowed to complete
They are allowed to:
- Document a patient’s entire visit for the provider
- Alert provider when test results become available
- Alert provider when there is a new patient if they are not already aware
- Alert nursing staff when new orders have been placed
- Give patients blankets and water if requested (check with nurse first)
- Get supplies for the provider (gloves, suture materials, saline, etc…. excluding EXCLUDING Medications
- Hold supplies for the provider (hold the light for the provider, hold a bottle of lidocaine for the provider, etc.)
What are medical scribes NOT allowed to do?
- TOUCH PATIENTS
- Make medical decisions
- Administer medications
- Obtain history from the patient independent of the provider– they should always accompany the provider
- Take vital signs (oxygen saturation, blood pressure, heart rate, temperature, etc.)
- Obtain specimens for labs (blood samples, flu tests, etc.)
- Perform CPR– when working as a scribe, they are to only scribe and must NOT TOUCH PATIENTS, regardless if they have a CPR certification
- Give results or diagnostic info to patients – leave this to the provider
- Give nurses verbal orders (“Give the patient Morphine” or “Give the patient 1 bolus of IV fluids”)
Is a Medical Scribe ever permitted to touch a patient
NAH NEVER
What are the three kinds of healthcare providers a scribe will work directly with on a regular basis?
A Physician (MD, DO) Physician Assistant (PA) Nurse Practitioner (NP)
What is a physician?
A medical doctor, either an M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathic Medicine), who has completed graduate training to diagnose and treat injuries or illnesses.
What are the 6 duties of a physician?
Examining Patients Taking medical histories Performing medical procedures/surgeries Prescribing medications Ordering/interpreting diagnostic tests Counseling patients on diet, hygiene, and preventive healthcare
What are the 6 duties of a physician assistant or PA?
Examining patients
Taking medical histories
Performing some and assisting in other medical procedures
Ordering/ interpreting diagnostic tests
Prescribing medications (in most states)
Counseling patients on diet, hygiene, and preventive healthcare
What is a Physician Assistant or a PA?
A mid-level healthcare provider who practices medicine in collab with physicians. They practice under the license of their supervising physician.
What is a nurse practicioner or NP?
An advanced practice registered nurse and a type of mid-level healthcare provider health care provider. NP’s like PA’s also practice in collab with a physician under the physician’s license, but additionally they have the capacity to work under their own license.
What are the 6 duties of a nurse practitioner or a NP?
Examining Patients Taking medical histories Performing medical procedures/surgeries Prescribing medications Ordering/interpreting diagnostic tests Counseling patients on diet, hygiene, and preventive healthcare
Medical providers, or simply providers, are unable to interview, examine, and document the patient’s entire visit… so who fills in?
Medical scribes, aka scribes.
What are medical scribes, or scribes, trained to do?
Accompany a provider during patient encounters to assist in documenting the entirety of the visit (from all answered questions to physical findings into the patient’s record)
Providers see patients in a variety of healthcare settings, therefore…
Scribes work in a variety of healthcare settings
What are the 12 additional healthcare roles?
*Nurse (RN/BSN) >Charge Nurse *Medical Assistant (MA) *Nurse Technician/Certified Nurse Assistant (CNA) *Paramedic (Medic) *Emergency Medical Technician (EMT) *Lab Technician *Phlebotomist *Pharmacist *Pharmacy Technician *Respiratory Therapist *Clerical Staff *Billing Staff
What is a nurse?
A healthcare professional who plays a significant supporting role in hospitals, clinics, and private practices.
____ make up the largest healthcare occupation in the U.S.
Nurses
What are the two types of nurses?
RNs (Registered Nurses) and those with a BSN (Bachelor’s of Science in Nursing)
What is the difference between RNs (Registered Nurses) and those with a BSN (Bachelor’s of Science in Nursing)?
The difference between the two titles relates to their years of schooling, but doesn’t change their responsibilities or duties.
What does a nurse’s duties include?
Communicating between patients and providers Caring for patients Assisting providers when needed Administering medicine Supervising nurses' aides
What is a charge nurse?
A charge nurse is in charge of the nursing staff of a specific ward at a healthcare facility
What re the duties of a charge nurse?
Caring for patients and other typical nursing tasks
Supervising Staff
Ensuring that everything runs smoothly during their shift
What is a medical assistant, or a MA?
A health careprofessional who supports the work of physicians and other health professionals
What are the duties of a medical assistant or a MA?
- Verifying patient by interviewing patients
- Recording medical history
- Confirming the purpose of the visit
- Preparing patients for examination by performing preliminary physical tests and taking blood pressure, weight, and temp
- Reporting patient history summary to the provider
A nurse technician is also referred to as?
A nurse tech, nursing aide, or certified nursing assistant (CNA).
What are the duties of a nurse technician?
- Feeding, bathing, and dressing patients
- Taking patient vital signs
- Serving meals, making beds, and keeping rooms clean
- Setting up medical equipment and assisting with some medical procedures
- Answering calls for help
- Observing changes in a patient’s condition or behavior
What is a nurse technician?
A healthcare professional who helps patients with activities of daily living and other healthcare needs under the direct supervision of a nurse
What is a job task that a nursing technician DOES NOT DO?
They don’t administer medications or start I.V.S
What is a paramedic, or a medic?
A professional who responds to emergency calls for medical help outside of a hospital. Paramedics mainly work as part of emergency medical services and are often also firefighters
What are the three duties of paramedic?
- Responding to 911 calls for emergency medical assistance
- Assessing a patient’s condition and administering treatments (including invasive treatments such as starting IV’s, giving medications, intubating the patient, etc.)
- Providing first-aid or life support care to sick or injured patients
What is an EMT, or an Emergency Medical Technician?
A healthcare professional who is trained to respond quickly to emergency situations regarding medical issues, traumatic injuries, and accident scenes
What are the duties of an Emergency Medical Technician (EMT)?
- Responding to 911 calls for medical assistance
- Assessing a patient’s condition and administering treatment (not including invasive treatments)
- Providing first-aid or life support care to sick or injured patients
What is the difference between an EMT and a paramedic?
Their level of education and procedures thy are allowed to perform.
EMTS can administer CPT, glucose and oxygen (noninvasive treatments),
Paramedics can perform more complex procedures such as inserting IV lines, intubations, administering drugs, and applying pacemakers (invasive treatments)
What is a lab technician?
A skilled healthcare professional that works with complex systems to perform highly technical mechanical or diagnostic tests in medical labs
What are the duties of a lab technician, aka lab tech?
- Setting up and sanitizing laboratories
- Preparing specimens
- Matching blood compatibility for transfusions
- Analyzing fluid chemical content
- Collecting blood samples
What is a phlebotomist?
A healthcare professional trained to draw blood from a patient (mostly from veins) for clinical or medical testing, transfusions, donations, or research
What are the 5 duties of a phlebotomist?
- Collecting blood samples from patients
- Labeling vials with patient names and dates
- Identifiying the best method for drawing blood depending on the specific patient
- Transport all specimen samples to a nearby lab
- Centrifuging blood samples– depending on if this is allowed in the state they are working in
What are the differences between a phlebotomist and a lab tech?
Both of them collect bodily fluids from patients. However, phlebotiomists take only blood samples and perform more clerical tasks like printing orders and storing supplies. Lab techs, on the other hand, help lab technologist collect samples and run tests in a lab.
What is a pharmacist?
A healthcare professional who specializes in the use of medicines, with extensive knowledge of their composition, effects, mechanism of action, and proper and effective usage of drugs.
What are the duties of a pharmacist?
- Preparing medications by reviewing and interpreting physician orders
- Detecting therapeutic incompatibilities
- Dispensing medications by compounding, packing, and labeling pharmaceuticals
- Controlling medications by monitoring drug therapies and advising interventions
What is a pharmacy technician, or pharmacy tech?
A healthcare professional who performs pharmacy-related functions, such as dispensing medications, while working under the supervision of a licensed pharmacist
What are the duties for a pharmacy tech?
- Dispensing medications for patients
- Receiving and verifying prescriptions
- Pricing and filling prescriptions
- Obtaining pharmacist’s approval
- Completing patient paperwork related to the filling of prescriptions
What is a respiratory therapist or a RT?
A specialized healthcare practitoner trained in critical care and cardiopulmonary medicine in order to work therapeutically with people suffering from acute critical conditions, as well as cardiac and pulmonary disease
What are the 6 duties of a respiratory therapist?
- Interviewing and examining patients with breathing or cardiopulmonary disorder
- Consulting with physicians
- Performing diagnostic tests, such as measuring lung capacity
- Treating patients using a variety of methods, including aerosol medications
- Monitoring and recording a patients’ progress
- Teaching patients how to take medications and use equipment, such as at-home ventilators
What is a health information clerk, aka medical records clerk?
A healthcare professional responsible for the medical records of patients. They are often a patient’s first point of contact
What are the duties of a health information clerk, aka medical records clerk?
- Compiling, coding, organizing and evaluating a patient’s medical records
- Creating a new medical record for new patients
- Closing medical records as needed
- Organizing patient appointments
What is a medical biller, aka medical coder?
A healthcare professional in charge of calculating and collecting payments for medical procedures and services. They work in medical administrative offices to ensure that patients are billed quickly and accurately
What are the duties of a medical biller, aka medical coder?
- Ensuring accuracy of patient note coding for precise billing
- Developing payment plans for patients to pay off their medical debt
- Preparing invoices to be sent to patients
What is HIPPA?
A law passed in 1996 that protects the privacy of patient info in the form of Protected Health Information, of PHI.
What does the law state about HIPAA?
That healthcare professionals may only access information necessary to do their job and to only share said information with others who need it to do their job. This is known as the Minimum Necessary Standard and covers written, spoken, or electronic forms of communication
What is the Minimum Necessary Standard ?
That healthcare professionals may only access information necessary to do their job and to only share said information with others who need it to do their job. (covers written, spoken, or electronic forms of communication)
What are the two types of penalties for violating HIPAA?
*Civil Penalties
>100-50k in fines per year, per violation
*Criminal Penalties
>50k - 1,500,000 in fines per year, per violation
>Possibility of imprisonment for up to 10 years
What is Protected Health Information of PHI?
Any health data created, received, stored, or transmitted by HIPAA-covered entities and their business associates in relation to the provision of healthcare, healthcare operations, and payment for healthcare services
What is considered PHI?
There are 18 items that are considered pieces of personal info or identifiers under HIPAA:
- Name
- Postal Address
- All elements of dates except year
- Phone number
- Fax Number
- Web Universal Resource Location (URL)
- Internet Protocol
- Social Security Number (SSN)
- Other account numbers
- Certificate/driver’s license number
- Medical record number (MRN)
- Health plan (insurance) beneficiary number
- Medical device identifiers and serial numbers
- Vehicle identifiers i.e. VIN, license plate number, etc.
- Biometric information, i.e. DNA, fingerprints, etc.
- Full face photos
- Any other unique identifying number code, or characteristic
When linked to a patient using a personal identifier, what is also considered PHI?
- Health records
- Patients’ past and present physical and mental health conditions
- Diagnostic results
- Medical bills
What is a privacy breach?
The acquisition access, use, or disclosure of Protected Health Information in a prohibited manner which compromises the security or privacy of the protected health information
What are the types of privacy breaches?
- Compromised computer system i.e. Hacking
- Info which is lost/stolen, i.e., papers, electronic devices, films, tapes, etc.
- Sending info which is not HIPAA compliant, i.e. sending unencrypted info which includes patient identifiers
- Sending info to the wrong person
- Talking in public areas too loudly and/or to someone not covered by the Minimum Necessary Standard
- Allowing or granting patient record access to someone other than the login owner (sharing log-in)
Scribes are healthcare professionals and meet the minimum necessary standard and may access info necessary to do their job and…
only share info with others who need it to do their job.
The access to information that medical scribes have may create the risk of privacy ____
breaches
How can I scribe prevent a privacy breach from occurring?
Protecting the access they have been granted by safeguarding their logins and only accessing the Electronic Medical Records while following appropriate protocols
While I am on shift, I see a famous celebrity check in. It is Nahko Bear. Although, I won’t see Nahko, I am curious about the conditions that they have and why they are being seen. So, I decide to open up the record, but I don’t read any past charts…. Did I violate HIPAA?
Yeah, thats a HIPAA violation. Despite not reading any past charts. The Minimum Necessary Standard states that only those who need PHI to complete their job are permitted to access a patient’s record.
Since the scribe was not going to be seeing the patient, they did not fulfill the requirements of the Minimum Necessary Standard
I decide to go into the shift after I find out that my cousin is admitted at their facility. The scribe wishes to send their cousin an appropriate “get well” card, but isn’t sure why the cousin was admitted…
How should I approach finding out why my cousin was admitted without violating HIPAA?
I should ask my cousin or family directly. Accessing the cousin’s recrd or asking their physician for information would be HIPAA violations.
Me, as the scribe, may not access my own health record, as this would also be a HIPAA violation.
While I am on shift, a scribe recognizes a patient walking down the hall as a friend from highschool. Wanting to catch up, the scribe approaches their friend and strikes up a conversation. They don’t discuss the reason why the friend is patient. This is still a violation of HIPAA…..
So what did the scribe do wrong??
The scribe should have not approaches their friend and should have treated the friend the same way as other patients. Doing so was a HIPAA violation; the scribe revealed personal information about the scribe about the patient –their connection to the scribe….
However if the patient approached the scribe to engage in conversation, it would not have been the patient’s decision to disclose their connection to the scribe
Scribe #1 has split their shift with another Scribe who is just coming in to take over. As the Scribe #1 is leaving, the provider asks them to email any notes they have on active patients to Scribe #2 before they leave
So, is this a HIPAA violation?
Yes, both Scribes #1 and #2 would be violating HIPAA by sharing PHI through non-encrypted means.
The best way to handle this situation would be for Scribe #1 to give a verbal report on each active patient to Scribe #2 before leaving
Throughout a busy shift, a scribe was unable to finish their charts. By the scheduled end of their shift, the scribe has various tasks to complete in a number of charts. The scribe decides to write everything down to bring home with them so they can eat dinner and come back to finish up the charts.
Was this a HIPAA violation?
Noooo not yet, but the scribe is creating a potential HIPAA vilation by removing documents with PHI from the facility and putting them in a vulnerable location where they could potentially be viewed by those not involved in the patient’s case….
Best way to handle this situation would have been to notify the Leadership team/Provider and stay after shift or come in early during the next shift to finish the notes
I’m waiting in line at Starbucks before my shift. I hear a scribe talk to a nurse and a CNA discuss a patient. They use the patient’s name. They don’t say anything negative about the patient. They disclose why he was in the hospital and some of his test results.
Was this a HIPAA violation?
Yes, the nurse and CNA both violated HIPAA by discussing a patient in a public place and using the patient’s name which is PHI.
What should the scribe do….
Report the violation to their immediate supervisor/ lead scribe, who will pass it to the appropriate parties
While at the grocery store, a scribe sees a patient how they saw recently on shift. The patient had a very difficult recovery and the scribe is excited to see they are up and about. The scribe decides to walk up to the patient and ask how they are doing.
Was this a HIPAA violation?
Yeah, the scribe violated HIPAA by approaching the patient outside of the hospital and healthcare setting where the patient was treated.
It would not be a HIPAA violation if the patient decided to approach the scribe.
What is the purpose of Occupational Safety and Health Administration (OSHA)?
To ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training outreach, education, and assistance
What is the mission of OSHA?
- Prevent work injuries, illnesses, and deaths
- Develop job safety and health standards and enforce them through worksite inspections
- Have worksites maintain a reporting and recordkeeping system to keep track of job-related injuries and illnesses
- Provide training programs to increase knowledge occupational safety and health
What is the Joint Commission?
A non-profit organization that sets standards and accredits healthcare organizations and programs based on their safety standards and quality of care
What is the overall mission of the Join Commission?
- Continously improve the safety and quality of healthcare provided to the public through the provision of accreditation and related services
- Evaluate healthcare organizations and inspire them to excel in providing safe and effective care of the highest quality and value
T/F
The Joint Commision DOES NOT endorse, nor prohibit the use of Medical Scribes…
True..
When scribes are used, what conditions must they follow according to the Joint Commission
They must complete training on the following topics:
> Medical terminology
> Health INsurance Accountability Act of 1996 (HIPAA)
>Principles of billing, coding, and reimbursement
>Patient record navigation
>Computerized order entry
*Scribes must sign and date theri entry into the patient’s record. This is known as the scribe attestation
>The provider will also sign and date, acknowledging the scribe’s entries. The scribe cannot enter the date or time for the provider.
What is the Centers for Medicare & Medicaid Services OR CMS?
An organization that oversees many federal healthcare programs, including those that involve health info technology, such as the meaninful use incentive program.
- This program offers incentive payment sthrough Medicare and Medicaid to providers and hispitals when they use electronic records to achieve specified improvements in healthcare delivery.
According to the CMS, Centers of Medicare & Medicaid Services, the U.S. healthcare system is moving from that pays for the _____ of services to one that pays for the ____ of services
volume; value
What is the core goal of the CMS, Centers for Medicare & Medicaid Services?
Their goal is to standardize how to document, how to report treatment information for billing, and how payments for medical services are made based on quality of care.
How does the CMS, Centers for Medicare & Medicaid Services, aim to meet their core goals?
They have put in place a set of core measures that are designed to be meaningful to patients, consumers, and physicians.
What is the American Medical Association? (AMA)
The American Medical Association, or AMA, is the largest association of physicians - both MDS and DOs- and medical students in the United States.
What are the original goals of the American Medical Association at the time of their establishment in 1845?
- Scientific advancement
- Standards for medical education
- Launching a program of medical ethics
- Improved public health
What is the stated mission of the AMA?
To promote the art and science of medicine and the betterment of public health
The AMA is dedicated to driving medicine toward a more equitable future, removing obstacles that interfere with patient care and confronting the nation’s greatest public health crises.
What does the AMA advocate for?
The use of scribes in various clinical settings, citing the benefits their use has on overall patient care.
What is anatomical positioning?
The standardized method of describing the position of any region or part of the body at any given time.
Why is anatomical positioning standardized?
This method is standardized so that anyone reading the note after the patient has been evaluated will know exactly what area of the body is being referenced
What is anatomical position?
A standard position of the patient’s body used as a reference in describing the relation of body parts to one another
What are anatomical planes?
Hypothetical planes used to transect the body, in order to describe the location of structures or the direction of movements
Define the term anatomical position
Standing erect, feet together, and arms at the sides with palms facing forward
(Icon of someone standing tall - visualized )
Define transverse plane
Divides the body into upper (superior) and lower (inferior) sections
(There is a photo of a body model with a square horizontally positioned at the pelvis level)
Define the sagittal plane
Divides the body into right and left sections that may be even (midsagittal) or uneven
(Vertically positioned rectangle around the model that is dividing the model into two sections)
Define Coronal (frontal) plane
Divides body into front (anterior) and back (posterior) sections
*(A rectangle positioned at the crown of head and around the body, dividing the body into front and back sections)
What are anatomical directions?
Directions used to describe the locations of structures in relation to other structures or locations in the body, in the same way the directions North, South, East, and West are used on a map
What are the terms that describe anatomical directions?
Prone Supine Anterior Posterior Ventral Dorsal Superior Inferior Superficial Deep Medial Lateral Proximal Distal
Define Prone
Anatomical Direction
The body lying flat, facing downward
(Model lying down flat and facing downward)
Define the term Supine
Anatomical Direction
The body lying flat, facing upward
Model lying flat and facing upward
Define the term Anterior
Anatomical Direction
In front of or further toward the front
EX: The sternum is anterior to the heart
*(Body model is facing left with arrows facing in the left direction, signaling to look in front of the model)
Define the term Posterior
Anatomical Direction
Further back in position; of or nearer to the rear or hind end
EX: The spine is posterior to the sternum
(Body model facing left with arrows facing right, signaling behind the body)
Define the term Ventral
Anatomical Direction
Pertaining to the front of any structure. The ventral surfaces of the body include the chest, abdomen, shins, palms, and soles
(Body with arrows facing forward - sternum, pelvis, and leg… and arrow signaling down to soles of feet)
Define the term Dorsal
Anatomical Direction
Pertaining to the back of any structure. The dorsal surfaces of the body are the back, buttocks, calves, and the knuckle side of the hand
(Body icon showing arrows signaling to the back of the body)
Define the term Inferior
Anatomical Direction
Lower, below, or farther from the top of the head
EX: The feet are inferior to the knees
Define the term Superficial
Anatomical Direction
Nearer to the surface
EX: The skin is superficial to the bones
(Body model has straight lines around the pecs…)
Define the term Deep
Anatomical Direction
Farther away from the surface
EX: The heart is deep to the ribs
(Two Lines around pecks pointing at each other)
Define the term Medial
Anatomical Direction
Nearer to the midline. May also be the midline of an individual body part
EX: The medial aspect of the left forearm
(There is a middline line in the body… two lines on each side of the middle line pointing at it around the pecks area)
Define the term Lateral
Anatomical Direction
Farther from the midline. May also be the midline of an individual body part
EX: The lateral aspect of the left forearm
(Arrows facing away from the Midline)
Define the term Proximal
Anatomical Direction
Closer to the center of the body or point of attachment
EX: The elbow is proximal to the hand
(Arrows on the side of the arms and legs facing upward)
Define the term Distal
Anatomical Direction
Further away from the center body or point of attachment; nearer to the end
EX: The foot is distal to the knee
(Arrows pointing down from the sides of the arms and legs)
What are anatomical movements?
Terms used to describe movement of organs, joints, limbs, and specific sections of the body
Review anatomical movement terms
Flexion
Extension
Supination
Pronation
Abduction
Adduction
Define the term Flexion
Anatomical Movements
To bend, decreasing the angle between body parts
EX: Bending the knee is flexion
Define the term Extension
Anatomical Movements
To straighten, increasing the angle between body parts
EX: Bending the knee is flexion
(A leg moving itself back «< is flexion and forward»_space;> extension)
Define the term Supination
Anatomical Movements
Turning the palm of the hand upward by rotating the forearm
EX: Pain with supination
(Think carrying bowls of soup = supination)
Define the term Pronation
Anatomical Movements
Turning the palm of the hand downward by rotating the forearm
EX: Pain with pronation
THINK “Dribbling like a pro-basketball player = pronation.”
Define the term Abduction
Anatomical Movements
A motion where the body part goes away from the body
EX: Pain with should abduction
THINK: Providers will sometimes say A-B-duction.” Think: Abduction abducts from the body
(Model is lifting arm)
Define the term Adduction
Anatomical Movements
A motion where the body part goes towards the body
EX: Pain with should adduction
THINK: Providers will sometimes say A-D-duction…. adduction adds to the body think…
What are abdominal quadrants?
Any one of the 4 areas on the anterior of the abdoment formed by the 2 imaginary lines one vertical and one horizontal intersecting at the navel.
What are the terms for the abdominal quadrants?
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Define the term Right Upper Quadrant
Abdominal Quadrant
Abbreviation: RUQ
Location of the gallblader
Think - North Left
Define the term Right Lower Quadrant
Abdominal Quadrant
RLQ
Location of the appendix and the right ovary in females
South Left
Define the term Left Upper Quadrant
Abdominal Quadrant
Abbreviation: LUQ
Location of the stomach and spleen
North Right
Define the term Left Lower Quadrant
Abdominal Quadrant
Abbreviation: LLQ
Location of the sigmoid colon and left ovary in females
What are abdominal regions?
Any of the topographical subdivisions of the abdomen, including one posterior region
What terms are associated with abdominal regions?
Epigastric Region
Periumbilical Region
Suprapubic Region
Costovertebral Angle
Define the term Epigastric Region
Abdominal Regions
AKA - Midepigastric Region
The region of the upper abdomen immediately below the ribs
Define the term Periumbilical Region
Abdominal Regions
AKA - Umbilical Region
Def - The region surrounding the umbilicus
(Center of the model - or stomach)
Define the term Suprapubic Region
Abdominal Regions
AKA Pelvic Region
The region of the abdomen located below the umbilical region
Define the term Costovertebral Region
Abdominal Regions
Abbreviation: CVA
AKA - Right and left flanks
A region on the back between the 12th rib and the vertebral column, overlying the kidneys
Video for reference…
https://youtu.be/fSIiAH1KaJI
Define skull regions
Skull regions are divided by three of the four cranial sutures which fuse together over time. Each region is named after the respective underlying bone.
What terms are associated with the skull regions?
Frontal Region
Retro Orbital Region
Temporal Region
Parietal Region
Occipital Region
Define Frontal Region
Skull Regions
The region overlying the forehead. Can be a location for headaches.
Literally its the front of the forehead….
EX: Patient Reports a frontal Headache
Define Retro Orbital Region
Skull Regions
The region behind the eyes. Common place for migraines.
(Right behind eye sockets)
EX: Patient reports a retro orbital headache
Define Temporal Region
Skull Regions
The region over the temple/ears. Can be a location for headaches
EX: Patient reports a temporal headache
(* Think ear muffs area or headphones* )
Define Parietal Region
Skull Regions
The region at the top of the head. Can be a location for headaches
EX: Patient reports a parietal headache
(Start around crown and covers some of the upper back of the head and a bit above the temporal area)
Define Occipital Region
Skull Regions
The region at the back of the head. Can be a location for headaches.
Example: Patient reports a occipital headache
(Lowerback of head)
What is a patient encounter/ visit and what is the provider responsible for during the encounter/ visit?
Each time a patient is treated by a Medical Provider (MD, DO, PA, NP), thi sis called a patient encounter or visit and the provider is responsible for documenting what occurred during that patient encounter/visit.
How is the patient encounter/visit recorded?
It is recorded in distinct and separate sections; each section has an exact purpose and contains a specific type of information
What is a note?
Also known as the patient’s encounter note
It is The final document that is created with all of the distinct and separate sections recorded for the patient’s encounter/visit
Where are the patient encounter notes and other data that make up the patient’s medical records?
This info is housed in a computer program called an Electronic Health Record, or EHR. There are many different EHRS in healthcare (site-specific EHR training will occur at a later stage).
Providers see patients in a variety of healthcare settings, therefore…
scribes work in a variety of healthcare settings
Healthcare Setting:
Acute Care Setting- Emergency Department (ED) Inpatient Intensive Care Units (ICUs) Urgent Care
How many hours are these facilities running for?
24/7 or extended hours
Healthcare Setting:
Acute Care Setting- Emergency Department (ED) Inpatient Intensive Care Units (ICUs) Urgent Care
What is the acuity level for these facilities?
Low, medium, and high
Healthcare Setting:
Acute Care Setting- Emergency Department (ED) Inpatient Intensive Care Units (ICUs) Urgent Care
What type of visit is this for?
New complaints/ symptoms
What are the four examples of acute care setting?
Emergency Department (ED)
Inpatient
Intensive Care Units (ICUs)
Urgent Care
What does acuity mean?
What is an example?
Acuity means the level of severity.
EX: A hatchet sticking out of someone’s chest is Acuity level 1 (high acuity) where as a stubbed tow would be an Acuity level 5 (low acuity)
Ambulatory Care Setting:
Primary Care clinics -
(Family medicine, OB/Gyn, Pediatrics)
Specialty Medicine Clinics -
(Cardiology, Neurology, Pulmonology, etc.)
What are the business hours for these care settings?
M-F 8am-5pm
Ambulatory Care Setting:
Primary Care clinics -
(Family medicine, OB/Gyn, Pediatrics)
Specialty Medicine Clinics -
(Cardiology, Neurology, Pulmonology, etc.)
What are the acuity levels for these care settings?
Low
Primary Care clinics -
(Family medicine, OB/Gyn, Pediatrics)
What types of visits are these care settings for?
Chronic & Long-term conditions, new complaints/ symptoms
Specialty Medicine Clinics -
(Cardiology, Neurology, Pulmonology, etc.)
What type of visits are these for?
Very specialized & long-term conditions, new complaints/ symptoms
Review Patient Note Sections for an Ambulatory Care Setting
>Reason for visit >History of present illness (HPI) >Review of Systems (ROS) >Past Medical + Surgical, Family, and Social History (PMFSHx) >Allergies/Home Medications >Physical Examination >Procedures >Impression/Assessment/Diagnosis >Plan *Patient instructions *Patient Education *Orders --Labs, imaging, other testing *Follow up info
Review Patient Note Sections for Acute Care Settings
>Reason for visit >History of present illness (HPI) >Review of Systems (ROS) >Past Medical + Surgical, Family, and Social History (PMFSHx) >Allergies/Home Medications >Physical Examination >Medical Decision Making (MDM) *Differential Diagnosis *Diagnostic Studies (Labs, Imaging, EKGs) *Procedures *Reevaluations *Consultations >Impression/Assessment/Diagnosis >Disposition >Plan *Patient Instructions *Patient Education *Follow Up Information
Each note section has specific info that belongs to it - Review note sections
SUBJECTIVE FROM PATIENT >Reason for visit >History of present illness (HPI) >Review of Systems (ROS) >Past Medical + Surgical, Family, and Social History (PMFSHx)
OBJECTIVE >Physical Examination >Medical Decision Making (MDM) *Differential Diagnosis *Diagnostic Studies (Labs, Imaging, EKGs) *Procedures *Reevaluations *Consultations >Impression/Assessment/Diagnosis >Disposition >Plan *Patient Instructions *Patient Education *Follow Up Information
What is the Reason for Visit, or the Chief Complaint?
The main reason the patient is being seen by the provider. The reason for visit is subjective and comes directly from the patient and/or their family. The reason for visit is usually one symptom or one reason.
EX: Chest pain, Asthma follow up, Medication refill etc.
What is the History of Present Illness aka HPI?
A paragraph of multiple paragraphs further expanding on and describing the Reason for Visit.
The History of Present Illness (HPI) is _____ and comes directly from the patient and/or their family
subjective
Provide an example of how HPI is subjective and comes directly from the patient and/or their family
2 Patients Complain of Cough
1 experiences Cough fever and green sputum
Another patient may be experiencing a cough, scratchy throat and watery eyes. The symptoms and and details for each individual HPI are different.
Provide an example of HPI
Mary Wallace is a 45 yr old female with a history of htn who presents to the ed with complaints so fsharp chest pain which began 3 days ago. Her chest pain radiates down her left arm. She reports associate dnauser ana dplalitations she reports improvemetn after taking tylenol.
SOOOO the reason for visit is “chest pain” and
everything else is HPI
The HPI is written in a very specific way. T/F
T
What is a completed review of systems, or ROS, or systems inquiry, or systems review?
(its all the same name)
A template of body systems (cardiovascular, neurological, etc.) which each contain specific symptoms. The ROS is a more condensed, easy to read list of all symptoms. The ROS is subjective and comes directly from the patient and/or their family. Any and all symptoms that the patient is experiencing must be listed in the ROS.
Who is responsible for documenting all the symptoms a patient is experiencing as either positive or negative, respectively?
Medical Scribe
Most symptoms will be documented in ____ and all symptoms will be listed in the ___
HPI;ROS
What are the 14 most commonly recognized body systems?
Constitutional Skin Eyes ENMT (Ears, Nose, Mouth, and Throat) Respiratory Cardiovascular Gastrointestinal Geintourinary Musculoskeletal Neurologic Psychiatric Endocrine Heme/ Lymph (Hematologic/ Lymphatic) Allergy/Immunologic
Review a completed review of systems template
Constitutional: Negative for fever or chills
Skin: Negative for rash or open wounds
Eyes: Negative for blurred vision or double vision
ENMT: Negative for sore throat, ear pain, or rhinorrhea
Respiratory: Negative for shortness of breath or coughing
Cardiovascular: Positive for chest pain and palpitations
Gastrointestinal: Positive for nausea. Negative for vomiting, diarrhea or abdominal pain
Genitourinary: Negative for dysuria or hematuria
Musculoskeletal: Negative for back pain, joint pain, or joint swelling
Neurological: Negative for headache, dizziness, weakness, numbness, or tingling
Psychiatric: Negative for suicidal ideations or auditory or visual hallucinations
What does the Past Histories section of a patient’s note include
Past Medical + Surgical, Family, and Social Histories. Each section contains specific information.
EX:
Past Medical History: Hypertension
Surgical History: Tonsillectomy
Family History: No family history of hypertension
Social History: Non smoker
What does Past Medical History refer to?
The patient’s long term, previously diagnosed medical conditions
EX: Hypertensions (HTN) - high blood pressure
Hyperlipidemia (HLD) high cholesterol
Gastroesophageal Reflux Disease (GERD) - acid reflux
Asthma - Respiratory Illness
The Past Medical History sections is typically subjective and can also include info from sources other than the patient ( family member, prior visits, PCP, etc.)
What is past surgical history?
This refers to the patient’s prior medical procedures and surgeries. This is considered part of Past Medical History, but often documented differently.
EX: Coronary Artery Bypass Graft (CABG) - heart “bypass” surgery
Hysterectomy - removal of the uterus
Colonoscopy - Exploration of the rectum, colon, and lower gastrointestinal tract by camera
This is also considered subjective, and can include info from other sources other than patient (family member, prior visits, operative report, etc.)
What do you do if there isn’t a separate section for Past Surgical History?
The patient’s prior procedures and surgeries can be recorded in the Past Medical History section.
What is past family history?
The long-term diagnosed medical conditions that affect a patient’s immediate family members
EX: father has hypertensions
Mother died of myocardial infarction at 45
brother has diabetes
Past Family History is typically subjective, although we can include info from sources other than the patient…
EX: Family member, prior visits, pcp, etc…)
Patients may misunderstand and give history of their spouse or step-relative…. Providers only include history from a __________ who have have had similar hereditary conditions
blood relative
What is Past Social History?
The patient’s social status and habits that may affect their medical history
EX: Tobacco use, Alcohol use, illicit drug use, marital status, employment status, living situation, activity level (sedentary vs. active)
The past social history is usully subjective although we can also include info form sources other than patient (fami, prior v, casework, etc)
What is a completed physical examination or physical exam?
A template of body systems (cardiovascular, neurological, etc.) each of which contain specific findings. Providers will communicate the exam findings directly to the scribe, who will record them verbatim into the note. These body system findings can be normal or abnormal.
When it comes to physical examinations, do providers perform the same exam on every patient?
Yeah, although there are exceptions based on reason for visit.
The physical examination section is __________ and only includes findings from the _______. This means that the patient reports will not be recorded here.
Objective; findings from the provider
When it comes to physical exams, providers typically have their routine exam as a _________, which can be _______ after it is generated into each note.
template; modified
What is an example of a normal Physical Exam template?
Constitutional: Alert, no acute distress
Skin: Warm. Dry. Intact.
Head/Neck: Normocephalic. Atraumatic. Neck soft and supple. Trachea midline.
Eyes: PERRL. EOMI. Normal conjunctiva
ENMT: TMs clear. Moist mucous membranes. No pharyngeal erythema or exudate.
Lymphatics: No lymphadenopathy
Cardiovascular: Regular rate and rhythm. No murmur. No edem.
Respiratory/Chest Wall: Lungs CTA. Non-labored respirations. No wheezes, rales, or rhonchi. No chest wall tenderness or deformity.
Gastrointestinal: Soft, nontender, nondistended No rebound or guarding
Genitourinary: Normal external genitalia
Musculoskeletal/Back/Extremeties: Normal ROM of back and extremities. Normal strength. No back or extremeity tenderness. No swelling. No deformities.
Neurological: A/O x4. Cranial nerves II-XII intact. No focal neurologic deficits. Normal speech.
Psychiatric: Cooperative. Normal affect.
What is the medical decision making or MDM section?
This section includes documentation for everything that occurred to or for the patient during the visit.
This includes:
- Differential diagnosis (possible other causes of symptoms)
- Diagnostic Studies (Labs, Imaging)
- Procedures
- Reevaluations
- Consultations (speaking with another provider for assistance on case)
- … and many more
The MDM section may vary based in the acute care or ambulatory setting
The MDM is objective and based on provider findings
What is the most complex section of the patient’s note?
The MDM is the most complex section. Some providers will fill out areas of the MDM on their own or dictate them to the scribe, such as the differential diagnosis.
What is the differential diagnosis?
An initial list of possible conditions or diseases that could be causing the patient’s symptoms
For example, a paitnet presents to a clinic coplaining of a cough and fever the differential diagnosis may include:
- Asthma
- Bronchitis
- Pneumonia
- Viral upper respiratory infection
- Influenza
- … and many more
How does a provider further narrow down the final diagnosis when it comes differential diagnosis?
They may order testing to further down the final diagnosis. Its typically only one, or in rare cases two, of the Differential Diagnoses are determined to be the final cause of the patient’s symptoms.
Who may a provider dictate a patient’s differential diagnosis to? What will they do?
They will dictate a patient’s differential diagnosis to a Medical Scribe who will record them vertabim in the Medical Decision Making section of the chart
What are laboratory studies or labs?
Tests ordered to measure levels of specific chemicals in the patient’s body. The results of these levels assist the provider in determining any abnormalities in the patient. Lab results are objective.
Where are a patient’s individual lab results compared to a “reference range” (a normal value across all populations) ?
The lab section
Can lab results be generated into a note with a click of a button, or copy and pasted from another location?
Yeah, they can depending on the EHR used.
Can labs be order in an ambulatory care setting?
Yeah, but results aren’t available until several days later. The results are documented in at their follow up visit.
What are imaging studies or imaging?
Techniques and processes of creating visual representations of the interior of a body for representations of the interior of a body for diagnostic and treatment purposes. Imaging is objective.
Can imaging results be generated into the note with the click of a button or copy and pasted from another location?
It would depend on the EHR used.
What may a provider do if there isn’t a designated section in an ambulatory care note for imaging?
The provider may still order imaging for the patient that will be included in the Plan, as a referral.
What are the different imaging modalities which can be selected by the provider to evaluate for specific concerns?
- X-rays
- Ultrasonography/Ultrasound (US)
- Computed Tomography scan (CT)
- Magnetic Resonance Imaging (MRI)
- Nuclear Medicine
Who reviews images from a study? What do they do after they review it?
Visual images from a study are reviewed by a radiologist who then creates a narrative summary of the results, often called the “report.” This report is copied verbatim into the patient note.
Do all providers wait for a radiology report?
Some providers will review and interpret their own x-rays without waiting for the radiology report. However, providers don’t read other modalities given their complexity.
What is a procedure?
Any activity directed at or performed on a patient with the purpose of improving health, treating disease or injury, or determining a diagnosis.
This includes: Foreign body removal Pap smear Laceration repair Intubation CPR
Procedures are objective….
Are procedures exclusive to the acute care setting?
They are not exclusive to the acute care setting. There are many outpatient procedures performed in the ambulatory care setting such as colonoscopy, speculum (pelvic) exam, etc.
What are re-evaluations - or revals or reexams?
Any instance when the provider’s attention is brought back to the patient case after the initial evaluation.
Reevaluations typically consist of updates on the patient case.
Reevals are objective.
EX:
2034 - On reexam, patient reports feeling improved after ibuprofen 800 mg. Still reporting nausea and one episode of vomiting despite medication. Will order additional dose. Pending CT imaging.
What do reevaluations always include and in what format?
They always include a timestamp in military time and provide as much detail as possible.
What are consultations or consults?
Any instance when the provider speaks with another healthcare professional for assistance on the patient’s case; this healthcare professional is often a specialist in their field
(Cardiologist, Pharmacist, Social Worker, etc.).
EX:
1809 - Called and spoke with Dr. Murphy, OG/GYN and discussed patient’s case at length. Recommend ultrasound to evaluate for ovarian cyst. Will see patient in the ED.
Consults are objective.
What must a consultation include?
A timestamp, name of the consulting professional, the specialty of the consulting professional, what was discussed, and the outcome of that discussion.
What is an impression / assessment / diagnosis?
A clinical summation of info and/ or an opinion based upon the patient’s symptoms, their clinical history and presentation, as well as the outcome of the objective data and findings.
- Acute care setting = Impression
- Ambulatory care setting = Assessment
- In both settings = Diagnosis
The assessment is objective and is based on the provider’s findings
What is the disposition?
This refers to where the patient goes after leaving a healthcare setting; the patient can be dispositioned to a lower or higher level of care based on their status and/or findings.
These include: *Lower acuity >Discharged home >DChg to rehab >DCHg to Skilled Nursing Facility
*High Acuity
>Admitted to hospital (ICU)
>Admitted to the cardiac catheterization lab (cath lab)
>Transferred to an outside hospital (OSH)
What is an outside hospital?
A healthcare facility that a patient needs to be transferred to for additional care or monitoring
What is the plan section?
An explanation of how the provider would like to treat the patient’s diagnosis and can include the following:
- Changes in or new medications
- Orders for labs, imaging, or additional testing
- Referals to other healthcare professionals
- Procedures to be performed
EX:
PLAN: Patient’s imaging today shows evidence of pneumonia. We will treat with Z-pak. She can take Tylenol as needed for pain or fever. I also encouraged her to continue using her albuterol inhaler. Given that she had had pneumonia 3 times in the past 2 months, will place a referral to pulmonology for further evaluation. She understands to present to the ED for any worsening shortness of breath, uncontrollable fevers, or other concerning symptoms.
The assement and the plan are usually…
Grouped together
What are patient instructions?
A shorter, easy to read version of the Plan which is often printed and physically handled to the patient
EX: 1. Start Z-pak
- Continue to use your albuterol inhaler
- Take tylenol as needed for pain and fever
- follow up with the referral to pulmonology
- Present to the ED for any worsening pain, uncontrollable fevers, or other concerning symptoms
What is patient education?
Educational materials on each specific diagnosis which is often printed and physically handed to the patient as well
EX:
How to treat pneumonia
Proper use of inhalers
What is the core goal of the Centers of Medicare & Medicaid Services
(CMS)
Their goal is to standardize how to document, how to report treatment info for billing, and how payments for medical services are made based on quality of care
What is the chief complaint also known as
The reason for visit
What is the main reason a patient is seen for the provider
The Reason for Visit AKA Chief Complaint
What are some examples for a reason for visit
Typically one symptom or reason
EX:
- Chest pain
- Routine follow up
- Urgent Follow up
The reason for visit is subjective and comes directly from the patient and/or their family
The reason for visit will vary based on…
the healthcare setting
What are some example reasons for visit in an acute care care setting?
- Acute complaint
- Medication refill
- Sent in by another provider
What are example reasons for visits in an ambulatory care setting for new patients?
- Establish care
- Establish care + Acute complaint
- Initial consultation
What are some reasons for visit for established patients in an ambulatory care setting?
- Acute complaint
- [Medical Condition] routine follow up
- [Medical Condition] urgent follow up
- Follow up after acute care setting visit
An acute complaint is a…
new symptom or problem the patient would like evaluated by a healthcare provider
What is are examples of acute complaints?
- Chest pain
- Vomiting
- Right-sided weakness
- Rash
- Sore throat
- Coughing
- Left ear pain
- Headache
Providers only aim to focus on ____ reason for visit
one
Due to the occasional delay between healthcare visits, what will patients do?
report a list of multiple issues at once *
Where are home medications typically prescribed and refilled?
Ambulatory care settings such as a primary care clinic
Can a patient present to an acute care setting to request a prescription refill?
Yes, they may if they are unable to obtain their home medications from their usual provider for various reasons
EX; Not calling the office, or not being seen in the office regularly enough for refills, traveling, losing their medications, etc.
What is a medication refill visit?
Acute care setting visit to refill a home medication
What will typically happen during a medication refill visit?
The acute care provider will often refill the medication for a short time to bridge the patient until they can be seen by their usual provider for a longer refill.
What will typically happen in an ambulatory care setting?
Patients seen may occasionally have abnormal symptoms, vital signs, imaging or testing results which would require an emergent evaluation.
If a patient was at an ambulatory setting and an emergent evaluation is needed, where would a patient go and why?
They’d go to an acute care setting, such as a Emergency Department for further evaluation. The ambulatory setting ( like a primary office ) is typically not designed for an emergent evaluation.
These visits are referred to as SENT IN BY ANOTHER PROVIDER
EX:
- Abnormal CT imaging scan
- Hypokalemia (low potassium levels)
- Elevate blood pressure
- Vision changes
Where are chronically ill, elderly, and/or complex patients commonly sent and why?
They are sent to the Emergency Department with abnormal symptoms or testing results to expedite their treatment and minimize complications.
Why would patients be seen in an ambulatory setting, such as a primary care clinic?
To evaluate and monitor non-emergent conditions
What will happen to a patient prior to the first time being seen?
They will be considered a new patient and will need to schedule a clinic visit to ESTABLISH CARE with the provider
What does it mean to establish care and after it is established what happens?
The provider will often spend a longer amount of time with the patient during their first visit and will go into greater detail about their Past Medical, Surgical, Family and Social History (PMFSHx)
This is where a relationship with a provider will be established
What will occasionally happen with new patients establishing care?
New patients establishing care will occasionally have an acute complaint they would like evaluated during their visit as well
What will happen happen to a patient who has a more complex symptom or problem?
They may need to be seen by a specialist in a specific ambulatory setting, like a cardiology office
What will a patient need in order to be seen by a specialist?
They’d need a referral (documented recommendation from their usual provider in order to be seen by the specialist…
After the referral is placed, the patient will be considered a new patient by the specialty clinic and the patient will schedule an INITIAL CONSULTATION visit
What happens during an initial consultation visit?
The provider and the patient will discuss the symptom or problem. The provider will examine the patient and may recommend a treatment, further testing, or no intervention at all.
When can a patient go back to visit a clinic on a regular, ongoing basis?
After the patient is seen in the ambulatory care setting for the first time to establish care or for an initial consultation.
What are routine follow up appointments and how are they used by providers?
Regular visits to a clinic on an on-going basis. They are used by providers to monitor the patient’s medical conditions. They’d be ideally used to prevent the development of disease-related complications.
To prevent the development of disease-related complications, when should a patient be seen (routine follow up)
they should be seen at scheduled intervals on a regular basis
What happens during a routine follow up?
The provider will evaluate the patient and discuss any changes or ongoing problems, order labs/diagnostic testing, and update medication dosages as needed.
What is an urgent follow up and what happens during these appointments?
When a patient is needed to be seen more urgently in a clinic. During these visits, the provider will address more urgent issues like a new symptom, side effects from meds, recent abnormal labs/imaging results, or other urgent concerns.
Referrals may be given so a patient can see a specialist for an initial consultation, the provider may prescribe new medication, change existing medications, or order additional testing.
What happens if a patient’s complaints are more severe during an urgent follow up appointment?
The patient may be referred directly to the ED for a more emergent work up.
Patients often need to follow up after _________
an acute care visit
Where will patients follow up after an acute care visit?
They will do this with providers in an ambulatory setting, like their primary care provider and/or other specialists, such as Cardiology.
What will a provider determine during a follow up after an acute care visit?
This is where the provider will determine that the problem which brought the patient to the acute care setting was properly evaluated and tested. The provider will ensure the patient is receiving proper treatment and that their problem is improving, or has resolved. Additional testing or referrals may be given for the patient to follow up with another provider if it is necessary.
What is the history of present illness, HPI?
A paragraph or multiple paragraphs further expanding on and describing the patient’s reason for visit.
Is the HPI objective or subjective?
Subjective
It usually comes directly from the patient and/or their family
Since the HPI is subjective….
Two patients come in for cough, but their HPI is
unique to the specific patient. One might have watery eyes whereas the other may have scratchy throat
Where can patients be seen?
In both Acute Care and Ambulatory Settings
Will the HPI structure vary based on the healthcare setting?
Yes
Although HPI structures vary depending on the healthcare setting, the HPI will begin with what?
A specific formatted sentence which will introduce the patient, their age, sex, pertinent history and reason for visit
What is the HPI structure for an Acute Care Setting?
Patient is a (AGE) year old (SEX) with a history of (PERTINENT MEDICAL/SURGICAL HISTORY) who…
What is the HPI structure for an Ambulatory Care Setting?
(Patient Name) is a (Age) year old (Sex) with a history of (Pertinent Medical/Surgical History) who…
What is the difference between the HPI structure in an acute care setting and an ambulatory care setting?
In an acute care setting, HPI begins with just PATIENT whereas in an ambulatory care setting the HPI begins with the patients first and last name
What is an example of the HPI structure in an acute care setting?
Patient is 16 years old male with a history of asthma who presents to the ED with complaints of…
What is an example of the HPI structure in an ambulatory care setting?
Donald Duck is a 16 year old male with a history of asthma who presents to the Primary Care Clinic with complaints of…
What is an example of a HPI structure in an acute care setting?
Patient is 53 year old female with a history of hypertension and COPD who presents to the ED for a medication refill
What is an example of a HPI structure in an ambulatory care setting?
Daisy Duck is a 53 year old female with a history of hypertension and COPD who presents to the Primary Care Clinic for a routine follow up visit.
What are the reasons that a patient would present for an evaluation at an acute care setting?
- Acute complaint
- Medication refill
- Sent in by another provider
What are the reasons that a NEW patient would present for an evaluation at an ambulatory care setting?
- To establish care
- To establish care &&& Acute Complaint
- Initial consultation
What are the reasons that an ESTABLISHED patient would present for an evaluation at an acute care setting?
- Acute complaint
- [MEDICAL CONDITION] routine follow up
- [MEDICAL CONDITION] urgent follow up
- Follow-up after ED visit or hospitalization
What is an acute complaint?
A new symptom or problem the patient would like evaluated by a healthcare provider
What are the 8 elements used to describe an acute complaint?
You’d use a mnemonic, SCRATCH-MD for the 8 elements.
Severity Context Region/Radiation Associated Symptoms Timing Character History Modifying Factors Duration/Onset
What is severity?
SCRATCH-MD
Refers to the intensity of the complaint
How is severity reported?
Mild, moderate or severe
On a scale of 1 - 10/10
EX:
She grades her pain as a 6/10
Her pain is MILD and improves with certain position changes
Patient’s abdominal pain is currently a 5/10, but was an 8/10 after eating this morning
How is severity commonly documented?
Using the number scale
When documenting severity, HPI rarely used the term ____ in the HPI?
Severe
What is context?
SCRATCH-MD
Refers to the circumstances surrounding the acute complaint. Essentially, what the patient was doing when symptoms began or the circumstances that lead to the development of the complaint
What is an example of context?
SCRATCH-MD
- Patient was attempting to jump over a fence, but caught her right arm on a piece of metal*, resulting in a laceration to her right forearm.
- He was mowing the lawn* when his chest pain began.
His shortness of breath began about 10 hours after he arrived home after undergoing a colonoscopy earlier this morning.
What is region?
(SCRATCH-MD)
What is Radiation?
(SCRATCH-MD)
R/R are together in the scratch
Region: This refers to the location of the body that is affected by the acute complaint
Radiation: to any area on the body besides the primary location that is also affected by the acute complaint
EX: He is complaining of right low back pain which radiates down his right leg to the level of his knee.
…presents with complaints of nonradiating, right upper quadrant abdominal pain.
What does the term migration?
Rare term used is when pain starts in one area and moves into a completely different area of the body and is no longer present in the first area
What are associated symptoms?
SCRATCH-MD
Symptoms the patient reports or denies which are directly related to the acute complaint
EX:
She reports chest pain with associated shortness of breath and nausea
Patient notes associated nausea and 2 episodes of vomiting today, but denies fever or diarrhea
What is timing?
SCRATCH-MD
Refers to how frequently the acute complaint occurs.
What are the several specific terms used to describe timing?
- Constant
- Constant and fluctuates with intensity
- Intermittent
- Episodes
- Progressively worsening
- Resolved
What is constant?
Term used to describe timing from SCRATCH-MD
Acute complaint is there the whole time and doesnt change
What is constant and fluctuates in intensity?
Term used to describe timing from SCRATCH-MD
Acute complaint always present, but gets better and worse
What is intermittent?
Term used to describe timing from SCRATCH-MD
Acute complaint comes and goes. There may be periods of time it does not occur.
What is episodes?
Term used to describe timing from SCRATCH-MD
Similar to intermittent, but can be quantified. typically used for vomiting, diarrhea, syncope, and seizures.
What are progressively worsening?
Term used to describe timing from SCRATCH-MD
Acute complaint is becoming worse
What is resolved?
Term used to describe timing from SCRATCH-MD
acute complaint has gone away
What are timing examples?
SCRATCH-MD
His abdominal pain is constant and fluctuates in intensity
She reports 3 episodes of vomiting since yesterday
Patient states her pain has been progressively worsening since initial onset.
What is character?
SCRATCH-MD
Refers to how the patient describes the acute complaint.
What are common terms that a patient may used to characterize an acute complaint?
*Dull Sharp Stabbing Aching Burning Pressure
EX: Her pain is sharp and fluctuates with intensity
He describes a burning in his right upper quadrant after eating
What is history?
SCRATCH-MD
Refers to any pertinent past history listed directly in the HPI’s first sentence, as well as any past events or history directly related to the acute complaint such as prior episodes of similar symptoms or other recent evaluations for the current symptoms
What are examples of history
SCRATCH-MD
Patient is 32 year old male with a history of hypertension who…
Patient states *he was seen by his PCP for these symptoms 2 days ago and he was prescribed Penicillin, which he has been compliant with.
She reports a similar episode of pain 2 months ago.
What is the only element in the HPI that is not included in billing?
History
What are Modifying Factors?
SCRATCH-MD
Anything the patient does or takes which causes a change (or no change) to their symptoms
These include:
- Medications/localized treatments
- Actions (walking, eating, vomiting, etc.)
- Inaction (no attemmpt was made by the patient to treat the acute complaint)
- Events (prior urgent care visit, etc.)
What are some examples of Modifying Factors?
SCRATCH-MD
Patient reports improvement after taking Tylenol
Her pain is alleviated by sitting
His sore throat is *worse with swallowing, though he notes some relief from drinking hot beverages
What is Duration aka Onset?
SCRATCH-MD
When the acute complaints began and how long it has been ongoing
What are some examples of Duration?
presents to the ED with complaints of upper abdominal pain which began 6 hours ago.
… presents to the ED with complaints of intermittent chest pain for the past 2 weeks
…with complaints of left flank pain which started yesterday afternoonand became worse today.
When it comes to Duration it is best to be ____ ? (SCRATCH-MD)
To be specific - “2 days ago” is more clear than “on monday” Full dates are also a good way to be specific, For example. “Patient has been having pain since her hysterectomy on 2/12/2012)
What is an example template of how to use t he elements of SCRATCH-MD to construct an acute complaint:
[PATIENT/PATIENT NAME] is [AGE year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to ED with complaints of [REGION/TIMING/CHARACTER] [CHIEF COMPLAINT] which began [DURATION/ONSET]. Her pain is… (connect remaining elements directly describing the chief complaint [REGION/RADIATION, CHARACTER, SEVERITY that were not already included in the first sentence). She reports [Modifying Factors]. Patient notes associated [Associated Symptoms]. Patient denies a history of similar pain, but states… [PERTINENT HISTORY specifically related to the complaint, CONTEXT]. Additionally,… (add any info not related to chief complaint, such as social history or other unrelated complaints).
Review an example of an acute complaint using the elemtns of Scratch MD
Patient is a 3 year old female with a hisotyr of uterine cancer in 2013 who presents to the ED with complaints of sharp, intermittent epigastic abdominal pain which began 3 days ago. She rates her pain as a 7/10 and reports radiation to the bilateral upper quadrants. She states her pain is worse after eating and unchanged by Tyms. Patient notes associated nausea and one episode of vomiting yesterday though she dnies fever or diarrhea. Patient states she was seen by her pcp at onset, but was not prescribed anything for her symptoms. She denies any notable triggering factors. Additionally, she notes hse has been having difficulty sleeping since shortly before onset, though she believes this to be unrelated to her pain.
How does SCRATCH-MD relate to an acute complaint?
Patient is a 3 year old female with a
HISTORY
hisotyr of uterine cancer in 2013 who presents to the ED with complaints of
- CHARACTER* sharp,
- TIMING* intermittent
- REGION VARIATION* epigastic abdominal pain which began
DURATION/ONSET 3 days ago.
SEVERITY
She rates her pain as a 7/10 and
REGION/RADIATION
reports radiation to the bilateral upper quadrants. She states
MODIFYING FACTORS
her pain is worse after eating and unchanged by Tyms. Patient notes
- ASSOCIATED SYMPTOMS* associated nausea and one episode of vomiting yesterday though she dnies fever or diarrhea. Patient states
- HISTORY* she was seen by her pcp at onset, but was not prescribed anything for her symptoms.
She denies
CONTEXT
any notable triggering factors.
Additionally, she notes has has been having difficulty sleeping since shortly before onset, though she believes this to be unrelated to her pain.
What is a medication refill?
A visit in an acute care setting where a patient present to request a prescription refill if they are unable to obtain their home medications from their usual provider
What happens during a medication refill visit?
The provider will ask and the scribe will document, info directly related to the medication such as info about the patient’s long term medical condition which requires the medication past or current symptoms. As well as past, recent, or ongoing treatments.
The provider will use this info to determine if refilling the patient’s medication is the safest and best course of action to bridge the patient until they can be seen by their usual provider for a longer refill.
What will an HPI template look like in an acute setting for a patient who is requesting a medication refill?
Patient is [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to the ED requesting a medication refill
What is an example of what an HPI look like in an acute setting for a patient who is requesting a medication refill?
Patient is a 53 year old female with a history of hypertension who presents to the ED requesting a medication refill. She states she ran out of her blood pressure medication, Losartan, 2 days ago. Since then, her blood pressure has been elevated around 165/89. She states her PCP, Dr. Johnson normally refills her medication, but she had to cancel her most recent appointment and she has not followed up.
What will an HPI template look like in an acute setting for a patient who is requesting a medication refill?
lkk
What is a “sent in by another provider” visit?
This occurs when a patient seen in the ambulatory care setting has abnormal symptims, vital signs, imaging or testing results which requires an emergent evaluation.
What happens in a “sent in by another provider” visit?
Patients are sent to an acute care setting for further evaluation.
The provider will ask the patient, family, EMS or anyone present for info on the abnormal findings that caused the patient to be sent in. There may be testing and other results that have already been performed and will included in the HPI. Although this info is technically objective, it lead to the patient being sent into the ED and is considered Context.
What will an HPI template look like in an acute setting for a patient who is sent in by another provider?
PATIENT is a [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to the ED sent in by…
What will an example HPI template look like in an acute setting for a patient who is sent in by another provider?
Patient is a 53 year old male with a history of HTN and DM who presents to the ED sent in by his PCP after labs revealed a hemoglobin of 6.2. Patient reports episodes of light headedness and shortness of breath which prompted his visit to his PCP. He denies a history of anemia or prior blood transfusion. He denies any known bleeding
What happens when patients visit a provider to establish care?
A patient is being seen for the first time. The provider will ask patients about their pertinent medical conditions and the circumstances surrounding them: active symptoms, current medications, and most recent testing.
Where are patients seen to establish care?
In the ambulatory care setting such as a primary care clinic
What will the HPI outline for an establish care visit?
After the provider better understands the medical conditions and circumstances; active symptoms, current meds, and most recent testing
The HPI will outline each medical condition or a specific medical condition in detail
What is an example of HPI for an establish care visit?
Daisy Duck is a 35 year old female with a history of DM and osteoarthritis who presents to the Primary Care Clinic to establish care.
She reports a history of DM and states her sugars are well controlled. She has not had recent labs, but her most recent Hb A1c was 7.8%.
She reports a history of osteoarthritis. Her last DEXA scan was in 2018. She denies recent falls.
What happens during an establish care & acute complaint visit?
Patients are seen in the ambulatory care setting, such as in a primary care clinic, to evaluate and monitor conditions long-term and they also have an acute complaint which needs to be evaluated.
What would the HPI in an establish care & acute complaint look like?
A combination of an established care template where you detail a chronic condition and the SCRATCH-MD template to outline an acute complaint
What would the HPI in an establish care & acute complaint look like?
[PATIENT NAME] is a [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents the [SPECIALTY] Clinic to establish care
EX: Daffy Duck is a 75 yr old male with a history of DM who presents to the Primary Care Clinic to establish care.
He states his diabetes was previously monitored by his PCP in florida, but he recently moved here. He is unsure when he last had testing. He is currently on insulin.
He reports numbness and tingling in his bilateral hands which began 6 months ago and has been progressively worsening. He denies weakness. He denies neck pain.
Where are patients seen for an initial consultation visit?
Patients are seen in an ambulatory care setting by a specialist in their field like a Cardiologist.
What happens during an initial consultation visit?
The provider will ask many, if not every detail surrounding the patient’s chronic medical condition including: when their symptoms first began, any and all testing and treatments the patient has received, as well as any other details
How would the template for an HPI look like for an initial consultation?
[PATIENT NAME] is a [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to the [SPECIALTY] Clinic for an initial consultation
How would the an example of a HPI look like for an initial consultation?
Daffy Duck is a 75 year old male with a history of coronary artery disease who presents to the Cardiology Clinic for an initial consultation.
His CAD was first diagnosed in 2012 after coronary angiogram revealed a 100 percent block of his LAD. His LAD was stented. He was followed by Cardiology in Michigan and states his most recent stress test was last year and was normal. He reports chest pressure and shortness of breath with minimal exertion which began 6 months ago and has been progressively worsening.
When can a patient continue to visit a clinic on a regular, on going basis for routine or urgent follow up?
After the patient is seen in the ambulatory care setting for the first time to establish care or for an initial consultation
What will a provider do during a routine follow up?
The provider will review and discuss with the patient their previous visit to the office and then discuss any changes that have occurred in the interim between visits.
How would the HPI template look like for a routine follow up?
[PATIENT NAME] is a [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to the [SPECIALTY] Clinic for follow up
What is an example of how an HPI would look like for a routine follow up?
Daffy duck is a 75 year old male with a history of HTN who presents to the Primary Care Clinic for follow up. He was last seen in the clinic on 1/1/1999. At that time, his bloo dpressure had been elevated and lisinopril was increased from 10mg to 20mg.
Today, he states he has been taking the higher dose of lisinopril and his blood pressure has been much better controlled. He denies any side effects.
Since his last visit, he was seen by dermatology and diagnosed with basal cell carcinoma.
What will patients need to do after an acute care visit?
They need to follow up. They will do so with providers in an ambulatory care setting as their primary care provider and/or other specialists, such as Cardiology.
What will a provider do during a follow up after an acute care visit?
The provider will determine that the problem which brought the patient to the acute care setting was adequately evaluated and treated. The provider will determine if the problem is improving, or has resolved. The provider may also order additional testing or place referrals for the patient to follow up with other providers, if needed.
What would a HPI template look like for an individual who is receiving a follow up?
[Patient Name] is a [AGE] year old [SEX] with a history of [PERTINENT PAST HISTORY] who presents to the [SPECIALTY] Clinic for follow up after being hospitalized at…
What would a HPI look like for an individual who is receiving a follow up?
Daffy Duck is a 75 year old male with a history of HTN who presents to the Primary Care Clinic for follow up after being hospitalized at Wonderland Hospital from 01/01/1999 -01/13/1999 for pneumonia.
He presented to the ED on 1/1/1999 with shortness of breath and chest xray showed pneumonia. He was treated with Levaquin IV and then discharged with azithromycin. He states his symptoms have significantly improved and he no longer has any shortness of breath.
What does ROS stand for?
It is called Review of Systems
NOT
review of symptoms
What is a ROS?
A list of body systems (cardiovascular, neurological, etc.)
Within each body system are common symptoms. The medical provider will ask the patient whether or not they have certain symptoms. The patient will answer “yes” or “no”
When a provider reviews the symptoms of different body systems, what will the patient respond and what will the scribe do?
Patient will respond with yes or no.
The scribe is responsible for documenting all symptoms, positive and negative.
What is an example of how a scribe would document the symptoms that a patient has? (ROS)
EX:
Ears: Negative for blurry vision
Ears: Negative for ear pain
Gastrointestinal: Positive for nausea. Negative for vomiting or diarrhea.
Neurological: Positive for numbness. Negative for weakness, slurred speech, or seizure.
What is the review of systems meant to be?
A quick reference of any symptoms the patient is experiencing and is not experiencing
So the symptoms are also going to be used as a reason for visit or as other symptoms in the HIP
What are some examples of body systems commonly represented in the ROS?
- Superficial
- Skin
- Eyes
- ENMT
- Respiratory
- Cardiovascular
- Gastrointestinal
- Geintourinary
- Musculoskeltal
- Neurological
- Psychiatric
- Endocrine
- Heme/Lymph (Hematologic/Lymphatic)
- Allergy/Immunologic
What are findings in the ROS section considered….
Objective or Subjective
Subjective
The systems included into the ROS between different EHR vary? True or False
True!
Some group Eyes into ENMT and it becomes HEENT (Head, eyes, ears, nose, throat) Others remove Heme/Lymph
What are constitutional symptoms?
Any symptoms related to the body as a whole
What are some examples of constitutional symptoms?
*Subjective fever Measured fever Chills Sweating Diaphoresis Generalized weakness Fatigue Malaise Decreased appetite Decreased oral intake Weight gain Weight loss
What is subjective fever
Feeling “hot” or “warm”, but without having measured temperature
What is measured fever
Temperature that is Greater than 100.4 F or Greater than 38 degree celsius
What are chills?
Feeling of coldness/ goosebumps occuring during a fever
What is sweating?
Abnormal perspiration, typically due to heat or stress, i.e. fever
What is generalized weakness
lack of strength throughout the body
How is generalized weakness different from focal weakness?
focal weakness is localized to specific body parts and is considered a neurological symptom
What is fatigue
extreme tiredness, typically caused by systemic stress
Malaise
MAH-LAYS
generalized discomfort and weakness
What is decreased appetite
Lacking the desire to eat
What is decreased oral intake
Not eating as much as typically would
What is weight gain/ weight loss
Weight fluctations; may be intentional or unintentional
What are common skin symptoms?
Urticaria Rash Itching Redness Ecchymosis Abrasion Laceration Burn Dryness Lesion Jaundice Cyanosis Dog bite/Human bite
What is urticaria
er-tih-care-ee-ya
hives
What is a rash
area of irritated or swollen skin
What is itching
irritating sensation that prompts scratching
what is redness
focal area of inflammation, characterized by red discoloration
What is ecchymosis
ECK-EE-MO-SIS
Bruising
What is abrasion?
Scrape in the skin
What is Laceration
Cut in the skin which may require artificial
What is a burn
Damage caused by extreme heat, flame, heated objects, or chemicals
What is Dryness
Decrease in normal lubrication of the skin
What is Lesion
Abnormal lump, bump, ulcer, sore, or colored area
What is Jaundice
yellow discoloration of the skin
What is cyanosis
sigh-an-oh-sis
Bluish cast to the skin and mucous membranes
What is animal/human bite
area of trauma to the skin caused by a bite from a person or animal
What are breast findings
Any finding related to the breasts (ex: pain, lumps, nipple discharge, etc.)
Where might breast findings go in another section of the ROS depending on…
The EHR being worked in. OTher sections include chest wall or miscallaneous
What are symptoms that include the system - eyes?
Common eye symptoms: Blurred vision Diplopia Visual Changes Eye Pain Eye Discharge Mattering Eye discoloration Eye foreign body Excessive tearing Eyelid Swelling
What is blurred vision
Loss of sharpness of vision, making objects appear out of focus and hazy affecting the visual field(s)
(Visual field is the entire area that a person is able to see when their eyes are fixed in one position)
What is Diplopia
“dih-plo-pee-ah”
Simultaneous perception of two images, affecting the visual field(s)
This term is aka “double vision”
What is visual changes
Only used as a negative to deny any changes to vision
When visual changes are present, what terms should you use
use the specific term diplopia or blurred vision
What is eye pain
pain in the eye(s)
What is eye discharge
drainage from the eye(s)
What is mattering
mucus, oil, skin cells and other debris that accumulates in the eye(s) that can be wet/sticky or dry/ crusty
Often associated with bacterial infections of the eye
What is eye discoloration
Any color change to the white part of the eye(s)
Eye color change can indicate many things like infection (injected conjunctiva) liver failure (icterus) or anemia (pale conjunctiva)
What is eye foreign body
Sensation of or actual foreign object in the eye(s)
What is excessive farting
Excessive water from eye(s)
What is eyelid swelling
Puffiness of the eyelid(s)
What are symptoms related to the ears, nose, mouth, and throat?
ENMT??
Common ENMT Symptoms:
Ear Pain Ear Discharge Tinnitus Decreased Hearing Hearing loss Nasal congestion Rhinorrhea Epistaxis Mouth Pain Dental Pain Tongue Swelling Oral lesions Bleeding gums Dry mouth Sore throat/throat pain Difficulty swallowing Throat swelling
Ear Pain
Pain the ear(s)
What is ear discharge
discharge from the ear(s)
What is tinnitus
Ringing in the ear(s)
What is decreased hearing
diminished hearing
What is hearing loss
Inability to hear
What is nasal congestion
Congestion in the nose
What is rhinnorhea
ri-nor-ee-ah
Drainage from the nose
Post nasal drip meaning
mucus draining down the back of the throat that often causes cough
What is epistaxis
ep-ih-stacks-is
Nose bleed from one or both nares (nostils)
What is mouth pain
Pain of the mouth
What is dental pain
Pain related to or caused by teeth
What is tongue swelling
Tongue larger than in size than normal
What is tounge swelling associated with…
Allergic reactions and a dangerous condition called angioedema
What are Oral lesions
Sore that occurs on the mucous membrane of the mouth
What are bleeding gums
Abnormal bleeding from the gingiva
What is dry mouth
Lack of natural lubrication of the oral mucosa
What is sore throat/ throat pain
Pain in the throat
What is throat swelling
Inflammation of the throat, causing irritation
What are symptoms related to the lungs and breathing?
BODY SYSTEM: Respiratory
Common respiratory symptoms: Dyspnea/ Shortness of breath Orthopnea Cough Hemoptysis Sputum Production Wheezing
What is Dyspnea -
Disp-nee-ah
Difficulty breathing
Shortness of Breath
BTW - NEVER RIGHT “SOB” in a patient’s chart
What is orthopnea
or-throp-nee-ah
Difficulty breathing when lying flat
It is often associated with chronic respiratory conditions. Patients may report using multiple pillows to prop themselves up while they sleep
Cough - definition
Sudden repetitive reflex which helps to clear the breathing passages from irritants
What is hemoptysis
hee-mop-tih-sis
Coughing up blood
What is sputum production
Material produced from the respiratory tract when coughing
Sputum is a synonym for phlegm or mucus
What is wheezing
Whistling sound heard when breathing
What are symptoms related to the cardiac and circulatory systems
BODY SYSTEM: Cardiovascular
Common Cardiovascular symptoms:
Chest pain Palpitations Syncope Diaphoresis Peripheral Edema
What is chest pain?
Discomfort in the chest
How may chest pain be characterized
Sharp, crushing, dull, burning, pressure, tightness
What are palpitations
Feeling a rapid, strong, irregular, or fluttering heartbeat
What is syncope
sin-cuh-pee
Fainting, or a sudden temporary loss of consciousness
(It is typically caused by lack of blood flow to the brain which is why it is documented in Cardiovascular, not neurological)
What is diaphoresis
Di-ah-for-ee-sis
Excessive, heavy sweating
( This is different from pathological sweating in that it is often accompanied by cardiac complaints, therefore it is documented in Cardiovascular. )
What is peripheral edema
swelling due to excessive fluid collecting in the tissues, typically in the legs
(this often affects the legs, leading scribes to think it is a musculoskeletal symptom. However, edema is caused by excess fluid in the blood, making it a cardiovascular symptom)
What are common symptoms that are related to the digestive tract / gastrointestinal symptoms:
Abdominal pain >Pelvic pain >Flank pain Nausea Vomiting Post-tussive emsis Hematemesis Diarrhea Hematochezia Melena Constipation Dysphagia Rectal Bleeding Rectal Pain
Abdominal Pain
Pain in the abdomen, in any of the quadrants or regions
Pelvic Pain
Pain in the pelvic region, typically in female patients
Flank pain
Pain in the flank(s)
Typically caused by kidney pain
Nausea
Uneasiness of the stomach that often precedes vomiting
Emesis
em-eh-sis
Throwing up the contents of the stomach
Vomiting
Post-tussive emesis
Throwing up after coughing
Hematemesis
Hee-mah-te-ma-sis
Vomiting blood
Diarrhea
Loose or water stool
Hematochezia
hee-mah-to-kees-ya
Bright, red blood in the stool
Sign of a lower GI bleed
Often omitted from the HPI in favor of the more general “bloody bowel movements”
Melena
Meh-leh-na
Dark black, tarry stool
Sign of an upper GI bleed
Constipation definition
Infrequent bowel movements, typically with small hard stools
Dysphagia
dis-fay-zuh
Difficulty swallowing
This refers to esophagus NOT ENMT - making it more accurate to record it as a gastrointestinal symptom
Rectal bleeding
Bleeding from the anus, typically with bowel movements
Rectal pain
Pain at or near the end portion of the GI tract
What are the symptoms that are related to the kidneys, bladder, urination, and genitals?
GENITOURINARY - BODY SYSTEM
- Dysuria
- Hematuria
- Urinary Incontinence
- Urinary Frequency
- Urinary Urgency
- Urinary Retention
- Nocturia
- Vaginal Bleeding
- Vaginal Discharge
- Metrorrhagia
- Genital lesions
- Testicular Pain
- Penile Pain
- Penile Discharge
Dysuria
dis-ur-ee-ah
painful or burning urination
this is the catch-all term for any kind of discomfort with urination
What is hematuria?
“hee-mah-ter-ee-ah”
Blood in the Urine making it pink or red
Urinary incontinence
Involuntary leakage of urine
(This can be both a Neurological and Genintourinary symptom. Deciding where it goes in the ROS depend son the context and other associated symptoms)
What is urinary frequency
Needing to urinate more often than usual
What is urinary urgency
A sudden compelling urge to urinate
What is urinary retention
Inability to fully empty bladder
This affects men more often than women due to prostate enlargement that comes with age
Nocturia
Waking up to urinate at night
“nock-ter-ee-ah”
Vaginal Bleeding
VB
Bleeding from the vagina
Vaginal Discharge
Abnormal discharge from the vagina
May be discolored or malodorous
Metrorrhagia
(meh-troh-rah-zah)
(THIS IS DIFF THAN MENORRHAGIA)
Irregular menstrual periods
What are gential lesions
Sores on or around the genital area including the vulva, penis and scrotum
Typically caused by STIs
Testicular pain
pain in the testicles
Scrotal swelling
Swelling of the scrotum
Penile pain
Pain of the penis
Penile discharge
Discharge from the urethra of a penis; may be discolored or malodorous
Any symptoms relating to the MUSCLES AND BONES
BODY SYSTEM: Musculoskeletal
Common musculoskeletal symptoms:
- Back pain
- Neck pain
- Myalgias
- Arthalgias
- Extremity pain
Back pain
Pain in the thorarcic and/or lumbar regions of the spine
Neck pain
Pain localized to the cervical region of the spine
Myalgias
my-al-gahs
Diffuse muscle pain
- This is sometimes recorded as part of the constitutional symptoms when reported in addition to fever and the like -
Cephalgia
Neurological
Headache; pain within the head
Arthralgias
“are-thuh-ral-guhs”
Pain in the joints
Extremity Pain
Pain localized to the extremities; right, left, or bilateral ; upper or lower
BODY SYSTEM: Neurological
Any symptoms relating to the brain and nerves…
Common neurological symptoms?
Common neurological symptoms: *Headache *Photophobia *Phonophobia *Dizziness >Lightheadedness >Rotational *Aletered level of consciousness *Numbeness *Tingling *Weakness *Seizure *Dysarthria *Dysphasia *Bowel/bladder incontinence *Saddle anesthesia
Photophobia
Sensitivity to the light
(This is commonly associated with headaches and migraines. It is actually a Neurological symptom, but is frequently recorded in EYES)
Phonophobia
Sensitivity to sound
(Commonly associated with headaches and migraines. It is actually a NEUROLOGICAL Symptom, but is frequently recorded in Ears)
Dizziness
Neurological Symptom
Feeling close to passing out
(This is sorted into two categories; lighteaded and rotational. If the patient is unsure how their dizziness is making them feel, then they are experiencing general dizziness)
What is rotational dizziness
Neurological symptom
Feeling like the room is spnning
(Dizziness is sorted into 2 categories: lighthead and rotational. If the patient is unsure how their dizziness is making them feel, then they are experiencing general dizziness)
Altered level of consciousness
(ALOC)
Altered mental status
(AMS)
(NEUROLOGICAL BODY SYSTEM)
Any measure of responsiveness other than normal
Numbness
NEUROLOGICAL
Loss of sensation or feeling a part of the body
Numbness + Tingling = Paresthesias “pare-uh-stee-zuhs”
What is tingling
NEUROLOGICAL
Slight pricking sensation, similar to “pins and needles”
Numbness + tingling = Paresthesias
“Pare-uh-stee-zuhs”
What is focal weakness?
Lack of strength in a focal part of the body; right, left, or bilateral; upper or lower
(Focal weakness in one side of the body is characteristic of a stroke)
What is a seizure
NEUROLOGICAL SYMPTOMS
Convulsions, sensory disturbances, or loss of consciousness resulting from abnormal elctrical discharges in the brain
What is dysarthria
(dis-are-three-uh)
(NEUROLOGICAL)
Speech that is slow, and difficult to understand
What is dysphasia
“dis-fay-zuh”
Not confused with the term dysphagia which means difficulty swallowing. Thy are pronounced similarly.
An impairment or difficulty with expression through speech
Aphasia
“ay-fay-zuh’
(NEUROLOGICAL SYMPTOM)
Inability to communicate through writing or speech; may improve with time
Bowel/urinary incontinence
NEUROLOGICAL
Loss of bowel or bladder control
Saddle anesthesia
NEUROLOGICAL
Numbness specifically in the groin a.k.a. the area of the body that comes into contact with a horse’s saddle
BODY SYSTEM: Psychiatric
Any symptoms related to how patients feel and interact with others….
What are some common psychiatric symptoms?
Common psychiatric symptoms: Anxiety Depression Mania Suicidal Ideation Homicidal Ideation Auditory or Visual Hallucinations Insomnia Substance abuse Eating Disorders
Anxiety
PSYCHIATRIC
Feelings of worry and stress that is out of proportion to the impact of the event
Depression
PSYCHIATRIC
Persistent feeling of sadness and loss of interest
Mania
“may-nee-uh”
PSYCHIATRIC
Excitement manifested by mental and physical hyperactivity, disorganization of behavior, and elevation of mood
Suicidal Ideation (SI) (PSYCHIATRIC)
Thoughts of harming oneself
(If suicidal ideation is mentioned in the ROS, homicidal ideation must alos be addressed, regardless of if it is positive or negative)
What is homicidal ideation
(HI)
(PSYCHIATRIC)
thoughts of harming others
(if homicidal ideation is mentioned in the ROS, suicidal ideation must also be addressed, regardless of it is positive or negative. )
AUDITORY Hallucinations
Visual Hallucinations
(PSYCHIATRIC)
Hearing or seeing things that are not there
Insomnia
PSYCHIATRIC
Persistent problems falling and staying asleep
Substance Abuse
PSYCHIATRIC
The excessive use of a mind- altering substance, such as drugs of alcohol
Eating Disorders
PSYCHIATRIC
Serious disturbances in eating behaviors, such as starving oneself or binge eating then purging
BODY SYSTEM: Endocrine
Any system related to the endocrine system
COMMON ENDOCRINE SYMPTOMS:
Common endocrine symptoms: Polyuria Polydipsia Polyphagia Hyperglycemia Hypoglycemia Heat/Cold intolerance Hirsutism Alopecia Hot Flashes
Polyuria
Pall-ee-ur-ee-uh
Excessive urination
an endocrine symptom (versus genitourinary) because it is almost always a result of hyperglycemia related to diabetes
What is polydipsia
“Pall-ee-dip-see-uh”
(ENDOCRINE)
Excessive thirst
(Polydipsia is an endocrine symptom (versus gastro intestinal) because it is almost always a result of hyperglycemia related to diabetes.)
What is polyphagia
“Pall-ee-fay-zuh”
(ENDOCRINE)
Excessive hunger
(Polyphagia is an endocrine symptom (vs. gastrointestinal) because it is almost always a result of hyperglycemia related to diabetes.
What is hyperglycemia
ENDOCRINE
Abnormally elevated blood sugar
What is Hypoglycemia
ENDOCRINE
Abnormally low blood sugar
What is heat intolerance / cold intolerance
ENDOCRINE
Inability to tolerate heat or cold
What is hirsutism?
“hur-suh-ti-zm”
(ENDOCRINE)
Male pattern hair growth, typically affecting women
Alopecia
“Al-oh-pee-shuh”
(ENDOCRINE)
Hair loss from the scalp or elsewhere on the body
What are hot flashes
ENDOCRINE
A sudden, brief sensation of heat usually associated with menopausal endocrine imbalance
BODY SYSTEM: Hematologic/ Lymphatic
Any symptoms relating to the blood or immune system
Common hematologic/lympathic symptoms:
Common hematologic/ lymphatic symptoms:
- Bleeding tendency
- Bruising tendency
- Petechiae
- Swollen lymph nodes
Bleeding tendency
Hematologic
Abnormal amounts of bleeding
May be caused by blood thinning medications or clotting disorders
Bruising tendency
Hematologic
Easy bruising, typically caused by clotting disorders or blood thinning medications
Petechiae
Hematologic
Small red or purple spots caused by bleeding into the skin
Swollen lymph nodes
Hematologic
Swelling of the lymph nodes, typically of the neck
BODY SYSTEM:
Allergy/ Immunologic
Any symptoms relating to the immune system
Common allergy/ immunologic symptoms:
Common allergy/ immunologic symptoms:
- Seasonal allergies
- Food allergies
- Recurrent infections
- Impaired immunity
- Immunosuppressive therapy
Seasonal allergies
ALLERGY / IMMUNOLOGIC
Allergies that result from exposure to airborne substances that appear only during certain times of the year
Food allergies
ALLERGY / IMMUNOLOGIC
Allergies that result from exposure to or ingestion of any number of foods
What are recurrent infections?
ALLERGY / IMMUNOLOGIC
Infections that are too great in number (>2/ year), too severe, or too long lasting
What is impaired immunity
ALLERGY / IMMUNOLOGIC
An immune system that cannot effectively defend the host
May be caused by illness, medications, or substance use
What is immuno-suppressive therapy?
ALLERGY / IMMUNOLOGIC
Drugs that inhibit or prevent activity of the immune system
What will a provider ask their patients and what is the medical scribe’s job to record?
They will ask their patients their reason for visit, associated symptoms as well as other symptoms.
It is the scribe’s job to document these symptoms in the ROS.
When a provider asks a patient about the same symptoms, we already have…
a templated ROS which already has symptoms listed as “Negative”
What is it a scribes job to do when using a templated ROS that already has information documented as negative?
To change the symptoms the patient says that they are experiencing to “Positive” as ell as add any additional “Negative” symptoms to the ROS
Review of systems with Negative symptoms:
Constitutional: Negative for fever or chills
Skin: Negative for rash or open wounds
Eyes: Negative for blurred vision or double vision
ENMT: Negative for sore throat, ear pain, or rhinorrhea
Respiratory: Negative for shortness of breath or coughing
Cardiovascular: Negative for chest pain or palpitations
Gastrointestinal: Negative for nausea, vomiting, diarrhea, or abdominal pain
Genitourinary: Negative for dysuria or hematuria
Musculoskeletal: Negative for back pain, joint pain, or joint swelling
Neurological: Negative for headache, dizziness, weakness, numbness, or tingling
Psychiatric: Negative for suicidal or homicidal ideations. Negative for auditory or visual hallucinations
Completed Review of Systems
Constitutional: Positive for fever and chills
Skin: Negative for rash or open wounds
Eyes: Negative for blurred vision or double vision
ENMT: Negative for sore throat, ear pain, or rhinorrhea
Respiratory: Negative for shortness of breath or coughing
Cardiovascular: Negative for chest pain or palpitations
Gastrointestinal: Positive for nausea and vomiting. Negative for dysuria or hematuria
Musculoskeletal: Negative back pain, joint pain, or joint swelling
Neurological: Positive for headache. Negative for dizziness, weakness, numbness or tinging.
Psychiatric: Negative for suicidal or homicidal ideations. Negative for auditory or visual hallucinations.
What does the past histories section of a patient’s note include
The patient’s past medical + surgical, family, and social histories.
Each section contains specific information:
Past medical history: Chronic long term conditions, surgeries and procedures
Family History: Immediate family members with chronic conditions
Social History: Tobacco use, alcohol use, employment, living status, etc.
What does past medical history or PHMx refer to?
This refers to the patient’s long term diagnosed medical conditions
EX: Hypertension Hyperlipidemia GERD History of breast cancer Recurrent UTIs
Is past medical history objective or subjective?
Subjective, although we also include info in this section from sources other than the patient
What is past surgical history?
The patient’s prior medical procedures and surgeries. It is considered part of Past Medical History, but is often documented separately.
EX:
Coronary artery bypass Graft (CABG) - heart “bypass” surgery
Hysterectomy - removal of the uterus
Colonoscopy - Exploration of the rectum, colon, and lower gastrointesntinal tract by camera
Is the Past Surgical History objective or subjective?
Subjective, although we also include info in this section from sources other than the patient
What is past family history or PFHx?
This refers to long-term, diagnosed medical conditions that affect a patient’s immediate family members ( grandparents, parents, and siblings)
EX:
Father has hypertension
Mother died of myocardial infarcation ( age 45 )
Brother has diabetes
Is past family history PFHx objective or subjective?
This is subjective although we also include infoamtion in this section from sources other than the patient
What does past social history refer to?
The patient’s social status and habits that may affect their medical history
EX: Tobacco use Alcohol use Illicit drug use Marital status Employment status Living situation Activity level
Is past social history objective or subjective?
Subjective, although we also include info in this section from sources other than the patient
What are Allergies?
A record of reactions to medications and foods that a patient has experienced previously
What are home medications?
a record of all medications a patient takes at home on a regular basis
Ex:
- Medication: 50mg Zoloft, Instructions: Take 1 capsule every morning
- Allergy: penicillin, Start date: 1/1/2042 Severity: severe, Reaction: rash
While patient allergies and home meds are recorded in the history section of the EHR…. it is not the responsibility of the scribe to
document them into the chart. Although you should still pay attn when a patient is asked about them
What can listening to the medications a patient takes tell the scribes?
More info about their medical history than what the patient reports themselves
What are Medical Conditions and Diseases?
Afflictions of the body or mind which negatively affect a patient’s life and well-being. These conditions and diseases require the diagnosis of a medical provider. Once they have been diagnosed, the conditions and diseased become part of the patient’s past medical history.
How are the 13 body systems broken down?
Cardiovascular Electrophysiological Endocrine HEENT Gastrointestinal Genitourinary Hematologic Immunologic Integumentary Musculoskeletal Neurological Psychiatric Respiratory
How are the 13 body systems broken down?
Cardiovascular Electrophysiological Endocrine HEENT Gastrointestinal Genitourinary Hematologic Immunologic Integumentary Musculoskeletal Neurological Psychiatric Respiratory
What are a class of conditions and diseases that affect the heart or blood vessels?
Common type of cardiovascular conditions and diseases:
Cardiac Diseases
Electrical Conduction Deficits
Ischemic Injuries
Vascular Diseases
What are some heart conditions that include diseased vessels, structural problems, and blood clots?
Cardiomegaly Cardiomyopathy Endocarditis Heart Failure Heart murmur Pericarditis
What is cardiomegaly?
An enlarged heart, which is usually a sign of another condition
What is a common treatment for cardiomegaly?
Treatment of the underlying condition
What is cardiomyopathy?
An acquired or hereditary disease of the heart muscle which makes it more difficult for the heart to pump blood and can lead to heart failyre
What is a common treatment for cardiomyopathy?
antihypertensives
What is endocarditis?
An infection of the heart’s inner lining (endocardium), usually involving the heart valves.
What is a common treatment for endocarditis?
Antibiotics, valve replacement
What is heart failure?
Abbreviations: HFpEF, CHF
A chronic condition in which the heart doesn’t fill with or pump blood as well as it should
What are common treatments for heart failure?
Lasix, Digoxin, Antihypertensives
What are heart murmurs?
Sounds of blood flowing through the heart, due to a disease heart valve or other abnormality. One very common murmur is caused by a disease called aortic stenosis.
What is a common treatment for heart murmurs?
Surgical repair, anticoagulants
What is pericarditis?
Swelling and irritation of the sac around the heart (pericardium)
What are common treatments for pericarditis?
NSAIDs
What are the two terms that identify with a problem with the electrical system that makes your heart beat and controls its rate and rhythm?
- Atrial Fibrillation
* Supraventricular tachycardia
Who would typically manage atrial fibrillation and supraventricular tachycardia?
Cardiologist, although if they have severe symptoms, they may be referred to an electrophysiologist, a physician studies electrical conduction defects
What is atrial fibrillation?
A-fib
An irregular, often rapid heart rate that causes poor blood flow and increased risk of clots.
“Irregularly, irregular rhythm”
What are common treatments for atrial fibrillation?
Beta-blockers, anticoagulants, ablation
What is supraventricular tachycardia?
SVT
A faster than normal heart rate beginning above the heart’s two lower chambers ( ventricles)
What are common treatments for supraventricular tahcycardia?
Adenosine
electrical cardioversion
What are the terms that relate to damage to the heart of vasculature due to the lack of blood flow?
Abdominal Aortic Aneurysm
Aortic Dissection
Myocardial Infarction
What is abdominal aortic aneurysm?
Abreviation: AAA
An enlargement of the aorta at the level of the abdomen. Dissection (spontaneous tear) of any aneurysm is very dangeous.
What is a common treatment for abdominal aortic aneurysm?
Surgical repair
What is an aortic dissection?
A spontaneous tear in the inner layer of the aorta
What are common treatments for aortic dissection?
Beta blockers and surgical repair
What is a myocardial infarction?
Abbreviation MI
A blockage of blood flow to the heart muscle (myocardium) resulting in areas of cell death
Also known as Heart Attack
What are common treatments for myocardial infarction?
Cardiac stenting, bypass grafting, antihypertensives
What are terms that relate to any abnormal condition of the blood vessels ( arteries and veins).
Aortic stenosis Atherosclerosis Cornoary Artery Disease Deep vein thombosis Hyperlipidemia Hypertension Peripheral Vascular Disease
What is aortic stenosis?
The narrowing of the valve in the aorta, which restricts blood flow out from the heart to the rest of the body
What are common treatments for aortic stenosis?
Aortic valve replacement
What is atherosclerosis?
A disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls.
What are common treatments for atherosclerosis?
Diet and exercise, statins, possible surgery
What is coronary artery disease?
Abbreviation: CAD
A coronary artery disease is a damage or disease in the heart’s major blood vessels. It is a complication of atherosclerosis in which plaque builds up in the arteries of the heart, putting the patient at risk for a heart attack.
What are common treatments for CAD?
Cardiac Stenting, CABG, Statins, Antihypertensives
What is a deep vein thrombosis?
DVT
A blood clot in a deep (further from the surface) vein, usually in the legs, that restricts normal blood flow through the veins
What are common treatments for deep vein thrombosis?
Blood thinners, embolectomy
What is hyperlipidemia aka dyslipidemia aka high cholesterol?
(Abbreviation: HLD)
A condition in which there are high levels of fat particles (lipids) in the blood
What are common treatments for hyperlipidemia?
Statins and other cholesterol medications
What is hypertension?
Abbreviation: HTN
A condition in which the force of the blood against the artery walls is too high
What are common treatments for hypertension?
Antihypertensives and diuretics
What is a peripheral vascular disease?
Abbreviation: PVD
A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.
What are common treatments to peripheral vascular disease?
Statins, vasodilators, blood thinners, angioplasty
What are a class of conditions and diseases that affect the heart and are specifically seen on electrocardiograms (EKGs)?
Common types of electrophysiological conditions and diseases:
Axis Changes Interval Changes QRS Complex Changes ST Segment Changes T-wave Changes Ectopic Beats
What are terms related to abnormal changes of the QRS axis on the electrocardiogram?
Left axis deviation
Right axis deviation
Indeterminate axis
What is left axis deviation?
Abbreviation: LAD
A condition where in the electrical axis of ventricular contraction of the heart has a leftward shit as a result of the left-sided heart problems
What are common treatments for left axis deviation?
Treatment of the underlying cause
What is right axis deviation?
Abbreivation RAD
A condition where in the electrical axis of ventricular contraction of the heart has a rightward shift as a result of the right-sided heart problems
What is a common treatment for right axis deviation?
Treatment of the underlying cause
What is an indeterminate axis?
Also known as Northwest Axis
A condition wherein the electrical axis of ventricular contraction of the heart has an indeterminate shift between the angle of right and left deviations
What are common treatments for the indeterminate axis?
Treatment of the underlying cause
What are terms related to any abnormal changes of the intervals of the QRS complex on an electrocardiogram?
- Prolonged QT interval
- Firs degree AV block
- Interventricular conduction delay
What is a prolonged QT interval?
Also known as Long QT
It is an electrical seen on an EKG when the heart takes longer than normal to recharge between beats
What are common treatments for prolonged QT intervals?
Antiarrhythmics, beta blockers, pacemaker
What is a first degree av block?
aka first degree heart block
This occurs when conduction through the AV node is slowed thus delaying the time it takes for the ventricles to contract, marked by a prolonged PR interval on an ECG
What are common treatments for a first degree av block?
No necessary treament
What is an inter-ventricular conduction delay?
AKA In complete right bundle branch block
(Abbreivation - IVCD )
A slight widening of the QRS complex caused by a delay in the contractions between the right and left ventricles
What are terms related to any other abnormal changes of the QRS complex on an electrocardiogram?
- Poor R-wave progression
- Left bundle branch block
- Right bundle branch block
- Left anterior fascicular block
- Left ventricular hyptertophy
- Q-waves
- Low-voltage QRS
What is Poor R-wave progression?
This is caused by the absense of the normal increase in the size of the R-Wave while advancing through the precordial leads (V1-V6) of the EKG
(REFER TO PHOTO Slide number 38 - MSA 103B Medical Conditions and Diseases)
What is a left bundle branch block?
Abbreviation - LBBB
A delay or blockage of electrical impulses to the left side of the heart
What are common treatments for a left bundle branch block?
treatment of underlying causes
What is a right bundle branch block?
Abbreviation: RBBB
A delay or blockage of electrical impulses to the right side of the heart.
What are common treatments for right bundle branch block?
Treatment of underlying causes
What is a left anterior fascicular block?
Abbreviation - LAFB
This occurs when the anterior fascicle of the left bundle branch no longer able to conduct electrical impulses to the left ventricle
What are common treatments for a left anterior fascicular block?
Treatment of underlying causes
What is a left ventricular hypertrophy?
Abbreviation: LVH
The pathological enlargement of the muscle of the left ventricle. Electrical changes can be seen on an EKG.
What are common treatments for left ventricular hypertrophy?
Antihypertensives
What are Q-Waves?
Initially negative deflections of the QRS complex. When they are pathologic, they indicate the presence of a past or on-going heart attack.
(Photo has a wave going into the negative)
What are common treatments for Q-waves?
treatment for underlying causes
What is a low-voltage QRS?
This is caused by a decrease in voltage in ventricular contraction which leads to peak-to-peak amplitude differences between QRS peaks on the EKG.
What are common treatments for low-voltage QRS?
Treatment of underlying causes
What are terms related to any abnormal changes of the ST segment on an electrocardiogram?
- ST Depression
- ST elevation
- Early repolarization
What is ST depression?
This occurs when the J point is displaced below the baseline.
(See photo of a J Point on a graph) (#46 Medical Conditions and diseases)
What is ST depression?
This occurs when the J point is displaced below the baseline.
(See photo of a J Point on a graph) (#46 Medical Conditions and diseases)
What is ST elevation?
This occurs when the ST segment is abnormally high above the baseline. This is most commonly associated with an ST-elevation myocardial infarction (STEMI)
What are common treatments for ST elevation?
Antihypertensives, cardiac catheterization
What is early repolarization?
A term used classically for ST segment elevation without underlying disease
What are common treatments for early repolarization?
None unless patient develops complications
What are terms relate to any abnormal changes of the t-wave on an electrocardiogram?
T-wave inversion
T-wave flattening
What is a T-wave?
The EKG manifestation of ventricular repolarization of the cardiac electrical cycle and is usually a “bump” after the QRs complex.
What is a T-wave inversion?
T-waves that are upside down
What are common treatments for t-waves?
Treatment for underlying causes
What is T-wave flattening?
Occurs when the T-wave becomes flatter, but it is not inverted
What are common treatments for T-wave flattening?
Treatment for underlying causes
What are terms related to any abnormal changes of the ST segment on an electrocardiogram?
- Premature atrial contraction
* Premature ventricular contraction
What is a premature atrial contraction?
Abbreviation PAC
A premature heartbeatt hat occurs in the atria and can cause palpitations
What are common treatments for premature atrial contraction?
Treatment of underlying causes, lifestyle changes
What is a premature ventricular contraction?
Abbreviation PVC
A premature heartbeat that occurs in the ventricles and can cause palpitations
What are common treatments for Premature ventricular contraction?
Antiarrhythmics, treatment of the underlying causes
What are terms related to diseases that occur when the system responsible for hormone secretion regulation does not function properly?
Hypothyroidism
Diabetes
Diabetic Ketoacidosis
What is hypothyroidism?
A condition in which the thyroid gland doesn’t produce enough thyroid hormone
What are common treatments for hypothyroidism?
Levothyroxine (T4)
Liothyronine (T3)
What is diabetes?
This refers to a group of diseases that result in high blood glucose. There are different types, including diabetes mellitus types I and II, diabetes insipidus, and gestational diabetes.
What are common treatments for diabetes?
Oral medications, insulin, and lifestyle
What is a diabetic ketoacidosis?
Abbreviation DKA
A complication from diabetes where the body produces excess blood acids (ketones)
What are common treatments for Diabetic ketacidosis?
Fluid replacement, insulin
What are a class of conditions and diseases that affect the HEENMT? (Head, Eyes, Ears, Nose, Mouth, Throat.... think top of head moving down...)
Head conditions Eye conditions Ear conditions Nose conditions Mouth Conditions Throat Conditions
What are conditions affecting the structures of the head?
Sinusitis
What is sinusitis?
A condition in which the cavities around the nasal passages become inflamed
What are common treatments for sinusitis?
Nasal washing, decongestants, steroids, antibiotics
What are conditions affecting the globe of the eyes?
Conjunctivitis
Glaucoma
Cataracts
What is conjunctivitis?
An inflammation or infection of the outer membrane of the eyeball and the inner eyelid (conjunctiva)
What are common treatments for conjunctivitis?
Antibiotic eye drops, steroidal eye drops
What is glaucoma?
A group of eye conditions that damage the optic nerve and can cause blindness
What are common treatments for glaucoma?
Timolol, other beta blockers, laser surgery
What are cataracts?
Clouding ot the normally clear lens of the eye
What are common treatments of cataracts?
Surgery to remove cataracts
What are terms related to conditions affecting the external ear and the ear canal?
- Otitis media
* Otitis externa
What is otitis media?
Inflammation of the air-filled space behind the eardrum (the middle ear)
What are common treatments for otitis media?
NSAIDs, antibiotics
What is otitis externa?
AKA Swimmers Ear
Inflammation of the outer ear canal
What are common treatments for otitis externa?
Ear drops, supportive care
What are terms related to the conditions affecting the nasal passages?
Epistaxis
What is epistaxis?
Bleeding from the nose, either spontaneous of induced by nose picking or trauma
What are common treatments for epistaxis?
Compression, packing, cauterization
What are conditions affecting the oral mucosa and lips?
Hand, foot, and mouth disease
What are hand, foot, and mouth dieases?
A common virus affecting mainly children that causes sores in the mouth and a rash on the hands and feet
What are common treatments for hand, foot, and mouth disease?
NSAIDs
What are terms related to the conditions of the oropharynx?
Streptococcal pharyngitis
Tonsillitis
What is streptococcal pharyngitis?
A bacterial infection that may cause a sore, scratchy throat
aka strep throat
What are common treatments for streptococcal pharyngitis?
Penicillins, NSAIDs
What is tonsillitis?
Inflammation of the two oval-shaped pads of tissue at the back of the throat
What are common treatments for tonsillitis?
Antibiotics, NSAIDs, sometimes surgery
What are a class of conditions and diseases that affect the stomach intestines, and accessory digestive organs, such as the pancreas, liver, and appendix???
Common types of gastrointestinal (GI) conditions and diseases: Gastric Diseases Gastrointestinal Infections Gastrointestinal Inflammation Intestinal Conditions and Diseases Liver Diseases
What are diseases affecting the stomach?
- Gastroesophageal reflux disease
* Peptic ulcer disease
What is gastroesophageal reflux disease?
Abbreviation - GERD
A digestive disease in which stomach acide of bile irritates the food pipe (esophagus) lining
What are common treatments for gastroesophageal reflux disease?
Antacids, proton pump inhibitors
What is peptic ulcer diseases?
PUD abbreviation
A disease which causes prone-to-bleeding sores that develop on the lining of the esophagus, stomach, or small intestine
What are common treatments for Peptic Ulcer Disease?
Antibiotics, Antacids, Proton Pump Inhibitors
What are infections that affect the stomach and the intestines?
- Clostridium difficile
* Gastroenteritis
What is clostridium difficile colitis?
C. diff - Abbreviation
Inflammation of the colon cause by the bacteria Clostridium Difficule
What are common treatments for Clostridium difficile colitis?
Vancomycin, Flagyl
What is gastroenteritis?
An intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever
aka stomach flu
What are common treatments for gastroenteritis?
Fluids, antidiarrheals, sometimes antibiotics
What is a response to gastrointestinal injuries as a result of different stimuli such as a pathogens, damaged cells, or irritants?
Pancreatitis
Cholecystitis
Appendicitis
Gastritis
What is pancreatitis?
Inflammation of the pancreas
What are common treatments for pancreatitis?
Fluids, treating the underlying cause
What is cholecystitis?
Chole - Abbreviation
Inflammation of the gallbladder
What are common treatments for cholecystitis?
Antibiotics, avoiding fatty foods, cholecystectomy
What is appendicitis?
Appe - Abbreviation
A condition in whcih the appendix becomes inflamed and filled with pus, causing pain
What are common treatments for appendicitis?
Antibiotics, appendectomy
What is gastritis?
Any one group of conditions in which the stomach lining is inflamed
What are common treatments for Gastritus?
Antacids, proton pump inhibitors, antibiotics
What are diseases that affect the small and large intestines?
Diverticulosis Diverticulitis Crohn's disease Ulcerative Colitis Irritable bowel syndrome Small bowel obstruction
What is diverticulosis?
A condition in which small bulging pouches (diverticula) develop in the large intestine, most often in the sigmoid
What are common treatments for diverticulosis?
Dietary fiber
What is diverticulitis?
Inflammation or infection in one or more small pouches ( diverticula) in the large intestine
What are common treatments for diverticulitis?
Antibiotics, fluids
What is Crohn’s disease?
A chronic, autoimmune inflammatory bowel disease that affects the lining of the digestive tract
What are common treatments for Crohn’s disease?
NSAIDs, steroids, immuno-suppresive drugs
What is ulcerative colitis?
UC - Abbreviation
A chronic, autoimmune inflammatory bowel disease that causes inflammation in the large intestine
What are common treatments for Ulcerative colitis?
NSAIDs, steroids, immuno-suppressive drugs
What is irritable bowel syndrome?
IBS - abbreviation
An intestinal disorder causing pain in the belly, gas diarrhea, and constipation
What are common treatments for irritable bowel syndrome?
Fiber, antidiarrheals, gut antispadmodics
What is a small bowel obstruction?
SBO - abbreviation
A gastrointestinal condition in which digested material is prevented from passing normally through the bowel
What are common treatments for small bowel obstruction?
NG Tube, enema, surgery
What are diseases that affect the liver?
- Cirrhosis
* Hepatitis
What is cirrhosis?
A chronic liver damage from a variety of causes leading to scarring (fibrosis) and liver failure
What are common treatments for cirrhosis?
Lactulose, liver transplant
What is hepatitis?
Abbreviation - Hep A, B, C ( and others
Inflammation of the liver typically caused by infections, that may be acute or chronic.
What are common treatments for hepatitis
Depends on the type of hepatitis
What are a class of conditions and diseases that affect the urinary tact, male/female reproductive system and internal/external genitalia
Common types of genitourinary (GU) conditions and diseases:
Female Genitourinary Conditions Female Genitourinary Diseases Male Genitourinary Conditions Sexually Transmitted Infections Urinary and Renal Conditions and Diseases
What are conditions affecting only the female reproductive organs?
- Ectopic pregnancy
- Menorrhagia
- Ovarian Torsion
What is an ectopic pregnancy?
A pregnancy in which the fertilized egg implants outside the uterus, often in a fallopian tube
What are common treatments for ectopic pregnancy?
Surgical removal or embryo, possible salpingo-oophorectomy
What is menorrhagia?
Refers to heavy or prolonged vaginal bleeding with the menstrual cycle.
aka heavy periods
What are common treatments for Menorrhagia?
Birth control, NSAIDs
What is ovarian torsion?
A condition that occurs when an ovary twists around the ligaments that hold it into place
What are common treatments for ovarian torsion?
Surgical intervention
What are diseases that affect only the female reproductive organs?
Endometriosis
Pelvic Inflammatory Disease
Polycystic Ovarian Syndrome
What is endometriosis?
A disorder in which uterine tissue grows outside the uterus
What are common treatments for endometriosis?
Birth control, endometrial ablation, surgery
What is pelvic inflammatory disease?
PID - abbreviation
An infection of the female reproductive organs, usually due to untreated sexually transmitted infections, that may lead to irreparable damage
What are common treatments for pelvic inflammatory disease?
Antibiotics
What is polycystic ovarian syndrome?
PCOS - Abbreviation
A hormonal disorder causing enlarged ovaries with small cysts on the outer edges
What are common treatments for polycystic ovarian syndrome?
Metformin, statins, birth control
What are conditions and diseases affecting only the male reproductive organs?
Benign prostatic hypertrophy
Testicular torsion
Hydrocele
What is benign prostatic hyperplasia?
BPH - abbreviation
An age-associated prostrate gland enlargement that can cause urinary retention
What are common treatments for Benign Prostatic Hyperplasia?
Flomax, apha-5-reductase inhibitors, catheterization, surgery
What is testicular torsion?
A twisting of the testical around the vessel supplying blood to the scrotum
What are common treatments for testicular torsion
Surgery, possible orchiectomy
What is a hydrocele?
A fluid-filled sac around a testicle, often first noticed as swelling of the scrotum
What are common treatments for hydrocele?
Monitoring, surgery as needed
What are infections that are transmitted via sexual contact and occasionally contact with infected bodily fluids?
Herpes Chlamydia Gonorrhea Trichomoniasis Syphilis Human Immunodeficiency Virus Acquired Immunodeficiency Syndrome
What are herpes?
A common sexually transmitted viral infection marked by genital pain and sores
What are common treatments for herpes?
Antivirals
What is chlamydia?
A common sexually transmitted bacterial infection that may not cause symptoms and is most common in young women.
What are common treatments for chlamydia?
Azithromycin, Cipro
What is Gonorrhea?
GC- Abbreviation
A common sexually transmitted bacterial infection that if untreated may cause infertility
What are common treatments for gonorrhea?
Rocephin, doxycycline
What is trichomoniasis?
Abbreviation - Trich
A sexually transmitted infection caused by a parasite (trichomonas)
What are common treatments for Trichomoniasis?
Antibiotics
What is syphilis?
A bacterial infection usually spread by sexual contact that starts as a painless sore and may progress to stage 3, neurosyphilis?
What are common treatments for syphilis?
Penicillin
What is a human immunodeficiency virus?
HIV - abbreviation
A virus transmitted through contact with infected blood, semen, vaginal or anal fluids that interferes with the body’s ability to fight infections.
What are common treatments for human immunodeficiency virus?
Antiretrovirals
What is acquired immunodeficiency syndrome?
AIDS - abbreviation
Characterized by irreversible damage to the immune system caused by HIV that drastically limits the body’s ability to fight infections.
What are common treatments for Acquired Immunodeficiency syndrome?
Treat based on symptoms, no cure
What are conditions and diseases affecting the urinary tract, including the bladder, ureters, and kidneys?
- Urinary Tract Infection
- Pyelonephritis
- Renal Calculi
- End stage renal disease
What are urinary tract infections?
(UTI - abbreviation)
AKA Acute cystitis
Infections in any part of the urinary system, the kidneys, bladder, or urethra
What are common treatments for urinary tract infection?
Macrobid, Bactrim, other antibiotics
What is pyelonephritis?
Pyelo - abbreviation
Inflammation of the kidney due to a bacterial infection
AKA kidney infection
What are common treatments for Pyelonephritis?
Cipro, amoxicillin
What is a renal calculus?
A small, hard deposit that forms in the kidneys and is often painful when passed
aka kidney stones.
What are common treatments for renal calculus?
Flomax, analgesics, possible surgery
What is end stage renal disease?
ESRD - abbreviation
a long standing disease of the kidneys leading to renal failure?
What are common treatments for End Stage Renal Disease?
Dialysis, Kidney transplant
What are a class of conditions and diseases that affect the blood and blood-forming organs?
- Anemia
* Leukemia
What is Anemia?
A condition in which the blood doesnt have enough healthy red blood cells
What are common treatments for anemia?
Vitamins, blood transfusion
What is Leukemia?
AKA BLood cancer
A cancer of blood-forming tissues, which then produce abnormal or immature white blood cells (leukocytes) hinder the body’s ability to fight infection
What are common treatments for leukemia?
Chemotherapy, radiation, bone marrow or stem cell transplant
What are a class of conditions and diseases that affect the immune system’s ability to differentiate between host cells and invaders?
Conditions that result from immune system dysfunction:
Allergic reactions Adverse reactions Autoimmune disorders Cancer Metastatic cancer
What is an allergic reaction?
A condition in which the immune system reacts abnormally to a foreign substance, resulting in rashes, itching, and swelling, specifically
What are common treatments for an allergic reaction?
Benadryl, antihistamines, steroids, immunotherapy
What is an adverse reaction?
Any substance or dangerous reaction to a substance different from an allergy
What are common treatments to an adverse reaction?
Antihistamines, steroids, epinephrine
What is an autoimmune disorder?
A disease in which the body’s immune system attacks its own healthy cells
What are common treatments for an autoimmune disorder?
Steroids, immuno-suppresants
What is cancer?
CA - Abbreviation
A disease in which abnormal cells divide uncontrollably and destroy body tissue
What are common treatments for Cancer?
Chemotherapy, Radiation therapy, Surgery
What is metastatic cancer?
A cancer that has spread from its primary source to one or more secondary sites
also known as secondary location mets
What are common treatments for metastatic cancer?
Chemotherapy, radiation therapy, surgery
What are a class of conditions and diseases that affect the skin?
Common types of integumentary conditions and diseases:
Integumentary Infections
Integumentary Conditions
What are some infections of the skin?
Cellulitis
Abscess
What is cellulitis?
A common and potentially serious bacterial skin infection, characterized by pain, redness, swelling, and warmth
What are common treatments for cellulitis?
Antibiotics
What is an abscess?
A confined pocket of pus that collects tissues, organs, or spaces inside the body
What are common treatments for abscess?
Antibiotics, incision, and drainage
possible surgical debridement
What are conditions caused by the dysfunction of the structures of the skin?
Urticaria
Eczema
Psoriasis
What is Urticaria?
A skin rash triggered by a reaction to food, medicine, or other irritants
(also known as Hives)
What are common treatments for urticaria?
Antihistamines, steroids
What is atopic dermatitis?
An itchy inflammation of the skin in response to irritants
also known as eczema
What are common treatments to atopic dermatitis?
Steroids, topical antiseptics, antihistamines
What is psoriasis?
An autoimmune condition in which skill cells build up and form scales and itchy, dry patches.
What are common treatments for psoriasis?
Steroids, immuno suppressive drugs, vitamins
What are a class of conditions and diseases that affect the bones, muscles, tendons, and ligaments?
Common types of musculoskeletal condictions and diseases:
Acute Conditions
Chronic Conditions
Degenerative Diseases
What are conditions affecting the bones and muscles for a short period?
Costochondritis Dislocations Fractures Sciatica Subluxations
What is Costochondritis?
An inflammation of the cartilage that connects the ribs to the breastbone
What are common treatments to costochondritis?
NSAIDs, Steroids, Stretching, Exercise
What are dislocations?
Injuries where a joint is forced out of a normal position
What are common treatments for dislocations?
Joint reduction, immobilization
What are fractures?
Fx - abbreviation
Complete or partial breaks in a bone
What are common treatments for fractures?
Resetting bone, immobilization, possible surgery
What does sciatica refer to?
Pain radiating along the sciatic nerve which runs down one or both legs from the lower back.
What are common treatments for sciatica?
Icepacks, NSAIDs, muscle relaxers
What are subluxations?
Partial dislocations
What are common treatments for subluxations?
Reduction, immobilization
Conditions affecting the bones and muscles that are ongoing for a long period
- Chronic back pain
- Herniated Discs
- Osteoporosis
What is chronic back pain?
long term physical discomfort occuring anywhere on the spine or paraspinal muscles ranging from mild to debilitating
What are common treatments for chronic back pain?
Muscle relaxants, cold/heat therapy, antiinflammatories
What are herniated discs?
They occur when the rubbery disc between the vertebrae pushes through a crack in the tougher exterior casing
What are common treatments for herniated discs?
Pain medication, physical therapy, possible surgery
What is osteoporosis?
A condition in which bones become weak and brittle
What are common treatments for osteoporosis?
Fosamax, Vitamin D
What diseases result from continuous deterioration of bone, muscle, or connective tissues?
Degenerative disc disease
Osteaoarthritis
Rheumatoid arthritis
What is degenerative disc disease?
DDD - abbreviation
A condition related to aging where the discs between vertebrae fragment and herniate
What are common treatments for Degenerative disc disease?
Physical therapy, NSAIDs, discectomy, laminectomy
What is osteoarthritis?
OA - abbreviation
A form of arthritis that occurs when cartilage wears down that worsens over time.
AKA Degenerative Joint Disease
What are some common treatments for osteoarthritis?
Methotrexate, NSAIDs, physical therapy
What is rheumatoid arthritis?
RA - abbreviation
An autoimmune disorder where the joints and sometimes the internal organs are attacked by the immune system.
What are common treatments for Rheumatoid arthritis?
Anti-inflammatories, immunosuppresants, arthrocentesis
What are a class of conditions and diseases that affect the brain, spinal cord, and nerves?
Common types of neurological conditions and diseases:
Neurological infections
Ischemic Injuries
Nerve Conduction Conditions and Diseases
Other Neurological Conditions
What infections are of the brain , spinal cord, or nerves
Bell’s palsy
Epidural Abscess
Meningitis
What is A Bell’s palsy ?
is a sudden weakness in the muscles on one half of the face caused by a viral infection affecting the cranial nerves
What are common treatments for Bell’s palsy?
Steroids, antivirals, artificial tears
What is an epidural abscess?
A collection of infected material between the outer covering of the brain and spinal cord (dura) and the bones of the skull or spine that is most commonly found in the lumbar region
What are common treatments for epidural abscess?
Surgical decompression, antibiotics
What is meningitis?
Inflammation of the brain and spinal cord membranes ( meninges) typically caused by an infection. May be bacterial or viral
What are common treatments for meningitis?
Antibiotics, steroids
What are terms related to the damage of the brain, spinal cord, or nerves caused by lack of blood flow?
Cerebrovascular accident
Transient Ischemic Attack
What is a cerebrovascular accident?
CVA- Abbreviation
An accident that results in damage to the brain from interruption of its blood supply caused by either a bleed (hemorrhagic) or blood clot (ischemic)
Also known as a stroke
What are common treatments for cerebrovascular accident?
tPA (clots only), surgery
What is a transient ischemic attack?
TIA- abbreviation
A brief stoke-like attack caused by fatty plaque build up in an artery supplying the brain with blood. May indicate risk for future stoke.
What are common treatments for a transient ischemic attack?
Blood thinners, surgery as needed
What are conditions and diseases affecting the ability of nerves to conduct electrical signals?
Cauda equina syndrome Multiple sclerosis Peripheral Neuropathy Spinal cord injury Spinal stenosis
What is cauda equina syndrome?
A condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged
What are common treatments for cauda equina syndrome?
Lumbar laminectomy
What is multiple sclerosis?
MS - abbreviation
A disease in which the immune system eats away at the protective covering of nerves (myeline) which may result in nervous system dysfunction
What are common treatments for multiple sclerosis?
Steroids, Immuno-suppressants
What is peripheral neuropathy?
Characterized by weakness, numbness, and pain from nerve damage usually in the hands and feet
What are common treatments for peripheral neuropathy?
Gabapentin, Lyrica
What is a spinal cord injury?
Results from damage to any part of the spinal cord or nerves at the end of the spinal cord
What are common treatments for spinal cord injury?
Spinal surgery, supportive care
What is spinal stenosis?
An abnormal narrowing of the spinal cord that results in pressure on the spinal cord or nerver roots, which may cause, paint ,paresthesias, and weakness
What are common treatments for spinal stenosis?
pain management, laminectomy
What are additional neurological conditions?
Epilepsy
Idiopathic intracranial hypertension
Migraines
Vertigo
What is epilepsy?
A disorder characterized by abnormal electrical activity in which nerve cell activity in the brain is disturbed, causing seizures
aka seizure disorder
What are common treatments for epilepsy?
Antiepileptics
Anticonvulsants
What is idiopathic intracranial hypertension?
A condition that occurs when pressure inside the skull increased due to increased cerebrospinal fluid for no obvious reason
(IIH - abbreviation)
also known as Pseudotumor cerebri
What are common treatments for idiopathic intracranial hypertension?
diuretic, VP shunt, surgery
What are migraines?
A specific type of headache of varying intensity, often accompanied by nausea and sensitivity to light (photophobia_ and sound ( phonophobia)
What are common treatments for migraines?
Triptans, NSAIDs, antipsychotics
What is vertigo?
A sudden internal or external spinning sensation that may be caused by underlying illness or more benign means such as canalith particles
What are common treatments for vertigo?
Meclizine, treating the underlying cause
What are a class of conditions and diseases that affect behavior and mood?
Conditions and diseases typically caused by abnormal neuroreceptor levels:
Generalized anxiety disorder Clinical Depression Post-Traumatic Stress disorder Bipolar DIsorder Schizophrenia Alcohol abuse Substance abuse
What is generalized anxiety disorder?
GAD - abbreviation
Characterized by severe, ongoing anxiety that interferes with daily activities
What are common treatments for generalized anxiety disorder?
SSRIs, benzodiazepines, other antidepressants
What is clinical depression?
AKA Major depressive disorder
A mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life
What are common treatments for clinical depression?
SSRIs, other antidepressants
What is post-traumatic stress disorder?
PTSD- abbreviation
A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event
What are common treatments for post-traumatic stress disorder?
SSRIs, therapy
What is bipolar disorder?
aka manic depression
A disorder associated with episodes of mood swings ranging from depressive lows to manic highs
What are common treatments of bipolar disorder?
Anticonvulsants, antipsychotics, SSRIs
What is schizophrenia?
A disorder that affects a person’s ability to think, feel, and behave clearly
What are common treatments of schizophrenia?
Antipsychotics
What is alcohol abuse?
(EtOH abuse)
aka Alcoholism
A chronic disease characterized by uncontrolled drinking and preoccupation with alcohol
What are common treatments for alcohol abuse?
Librium, benzodiaepines, detox, therapy
What is substance abuse?
Characterized by overindulgence in or dependence on an addictive substance, especially alcohol or drugs
What are common treatments for substance abuse?
Detox
What are a class of diseases and conditions that affect the lungs, trachea and ability to breathe?
Common types of respiratory conditions and diseases:
Chronic diseases Conditions due to fluid overload Respiratory Infections Inflammatory Conditions Conditions with Loss of Volume Vascular Conditions
What diseases are of the lungs that are ongoing for an extended period of time?
Chronic obstructive pulmonary disease
Emphysema
Obstructive sleep apnea
What is Chronic obstructive pulmonary disease?
COPD - Abbreviation
is a group of chronic diseases characterized by irreversible lung damage that block airflow and make it difficult to breathe
What are common treatments for chronic obstructive pulmonary disease?
Albuterol, ipratropium, steroids, supplemental oxygen
What is emphysema?
A condition in which the air sacs of the lungs (alveoli) are damaged and enlarged, causing breathlessness
What are common treatments for emphysema?
Bronchodilators
Inhaled steroids
Antibiotics
What is obstructive sleep apnea?
Abbreviation - OSA
Intermittent airflow blockage and subsequent apnea (temporary cessation of breathing) during sleep
What are common treatments for obstructive sleep apnea?
CPAP, BiPAP
What are conditions of the lungs caused by increased fluid retention?
Pleural effusion
Pulmonary edema
What is pleural effusion?
The buildup of fluid between the tissues that line the lungs and the chest (pleura)
What are common treatments for pleural effusion?
Chest tube, diuretics, antibiotics
What is pulmonary edema?
A condition caused by excess fluid in the lungs
What are common treatments for pulmonary edema?
Diuretics, low-sodium diet, supplemental oxygen
What are infections of the lungs and/or upper oropharynx?
- Infiltrate
- Pneumonia
- Upper respiratory infection
What is infiltrate?
The accumulation of foreign material collected in tissue, typically lungs in excess of normal. It is a common indicator of infection.
What are common treatments for infiltrate?
Varies by cause of the infiltrate
What is pneumonia?
PNA
An infection that inflames air sacs in one or both lungs, which may fill with fluid
What are common treatments for Pneumonia?
Cipro, Amoxicillin, other antibiotics, albeuterol
What is an upper respiratory infection?
URI - abbreviation
A common viral infection that affects the nose, throat, and airways
What are common treatments for upper respiratory infection?
Mucinex, NSAIDs
What are terms related to pathologic swelling of the structures of the respiratory tract?
Asthma
Bronchitis
Pleurisy
Reactive airway disease
What is asthma?
A condition in which a person’s airways become inflamed, narrow, swollen, and produce extra mucus, making it difficult to breathe
What are common treatments of asthma?
Albuterol, steroids
What is pleurisy?
Inflammation of the tissues that line the lungs and chest cavity
What are common treatments for pleurisy?
NSAIDs, other pain relievers
What is reactive airway disease?
RAD - abbreviation
A disease in which the bronchial tubes of the lungs overreact to an irritant, triggering wheezing and shortness of breath; this is used before a formal diagnosis of asthma is confirmed
What are common treatments for reactive airway disease?
Albuterol, steroids
What are respiratory conditions that result in the loss of lung capacity
Atelectasis
Hemothorax
Pneumothorax
What is atelectasis?
A complete or partial collapse of a lung or a lobe of a lung
What are common treatments for atelectasis?
Supplemental oxygen, albuterol
What is a hemothorax?
A collection of blood in the pleural cavity around a collapsed lung
What are common treatments for a hemothorax?
Chest tube / thoracentesis, supplemental oxygen
What is pneumothorax?
A collapsed lung with air in the pleural cavity
What are common treatments for pneumothorax?
Chest tube/ Thoracentesis, supplemental oxygen
What are respiratory conditions that are a result of pulmonary vascular dysfunction?
Pulmonary embolism
Pulmonary Hypertension
What is a pulmonary embolism?
PE - abbreviation
A condition in which one or more arteries in the lungs become blocked by a subtsance (usually a blood clot_ after it has migrated from else where in the body
What are common treatments for pulmonary embolism?
Blood thinners
What is pulmonary hypertension?
PH - abbreviation
A progressive type of high blood pressure that affects arteries in the lungs and the right side of the heart, making it harder to breathe.
What are common treatments for pulmonary hypertension?
Diuretics, Vasodilators, Oxygen
What is a disposition?
saiojda@@@@@@sojdasodja
Which of the following is an appropriate definition for a differential diagnosis?
FIND ANSWER
A list of possible conditions or diseases the patient is concerned they may have
A list of conditions or diseases the patient has experienced in the past
A list of possible conditions or diseases that could be causing the patient’s symptoms
A list of possible conditions or diseases the patienr’s family members believe the patient may be experiencing
Which of the following are sections of a patient’s medical record
Past Medical History Review of Sections Present Examination Review of Systems History of Patient's Symptoms Medical History Making History of Present Illness Past Symptom History Physical Examination
Which of the following are considered diagnostic studies?
Differential diagnosis Consultations Labs Procedures Imagine Re-evaluations
What is the name for the clinical summation of information and/or the opnion based on the patient’s symptoms, their clinical hisotyr, and the outcome of the objective data?
Plan
diagnosis
patient education
Disposition
Who provides the findings that are documented in the Physical Exam?
Medical Provider
Medical Scribe
Patient
Patient’s Family
Which of the following is NOT a recognized body system in charting?
Intellegumentary
ANSWER HERE
Which of the following would be included in the plan?
Changes in medications/ new medications being prescribed
Conversations with other providers during the treatment of the patient
Orders for labs, imaging, or other additional testing
A list of symptoms reported by the patient
All communications with nursing staff
Referrals to other healthcare professions
What is the purpose of an Electronic Health Record? (EHR)
An EHR is a computer program that houses the patient’s medical records
(ANSWERED HERE)
Who will perform a physical examination of a patient?
The provider will do this and the scribe will document this in the patient’s note
For a physical examination, will a provider run the same physical exam for each patient?
Yes, they typically would. Depends on the patient.
What are some examples of body systems that are represented in the physical exam?
Constitutional Skin Head/Neck Eyes ENT Lymphatics Cardiovascular Repiratory/Chest Wall Gastrointestinal Gentiourinary Musculorskeletal/Back/Extremeties Neurological Psychiatric
All findings are OBJECTIVE
Within each body system, there will what kind of findings made by the medical provider?
(Physical Exam - Body Systems)
“normal” findings or “abnormal” findings
EX: Normal finding: no acute distress
Abnormal finding: Moderate respiratory distress
What is an example of a Normal Physical Exam?
Constitutional: Alert. No acute distress
Skin: Warm. Dry. Intact.
Head/Neck: Normocephalic. Atraumatic. Neck soft and supple. Trachea Midline
Eye: PERRL. EOMI. Normal conjunctiva
ENT: TMs clear. Moist mucous membranes. No pharyngeal erythema or exudate
Lymphatics: No lymphadenopathy
Cardiovascular: Regular rate and rhythm. No murmur. No edema
Respiratory/Chest Wall: Lungs CTA. Non-labored respirations. No wheezes, rales, or rhonchi. No chest wall tenderness or deformity
Gastrointestinal: Soft. Nontender. Nondistented. No rebound or gurading
Genitourinary: Normal external genitalia
Musculoskeletal/Back/Extremities: Normal ROM of back and extremities. Normal strength. No back or extremity tenderness. No swelling. No deformities.
Neurological: A/O x4. Cranial nerves II-XII intact. No focal neurological deficits. Normal speech.
Psychiatric: Cooperative. Normal affect.
Example physical exam with normal and Abnormal findings
Constitutional: Alert. ““MODERATE ACUTE DISTRESS””
Skin: Warm. Dry. Intact.
Head/Neck: Normocephalic. Atraumatic. Neck soft and supple. Trachea midline.
Eye: PERRL. EOMI. Normal conjunctiva.
ENT: TMs clear. Moist mucous membranes. No pharyngeal erythema or exudate
Lymphatics: No lymphadenopathy
Cardiovascular: Tachycardic rate and regular rhythm. No murmur. No edema.
Respiratory/Chest Wall: Non-labored respirations. RLL Rhonchi. No wheezes or rales. No chest wall tenderness or deformity
Gastrointestinal: Soft. Nontender. Non distended. No rebound or guarding.
Genitourinary: Normal external genitalia
Musculoskeletal/Back/Extremities: Normal ROM of back and extremities. Normal strength. No back or extremity tenderness. No swelling. No deformities.
Neurological: A/O x4 Cranial nerves II-XII intact. No focal neurologic deficits. Normal Speech.
Psychiatric: Cooperative. Normal affect.
Will some physical exams findings fit more than one body system?
Yeah, they may also contradict finding in another system, so just cognizant when recording exams
What does constitutional mean when it comes to the body system?
The patient’s overall appearance and presentation
Common normal constitutional findings:
Alert
No acute distress
Well-developed well-nourished
When it comes to constitutional, what are some examples of normal findings? what about an abnormal finding?
Normal - Alert
Abnormal - Somnolent, Obtunded, Unresponsive
What does Alert mean when it comes to constitutional findings
Awake and responsive to all stimuli
What does Somnolent mean when it comes to constitutional findings
Abnormally drowsy, but able to be aroused
What does obtunded mean when it comes to constitutional findings
Awake but not alert
What does unresponsive mean when it comes to constitutional findings
Unconscious and unrousable to any stimuli
What are normal findings when it comes to constitutional findings? what about abnormal findings?
Normal - No acute distress
Abnormal findings - Mild distress, Moderate distress, Severe distress
What does no acute distress mean when it comes to constitutional findings?
Stable and will not become unstable within 5 minutes
NORMAL FINDING
What does mild distress mean when it comes to constitutional findings?
Stable, but may become unstable
ABNORMAL
What does moderate distress mean when it comes to constitutional findings?
It means stable, but likely to become unstable
ABNORMAL
What does severe distress mean when it comes to constitutional findings?
More unstable than stable
What are normal constitutional findings? What about abnormal constitutional findings?
Normal = Well-developed, Well-nourished
Abnormal = Cachectic, ill-appearing, Obese grossly overweight
What does Well-developed/ Well-nourished mean when it comes to constitutional findings?
Healthy weight and appearance
What does Cachetic mean when it comes to constitutional findings?
Body wasting due to severe chronic illness
What does ill-appearing mean when it comes to constitutional findings?
Looks to be sick
What does obese mean when it comes to constitutional findings?
Grossly overweight
What are the list of terms that are related to the skin and integumentary system?
BODY System: Skin
Common normal skin findings: Warm Dry Pink Intact No signs of infection No rashes No signs of trauma
What are normal findings when it comes skin findings? What about abnormal findings when it comes to skin findings?
Normal - Warm (Normal skin temp)
Abnormal - Cool (Lower than norm skin temp)
What are normal findings when it comes to skin findings? what are abnormal findings?
Normal - Dry
Abnormal - Moist, Clammy, Diaphoretic
What does dry mean when it comes to skin findings?
Normal skin condition without moisture
What does moist mean when it comes to abnormal skin findings?
Slightly, or moderately damp (ABNORMAL)
What does clammy mean when it comes to skin findings?
abnormal
Wet or sweaty skin
abnormal
What does diaphoretic mean when it comes
to skin findings?
Abnormally heavy sweating
ABNORMAL
What does pink mean when it comes to skin findings?
Normally colored skin ethnicity
NORMAL
What does Jaundice mean when it comes to skin findings?
Yellowing of the skin
ABNORMAL!!
What does Cyanotic mean when it comes to skin findings?
Bluish discoloration of the skin
ABNORMAL
What does pale mean when it comes to skin findings?
Loss of normal color of the skin
ABNORMAL
What are normal terms when it comes to skin findings? What are abnormal terms when it comes to skin findings?
Normal - Pink
Abnormal - Jaundice, Cyanotic Pale
What does intact mean when it comes to skin findings?
Skin is without injury (NORMAL)
What are normal terms when it comes to skin findings? What are abnormal terms when it comes to skin findings?
Normal - Intact
Abnormal - Laceration, Abrasion, Avulsion, Lesion
What does laceration mean (skin finding)?
Cut in the skin
(Abnormal(
What does abrasion mean?
Scrape
Abnormal
What does avulsion mean?
Injury from skin that was torn away
Abnormal
What does lesion mean?
Can be used to describe any abnormal change to the skin
Abnormal
What are normal terms when it comes to skin findings? What are abnormal terms when it comes to skin findings?
Normal findings - no skin infection
abnormal findings - fluctuance, induration, erythema,
purulent drainage, lymphangitis
What is fluctuance?
Moveable and compressible
ABNORMAL SKIN FINDING
What is induration?
Increase in fibrous tissue, resulting in loss of elasticity
ABNORMAL SKIN FINDING
What is erythema?
Redness
ABNORMAL SKIN FINDING
What is purulent drainage?
Discharge of pus
ABNORMAL SKIN FINDING
What is lymphangitis?
Streaking redness
ABNORMAL SKIN FINDING
What are normal terms when it comes to skin findings? What are abnormal terms when it comes to skin findings?
Normal - no rashes
Abnormal - Urticaria, Petechiae, Vesicles
What does urticaria mean when it comes to skin findings?
This means hives
abnormal
What does petechiae mean when it comes to skin findings?
Pinpoint flat, round, red spots under the skin surface
abnormal
What does vesicles mean when it comes to skin findings?
Blister
abnormal
What are normal terms when it comes to skin findings? What are abnormal terms when it comes to skin findings?
Normal - no signs of trauma
Abnormal - hematoma, ecchymosis
What does hematoma mean when it comes to skin findings
Solid swelling of clotted blood within the tissues
abnormal
What does Ecchymosis mean when it comes to skin findings?
Superficial bruising
abnormal
What are findings related to the head, neck
(excluding neurologic findings), and C-spine?
Common normal head/neck findings:
Normocephalic Atraumatic No head tenderness Supple Trachea midline No JVD No cervical lymphadenopathy No carotid bruit No neck tenderness No deformity
What are normal terms when it comes to head findings? What are abnormal terms when it comes to head findings?
Normal - Normocephalic
Abnormal Findings - Craniectomy Skull Malformations
What does normocepahlic mean when it comes to head findings?
Normally shaped head ( normal )
What does carniectomy mean when it comes to head findings?
Removal of part of the skull
abnormal
What does skull malformations mean when it comes to head findings?
abnormally shaped skull or facial bones
What are normal terms when it comes to head findings? What are abnormal terms when it comes to head findings?
Normal - Atraumatic
Abnormal - Battle sign, Contusions, Lacerations, Hematomas, Ecchymosis
What does atraumatic mean when it comes to head findings?
without trauma, injury (normal)
what does battle sign mean when it comes to head findings?
bruising to the skull behind the ear (abnormal)
What does contusion mean when it comes to head findings?
deep bruising
What are normal terms when it comes to head findings? What are abnormal terms when it comes to head findings?
Normal - no tenderness
Abnormal findings - Skull tenderness, Sinus tenderness
What does skull tenderness mean when it comes to head findings?
pain with pressure applied to the skull (abnormal)
What does sinus mean when it comes to head findings?
Pain with pressure applied above the sinuses
abnormal
What are normal terms when it comes to head findings? What are abnormal terms when it comes to head findings?
Normal - supple
abnormal - nuchal rigidity
What does supple mean when it comes to head findings?
Neck can be easily bent ( NORMAL)
What does nuchal rigidity mean it comes to neck findings?
Neck stiffness in meningitis
abnormal
What are normal terms when it comes to neck findings? What are abnormal terms when it comes to neck findings?
Normal - Trachea midline
Abnormal - Deviation
What does trachea midline mean when it comes to neck findings?
Trachea is centered
normal
What does trachea midline mean when it comes to neck findings?
Trachea is off-center
abnormal
What are normal findings when it comes to neck findings?
What about abnormal findings?
Normal finding - No JVD
Abnormal Finding - JVD
What does JVD mean when it comes to neck findings?
Jugular vein distention
What is a normal finding when it comes to neck findings?
What about an abnormal finding?
Normal finding - No cervical lymphadenopathy
Abnormal finding- - Cervical lymphadenopathy
What does Cervical lymphadenopathy mean when it comes to neck findings?
Swelling of the cervical lymph nodes under the ear
What are normal findings when it comes to neck findings?
What about abnormal?
No carotid bruit - Normal
Carotid bruit - Abnormal
What does carotid bruit mean when it comes to neck findings?
a vascular murmur heard in the carotid
What are abnormal findings when it comes to neck findings?
What about abnormal findings?
Normal - no tender
Abnormal findings - c-spine tenderness, paraspinal muscle
tenderness
trapezius tenderness
What does c-spine tenderness mean when it comes to neck findings?
Pain pressure applied to the bony spine (abnormal)
What does paraspinal muscle tenderness when it comes
to neck findings?
Tenderness of the muscles connected to the spine
abnormal
What does trapezius tenderness mean when it comes to the
neck findings?
Pain with pressure applied to the triangular shaped
muscles on either side of the C-spine
What are normal findings when it comes to neck findings?
What are abnormal findings when it comes to neck findings?
Normal - no deformity
Abnormal - bony crepitus, Step-offs
What does bony crepitus when it comes to neck findings?
Crackling sound produced by the rubbing together of ragments of fractured bone
(abnormal)
What are step-offs when it comes to neck findings?
Malalignment of bones that can be felt or seen
ABNORMAL
What is under the body system, eyes?
All findings related to the eyes, eyelids, and vision.
What are common normal eye findings?
PERRLA
EOMI
Norma conjunctiva
Anicteric sclera
What are normal eye findings?
What about abnormal eye findings?
Normal - PERRLA
Abnormal - Sluggish pupils, Blown pupil
Dilated pupils
Fixed pupils
What is PERRLA? ( Eye finding)
Pupils are Equal, Round, and Reactive to Light Accomodation
NROMAL
What are sluggish pupils when it comes to eye findings?
Slow to react to tracking light
abnormal
What are blown pupils when it comes to eye findings?
One pupil is noticeabley larger in size and doesn’t react
to light
What are dilated pupils when it comes to eye findings?
Larger than normal pupils that still react to light
Abnormal
What are fixed pupils when it comes to eye findings?
Pupils that are do not react to light
What are eye findings that are normal ?
abnormal?
Normal - EOMI
Abnormal - Nystagmus, Entrapment
What is EOMI mean when it comes to an eye finding?
Extraocular Movement Intact
NORMAL
What does Nystagmus mean when it comes to eye findings?
Involuntary and horizontal vertical eye movement
abnormal
What is entrapment when it comes to eye findings?
Inability to move eye
What are normal findings when it comes to eye finding?
What about abnormal findings?
Normal - normal conjunctiva
Abnormal - Injected conjunctiva, Pale conjunctiva
What does Conjunctiva mean when it comes to eye findings?
Tissue that lines the surface of the eyelids
and covers the surface of the sclera
(Normal)
What does injected conjunctiva mean when it
comes to eye findings?
Redness of the conjunctiva
abnormal
What does pale conjunctiva mean when it comes to eye findings?
Paleness of the conjunctiva
abnormal
What are normal findings when it ccomes to
eye findings? WHat about abnormal?
Normal - Anicteric sclera
Abnormal - Sclera Icterus
What does Anicteric sclera mean when it comes
to eye findings?
Normal (white) sclera
NORMAL
What does Scleral Icterus mean when it
comes to eye findings?
Yellow discoloration of the sclera
abnormal
What does ENMT stand for?
Ears, nose, mouth, throat
What are common ENMT findings?
ENMT Body SYSTEM
TMs clear
Normal nares
Moist mucous membranes
Normal Oropharynx
(Master list)
What are normal findings when it comes to ENMT
Findings?
What about abnormal?
TMs clear - Normal
Abnormal: Retracted TM Bulging TM Eruthematous TM Dull TM Hemotympanum TM obscured by cerumen
What does TMs clear mean when it comes to ENMT findings?
This means normal tympanic membranes
Normal
What does retracted or bulging tms mean
when it comes ENMT Findings?
Dperessed of swollen tympanic membrane
Abnormal
What does erythematous TM mean when it comes
to ENMT findings?
Redness of inner ear
abnormal
