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?
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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
What does Hemotympanum mean when it comes
to ENMT findings?
Blood behind the tympanic membrane
abnormal
What does obscured TM mean when it comes
to ENMT findings?
Hard-to-see TM, often due to too much earwax
Abnormal
What are normal findings when it comes ENMT
findings? What about abnormal?
Normal - Normal nares (nostrils)
Abnormal findings - Epistaxis Rhinorrhea Septal hematoma Boggy turbinates Nasal deformity
What does Epistaxis mean when it comes to
ENMT findings?
Bloody nose ( abnormal)
What does Rhinorrhea mean when it comes
to ENMT findings?
Clear or colored drainage from nose ( not blood)
ABNORMAL
What does septal hematoma mean when it
comes to ENMT findings?
Blood collection in the area between nares
abnormal
What does nasal deformity mean when it comes to
ENMT findings?
Abnormality in the structure of the nose
ABNORMAL
What are normal findings when it
comes to ENMT findings? What about
abnormal findings?
Moist mucous membranes - NORMAL
Dry Mucous membranes - ABNORMAL
What does Moist mucous membranes mean when
it comes to ENMT findings?
Well-hydrated membranes such as oral (mouth)
nasal (nose), and ocular (eyes)
(NORMAL FINDING)
What does dry mucous membrane mean when it comes
to ENMT findings?
Abnormal dyness of membranes
ABNORMAL
What are normal findings when it comes to
ENMT findings?
What about abnormal findings?
Normal finding - Normal oropharynx
Abnormal Findings - Dental caries, Edentulous, Gingival abscess Tonsillar hypertrophy Pharyngeal erythema Pharyngeal exudates Cobblestoning
What does Oropharynx mean when it comes to
ENMT findings?
The part of the throat that is at the back of the mouth
NORMAL
What does dental caries mean when it
comes to ENMT findings?
Dental decay
What does Edentulous mean when it comes to
ENMT findings?
Without teeth
ABNORMAL
What does gingival abscess mean when it comes
to ENMT findings?
Infectious fluid collection of the gums
abnormal
What does tonsillar hypertrophy mean when it comes to ENMT findings?
Enlarged tonsils
Abnormal
What does Pharyngeal erythema mean when it comes
to ENMT findings?
Swelling of the throat
Abnormal
What does pharyngeal exudate mean
when it comes ENMT findings?
Gray/White coating of the throat
ABNORMAL
What does cobblestoning mean when it
comes to ENMT findings?
Lumpy appearance of throat
ABNORMAL
What are common normal lymphatic findings?
ALL NORMAL FOR THE CATEGORY OF LYMPHATICS BODY SYSTEM
No lymphadenopathy
What is an normal finding when it comes to Lympathic
findings? What about abnormal?
No lymphadenopathy ( Normal) Lymphadenopathy (Abnormal)
What does Lymphadenopathy mean when it comes
to ENMT findings?
Swelling of the lymph nodes
ABnormal
What are all common normal cardiovascular
findings?
(BODY SYSTEM: CARDIOVASCULAR)
Regular rate Regular rhythm No edema Good capillary Refill Strong, equal distal pulses Normal heart sounds
What are normal findings when it comes to cardiovascualr
findings?
Regular rate - normal
Tachycardia - abnormal
Bradycardia - abnormal
What does regular rate mean when it comes to
cardiovascular findings?
Heart beat between 60 and 100 bpm
Normal
What does Tachycardia mean when it comes to
Cardiovascular findings?
Fast heart rate (>100 bpm)
abnormal
What does bradycardia mean when it comes to
cardiovascular findings?
slow heart rate
>60 bpm
What are normal cardiovasuclar findings?
What are abnormal cardiovascular findings?
Normal - regular rhythm
Abnormal - Arrhythmia, Atrial fibrillation
What does Regular rhythm mean it comes
to cardiovascular findings?
Steady beating of the heart in typical “lub/dub” pattern
Normal
What does arrhythmia mean when it comes to
Cardiovascular findings?
Irregular rhythm
ABNORMAL
What does Atrial fibrillation mean when it comes to Cardiovascular findings?
Irregularly, irregular rhythm
ABNORMAL
What are some normal findings when it comes
to Cardiovascular findings? What are
abnormal findings?
No edema - NORMAL
Peripheral Edema - ABNORMAL
What does Edema mean when it comes to
cardiovascular findings?
Swelling caused by excess fluid trapped in the body’s tissues
(Abnormal)
What does peripheral edema mean when it comes
to cardiovascular findings?
Swelling in the extremities
ABNORMAL
What are some normal cardiovascular
findings? What about abnormal findings?
Normal - Good cap(illary) refill
Abnormal - Delayred cap(illary) refill
What does Capillary refill mean when it comes to
Cardiovascular findings?
The time it takes for the capillaries to refill after
being compressed
What does good capillary refill mean when it
comes to cardiovascular findings?
Capillaries take < 2 seconds to refill after compression
NORMAL
What does delayed capillary refill mean
when it comes to cardiovascular findings?
Capillaries take > 2 seconds to refill after
compression
(ABNORMAL)
What are some normal findings when it comes to
Cardio vascular findings?
What about abnormal)
Strong, equal, distal pulses, (2+) - Normal finding
Absent pulse (0+) - (ABNORMAL) Bounding (4+) (ABNORMAL)
What does Distal pulses mean
when it comes to Cardiovascular findings?
Pulses in the extremities:
1) Radial (arm)
2) Carotid (neck)
3) Femoral (thigh)
4) Dorsalis pedis (DP, top of foot)
5) Posterior tibialis (PT, back of the ankle)
What does strong, equal distal pulses mean
when it comes cardiovascular findings?
2+ pulses at the same location in bilateral extremeities
are similar and easily detectable
(NORMAL)
What does Absent pulse mean when it comes to
cardivascular findings?
0+ Pulse, unable to be felt
ABNORMAL
What does bounding pulse mean when it comes
to Cardiovascular findings?
4+ pulse, abnormally strong or fast
ABNORMAL
What are some normal findings when it comes
to cardiovascular findings? What about abnormal?
Normal heart sounds - Normal
Rubs, Gallops, Murmurs - Abnormal
What does Normal heart sounds mean when it
comes to Cardiovascular findings?
“Lub dub” sound that occurs in sequence
NORMAL
What does Rubs mean when it
comes to Cardiovascular findings?
Sound caused by the rubbing together of two serious
surfaces
(ABNORMAL)
What does Gallops mean when it
comes to Cardiovascular findings?
Three distinct sounds with each heartbeat
ABNORMAL
What does Murmur mean when it comes to
Cardiovascular findings?
Sound made by vibrations from blood throw through
the heart
(ABNORMAL)
What are common normal respiratory and chest
wall findings?
(MASTER LIST - BODY SYSTEM: RESPIRATORY/CHEST
WALL)
These are all findings related to the lungs, respirations, chest wall, and breasts in females. (excludes cardiac findings)
Lungs CTA Equal breath sounds Non-labored respirations No chest wall tenderness No chest wall deformity Normal breast exam
What are normal findings related to the
respiratory system? what about abnormal?
Normal - Lung CTA
Abnormal - Wheezes, Crackles, Rales, Rhonchi, Stridor
What is Lung CTA when it comes to respiratory
CTA?
Lungs are clear to auscultation (listening)
NORMAL
What does wheezes mean when it comes to Respiratory findings?
A high-pitch whistling sound made while breathing
Abnormal
What does Crackles mean when it comes to Respiratory findings?
Discontinous clicking or rattling sounds
Abnormal
What does Crackles mean when it comes to Respiratory findings?
Discontinuous clicking or rattling sounds
Abnormal
What does Rales mean when it comes to
respiratory findings?
Cackling breath sound
Abnormal
What does Rhonchi mean when it comes
to Respiratory findings?
Rattling breath sounds
Abnormal
What does stridor mean
when it comes to respiratory findings?
Whistling, musical breath sounds with inspiration ( ABNORMAL)
What are some normal findings when
it comes to respiratory findings?
What about abnormal?
Equal breath sounds - normal
Diminished breath sounds - abnormal
What does breath sounds equal mean when it comes
to respiratory findings?
Sounds heard from the lungs are equal
NORMAL
What does dminished breath sounds mean
when it comes to respiratory findings?
Lack of airflow in the lungs
abnormal
What are some normal findings/ abnormal
findings when it comes to respiratory findings?
Non-labored respirations - NORMAL
Tachypnea, Bradypnea, Apnea - ABNORMAL
What does non-labored respirations mean when it comes to
respiratory findings?
Normal breathing rate without exertion - NORMAL
What does tachypnea mean when it comes to
respiratory findings?
Abnormally rapid breathing
ABNORMAL
What does bradypnea mean when it comes
to respiratory findings?
Abnormally slow breathing
Abnormal
What does Apnea mean when it comes to respiratory findings?
Absence of breathing
ABNORMAL
What are some chest wall findings that are
normal/abnormal?
Normal - No chest wall tenderness
Abnormal - Tenderness
What does tenderness mean when it comes
to chest wall findings?
Pain with applied pressure
ABNORMAL
What are some chest wall findings that
are normal/abnormal?
No deformity - Normal finding
ABNORMAL BELOW
Crepitus, Seat belt sign, Ecchymosis, Emphysema
What does no deformity mean when it comes to chest wall findings?
No abnormal structural changes (normal)
What does crepitus mean when it comes to
chest wall findings?
Crackling, crinkly or grating feeling or sound under the skin (ABNORMAL)
What does seat belt sign mean when it comes
to chest wall findings?
Bruising/abrasions in the distribution of a seat belt
ABNORMAL
What does Emphysema mean when it comes to
Chest Wall findings?
Air that is abnormally present in the tissues
Abnormal
What are some chest wall findings that relate
to the females only?
Normal breast exam - Female only
Abnormal Findings - Masses, Nipple discharge, tenderness
What does normal breast exam mean when it comes to
chest wall findings?
Bilateral breasts are symmetrical, nontender, without masses, skin or nipple changes
(NORMAL)
What are breast masses when it comes
to chest wall findings?
Localized swelling that feels different
from surrounding tissue
(ABNORMAL)
What does nipple discharge mean
when it comes to chest wall findings?
Any abnormal fluid or other liquid that
comes out of the nipple
(ABNORMAL)
What does breast tenderness mean
when it comes to chest wall
findings?
Pain with applied pressure
Abnormal
What are a list of all common normal respiratory and chest wall findings?
(BODY SYSTEM: Gastrointestinal)
Soft Nontender Nondistended Normal bowel sounds No palpable masses Normal rectal exam
What are some normal findings when it comes to gastrointestinal
findings? WHat about abnormal?
Normal - SOFT
Abnormal - Rigid (Involuntary guarding)
What does soft mean when it comes to gastrointestinal findings?
Abdomen is easily compressed
Normal
What does rigid mean when it comes to gastrointestinal
findings?
Stiffness of the stomach muscles
abnormal
What are some normal/ abnormal findings when it comes
to gastrointestinal findings?
Nontender - normal
ABNORMAL BELOW: Mild tenderness Moderate tenderness Severe tenderness Rebound tenderness Voluntary guarding Murphy's sign Mcburney's point tendrness Psoas sign Obturator sign Rovsing's sign
What does nontender mean when it comes to gastrointestinal
findings?
No pain with applied pressure
What does tenderness mean when it comes to gastrointestinal findings?
Pain with applied pressure can be anywhere between barely noticeable
(mild) to debilitating (severe)
(ABNORMAL)
What does rebound tenderness mean when it
comes to gastrointestinal findings?
Tenderness that occurs upon release
of pressure on the abdomen (ABNORMAL)
What does guarding mean when it comes to gastrointestinal
findings?
An involuntary or voluntary response to prevent pain caused
by pressure applied to the abdomen
(abnormal)
What does murphy’s sign mean when it comes to gastro-
intestinal findings?
Right upper quadrant sign of cholecystitis
Abnormal
What does Mcburney’s point of tenderness
Psoas sign
Obturator sign
Rovsing’s sign
all mean??
Right lower quadrant sign of the appendicitis
What are some normal /abnormal findings for gastrointestinal findings?
Nondistended - NORMAL
Distended - Abnormal
What does nondistended mean when it comes to gastrointestinal findings?
Abdomen is normal sized
Normal!
What does Distended mean when it comes to gastrointestinal findings?
Occurs when substances, such as air or fluid accumulate
in the abdomen causing its expansion
(Abnormal)
What are some normal/ abnormal findings when it comes to gastrointestinal findings?
Normal - Normal bowel sounds
Abnormal - Absent, Hyperactive, Hypoactive
What does normal bowel sounds mean when it comes to gastrointestinal findings?
Consist of clicks and gurgles and 5-30 per minute
normal
What does absent mean when it comes to gastrointestinal
findings?
No bowel sounds heard on auscultation
abnormal
What does hyperactive mean when it comes to gastrointestinal
findings?
Increased bowel sounds heard on auscultation
Abnormal
What does hypoactive mean when it comes to gastrointestinal
findings?
Decreased bowel sounds heard on auscultation
Abnormal
What are some normal/abnormal findings when it comes to
gastrointestinal findings?
Normal - No palpable masses
Abnormal Findings - hernia (umbilical, inguinal, etc/ reducible, unable to reduce)
What does palpable masses mean when iti comes to gastrointestinal findings
Any abnormal bulge felt through the skin
Abnormal
What does hernia mean when it comes to gastrointestinal
findings?
A bulging of an organ or tissue through an
abnormal opening
(Abnormal)
What are some normal / abnormal findings when it comes to gastrointestinal findings?
NORMAL:: Normal tone Brown stool Guaiac negative No hemorrhoids
ABNORMAL:: Decreased toned Black (melanotic), red, white stool Guaiac positive Internal/external/thrombosed hemorrhoids
What are rectal tones when it comes to gastrointestinal
findings?
Strength of the rectal muscles
What are melanotic stool when it comes to gastrointestinal findings?
Black tarry stool
ABNORMAL
What does guaiac positive/negative mean when it comes
to gastrointestinal findings?
Stool that is positive or negative for blood
if negative = normal, if positive = abnormal
What does hemorrhoids mean when it comes to gastrointestinal findings?
Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding
(if none hemrrohoid then normal!)
What do thrombosed hemorrhoids mean when it comes
to gastrointestinal findings?
An internal or external hemorrhoid that has filled with blood
clots
(abnormal)
What are all common normal genitourinary findings?
(Body system Genitourinary!!! - this relates to the urinary tract
and genitalia)
Normal external female genitalia
Normal bimanual exam
Normal speculum exam
Normal external male genitalia
What are some normal findings when it comes to genitourinary
findings?
Normal external female genitalia - NORMAL
Sores, Lesions, Rashes - Abnormal
What does Normal external female genitalia mean when it
comes to genitourinary findings?
Normal vula ( mons pubis, labia majora, labia minora, bartholin glands, and clitoris)
(Normal)
What do sores/lesions mean when it comes to genitourinary
findings?
Bumps on or around the vulva that may be itchy, painful
or produce discharge
(Abnormal)
What do rashes mean when it comes to genitourinary findings?
A spread of bumps, lesions, or irregular patches
of skin on the genitals
(Abnormal)
What are some normal findings when it comes to genitourinary
findings?
Normal bimanual exam ( female only ) - NORMAL
Cervical motion tenderness, Adnexal tenderness ( ABNORMAL)
What does bimanual exam mean when it comes to
genitourinary findings?
Method of evaluating the size, shape, and position of the
uterus
(NORMAL)
What does the normal bimanual exam mean when it comes to
genitourinary findings?
No pain with exam ( normal)
What does cervical motion tenderness mean when it
comes to genitourinary findings?
Pelvic exam finding characteristic for pelvic inflammatory disease
(PID)
(ABNORMAL)
What does adnexal tenderness mean when it comes to genitourinary
findings?
Pain caused by an adnexal mass, such as an ovarian cyst
or ecotopic pregnancy
(ABNORMAL)
What are some normal/abnormal findings when it comes to genitourinary findings?
Normal - Normal speculum exam: cervical os closed no blood or
dischare in the vaginal vault
Abnormal - Cervical os open blood or malodorous/ discolored discharge
in the vault
What does Cervical OS mean when it comes to Genitourinary
Findings?
Opening of the cervix, when open indicates fetus
or egg will be passing through from the
uterus
(Abnormal)
What does Vaginal Discharge mean when it comes to genitourniary findings?
A mix of fluid and cells form the vagina that varies in color and consistency possible associated with an odor
(Abnormal)
What are some normal /abnormal findings when it comes to genitourinary findings?
Normal - Normal external male genitalia, Circumsized/uncircumsized
Abnormal -
Penile lesions, Penile Sores, Uretheral discharge
Indwelling catheter, Testicular tenderness, Scrotal Swelling,
Testicular mass
Inguinal hernia
What does urethral discharge mean when it comes to
genitourinary findings?
Abnormal purulent or mucoid secretions from the penis
Abnormal
What does circumsized/ uncircumsized mean when it comes
to genitourinary findings?
surgically removed foreskin/foreskin intact
normal
What does penile lesions/ sores mean when it comes to
genitourinary findings?
Bumps on or or around the penis that may be itchy, painful,
or produce discharge; may also be present on the scrotum
(Abnormal)
What does indwelling catheter mean when it comes to genitoruniary findings?
A.k.a. foley catheter, which can be left in the bladder to drain
urine
(Abnormal)
What does testicular tenderness mean when it
comes to genitourinary findings?
Pain when pressure is applied to on or both testicles
Abnormal
What does scrotal swelling mean when it comes to genitourinary findings?
an enlargement of the scrotal sac, which houses the testicles
What does testicular/ scrotal mass mean when it comes to
genitourinary findings?
An abnormal bulge or lump in the testicles inside the scrotum
(Abnormal)
What does inguinal hernia mean when it comes
to Genitourinary findings?
Hernia that forms in the region of the groin
ABNORMAL
What are common normal musculoskeletal, back, and extremity
findings?
(MASTERLIST: Musculoskeltal/Back/Extremities BODY SYSTEM)
ALL FINDINGS to muscles, bones, back, and extremities
Nontender bones/muscles Full range of motion (extremities) Normal muscle strength Distal neurovascular intact No bony deformity Nontender back No back deformity Full range of motion (back)
What are normal findings related to the musculoskeletal
niche?
Normal - Nontender
Abnormal Findings - Bony tenderness, Soft tissue tenderness, Calf Tenderness
What does bony tenderness mean when it comes to musculo
skeletal findings?
pain with pressure applied over the bones
abnormal
What does soft tissue tenderness mean when it comes to musculo
skeletal findings?
Pain with pressure applied over the soft tissues
abnormal
What does calf tenderness mean when it comes to musculo
skeletal findings?
Pain in the calf muscle, indicative of DVT
abnormal
What are some normal/abnormal findings when it comes
to musculoskeletal findings?
Normal - Full range of motion
Abnormal - Decreased/Limited range of motion
What does full range of motion mean when it comes to
musculoskeltal findings?
Good flexibility of a joint
normal
What does decreased/limited range of motion
mean when it comes to
musculoskeltal findings?
Poor flexibility of a join; may be limited by pain or underlying
disease/injury
(ABNORMAL)
What are some normal findings for musculoskeletal findings?
Normal - normal muscle strength
Abnormal - Muscle weakness
What is constituted as normal muscle strength?
0/5; no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against gravity
3/5: movement possible against gravity, but not against
resistance by the examiner
4/5: movement possible against some resistance by the examiner
5/5: NORMAL STR EVEYERHTING ELSE ABNORMAL
What does muscle weakness mean when it comes to
musculoskeltal findings?
Lack of muscle strength; rated on the 0 -5/5
scale
(ABNORMAL AF)
What are some normal/abnormal findings when it comes to the
muskuloskeletal findings?
Normal - Distal neurovascular intact
Abnormal - Capillary refill delay, poor distal pulses, Edema
What does Distal neurovascularly intact mean when it
comes to Musculoskeltal findings?
Distal neuro and vascular functions are normal
NORMAL
What does capillary refill delay mean when it comes to
musculoskeltal findings?
Capillary refill time in the extremities >2 seconds
ABNORMAL
What does poor distal pulses mean when it comes
to musculoskeletal findings?
Reduced or absent arterial pulses that are a sign of impaired
blood flow
(Abnormal)
What does Edema mean when it comes to Musculoskeletal findings?
Swelling caused by excess fluid trapped in the body’s tissues
(ABNORMAL)
What are some normal/ abnormal findings when it comes
to Musculoskeletal findings?
Normal - no deformity
Abnormal - Joint laxity, Bony crepitus, Obvious deformity
Malalignment
Palpable cords
Homan’s sign
What does no deformity mean when it comes to musculorskelteal findings?
No abnormal structural changes
What does join laxity mean when
it comes to musculoskeltal findings?
Excessive flexibility of the ligaments and
tendons
(abnormal)
What does bony crepitus mean
when it comes to musculoskeltal findings?
Crackling sound produced by the rubbing
together of fragments of fractured bone
(Abnormal)
What does obvious deformity mean
when it comes to musculoskeltal findings?
Easily apparent misshapen appearance
of a, body part, usually an extremity
What does malalignment mean when it comes to
musculoskeltal findings?
Incorrect/imperfect alignment of teeth
or bones at a joint
(Abnormal)
What does palpable cords mean when it
comes to musculoskeletal findings?
Dilated superficial veins cuased
by obstruction of the deep venous system
that are felt through the sin
(abnormal)
What does Homan’s sign mean when it
comes to musculoskeltal findings?
Calf pain with dorsiflexion of the foot,
indicative of DVT
(Abnormal )
What are some normal/abnormal findings
when it comes to the musculoskeltal
structure?
Normal - Nontender
Abnormal - T/L spine tenderness
CVA tenderness
Paraspinal muscle tenderness
What does Thoracic/Lumbar (T/L) bony spine tenderness
mean when it comes to
musculoskeletal findings?
Pain with pressure applied over the bones
of the spine
(Abnormal)
What does CVA tenderness mean when
it comes to musculoskeletal system
findings?
Pain in the costovertebral angle that overlies
the kidney
(Abnormal)
What does Paraspinal muscle tenderness
mean when it comes to muskuloskeltal
findings?
Pain in the muscles that surround and connect to the spine
ABNORMAL
What are some normal/abnormal
findings when it comes to back findings?
Normal - No deformity
Abnormal - Crepitus, Step-offs, Kyphosis
What does no deformity mean when it comes to back findings?
No abnormal structural changes
NORMAL
What does Bony crepitus mean when it comes to back findings?
Crackling sound produced by the rubbing together of fragments of fractured bone
(abnormal)
What does step-offs mean when it comes to back findings?
malalignment of bones that can be felt or seen
abnormal
What does kyphosis mean when it comes to back findings?
Excessive outward curvature of the spine, causing hunching of the back
(ABNORMAL)
What are some normal/abnormal findings when it comes to back findings?
Normal - Full range of motions
Abnormal - Decreased/ limited range of
motion
What does full range of motion mean when it
comes to back findings?
(FROM)
Good point of flexibility of the spine
NORMAL
What does decreased/limited range of motion
(ROM) mean when it comes to back findings?
Poor flexibility of a the spine; may be limited by pain
or underlying disease/injury
(ABNORMAL)
What is the master list of all the normal neurological findings?
(MASTERLIST - BODY SYSTEM NEUROLOGICAL & Related to the Brain
and the nerves)
A/O x4 Normal speech No focal neuro deficits Normal sensation Normal deep tendon reflexes Normal gait Normal finger-to-nose, heel-to-shin Negative Romberg's No meningismus
What are some normal /abnormal findings for neurological findings?
Normal : A/O x4
Abnormal: Disoriented to 1 or more Somnolent Obtunded Responsive only to voice/painful stimuli Unresponsive Does not follow commands
What does A/Ox4 mean when it comes to neurological findings?
Alert and oriented to self, place, time, and situation
NORMAL
What does disoriented mean when it comes to neurological findings?
A usually transient state of confusion especially as to time, place, or
identity
(ABNORMAL)
What does somnolent mean when it comes to neurological findings?
Abnormally drowsy, but able to be roused
ABNORMAL
What does Obtunded mean when it comes to neurological
findings?
Awake, but not alert
ABNORMAL
What does responsive to only stimuli mean
when it comes to neurological findings?
Unresponsive except to pain
ABNORMAL
What does Unresponsive mean when it comes
to neurological findings?
Unconscious and unrousable to any
stimuli
(Abnormal)
What does does not follow commands mean
when it comes to neurological findings?
Awake and possibly responsive, but will
not participate in exam as instructed
(ABNORMAL)
What are some normal/abnormal neurological
findings?
Normal - Normal speech
Abnormal - Dysarthria
Dysphasia
Aphasia
What does Dysarthria mean when it comes
to neurological findings?
Slurred or slow speech
Abnormal
What does dysphasia mean when it comes to
neurological findings?
impairment of the power of expression by or ability
to understand speech, writing
or signs
(abnornmaL)
What does aphasia mean when it comes
to neurological findings?
Inability to speak , write , or understand
language
(ABNORMAL)
What are some normal findings/ abnormal
findings when it comes to neurological findings?
Normal - No focal neurodeficits
Normal (5/5 strength)
Abnormal Findings: Extremity weakness
Pronator drift
Decreased grip strength (< 5/5)
Tremors
What does no focal neuro deficits mean when it comes to neurlogical findings?
It means normal strength
5/5 is normal strength
4/5 movement possible against some resistance
3/5 movemetn possible against gravity but
not against resistance by the examiner
2/5 movement possible, but not against
gravity
1/5 muscle flicker, but no movement
0/5 no contraction
What does extremity weakness mean when
it comes to neurological findings?
Lack of strength in the extremeties;
rated on the 0-5/5 scale
(abnormal)
What does positive pronator drift mean
when it comes to neurological findings?
Drift in one arm when a patient holds their arms
out in front of them, parallel
(abnormal)
What does grip strength mean when it
comes to neurological findings?
The force applied by the hands to squeeze
abnormal
What does tremors mean when it
comes to neurological findings?
An involuntary quivering movement
Abnormal
What are some neurological findings
both normal / abnormal?
Normal - normal sensation
Abnormal - Paresthesias
decreased sensation
What does paresthesias mean when it comes to
neurological findings?
Numbness/ tingling sensation
ABNORMAL
What are some normal findings/ abnormal
findings when it comes to neurological findings?
Normal deep tendon - NORMAL
Abnormally fast or slow reflexes - ABNORMAL
What does deep tendon reflexes mean when it comes to
neurological findings?
Muscle stretch reflexes
ABNORMAL
What does Normal DTR mean when it
comes to neurological findings?
Reflexes are symmetric and rated as 1+
2+ or 3+
(NORMAL!)
What does Abnormal DTR mean when it comes
to Neurological Findings?
Reflexes are asymmetric or rates as 0, 4+, or 5+ (too slow
[hyporflexia] or too fast [brisk])
What are some normal/abnormal findings
when it comes to neurological findings?
NORMAL - Cranial Nerves II- XII intact
ABNORMAL - Changes in neuro functions
that affect eyes to upper shoulders, including
the eyes
What is the coding sheet for cranial
nerves?
II- sight III- eye movements IV - eye movements V - trigeminal nerve VI - eye movements VII - facial expression VIII - hearing and balance IX - oral sensation, taste, and salivation X - Vagus nerve XI- shoulder elevation and head- turning XII- tongue movement
Normal finding = Cranial Nerves II- XII intact??
What are some normal/abnormal findings on neurological
findings?
Normal - Normal gait
Abnormal - Ataxia
What does normal gait mean when it comes
to neurological findings?
Ability to walk in a straight line without loss of balance (NORMAL)
What does ataxia mean when it comes
to neurological findings?
Lack of voluntary coordination of muscle movements
abnormal
What are some abnormal + normal findings when it
comes to neurological findings?
NORMAL: Normal finger-to-nose
heel-to-shin
ABNORMAL: Dysmetria
What does finger-to-nose mean when
it comes to neurological findings?
The patient is instructed to touch the examiners
finger, then their own nose using the index finger
(NORMAL)
What is heel-to-shin mean when it comes
to Neurological findings?
The patient is instructed to slide the heel of their
foot down the top of the opposite shin as
quickly as possible without mistakes
(NORMAL)
What is dysmetria when it comes to
neurological findings?
The undershoot or overshoot of inteded
position; type of ataxia
(abnormal)
What are some normal and abnormal
signs when it comes to neurological findings?
Normal : NEGATIVE romberg’s sign
Abnormal: Positive Romberg’s sign
What does Negative Romberg’s sign
mean when it comes to neurological findings?
No loss of balance while standing in place
with eyes closed versus open
(NORMAL)
What does positive romberg’s sign mean
when it comes to neurological findings?
Increased loss of balance while standing in
place with eyes closed versus open
(ABNORMAL)
What are some normal/abnormal findings
when it comes to neurological findings?
Normal - No meningismus
Abnormal findings: Meningismus
What does meningismus mean when it
comes to neurological findings?
Meningeal irritation with symptoms suggesting
meningitis
(ABNORMAL)
What are all the findings related to the behavirs
and mental state of the patient….
Common normal psychiatric findings?
(MASTER-LIST OF FINDINGS FOR
PSYCHIATRIC BODY SYSTEM all normal
terms)
Cooperative behavior
Appropriate mood and affect
Normal judgement
Non-suicidal
What are some normal and abnormal
findings when it comes to psychiatric
findings?
Normal - Cooperative behavior
Abnormal - Uncooperative, Belligerent, Relaxed
What does Cooperative mean when it comes to
psychiatric findings?
Agreeable and participated in exam without
issue
(NORMAL)
What does uncooperative mean when it
comes to psychiatric findings?
unagreeable and refuses to participate
in exam
(ABNORMAL)
What does belligerent mean when it
comes to psychiatric findings?
Hostile and aggressive
ABNORMAL
What does relaxed mean when it comes
to psychiatric findings?
Calm demeanor
ABNORMAL
What are some normal and abnormal
findings when it comes to psychiatric
findings?
Normal - Appropriate mood and affect
Abnormal - Anxious, Depressed, Tearful
Hostile, Flat, Paranoid
What does appropriate mood and affect
mean when it comes to psychiatric findings?
behaving appropriately to context and
situation
(NORMAL)
What does anxious mean when it comes
to psychiatric findings?
Experiencing worry, unease, or nervousness
What does depressed mean when it
comes to psychiatric findings?
State of general unhappiness or despondency
Abnormal
What does tearful mean when it comes
to psychiatric findings?
Crying or inclined to cry
abnormal
What does hostile mean when it comes to
psychiatic findings?
Unfriendly; antagonistic
Abnormal
What does flat affect mean when it
comes to psychiatric findings?
diminished emotional expression
Abnormal
What does paranoid mean when it
comes to psychiatric findings?
An unrealistic distrust of others
Abnormal
What are some normal/ abnormal findings
within the psychiatric findings niche?
Normal - Normal judgement
Abnormal Findings - Appears intoxicated
What does normal judgement mean when
it comes to psychiatric understandings?
Ability to evaluate aspects of a behavior or situat
and act or react appropriately
(NORMAL)
What does appearing intoxicated mean when
it comes to psychiatric understanding?
Stimulation, excitement or impaired judgement
caused by a chemical substance, or as if
by one
(Abnormal)
What are some general/ abnormal findings
within the psychiatric findings niche?
Normal - Non-suicidal
Abnormal - (Abnormal psychotic thoughts):
Suicidal Homicidal Hallucinations Tangential Flight of ideas
What does non-suicidal mean when it
comes to psychiatric understanding?
No thoughts of self-injury
NORMAL
What does suicidal/ homicidal mean
when it comes to psychiatric understanding?
Thoughts of hurting oneself or others
ABNORMAL
What does hallucinations mean
when it comes to psychiatric understanding?
Hearing or seeing things that are not there
“abnormal””””
What does tangential mean when it
comes to psychiatric findings?
A pattern of speech characterized by oblique,
digressive, or irrelevant replies to questions
(ABNORMAL)
What does flight of ideas mean when it
comes to psychiatric findings?
A rapid of shifting of ideas with only superficial
associative connections between them
expressed as a disconnected rambling from
subject to subject
(ABNORMAL)
What does the medical decision making include and where is this most often seen? (MDM)
The MDM section includes documentation for everything
that occurred to or for the patient during their
visit.
The MDM section most often seen in Acute
Care settings. in Ambulatory Care settings, many of the sections
documented in the MDM are recoded
in their own section..
What information is documented in the MDM section? (The medical decision making section.)
Differential diagnosis Diagnostic Studies Procedures Reevaluations Consultations
What is the differential diagnosis?
aka the differential..
An initial list of possible conditions or diseases that could be causing the patient’s symptoms
What is an example of differential diagnosis?
A patient presents for evaluation complaining of a cough and shortness of breath… so the differential diagnosis is…
- Asthma
- Bronchitis
- Pneumonia
- Viral upper respiratory infection
- Influenza
Some providers may dictate a patient’s differential diagnosis to the
scribe who will…
record it verbatim into the MDM….
depends on the provider. Some may just document it themselves.
Why will provider often order diagnostic testing?
They can further narrow down from differential diagnosis to final diagnosis
Typically only one, or in rare cases two, of the differential diagnoses are determined to be the final cause a patient’s symptoms.
What are diagnostic studies?
Any form of testing used to help evaluate a patient’s condition
EX:
Labs
Imaging
Other testing, such as electrocardiograms (EKGs)
Where are diagnostic studies tests included in when documented into the
note?
They are included in the MDM in the form of orders and results
Who writes orders?
Orders are written by the provider indicating to the team what diagnostic
tests need to be completed
What are results?
A written final report from a radiologist or other healthcare professional
who interprets the raw data and creates a written summary of what the
test shows
What are laboratory studies, or labs?
They are a form of diagnostic testing which involves examning a sample of blood
urine or other bodily fluid.
What can Labs or laboratory studies help a provider with?
They can help them determine a diagnosis, plan treatment, check
to see if a treatment is working, or monitor a disease over time.
Lab tests are often part of a routine follow up to look for changes in the health
of a patient.
What are imaging studies or imaging?
A form of diagnostic testing performed with a variety of techniques that produce
pictures of the inside of a patient’s body for the purpose of making a clinical
decision, such as a treatment or diagnosis
What are some common imaging studies?
X-rays Computed (Axial) Tomography Magnetic Resonance Imaging >Magnetic Resonance Angiography >Magnetic Resonance Venography Nuclear Imaging >Ventilation/ perfusion scans >Stress tests
What are procedures?
Any activity directed at or performed on a patient with
the purpose of improving health, treating disease or injury, or determining a diagnosis
What are examples of procedures?
Foreign Body Removal Pap smear Laceration Repair Intubation CPR
What are re-evaluations?
aka reevals or reexams?
Any instance when the provider’s attention is brought back to the patient’s
case after the initial evaluation
They usually consist of updates on the patient case, such as a reassessment of the patient’s condition
What is an example of a reevaluation?
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 are reevals also known as? And are they subjective?
AKA - reevaluations or reexams
They’re actually objective!
What are consultations or consults?
Any instance when the provider speaks with another healthcare professional
for assistance on the patient’s case.
This health care professional is often a specialist in their field (Cardiologist,
Pharmacist, Social Worker, etc.) who will make recommendations on
the patient and/or their case.
What is an example of a consultation?
1809 - Called and spoke with Dr. Murphy OG/GYN, and discussed patient’s case at length. Recommended ultrasound to evaluate for ovarian cyst. Will
see patient in the ED.
Are consultations objective or subjective?
They are objective!
What is a lab study?
A form of diagnostic testing which involves examining
a sample of blood, urine, or other bodily fluid.
What do basic lab tests that are ordered the most do?
Allow the physician to evaluate multiple systems at a glance
EX: of common basic labs are…
Complete blood count
Basic metabolic panel
Comprehensive metabolic panel
What is a complete blood count or CBC?
A lab that is often ordered to look at the levels of different
levels of blood cells.
What are main components of a CBC blood count?
Red Blood Cell Count (RBC) White Blood Cell Count (WBC) Hemoglobin (Hb) Hematocrit (Hct) Platelets (Plt)
What is a red blood cell count or RBC?
A total count of the cells the body uses to transport oxygen
to and carbon dioxide away from your cells
NORMAL: Roughly 4-6 and varies from sites
What is it called if there is high red blood cell count?
Polycythemia (ABNORMAL)
What is it called if there is a low red blood cell count from a
RBC?
Anemia
What is white blood cell count or WBC?
A total count of the cells the body uses to fight infections
from bacteria, viruses, parasites, fungi, etc.
Normal range: Roughly 4 - 11
Normal ranges may vary from site to site
What is the term for high white blood cell count?
Leukocytosis!
What is the term for low blood cell count?
Leukopenia!
What does hemoglobin (Hb) and hematocrit (Hct) components
of the CBC measure?
It measures the levels of hemoglobin (blood protein) and
hematocrit (percentage of red blood cells to the whole
volume of blood) in the blood.
Normal range:
Hb: Roughly 12 - 17.5, varies by gender
Hct: Roughly 37 - 52% varies by gender
What is the term if the CBC measures a low /high level of platelets?
LOW: Thrombocytosis
HIGH: Thrombocytopenia
What is the difference between an H&H and a CBC?
H&H is a lab that is only looking at characteristics of
red blood cells.
What are the terms for high and low blood count from a
CBC blood test?
HIGH- Polycythemia
LOW - Anemia
What is the platelet (Plt)?
This is the component of the CBC that measure the level of
platelets in the blood, which are cell fragments that are responsible
for blood clotting.
What is the normal range for platelets?
Roughly 150 - 450
Varies from site to site
What is the normal range for platelets??
Roughly 150 - 450
Varies from site to site
What is a basic metabolic panel or BMP?
A lab often ordered to look at kidney function
electrolytes, acid/base balance, and the blood
glucose level, all of which have a hand in
metabolism
What are the main components of
BMP?
Glucose Calcium (Ca) Potassium (K) Sodium (Na) Chloride (Cl) Carbon dioxide/ Bicarbonate (CO2) Anion gap Blood urea nitrogen Creatinine Glomerular filtration rate (GFR)
What is the glucose component of the bMP?
This component measures the concentration of glucose (sugar) in the blood
NORMAL: Roughly 70 - 100 mg/ dL
What is the term for high/ low glucose count
in a Basic Metabolic Panel?
HIGH: Hyperglycemia
LOW: Hypoglycemia
What does the electrolyte component of BMP
measure?
It measures the concentration of
various electrolytes - Calcium (Ca), Potassium (K),
Sodium (Na), and Chloride (Cl) - in the blood
What are the normal ranges for
Calcium (Ca), Potassium (K), Sodium (Na), and
Chloride (Cl) in the blood?
Normal Range:
- Ca: 8 - 10 mg/dL
- K 3.5 - 5.0 mEq/L
- Na: 135 - 15 mEq/L
- Cl 96 - 106 mEq/L
What are the terms for high and low Ca count in a BMP?
HIGH: Hypercalcemia
LOW: Hypocalcemia
What are the terms for high / low count for Sodium (Na) in a BMP?
HIGH: Hypernatermia
LOW: Hyponatremia
What is the term for a high and low count of Potassium (K) in a BMP?
High: Hyperkalemia
Low: Hypokalemia
What is the term for high / low Chloride count in a BMP?
HIGH: Hyperchloremia
LOW: Hypochloremia
What is the carbon dioxide component of the BMP also called and what does it measure?
It is also called “bicarbonate” or “bicarb”, and it measures the concentration of carbon dioxide in the blood, which helps to balance its acidity.
What is the normal range for carbon dioxide in a BMP?
23 - 30 mEq/L
varies from site to site
What is it called when carbon dioxide count is high / low in a BMP?
High: Alkalosis
Low: Acidosis
What is the anion gap component of a BMP?
A measurement of the difference - or gap - between the negatively and positively charged electrolytes.
What happens if an anion gap is too high or too low?
It may be a sign of a disorder in the lungs, kidneys, or other organ systems.
What is the normal range for an anion gap?
Normal range: Roughly 3 - 10 mEq/L
What is the term if the anion gap is high / low?
HIGH: Acidosis
LOW: Hypoalbuminemia
What is the blood urea nitrogen or “BUN” component of a BMP and what does it measure?
The BMP measures the amount of nitrogen in the blood that comes from the waste product urea.
What is the normal range for a blood urea nitrogen or “BUN”?
Normal range: Roughly 7 - 20 mg/ dL
Varies depending n site
What is the term for a high blood urea nitrogen or low blood urea nitrogen count?
HIGH: Renal insufficiency
LOW: Normal
What is creatinine component of the BMP?
A waste product that forms when creatine in the muscles break down. It measures the level of creatinine in the blood.
What is the normal range for creatinine?
Roughly 0.5 - 1.2 mg/dL
Normal ranges may vary from site to site
What is the term if creatinine is high/low?
High: Renal insufficiency
Low: Normal
What is glomerular filtration rate or “GFR”?
A component of the BMP that measures how much blood is being filtered through the kidneys per minute.
What is the normal range for glomerular filtration rate?
Normal range: Roughly 90 - 120 mL/ min, but may be lower in the elderly and can
vary by race
What is the term for a high/ low level for glomerular fiiltration rate in a
BMP?
HIGH: :Normal
LOW: Renal insufficiency
What is a comprehensive metabolic panel or CMP?
This is a lab often ordered to look at all the same things
as a BMP, PLUS A LIVER FUNCTION!!!
What are the main components of a CMP?
*Basic Metabolic Panel (BMP
*Albumin
*Total Protein
*Liver Function Tests
> Alkaline phosphatase (Alk phos)
>Alanine aminotrasnferase (ALT)
>Aspartate aminotransferase (AST)
>Bilirubin
What are the components that are covered by the BMP?
Glucose Calcium Potassium Sodium Chloride Carbon dioxide/ Bicarbonate (CO2) Anion Gap Blood Urea Nitrogen (BUN) Creatinine Glomerular Filtration Rate (GFR)
What does the albumin component of the CMP measure?
It measures the level of albumin, a protein produced by the liver
in the blood
What is the normal range for albumin in a CMP?
3.4 - 5. g/dL
Normal ranges may vary from site to site
What does a high/low level of albumin indicate
High: Infections/ Physical Stress
Low: Liver/Kidney disease
What does the total protein component of the CMP measure?
It measures the total amount of albumin and globulin, two types
of proteins in the blood.
What is the normal range for Comprehensive Metabolic
Panel?
Roughly 6 - 8.3 g/dL
Normal varies depending on the site
What does a high level/ low level of total protein in a CMP
signify?
HIGH: Autoimmune disease
LOW: Liver/kidney disease
What is a liver function test or LFT?
Are a group of a blood tests that provide information about the state of a patient’s liver
What are the main components for a live function test?
*Alkaline phosphatase (Alk phos, ALP)
*Alanine aminotransferase (ALT)
*Aspartate aminotransferase (ASE)
Bilirubin
What is the alkaline phosphatase (Alk Phos) component
of the CMP and what does it measure?
It measures the level of alkaline phosphatase in
the blood. Alk phos is an enyzme that helps the body break
down proteins and is released by liver.
What is the normal range for alkalkine phosphatase?
Normal Range: Roughly 20 - 140 IU/L
What is the term for high/low level of alkaline phosphatase in a
CMP?
High - Liver/ gallbladder disease
Low - Malnutrition
What is the alanine aminotransferase or “ALT” component
of the CMP?
This measures the levels of ALT, another live enzyme, in the blood
What is the normal range for alanine aminotransferase
in CMP?
7 - 5 IU/L
What does a high / low level of alanine aminotransferase
indicate… whats the term?
HIGH - Liver disease ( hepatitis)
LOW - Normal
What is the aspartate aminotransferase or “AST” component
of the CMP?
It measures the level of AST, another live enzyme, in the blood
What is the normal range for aspartate aminotransferase in a CMP?
10 - 40 IU/ L
What does a high / low level of aspartate aminotransferase
indicate… whats the term ??
HIGH - liver disease ( hepatitis)
LOW - Normal
What is the bilirubin component of a CMP and what does
it measure?
It measure the level of bilirubin in the blood. Bilirubin is an orange- yellow pigment that occurs normally when part of your red blood
cells break down.
What is the normal range for bilirubin in a CMP?
Normal range: Roughly 0.3 - 1.9 mg/dL
What does a high / low level of bilirubin in CMP indicate?
HIGH: Hyperbilirubinemia / liver disease
LOW: Normal
What are coagulation factors?
The labs that are ordered to evaluate the patients ability to form blood clots
What are common coagulation factors?
Prothrombin Time/International Normalized Ratio (PT/INR)
Partial Thromboplastin Time (PTT)
What is the prothrombin time or “PT” test?
This is a test that measures how long it takes
the blood to clot
How is the international normalized ratio or INR calculated?
It is calculated from the PT as a measure of how
well blood thinning medications are working. These
results are reported together as PT/ INR
What is normal range for PT and INR?
PT: 11 - 13.5 seconds
INR: Below 1.1 in healthy patients and between 2.0 - 3.0
in patients who are anticoagulated
What does a high/ low level of PT/INR indicate?
This would vary by case and
anticoagulation therapy
What is the partial thromboplastin time or “PTT”test and what does it measure?
A test that measuress the time it takes for a blood clot to form.
What is the normal range for a PTT test
that it takes for a blood clot to form?
Normal: 60 - 70 seconds in healthy patients and 1.5 - 2.5x that range in anticoagulated patients
If the PTT is high/low these are the terms
HIGH - Hemophilia
LOW - Hypercoagulopathy
What are Cardiac tests?
The labs that are ordered to evaluate the health
of the patient’s heart and vasculature
What are some common cardiac labs?
- Troponin ( TROP)
- D-dimer
- Brain Natriuretic Peptide (BNP)
- Creatine Kinase (CK)
What is a troponin or “trop” ?
A test that measures the level of troponin in the
blood. Troponin is a complex of three regulatory
proteins that is released when there is muscle damage.
What is the normal range for a troponin test?
0 - 0.4 ng/mL
Normal ranges may vary from site to site
What are the terms for Positive/high & Negative/ Low
level of troponin?
POSITIVE/ HIGH: nSTEMI, heart damage
NEGATIVE/LOW: Normal
What is a D-dimer test?
A test that measures the amount of a protein
fragment, D-dimer, that becomes present in
the blood as it is released by a blood clot
What is the normal range for a D-dimer test?
Less than 0.50
Normal varies from site to site
What are the terms for a positive/ negative indiactor
for the D-dimer test?
POSITIVE: Nonspecific thrombus
NEGATIVE: Normal
What is a brain natriueretic peptide or “BNP” test
is a blood test that measures levels of the protein BNP that is made by the
heart and blood vessels
What are the normal ranges for a
brain natriueretic peptide or a BNP test?
Less than 100 pg/mL
What are the terms for a low/ high level
of a brain natriuretic peptide?
High: Heart failure
LOW: Normal
What is a creatine kinase or “CK” test?
A test that measures the levels of creatine kinase in the blood. CK is an enzyme found in multiple tissues throughout the body that is released when there is muscle damage.
What is the normal range for a creatine kinase or “CK” test?
Roughly 22 - 298 U/L
What are the terms for a high / low measurement of creatine kinase?
HIGH : Muscle damage
LOW: Normal
What are cholesterol tests?
Labs that are ordered to evaluate a patient’s cholesterol, or the blood fat (lipid) content. Also referred to as a “lipid panel”
What is a lipid panel?
Another word for blood faat (lipid ) content
What are the common cholesterol labs?
Total cholesterol
Trigylcerids
High-density Lipoprotein (HDL)
Low-density Lipoprotein (LDL)
What does the total cholesterol component of a lipid panel measure?
This measures the total amount of cholesterol in the blood and this includes HDL, LDL, and triglycerides
What is the normal range for a total cholesterol test?
Ideal level is less than 200 mg/dl
What are the high / low measurements for total cholesterol tests?
High - Hyperlipidemia
Low - Normal
What is the triglyceride component of the lipid panel and what does it measure?
Trigylcerides are another type of lipid ( fat) that make up typical body
fat. They measure the level of triglycerides in the blood.
What is the normal range for a triglyceride component in a cholesterol test?
High - Hyperlipidemia
Low - Normal
What is the high-density lipoprotein or HDL component of the lipid panel?
HDL is known as “good cholesterol: which helps clean arteries out. HDL component of the lipid panel measures the levels of high-density lipoprotein
in the blood.
What is the ideal level of high-density lipoprotein in the blood?
over 60 mg/dL
What is a high/ low level of high-density lipoprotein or HDL?
Hyperlipidemia - HIGH
Normal (as long as levels are above 40 mg/dL)
What is low-density lipoprotein or “LDL” and what does it measure?
LDL is known as the “bad cholesterol” that clogs arteries. The LDL component of a lipid test measures the level of low-density lipoproteins in the blood.
What is a normal range of low-density lipoprotein or “LDL” in the lipid panel?
HIGH - Hyperlipidemia
Low - Normal
What lab would you order to evaluate if a patient has an infection?
Infectious markers…
test results would be positive or negative
What are common labs that indicate infection?
Lactic acid (Lactate)
Procalcitonin (Procal)
Help T-cell Count (CD4 count)
What is lactic acid or “lactate” and what does this measure?
A lactic acid or “lactate” measures the level of lactic acid in the blood. Lac
What is the normal range for lactic acid in an infectious marker?
0.5 - 1 mmol/L
Normal ranges vary from site to site
What does a high range of lactic acid / low range of lactic acid ( Lactate)
mean?
HIGH - Systemic infection
LOW - Normal
What is a procalcitonin or procal test?
This test measures the level of procalcitonin in the blood as an indicator
of risk for severe infection
(infectious markers)
What is the normal range for procalcitonin or procal test?
0.10 - 0.49 ng/mL
What does a high/low level of procal or procalcitonin mean?
HIGH - Possible sepsis
LOW - Normal
What is a CD4 or Help T-cell count measure?
It is an infectious marker
It measures the level of helper T-cells, a specific type of white blood cell that plays a role in activating the immune system in response to
invaders
What is the normal range for CD4 / Helper T-cell count?
Roughly 500 - 1,500
What does a high / low level of CD4 or Helper T-cell count
mean?
HIGH - Typical infection
LOW - Active HIV infection
What is the list of infection markers?
Procal
Lactate
CD4
What are inflammatory markers?
The labs ordered to evaulate if a patient has inflammation, or swelling, ss a reaction to an irritant. Test will be positive or elevated if inflammation is present.
What are common labs that indicate inflammation?
- C- reactive protein (CRP)
* Erythrocyte Sedimentation Rate ( ESR, Sed rate_
What is a C-reactive protein or CRP test?
A test that measures the level of c-reactive protein in the blood which increases when there is inflammation
What is the normal range for a C-reactive protein or CRP test?
Less than 3.0 mg/ L
What is the term for a high / low level of c-reative protein?
HIGH - Nonspecific Inflammation
LOW - Normal
What is an erythrocyte sedimentation rate ( aka sed rate or esr)?
A rate that measures how long it takes for red blood cells to settle atthe bottom of a test tube. Typically, the ESR is relatively slow; ot becomes faster when there is inflammation
What is the normal range for erythrocyte sedimentation rate?
Roughly 1 - 13 ..//hr for males and 1 - 20 mm/hr for females
What is the term for high/ low level of erythrocyte sedimentation rate?
HIGH - inflammation / infection
LOW - Normal
What are the inflammatory markers that are paired together?
CRP + ESR
C-reactive protein
+
erythrocyte sedimentation rate
Why would a thyroid test be orderder?
To evaluate the function of the patients thyroid
What are the three common thyroid labs?
Thyroid stimulating hormone (TSH) Free Thyroxine (T4) Free Triiodothyronine (T3)
What is a thyroid stimulating hormone or a “TSH” test?
A test that measure the level of TSH in the blood. TSH is responsible
for prompting the thryroid to produce a variety of hormones.
What is the normal range for a thyroid stimulating hormone?
Normal : 0.4 - 4.0 mlU/L
Normal ranges may vary from site to site
What is a high / low level of thyroid stimualting hormone signify?
HIGH - Hypothyroidism
LOW - Hyperthyroidism
What is a free thyrone or “T4” measure?
A test that measures the levels of unbound T4, the thyroid
hormone thyroxine, in the blood. T4 levels fluctuate with thyroid
dysfunction
What is the normal range for free thyroxine or T4?
Normal range: Roughly 5.0 - 12.0 μg/dL
What is the high/ low term for measurement of freethyroxine or T4?
HIGH - Hyperthyroidism
LOW - Hypothyroidism
What is A free triiodothyronine or “T3” ?
A free triiodothyronine or “T3” measures the levels of unbound T3, the thyroid hormone triiodothyronine, in the blood. T3 levels fluctuate with thyroid dysfunction.
What is the normal range for free triiodothyronine or “T3”
Normal range: Roughly 100 - 200 ng/dL
What are the terms for high/low free triiodothyronine or “T3” ?
HIGH
Hyperthyroidism
LOW
Hypothyroidism
What are the three thyroid tests?
TSH
+
T4
+
T3
What are diabetes tests?
Diabetes tests are the labs ordered to screen for diabetes or evaluate complications related to diabetes.
What the The common diabetes labs?:
Hemoglobin A1c (Hb A1c) Ketones
What is a A hemoglobin A1c or “Hb A1c?
A hemoglobin A1c or “Hb A1c” measures the levels of hemoglobin that is chemically linked to a sugar molecule in the blood. An A1c can tell the blood sugar levels over the last 2 - 3 months.
What is the normal range for A hemoglobin A1c or “Hb A1c?
Normal range: Less than 6.0%
What are the high/ low levels hemoglobin A1c or “Hb A1c” referred to as?
HIGH
Diabetes mellitus
LOW
Normal
What is a serum ketones test?
serum ketones test measures the level of ketones in the blood. Ketones are a type of acid produced when the body is not able to break down enough sugar into energy.
What is the normal range for a serum ketones test?
Normal range: Less than 20 mg/dL
What do high/ levels of serum ketones mean?
HIGH
Diabetic ketoacidosis
LOW
Normal
What are both of the diabetes tests?
Hb A1c
+
Ketones
What are Hepatic and pancreatic function tests?
Hepatic and pancreatic function tests are the labs ordered to evaluate the function of the liver and pancreas outside of what is included in a CMP.
What are common Hepatic and pancreatic function tests?
Ammonia (NH3)
Lipase
Amylase
What is an ammonia or “NH3” test?
An ammonia or “NH3” test measures the level of ammonia in the blood. The liver typically turns ammonia into urea, which is secreted in the urine, unless there is liver damage preventing the conversion to urea.
What is the normal range for ammonia or “NH3” test?
Roughly 15 - 45 µ/dL
What are the terms for high/ low level of ammonia or NH3 test
HIGH
Encephalopathy (liver dysfunction)
LOW
Normal
What is a A lipase test ?
A lipase test measures the level of the protein lipase in the blood. Lipase is released by the pancreas to help digest fats and levels fluctuate when there is pancreatic dysfunction.
What is the normal range for a A lipase test ?
Normal range: Roughly 23 - 85 U/L
What do high and low terms for lipase test mean?
HIGH & LOW
Pancreatic dysfunction
What is An amylase test?
An amylase test measures the level of the protein amylase in the blood. Amylase is released by the pancreas to help digest carbohydrates and levels fluctuate when there is pancreatic dysfunction.
What is the normal range for An amylase test?
Normal range: Roughly 23 - 85 U/L
What do high and low levels in an amylase test signify?
HIGH
LOW
Pancreatic dysfunction
What are pregnancy test ?
Pregnancy tests are labs ordered to evaluate for the presence of pregnancy and monitor its progression by measuring the levels of human chorionic gonadotropin (hCG) in the mother’s blood.
What are common pregnancy labs?
Qualitative hCG
Quantitative hCG
What is a A qualitative hCG test?
A qualitative hCG test is a yes/no measure of pregnancy. It detects hCG in the mother’s urine or blood, but does not put a number to it.
What is the normal range for a A qualitative hCG ?
Normal range:
Not pregnant: < 5 mIU/mL
Pregnant: > 20 mIU/mL, sometimes as low as 6.3 mIU/mL
Between 6 and 24 mIU/mL is a grey area indicating a need for retesting
What does a high / low level for qualitative hCG mean??
HIGH
Pregnancy
LOW
No pregnancy
What is a A quantitative hCG test?
A quantitative hCG test is a numerical measure of pregnancy. It detects and measures the specific level of hCG in the mother’s blood.
What is a normal range for A quantitative hCG test?
Normal range:
Not pregnant: < 5 mIU/mL
Pregnant: > 25 mIU/mL, should increase exponentially throughout the first trimester
Between 6 and 24 mIU/mL is a grey area indicating a need for retesting
Normal ranges may vary from site to site.
What do high and low levels for a A quantitative hCG test signify?
HIGH Pregnancy LOW or DECREASING No pregnancy/ miscarriage
What are the pregnancy tests??
Qualitative hCG
+
Quantitative hCG
What are Urine tests ?
Urine tests are labs ordered to evaluate the contents of the urine for things like infection and kidney failure.
What are examples of common urine labs?
The common urine labs are:
Urinalysis
Urine Culture
A urinalysis or “UA”
A urinalysis or “UA” is a lab often ordered to look at the condition of the urine.
Main components of A urinalysis or “UA”
Main Components Color Appearance Glucose Bilirubin Ketones Specific gravity Blood pH Protein Urobilinogen Nitrites Leukocyte esterase White blood cells (WBC) Epithelial cells
Urine color can indicate …
Urine color can indicate a number of things including hydration level and presence of blood.
Urine color normal range?
Shades of yellow
Urine color terms for scoring positive or negative
POSITIVE Red, pink - hematuria Amber - dehydration NEGATIVE Normal
Urine appearance can indicate
Urine appearance can indicate the presence of white blood cells.
Normal range: Clear
Urine appearance positive and negative terms…
POSITIVE
Hazy - possible cystitis
NEGATIVE
Normal
Urine glucose testing can help do what?
Urine glucose testing can help determine blood sugar levels. When they are too high, glucose will be eliminated in the urine.
Urine glucose testing normal range?
Roughly 0 - 0.8 mmol/L
Urine glucose testing - positive and negative testing terms?
POSITIVE
Hyperglycemia
NEGATIVE
Normal
Urine bilirubin levels can be used to?
Urine bilirubin levels can be used to evaluate liver function. Bilirubin is dumped into the urine for elimination when there is liver dysfunction.
Urine bilirubin levels normal range?
None
Urine bilirubin levels - positive and negative terms
POSITIVE
Liver disease
NEGATIVE
Normal
Urine ketone levels can be used to…
Urine ketone levels can be used to evaluate risk for diabetic ketoacidosis. Elevated urine ketones indicate the body is burning fat because there isn’t enough sugar.
Urine ketone levels normal range
None
Urine ketone levels positive and negative terms
POSITIVE
Diabetic ketoacidosis (in diabetic patients)
NEGATIVE
Normal
What is Urine specific gravity?
Urine specific gravity is the measure of the concentration of solutes in urine and used to evaluate hydration level and kidney function.
Urine specific gravity normal range?
roughly 1.010 - 1.030
Urine specific gravity - high and low levels?
HIGH High urine concentration - dehydration LOW Low urine concentration -good/ overhydration
What can blood in the urine indicate?
Blood in the urine can be an indicator of infection or kidney dysfunction, but can also indicate more benign conditions.
Normal range: None
Blood in urine - POSITIVE/ NEGATIVE TERMS
urinalysis
POSITIVE
Hematuria
NEGATIVE
Normal
What does Urine pH measure?
Urine pH measures the acidity or alkalinity of the urine and is used to evaluate risk for kidney stones. Things such as diet and medications can affect urine pH.
What does a normal range of Urine PH look like?
Roughly 6.0 (slightly acidic)
Can range from 4.5 - 8.0
What are the terms for high/ low Urine PH?
HIGH
Alkalosis
LOW
Acidosis
Elevated urine protein can be an indication…
Elevated urine protein can be an indication of kidney dysfunction.
Elevated urine protein normal range?
0 - 20 mg/dL
Elevated urine protein - positive/ negative terms?
POSITIVE
Proteinuria
NEGATIVE
Normal
Elevated urine urobilinogen can be an indication of…
Elevated urine urobilinogen can be an indication of liver dysfunction. Urobilinogen is produced when the intestines reduce bilirubin.
elevated urine urobilinogen normal range?
Normal range: Roughly 0.1 - 1.8 mg/dL
elevated urine urobilinogen positive and negative terms?
POSITIVE
Liver disease
NEGATIVE
Normal
The presence of nitrites in the urine is a specific indicator of?
The presence of nitrites in the urine is a specific indicator of bacterial infection of the urinary tract. Some bacteria are able to convert nitrates into nitrites, resulting in nitrites being present in the urine.
The presence of nitrites in the urine has a normal range of…
NONE
The presence of nitrites in the urine - POSITIVE AND NEG TERMS
POSITIVE
Cystitis
NEGATIVE
Normal
The presence of leukocyte esterase in the urine?
The presence of leukocyte esterase in the urine is used as an indicator that there are white blood cells in the urine. Leukocyte esterase is produced by white blood cells.
The presence of leukocyte esterase normal range
none
The presence of leukocyte esterase in the urine - POSITIVE
AND NEG TERMS
POSITIVE
Nonspecific urinary tract infection
NEGATIVE
Normal
White blood cells or WBCs in urinalysis?
White blood cells or WBCs are able to be visualized in the urine during a microscopic urinalysis. The presence of these cells indicate infection.
Normal range of white blood cells in urinalysis?
Normal range: Roughly 0 - 5 WBCs
White blood cells or WBCs in urinalysis POSITIVE AND NEG
TERMS?
POSITIVE
Nonspecific urinary tract infection
NEGATIVE
Normal
Epithelial cells summary in urinalysis tests
Epithelial cells line the urinary tract and can contaminate urine specimens if the urethral opening is not cleaned prior to urine catch. They can also indicate infection in the presence of other positive indicators.
Epithelial cells line in normal range - urinalysis tests?
Normal range: Roughly 1 - 5 cells/HPF
Epithelial cells in urinalysis - HIGH/ LOW LEVELS?
HIGH
Contaminated sample/infection
LOW
Normal
What is a A urine culture?
A urine culture is a lab often ordered to evaluate the urine for presence of organisms in the urine that can cause infections. Cultures are meant to grow out certain organisms over others to help medical professionals determine the best treatment for each infection.
What are main components of a urine culture?
Main Components
Bacterial Growth
Urine culture sensitivity
What is a urine culture?
A urine culture is a test that looks for bacterial growth. If there is growth, the bacteria are placed on a microscope slide where they are stained and observed to determine what type of organism is causing the infection.
What a normal range for a urine culture?
Normal range: No growth
What are positive and negative terms for urine culture?
POSITIVE
Bacterial growth seen = infection
NEGATIVE
Normal
what is a A urine culture sensitivity test?
A urine culture sensitivity test measures the susceptibility of the organism causing infection to different treatments. This step is taken after the organism is identified using a culture.
normal range for a A urine culture sensitivity test
Normal range: Positive
What are the positive and negative terms for
urine culture sensitivity?
POSITIVE
Decreasing bacterial growth = susceptible
NEGATIVE
Continued bacterial growth = not susceptible
What are tests for acute illnesses?
Tests for acute illnesses are labs ordered to evaluate for the presence of acute (rapid onset, short-term) illnesses.
The common tests for acute ilnesses?
The common tests for acute illnesses are:
Rapid Strep Test (Rapid strep)
Flu test (Flu swab)
Monospot
what is A rapid strep test or just “rapid strep” ?
A rapid strep test or just “rapid strep” is a swab of the throat that tests specifically for Group A Streptococcus, which causes a bacterial infection of the throat.
What is the normal range for a A rapid strep test or just “rapid strep” ?
Negative
What are the pos and neg terms for a A rapid strep test or just “rapid strep”
POSITIVE
Strep pharyngitis
NEGATIVE
Normal/No strep
what is A flu test or “flu swab”
A flu test or “flu swab” is a nasal swab which tests specifically for Influenza A and Influenza B, the two most common causes of the flu.
When positive, they are 99% accurate; however, they also have a high rate of false negatives.
normal range for a A flu test or “flu swab”
negative
A flu test or “flu swab” - positive and negative terms
POSITIVE
Influenza A or B
NEGATIVE
Normal/No flu
whats a A Monospot
A Monospot is a rapid blood test that screens for the Epstein-Barr virus, which causes the common infection mononucleosis or “mono”.
Whats a normal range for a monospot?
negative
Whats the positive and negative terms for a monospot?
POSITIVE
Epstein - Barr Virus (EBV)/ Mononucleosis
NEGATIVE
Normal/No mono
3 tests for Tests for Acute Illness
Rapid Strep
+
Flu Swab
+
Monospot
What are Tests for altered mental status?
Tests for altered mental status are labs ordered when the patient is abnormally below baseline to evaluate for possible chemical causes, such as illicit substances and alcohol
What are the common screening tests for altered mental status
The common screening tests for altered mental status are:
Urinary Drug/Toxicology Screen (UDS/Utox)
Ethanol level (EtOH)
What is A urine drug screen, “UDS”, or urine toxicology screen, “Utox”?
A urine drug screen, “UDS”, or urine toxicology screen, “Utox”, is a urinalysis that looks specifically for the presence of illicit substances. False positives sometimes occur due to medications.
what do A urine drug screen, “UDS”, or urine toxicology screen, “Utox”, screen for the following….
Most screen for the following: Amphetamines Cocaine Barbiturates Benzodiazepines Methamphetamines PCP (Phencyclidine) Oxy (Oxycodone) THC (Marijuana)
What is the normal range for urine drug screen or UDS?
Normal range: Negative
A urine drug screen, “UDS”, or urine toxicology screen, “Utox”, - POsitive and negative terms
POSITIVE
Likely use of positive drug
NEGATIVE
Normal/No drug use
what is An ethanol level or “EtOH” ?
An ethanol level or “EtOH” is a blood test that screens for the presence of ethanol, a form of alcohol, in the blood.
Normal range: Negative
ethanol level or “EtOH” Positive and negative terms
POSITIVE
Alcohol intoxication
NEGATIVE
Normal/No alcohol use
Tests for Altered Mental Status
EtOH
+
UDS
Tests for Altered Mental Status
EtOH
+
UDS
what are Cultures?
Cultures are labs ordered to evaluate for the presence of infection and what organism is causing it. They are meant to grow out certain organisms over others to help medical professionals determine the best treatment for each infection.
common Cultures tests
The common cultures are:
Blood Culture
Sputum Culture
Bacterial Wound Culture
whats a A blood culture?
A blood culture is a test of a blood sample to find bacteria or other organisms that cause a blood infection.
Whats the normal range for a culture?
Normal range: Negative
A blood culture positive and negative terms?
POSITIVE
Bacteremia
NEGATIVE
Normal/No infection
What is a A sputum culture?
A sputum culture is a test to detect organisms such as bacteria that infect the lungs and breathing passages.
A sputum culture - normal range?
Normal range: Negative
sputum culture - pos and neg terms?
POSITIVE
Bacterial lower respiratory infections
NEGATIVE
Normal/No infection
What is a wound culture?
A wound culture is a test of the skin, tissue, or fluid to detect organisms such as bacteria that cause infection.
Wound culture - normal range?
Normal range: Negative
Wound culture - pos and negative terms?
POSITIVE
Wound infection
NEGATIVE
Normal/No infection
What are stool tests?
Stool tests are labs ordered to evaluate if there are substances in the stool that do not belong, such as blood or bacteria.
What are common stool tests?
The common stool tests are:
Fecal Occult Blood Test (Guaiac test)
Clostridium difficile stool test (C. diff)
what is a fecal occult blood test or “guaiac test”
A fecal occult blood test or “guaiac test” is a rapid test performed by the provider to determine if there is blood in the stool. Unlike the other tests in this presentation, these are the only results typically recorded in the physical exam and not the MDM or A/P.
A fecal occult blood test or “guaiac test” - NORMAL RANGE
Negative
A fecal occult blood test or “guaiac test” - POSITIVE / NEGATIVE TERMS
POSITIVE
Nonspecific GI bleed
NEGATIVE
No GI bleed
what is A Clostridium difficile or “C. diff” stool test
A Clostridium difficile or “C. diff” stool test is used to detect intestinal infection with the opportunistic bacteria Clostridium difficile, which causes severe diarrhea.
A Clostridium difficile or “C. diff” stool test normal range?
Negative
A Clostridium difficile or “C. diff” stool test- POSITIVE/ NEGATIVE TERMS?
POSITIVE
C. diff infection
NEGATIVE
No C. diff infection
Stool Tests
Guaiac test
+
C. diff
what are other labs do not fit into the aforementioned categories?
These common labs are:
Type and Screen/Cross (T & S/X)
Arterial Blood Gasses (ABG)
what is A type and screen or “T & S”, also known as type and cross or “T & X”?
A type and screen or “T & S”, also known as type and cross or “T & X”, is a blood test to determine blood type.
what is the normal range for A type and screen or “T & S”, also known as type and cross or “T & X”?
varies
A type and screen or “T & S”, also known as type and cross or “T & X” - What types of blood can be identified?
A, B, AB, O | Rh positive or negative:
A+, A-, B+, B-, AB+, AB-, or O+, O-
What is An arterial blood gas or “ABG” panel?
An arterial blood gas or “ABG” panel is a series of tests run on blood drawn from an artery (versus a vein like most other labs) to evaluate the acidity (pH) and the levels of oxygen/carbon dioxide in the blood. When there is an imbalance, the blood can become either too acidic or too basic.
what is the normal range for An arterial blood gas or “ABG” panel?
Varies by test
An arterial blood gas or “ABG” panel - HIGH/ LOW levels =
HIGH& LOW:
Metabolic or respiratory acidosis or alkalosis
Other Common Tests
T & X
+
PTT
what are Diagnostic studies?
Diagnostic studies are any form of testing used to help diagnose a patient’s condition. Diagnostic studies include labs, imaging, and other testing.
What are Imaging studies?
Imaging studies are a form of diagnostic testing performed with a variety of techniques that produce pictures of the inside of a patient’s body for the purpose of making a clinical decision, such as a treatment or diagnosis.
What are the the most common imaging studies?
Some of the most common imaging studies are: X-rays Computed (Axial) Tomography Ultrasounds Magnetic Resonance Imaging Magnetic Resonance Angiography Magnetic Resonance Venography Nuclear Imaging Ventilation/perfusion scans Stress tests
In the Ambulatory Care Setting imaging is often ordered to be completed … where??
In the Ambulatory Care Setting imaging is often ordered to be completed outside of the office, meaning the orders are recorded as a part of the Plan, versus including a completed imaging report.
Who reviews the images received from an imaging study?
The raw images obtained during these studies are reviewed by a radiologist who then creates a narrative summary of the results, called the “report.” This report is copied verbatim into the patient note.
What are X-rays ?
X-rays are images of the internal composition of a part of the body produced by x-rays being passed through and absorbed to different degrees by different materials based on density.
Bones are more ____ than ________ and appear the whitest in a normal X-ray and ______ in an inverted X-ray.
Bones are more dense than soft tissues and appear the whitest in a normal X-ray and darkest in an inverted X-ray. X-rays are most commonly viewed in Normal mode.
How are xrays commonly viewed?
X-rays are most commonly viewed in Normal mode.
Why would you order a chest x-ray?
Chest pain
Chest trauma
Shortness of breath
Cough
What would a normal interpretation look like for
imaging studies?
There are no bony abnormalities. Airspaces: No acute disease. No cardiomegaly. Mediastinal structures are within normal limits. Interpretation: No acute disease.
What would an abnormal findings look like for a chest
X-Ray?
Rib fractures Infiltrates Pneumonia Cardiomegaly Atelectasis Pneumothorax Hemothorax
Why would you order an abdominal X-ray?
Abdominal pain Abdominal distention Constipation Ingested foreign body CVA tenderness
What x-ray would you order to evaluate
kidneys, ureter, or bladder?
There is a specific type of abdominal x-ray called a KUB which is ordered specifically to evaluate the kidneys, ureter, and bladder.
What would normal findings look like
in abdominal x-ray?
No bony abnormalities. Nonspecific bowel gas pattern. No free air. No air fluid levels. No evidence of obstruction. Interpretation: No acute disease.
What would abnormal findings look like for an
abdominal x-ray exam?
Constipation
Small bowel obstruction
Renal calculi
Why would you order an extremity X-ray?
Extremity pain Extremity trauma Joint pain Joint trauma Possible foreign body
What would a normal interp for an extremity x-ray look like?
There are no bony abnormalities. Soft tissue spaces appear within normal limits. Joint spaces are intact. No fractures, dislocations, or subluxations. Interpretation: No acute abnormalities.
What would an abnormal extremity x-ray look like?
Fractures
Dislocations
Arthritis
Foreign body
Why would you order a spine x-ray?
Back pain
Back trauma
Neck pain
Neck trauma
What would a normal interp. for a spine x-ray look like?
There are no bony abnormalities. Soft tissue spaces appear within normal limits. Disc spaces appear preserved. No fractures or subluxations. Curvature lines intact. Interpretation: No acute abnormalities.
What would a abnormal interp. for a spine x-ray look like?
Vertebral fractures
Vertebral malalignment
Loss of disc height Abnormal curvature
What is a Computed (Axial) Tomography, also called a CT or CAT scan?
Computed (Axial) Tomography, also called a CT or CAT scan is a specialized test that produces cross-sectional images of the body using X-rays and a computer.
Can CTs be completed without contrast?
CTs can be completed with or without contrast, which is a special dye injected into the veins to outline organs and tissue
What would a normal interpretation for a spine x-ray look like?
There are no bony abnormalities. Soft tissue spaces appear within normal limits. Disc spaces appear preserved. No fractures or subluxations. Curvature lines intact. Interpretation: No acute abnormalities.
What would an abnormal finding look like for a spine x-ray?
Vertebral fractures
Vertebral malalignment
Loss of disc height Abnormal curvature
Why would you order a cat scan for abdomen + pelvis?
Hematuria CVA tenderness Abdominal pain Abdominal distension McBurney's point tenderness Nausea/vomiting Hernia
What would a normal interpretation for abdomen + pelvis CT
look like?
No acute findings
What would a abnormal interpretation for abdomen + pelvis CT
look like?
Kidney stones Pyelonephritis Diverticulosis Diverticulitis Appendicitis Gastritis Gastroenteritis Small bowel obstruction
Why would you order a head ct?
Headache
Head trauma
Changes in mentation or behavior
Neurologic changes
What would an normal interpretation for a head ct look like?
No acute findings
What would an abnormal finding for a head ct scan look like?
Hydrocephalus Subdural hematoma Subarachnoid hemorrhage Stroke TIA
Why would you order a Spine CT?
Back pain
Sciatica
Lower/upper extremity paresthesias/weakness
What would a normal interpretation for spine ct look like?
No acute findings
What would an abnormal finding for a Spine CT look like?
Vertebral fractures
Herniated discs
DDD
Osteoarthritis
Why would you order a chest CT?
Chest pain
Chest trauma
Shortness of breath
Cough
What is an Ultrasonography?
Ultrasonography, or US, is a diagnostic imaging technique which produces images through the therapeutic application of ultrasounds (the same waves used by bats and dolphins in echolocation).
Why would you order an abdominal US (ultrascan)
Abdominal pain
Murphy’s point tenderness
Abdominal distention
What would a normal interpretation for an Abdominal US look like?
No acute findings
What would an abnormal finding for a abdominal US study look like?
AAA Cholelithasis Cholecystitis Ascites Liver fibrosis Cirrhosis
What would a pelvic US (ultra sound) be ordered?
Pelvic pain
Abnormal vaginal bleeding
There are diff types of ultra sounds??
A pelvic ultrasound is ordered when a patient is not pregnant to evaluate pelvic pain/bleeding. A different ultrasound is ordered for pregnant women.
What would a normal interp for a pelvic U.S. look like?
no acute findings
What would an abnormal interpretation for a pelvic U.S.
look like?
Ovarian cysts
Ectopic pregnancy
Endometriosis
Why would you order a pregnancy US (ultrasound)?
To evaluate pregnancy
Abdominal pain with pregnancy
Vaginal bleeding with pregnancy
pregnancy US (ultrasound) normal interpretation?
Normal pregnancy
Pregnancy US - Abnormal findings?
Miscarriage
Subchorionic hemorrhage
Abnormal fetal development
Fetal demise
why would you order a Scrotal US
Scrotal pain
Scrotal swelling
Testicular pain
What would a normal interp for a Scrotal US look like?
No acute findings
What would an abnormal interp for a Scrotal US look like?
Hydrocele
Epididimitis
Why would you order an Arterial/Vascular US?
Soft tissue pain (especially calf pain)
Poor circulation
When looking at an Arterial/Vascular US what do the colors
signify?
The colored area in the above image are a visual representation of sound waves. The different colors indicate the speed and direction of blood flow.
Normal interp for an Arterial/Vascular US?
No acute findings
abnormal interp for an Arterial/Vascular US?
DVT
Atherosclerosis
What is Magnetic Resonance Imaging, or MRI?
Magnetic Resonance Imaging, or MRI, is a diagnostic imaging technique that uses strong magnetic fields, magnetic field gradients, and radio waves to generate images of the body.
Why would you order a brain MRI?
Headache Head trauma Vision changes Changes in mentation or behavior Paresthesias/weakness
What would a normal interp for a brain MRI look like?
no acute findings
abnormal findings for a brain mri?
Stroke TIA Subdural hematoma Subarachnoid hemorrhage Multiple sclerosis Structural abnormalities
Why would you order a cervical spine MRI?
Neck pain
Upper extremity paresthesias/weakness
Normal interp for a cervical spine MRI?
No acute findings
abnormal interp for a cervical spine MRI?
Spinal stenosis
Herniated disc
DDD
Multiple sclerosis
Why would you order a Lumbar Spine MRI?
Back pain
Lower extremity paresthesias/weakness
Bowel/bladder incontinence
Saddle paresthesias
normal interpretation for a lumbar spine MRI?
No acute findings
abnormal interpreation for lumbar spine MRI
Spinal stenosis Herniated disc DDD Cauda equina syndrome Epidural abscess
What is The Magnetic Resonance Angiogram, or MRA?
The Magnetic Resonance Angiogram, or MRA, is a form of MRI that is specialized for visualizing the anatomy of blood vessels using a specialized dye.
Why would you order a MRA?
Concern for vascular dysfunction
What would a normal interpretation for a MRA be?
No acute findings
What would an abnormal findings for a MRA look like?
Stroke Atherosclerosis Aneurysms Aortic dissection Aortic stenosis
What is Magnetic resonance venography, or MRV?
Magnetic resonance venography, or MRV, is a form of MRI that is used to visualize veins specifically.
Why would you order a MRV?
Concern for venous dysfunction
What would a normal interp for a MRV look like?
No acute findings
What would an abnormal interp for a MRV look like?
Stroke
IIH
What is Nuclear medicine imaging ?
Nuclear medicine imaging is a method of producing images by detecting radiation from different parts of the body after a radioactive tracer is given to the patient.
What is a ventilation/perfusion lung scan, also called a V/Q scan?
A ventilation/perfusion lung scan, also called a V/Q scan, is a imaging technique that uses scintigraphy and a radioactive tracer to evaluate the circulation of air and blood within a patient’s lungs, in order to determine the ventilation/perfusion ratio.
Why would you order a V/Q Scan?
Shortness of breath with elevated D-dimer
Concern for lung dysfunction
What would a normal interp for V/Q scan look like?
No acute findings
What would an abnormal finding for a V/Q scan look like?
Pulmonary embolism
COPD
Pneumonia
What is a stress test?
A stress test, also known as an exercise test or treadmill test, is a cardiac test that measures the heart’s ability to respond to external stress. The stress response is induced by exercise or by pharmacological stimulation.
Why would you order a Cardiac stress test?
Recent MI
Risk for heart disease/complications
Surgical clearance
Normal interp for a Cardiac stress test?
Normal cardiac function
What would an abnormal finding for a cardiac stress
test look like?
CAD
HFpEF
HFrEF
Post-MI scarring
What types of diagnostic studies that do not produce images:
Cardiac monitoring
Electrocardiogram
Holter monitor
Electroencephalography
What is Cardiac monitoring?
Cardiac monitoring is the continuous or intermittent monitoring of heart activity, generally by electrocardiography, with assessment of the patient’s condition relative to their cardiac rhythm.
Why would you order cardiac monitoring?
Chest pain
Palpitations
Syncope
Other high-acuity complaints
Normal interpretation for Cardiac monitoring?
Normal sinus rhythm.
No ectopy.
No ST elevations or depressions.
Abnormal interpretation for cardiac monitoring?
Arrhythmias Tachycardia Bradycardia ST elevation ST depression
What is an An electrocardiogram, or ECG/EKG?
An electrocardiogram, or ECG/EKG, is the interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body.
Why would you order a EKG?
Chest pain
Palpitations
Surgical/medication clearance
History of heart disease
EKG normal interpretation?
Normal sinus rhythm. No ectopy. Normal QRS interval. Normal QRS axis. There are no significant acute/new ST-T wave changes. Interpretation: No acute ECG changes noted.
EKG abnormal findings
Atrial fibrillation PSVT Ectopy Axis deviation Bundle branch block STEMI
What is a Holter monitor?
A Holter monitor is a small, battery-powered medical device that measures heart activity over 24 to 72 hours when more information is needed about how the heart functions than a routine electrocardiogram provides.
Why would you order a holter monitor?
Recurrent palpitations
Recurrent arrhythmias
Syncope
Recent MI
holter monitor normal interpretation?
No irregular cardiac activity
holter monitor abnormal findings??
Atrial fibrillation
PSVT
Bradycardia
Other irregular heart rates and rhythms
What is a EEG?
An electroencephalogram, or EEG, is a noninvasive test used to evaluate the electrical activity in the brain by placing electrodes placed along the scalp.
what is electrocorticography
There is another form of electroencephalography called electrocorticography which involves invasive electrodes that are placed directly into the brain.
Why would you order a EEG
Seizures Alzheimer's Dementia Unexplained memory loss Head injuries Sleep disorders
What is a normal interp for EEG
No abnormal electrical activity
What is an abnormal interp for EEG
Seizure disorder
Epilepsy
Sleep disorder
Migraines (in some cases)
What are nonsurgical procedures?
Nonsurgical procedures are very minimally invasive for the patient. The procedures included in this presentation are commonly seen in both the acute and ambulatory care settings, usually with only local anesthesia.
How do nonsurgical procedures differ from surgical procedures?
These differ from surgical procedures, which require general anesthesia or conscious sedation (putting the patient to “sleep”).
What are Cardiovascular procedures?
Procedures that target conditions affecting the heart and vasculature.
What are some examples of Cardiovascular procedures?
Cardioversion
Peripherally inserted central catheter
Port-a-Cath
What is cardioversion?
Cardioversion is a nonsurgical procedure where an abnormally fast heart rate (tachycardia) or cardiac arrhythmia is converted to a normal rhythm using electricity or medications.
What is a A peripherally inserted central catheter, or PICC, ?
A peripherally inserted central catheter, or PICC, form of intravenous access that can be used for a prolonged period of time (for chemotherapy regimens, extended antibiotic therapy, etc). Typically placed in the upper arm under local anesthesia. There is an access point for the line outside of the body at all times.
What is a A Port-a-Cath?
A Port-a-Cath is an intravenous catheter that is surgically implanted under local anesthesia and placed underneath the skin near the clavicle. Used for frequent administration of chemotherapy, blood transfusions, antibiotics, blood draws, etc. There is no extension of the port-a-cath outside the body as there is with a PICC line.
What are Dermatologic procedures?
Procedures that target conditions affecting the skin.
what is An incision and drainage, or I & D
An incision and drainage, or I & D, is a minor surgical procedure to release pus or pressure built up under the skin, from an abscess, boil, or other infections. A small incision is made in the skin above the affected area with a scalpel and the contents are expressed.
What is laceration repair
Laceration repair, or lac repair, is the act of cleaning, preparing, and closing a laceration, using a variety of materials. These include sutures, staples, Dermabond (tissue adhesive), or Steri-strips (surgical tape strips).
What is Wound debridement?
Wound debridement is the removal of damaged skin tissue to help a wound heal. It is also done to remove foreign material from tissue. Often performed on burns, lacerations, abrasions, and infected wounds.
What is Cryotherapy?
Cryotherapy is the use of extreme cold, usually in the form of liquid nitrogen, as a treatment for moles, skin tags, and warts. The freezing source is applied to the skin lesion to cause damage to the affected tissue.
What are procedures that target conditions affecting the ears, nose, and throat?
ENT procedures:
Cerumen disimpaction
Epistaxis management
What is Cerumen disimpaction?
Cerumen disimpaction is the removal of impacted cerumen (earwax) by microsuction, mechanical removal, and irrigation.
What is Epistaxis management ?
Epistaxis management involves variety of procedures used to stop epistaxis (nosebleeds). These methods include: topical vasoconstriction (Afrin), chemical cautery (silver nitrate), electrocautery, nasal packing, posterior gauze packing, and many more.
what are Genitourinary procedures:
Procedures that target conditions affecting the genitals and urinary tract.
what are the master list of Genitourinary procedures?
Hemodialysis
PAP smear
What is Hemodialysis?
Hemodialysis, also called dialysis or HD, is the process of purifying the blood of a person whose kidneys are malfunctioning. This type of dialysis removes waste products such as creatinine, urea, electrolytes, and free water from the blood when the kidneys are in a state of failure.
What is a PAP smear?
A PAP smear is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix of females.
What are Procedures that target conditions affecting the muscles, bones, and joints.?
Genitourinary procedures:
what are example Genitourinary procedures?
Closed joint reduction
Nerve block
Nail avulsion
Nail trephination
What is a closed joint reduction?
A closed joint reduction is the manipulation of a dislocated joint to its original position without overlying skin breakdown or surgical intervention. Commonly used to treat shoulder, knee, and phalangeal dislocations.
What is a nerve block?
A nerve block is an injection of local anesthetics to decrease inflammation or “block” a pain signal along a specific distribution of nerve. Common injections of this type are digital (finger/toe), dental, epidural, and occipital nerve blocks.
What is a nail avulsion?
A nail avulsion, or nail resection, is the removal of the nail plate (the hard part of the nail) from a finger or toe. Typically done to treat paronychia (nail infections), recurrent ingrown toenails, or traumatic nail injuries. A resection refers to a partial avulsion, commonly done to treat ingrown nails.
What is Nail trephination
Nail trephination is the act of draining of a subungual hematoma (blood under the nail bed). An electrocautery tool is used to poke a hole in the nail and drain excess blood responsible for causing pressure and pain.
What is the assessment?
The Assessment also known as the Impression or Final Diagnosis is the final determination of the patient’s Reason for Visit. This can be simply the diagnosis or a narrative paragraph describing the patient’s subjective history, objective findings and the final diagnosis.
What is an example of an assessment/impression/ final diagnosis?
Example:
Reason for Visit: Cough
Impression: Pneumonia
Example:
47-year-old female who presented with cough. Chest x-ray revealed infiltrate in the right lower lobe consistent with pneumonia.
What is The Disposition?
The Disposition refers to where a patient goes after they leave the healthcare setting in which you are working
In an acute care setting, where can patients be dispositioned to
In an acute care setting, patients can be dispositioned to three areas:
Discharged home
Admitted to the hospital
Transferred to another facility
In an ambulatory care setting, patients can be dispositioned to two areas , where can patients be dispositioned to?
In an ambulatory care setting, patients can be dispositioned to two areas:
Checked out to home
Sent to the hospital
What is the Plan?
The Plan refers to what the provider plans to do for the patient’s medical condition. This can be a bullet list or part of a narrative paragraph.
What is an example of the plan?
Example:
- Start azithromycin 500 mg BID x 5 days
- Use ProAir inhaler
- Monitor pulse ox at home
- Follow up with your PCP in 3 days
What is an example of the plan?
Example:
Given the patient’s pneumonia on chest x-ray, plan to start azithromycin 500 mg BID for 5 days and a ProAir inhaler to use as needed for shortness of breath. I discussed monitoring his pulse ox at home and if it drops below 90%, he should return to the ED. I recommend he follow up with his PCP in 3 days for reevaluation.
What is surgery?
Surgery is a technology consisting of a physical intervention on tissues. As a general rule, a procedure is considered surgical when it involves cutting of a person’s tissues or closure of a previously sustained wound.
What are Cardiovascular procedures:
Procedures that target conditions affecting the heart and vasculature.
What are example cardiovascular procedures?
AV fistula AV graft Pacemaker Automatic implantable cardiac defibrillator Cardiac ablation Cardiac catheterization Coronary artery bypass graft Coronary artery stenting Inferior vena cava filter Valve repair or replacement
What is An arteriovenous fistula?
An arteriovenous fistula, also called a dialysis fistula or AV fistula, is an abnormal connection between an artery and a vein. This particular connection is artificially made for hemodialysis. Since this connection bypasses the capillaries, blood flows more rapidly.
what are Arteriovenous grafts, also called dialysis grafts or AV grafts?
Arteriovenous grafts, also called dialysis grafts or AV grafts, are very similar to fistulas in most respects, except that an artificial vessel is used to join the artery and vein. Grafts are used when the patient’s native vasculature does not permit a fistula.
What is a pacemaker?
A pacemaker is a small device placed under the skin of the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are used to treat heart rhythms that are too slow, fast, or irregular.
What is An automatic implantable cardiac defibrillator, or AICD?
An automatic implantable cardiac defibrillator, or AICD, is a small device placed under the skin in the chest or abdomen to help monitor and control irregular heartbeats and risk for sudden cardiac arrest by sending electrical pulses or shocks to the heart when it senses any abnormalities in heartbeat.
What is Cardiac ablation?
Cardiac ablation is a surgical procedure to correct cardiac arrhythmias, such as atrial fibrillation. A catheter is inserted through a vein in the groin and threaded to the heart to correct structural problems of the heart that may be causing the arrhythmia.
What is Cardiac catheterization?
Cardiac catheterization is a surgical procedure used to diagnose and treat some heart conditions. A long, thin, flexible tube called a catheter is put into a peripheral blood vessel in the arm, groin (upper thigh), or neck and threaded to the heart to determine if there are blockages in the coronary arteries.
What is A coronary artery bypass graft, also called bypass or CABG?
A coronary artery bypass graft, also called bypass or CABG, is a surgical procedure used to treat coronary artery disease (CAD). A peripheral blood vessel, the graft, is removed from one area of the body (chest, arm, or leg) and placed in the heart around the area or areas of narrowing to “bypass” blockages and restore blood flow to the heart muscle.
What is Coronary artery stenting?
Coronary artery stenting is a surgical procedure in which a tube-shaped device is placed in the coronary arteries that supply blood to the heart, to keep the arteries open in the treatment of coronary artery disease (CAD).
What is Inferior vena cava filter placement, or IVC filter placement
Inferior vena cava filter placement, or IVC filter placement, is a surgical procedure in which a vascular filter is implanted into the inferior vena cava to trap blood clots and prevent them from traveling to the heart and lungs.
What is A valve repair or replacement
A valve repair or replacement is a surgical procedure used to repair or replace damaged or diseased heart valves. The most common types of replacement valves are bovine (cow), porcine (pig), or mechanical. Valves are important in preventing the backflow of blood once it has passed through a vessel.
What are Chest wall procedures?
Procedures that target conditions affecting the chest wall and breasts.
What are example chest wall procedures?
Lumpectomy
Mastectomy
What is a A lumpectomy?
A lumpectomy is the surgical removal of a suspected malignant (cancerous) tumor, or lump, and a small portion of the surrounding tissue from a woman’s breast. This tissue is then tested to determine if it contains cancerous cells.
What is A mastectomy
?
A mastectomy is the surgical removal of one or both breasts, partially or completely, possibly including surrounding lymph nodes. A mastectomy is usually carried out to treat breast cancer.
What are ENT procedures:
Procedures that target conditions affecting the ears, nose, and throat.
What is An adenoidectomy?
An adenoidectomy is the surgical removal of the adenoids when they obstruct breathing or block the eustachian tubes. Adenoids are a mass of lymphoid tissue located behind the nasal passages.
what are Pressure equalizer tubes, also called ear tubes?
Pressure equalizer tubes, also called ear tubes, are tiny, hollow cylinders, usually made of plastic or metal, that are surgically inserted into the eardrum. An ear tube creates an airway that ventilates the middle ear and prevents the accumulation of fluids behind the eardrum.
What is A tonsillectomy?
A tonsillectomy is the surgical removal of the tonsils. The procedure is mainly performed to treat recurrent tonsillitis, throat infections (such as strep throat), and obstructive sleep apnea.
what are Gastrointestinal procedures?
Procedures that target conditions affecting the stomach, intestines, and accessory digestive organs.
Master list of Gastrointestinal procedures:
Appendectomy Cholecystectomy Colectomy Colostomy Colonoscopy Endoscopy Gastric bypass Herniorrhaphy Splenectomy
What is An appendectomy?
An appendectomy, sometimes referred to as an appe, is the surgical removal of the appendix performed when an infection has made it inflamed and swollen (appendicitis). The infection may occur when the opening of the appendix becomes clogged with bacteria and stool, causing the appendix to become swollen and inflamed.
What is a A cholecystectomy?
A cholecystectomy, sometimes referred to as a chole, is the surgical removal of the gallbladder performed to treat gallstones (cholelithiasis) and the complications they cause, such as cholecystitis. May be emergent or elective.
What is a colectomy?
A colectomy, also called a bowel resection, is the surgical removal of all or part of the colon performed to treat multiple conditions, including: colon or rectal cancer, inflammatory bowel diseases such as Crohn’s or ulcerative colitis, and diverticulitis. When only part of the colon is removed, it is called a “partial colectomy.”
What is A colostomy?
A colostomy is the surgical formation of an artificial anus by connecting the colon to an artificial opening in the abdominal wall (stoma) as an alternative channel for feces to leave the body after trauma to the colon.
whats A colonoscopy
A colonoscopy is a nonsurgical procedure used to examine the inner lining of the large intestine (rectum and colon). A colonoscope — a long, flexible tube with a tiny camera at the tip — is used to look at the colon to monitor for polyps, which may or may not be cancerous.
whats an An endoscopy
An endoscopy is a nonsurgical procedure used to examine the upper digestive tract. An endoscope — a flexible tube with a light and camera attached — is lowered down the throat into the digestive tract to monitor for polyps, ulcers, and other problems of the upper digestive tract lining.
Whats a Gastric bypass ?
Gastric bypass is a surgical procedure for weight loss where the size of the stomach is shrunk, so the patient cannot eat as much as they normally do. The surgeon will also bypass part of the digestive system so not as much food is absorbed.
Whats a A herniorrhaphy?
A herniorrhaphy is the surgical repair of a hernia in which a surgeon repairs the weakness in the abdominal wall which has allowed an internal part of the body to push through, forming a hernia.
Whats a splenectomy?
A splenectomy is the surgical removal of the spleen due to severe damage or as therapeutic treatment of chronic conditions. The spleen helps fight infection and filters unneeded material, such as old or damaged blood cells, from the blood.
What are Genitourinary procedures:?
Procedures that target conditions affecting the urinary tract, kidneys, and reproductive organs.
Master list of all surgical Genitourinary procedures:
Caesarean section Dilatation and curettage Hysterectomy Lithotripsy Nephrectomy Oophorectomy Prostatectomy Salpingectomy Tubal ligation Vasectomy
What is A caesarean section, commonly referred to as a C-section?
A caesarean section, commonly referred to as a C-section, is a surgical procedure to deliver a fetus via incisions in the mother’s abdominal wall and the uterus.
What is Dilatation and curettage, also called a D & C?
Dilatation and curettage, also called a D & C, is a surgical procedure to remove tissue from inside the uterus. Providers perform dilation and curettage to diagnose and treat certain uterine conditions — such as heavy bleeding — or to clear the uterine lining after a miscarriage.
What is a hysterectomy?
A hysterectomy, sometimes abbreviated hyst, is the surgical removal of the uterus. The most common reasons for having a hysterectomy include: heavy periods, fibroids, endometriosis, untreated pelvic inflammatory disease (PID), and uterine cancer.
What is Lithotripsy?
Lithotripsy is a nonsurgical procedure which uses shock waves to break up stones in the kidney, bladder, or ureter. After the procedure, tiny pieces of stones pass out of the body in the urine.
What is a A nephrectomy?
A nephrectomy is the surgical removal of one or both of the kidneys performed to treat a number of kidney diseases including kidney cancer and polycystic kidney disease. It is also done to remove a normal healthy kidney from a living or deceased donor for a kidney transplant.
Whats is An oophorectomy?
An oophorectomy is the surgical removal of one or both of the ovaries often performed because of diseases such as ovarian cysts or cancer, as prophylaxis to reduce the chances of developing ovarian cancer or breast cancer, or in conjunction with a hysterectomy.
What is A prostatectomy?
A prostatectomy is the surgical removal of all or part of the prostate gland performed to treat BPH and prostate cancer.
what is The most common type of simple prostatectomy ?
The most common type of simple prostatectomy is a transurethral resection of the prostate, or TURP, which involves removing part of the prostate by instrumentation through the urethra.
what is A salpingectomy ?
A salpingectomy is the surgical removal of one or both of the fallopian tubes commonly done as treatment for ectopic pregnancies. This procedure is called a salpingo-oophorectomy when paired with an oophorectomy.
Whats A tubal ligation?
A tubal ligation, also called a tubal or BTL, is a surgical procedure for sterilization in women. The fallopian tubes are clamped and blocked, or severed and sealed with the goal of preventing eggs from reaching the uterus for fertilization.
whats A vasectomy?
A vasectomy is a surgical procedure for sterilization in men. During the procedure, the vas deferens are severed and then tied/sealed in a manner to prevent sperm from entering into the seminal stream (ejaculate) and thereby prevent fertilization.
what are Musculoskeletal procedures?
Procedures that target conditions affecting the muscles, bones, and joints.
What are the list of Musculoskeletal procedures:?
Above the knee amputation
Below the knee amputation
Arthroplasty
Spinal fusion
whats an An above the knee amputation, or AKA
An above the knee amputation, or AKA, is the surgical removal of part of a lower extremity above the knee joint when that limb has been severely damaged or diseased (such as from diabetes).
Whats A below the knee amputation, or BKA,?
A below the knee amputation, or BKA, is the surgical removal of part of a lower extremity below the knee joint when that limb has been severely damaged or diseased (such as from diabetes).
Whats An arthroplasty?
An arthroplasty is a surgical procedure to restore the integrity and function of a joint performed when the joint has become severely diseased or damaged.
Whats A spinal fusion, also referred to as a C, T, or L spine fusion?
A spinal fusion, also referred to as a C, T, or L spine fusion, is a surgical procedure used to correct problems of the vertebrae, commonly used to treat degenerative disc disease. It is essentially the “welding” of two or more vertebrae so that they heal into a single, solid bone.
What are Neurological procedures?
Procedures that target conditions affecting the brain, skull, and nerves.
What are example Neurological procedures?
Craniotomy
Ventriculoperitoneal shunt placement
What is A craniotomy?
A craniotomy, also referred to as a crani, is a surgical procedure in which a bone flap is temporarily removed from the skull to access the brain. This procedure is commonly used to access the brain in order to treat brain tumors, aneurysms, and blood clots/bleeds.
What is Ventriculoperitoneal shunt placement, or VP shunt placement,
Ventriculoperitoneal shunt placement, or VP shunt placement, is a surgical procedure in which a shunt in placed in the head to drain excess cerebrospinal fluid into the abdomen (specifically the peritoneal space), leading to a decrease in intracranial pressure. Primarily used to treat the conditions hydrocephalus and idiopathic intracranial hypertension (IIH).
What are Pulmonary procedures?
Procedures that target conditions affecting the trachea, lungs, and breathing.
What are example surgical Pulmonary procedures:?
Bronchoscopy
Lobectomy
Tracheostomy
What is A bronchoscopy?
A bronchoscopy is a nonsurgical procedure to visualize the lungs and air passages, performed to diagnose a variety of lung diseases. A bronchoscope — a long, thin tube with a light and camera attached — is passed through the nose or mouth, down the throat, and into the lungs.
What is A lobectomy?
A lobectomy is the surgical removal of one or more of the lobes of the lung performed to treat severe disease or damage of that part of the lung. The right lung has 3 lobes and the left lung has 2 lobes.
What is a tracheostomy?
A tracheostomy is a surgical procedure in which an opening in the neck (stoma) below the vocal cords is created in order to place a tube into the trachea to allow air to enter the lungs when the upper airway is obstructed, to remove secretions, and to more safely deliver oxygen.
Where medical abbreviations used?
Medical abbreviations are used regularly in patient notes and in conversation in medicine. These abbreviations are widely accepted in the medical field.
Some abbreviations should be never be used… yes or no?
However, some abbreviations should never be used in a note, so take pay attention.
A & O
MEANING: Alert and Oriented
Placement: Physical Exam
(Typically followed by “x3” or “x4,” meaning the patient is oriented to person, place, time, and situation.)
What is a fib?
MEANING:Atrial fibrillation
Placement: Past medical history, physical exam, diagnosis, assessment
What is AAA?
Meaning: Abdominal Aortic Aneurysm
Past medical history, diagnosis, assessment
Abd
Meaning: Abdominal or Abdomen
Where: All sections
Do NOT use in note - spell it out
ABG
Meaning
Arterial Blood Gas
Location in Note
Labs
Abx
Meaning
Antibiotics
Location in Note
HPI, assessment and plan, disposition
Notes
Do NOT use in note - spell it out
ADD
Meaning
Attention Deficit Disorder
Location in Note
Past medical history, diagnosis, assessment
ADHD
Meaning
Attention Deficit and Hyperactivity Disorder
Location in Note
Past medical history, diagnosis, assessment
AICD
Meaning
Automated Implantable Cardiac Defibrillator
Location
in Note
Past surgical history, physical exam, diagnosis, assessment
AIDS
Meaning
Acquired Immunodeficiency Syndrome
Location in Note
Past medical history, diagnosis, assessment
ALOC
Meaning
Altered Level Of Consciousness
Location in Note
HPI, physical exam, diagnosis, assessment
Notes
Do NOT use in note - spell it out
AMA
Meaning
Against Medical Advice
Location in Note
Disposition
AMS
Meaning
Altered Mental Status
Location in Note
HPI
Notes
Do NOT use in note - spell it out
What is
APGAR
Meaning
Appearance, Pulse, Grimace, Activity, Respiration
Location in Note
Physical exam - infants only
Appe
Meaning
Appendectomy
Location in Note
Past surgical history
ARDS
Meaning
Acute Respiratory Distress Syndrome
Location in Note
Past medical history, diagnosis, assessment
ASA
Meaning
Aspirin
Location in Note
HPI, medications
Notes
Do NOT use in note - spell it out
BAC
Meaning
Blood Alcohol Content
Location in Note
Labs
BG
Meaning
Blood Glucose
Location in Note
Labs
Notes
Do NOT use in note -spell it out
BID
Meaning
Twice a day
Location in Note
Medications
Bilat
Meaning
Bilateral
Location in Note
HPI, physical exam
Notes
Do NOT use in note - spell it out
BiPAP
Meaning
Biphasic Positive Airway Pressure
Location in Note
Past medical history, vital signs
BLE
Meaning
Bilateral Lower Extremities
Location in Note
HPI, physical exam
Notes
Spell it out unless told otherwise by provider
BM
Meaning
Bowel Movement
Location in Note
HPI
Notes
Do NOT use in note - spell it out
BMP
Meaning
Basic Metabolic Panel
Location in Note
Labs
BNP
Meaning
Brain Natriuretic Peptide
Location in Note
Labs
BP
Meaning
Blood Pressure
Location in Note
Vital signs
Notes
Do NOT use in note - spell it out
BPH
Meaning
Benign Prostate Hyperplasia
Location in Note
Past medical history, diagnosis, assessment
BPM
Meaning
Beats Per Minute
Location in Note
Vital signs, physical exam
BRBPR
Meaning
Bright Red Blood Per Rectum
Location in Note
Physical exam, diagnosis, assessment
BS
Meaning
Blood Sugar or Bowel Sounds or Breath Sounds
Location in Note
Labs
Physical exam
Notes
Do NOT use in note - spell it out
BTL
Meaning
Bilateral Tubal Ligation
Location in Note
Past surgical history
BUE
Meaning: Bilateral Upper Extremities
Location: HPI, physical exam
Do NOT use in note - spell it out
BUN
Meaning
Blood Urea Nitrogen
Location in Note
Labs
C. diff
Meaning
Clostridium difficile
Location in Note
Past medical history, labs, diagnosis, assessment
CA
Meaning
Cancer
Location in Note
Past medical history, diagnosis, assessment
Notes
Do NOT use in note - spell it out
Cancer is normally accompanied by the type….
While cancer is a diagnosis, assessment, it is normally accompanied by the type. For example, “breast cancer” or “metastatic colon cancer”.
CABG
Meaning
Coronary Artery Bypass Graft
Location in Note
Past surgical history
CAD
Meaning
Coronary Artery Disease
Location in Note
Past medical history, diagnosis, assessment
CT
Meaning
Computed Tomography
Location in Note
Imaging
Cath
Meaning
Catheter
Location in Note
Physical exam, procedure
What can cath mean? Why is context important?
The term “cath” can be a number of things, from a urinary catheter to a cardiac catheterization. Context is important to determine which is meant.
CBC
Meaning
Complete Blood Count
Location in Note
Labs
CHF
Meaning
Congestive Heart Failure
Location in Note
Past medical history, diagnosis, assessment
Chole
Meaning
Cholecystectomy
Location in Note
Past surgical history
CK
Meaning
Creatinine Kinase
Location in Note
Labs
CKD
Meaning
Chronic Kidney Disease
Location in Note
Past medical history, diagnosis, assessment
CMP
Meaning
Comprehensive Metabolic Panel
Location in Note
Labs
What is CMT?
Meaning
Cervical Motion Tenderness
Location in Note
Physical exam
CNS
Meaning
Central Nervous System
Location in Note
Physical exam
c/o
Meaning
Complaints Of
Location in Note
HPI
CO
Meaning
Carbon Monoxide
Location in Note
Labs
CO2
Meaning
Carbon Dioxide
Location in Note
Labs
COPD
Meaning
Chronic Obstructive Pulmonary Disease
Location in Note
Past medical history, diagnosis, assessment
CP
Meaning
Cerebral Palsy or Chest Pain
Location in Note
Past medical history
HPI
Notes
Do NOT use in note - spell it out
CPAP
Meaning
Continuous Positive Airway Pressure
Location in Note
Past medical history, vital signs
CPR
Meaning
Cardiopulmonary Resuscitation
Location in Note
HPI, procedures
CRP
Meaning
C-Reactive Protein
Location in Note
Labs
C-section
Meaning
Caesarean Section
Location in Note
Past surgical history
C-spine
Meaning
Cervical Spine
Location in Note
Physical exam
CSF
Meaning
Cerebrospinal Fluid
Location in Note
Labs
CTA
Meaning
Clear To Auscultation or Computed Tomography Angiography
Location in Note
Physical exam
Imaging
CV
Meaning
Cardiovascular
Location in Note
Physical exam
CVA
Meaning
Cerebrovascular Accident or Costovertebral Angle
Location in Note
Past medical history, diagnosis, assessment
Physical exam
CXR
Meaning
Chest X-Ray
Location in Note
Imaging
Notes
Do NOT use in note - spell it out
DC
Meaning
Discontinue
Location in Note
Assessment and plan, disposition
Notes
Do NOT use in note - spell it out
D/C
Meaning
Discharge
Location in Note
Disposition
D & C
Meaning
Dilation and Curettage
Location in Note
Past medical history, procedures
DDD
Meaning
Degenerative Disc Disease
Location in Note
Past medical history, diagnosis, assessment
DIP
Meaning
Distal Interphalangeal joint
Location in Note
Physical exam
Dispo
Meaning
Disposition
Location in Note
Last section of ED note
DJD
Meaning
Degenerative Joint Disease
Location in Note
Past medical history, diagnosis, assessment
DKA
Meaning
Diabetic Ketoacidosis
Location in Note
Past medical history, diagnosis, assessment
DM
Meaning
Diabetes Mellitus
Location in Note
Past medical history, diagnosis, assessment
What are the two types of DM
There are two types of DM: insulin dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM).
DNR
Meaning
Do Not Resuscitate
Location in Note
Patient information
DOA
Meaning
Dead On Arrival
Location in Note
HPI, disposition
Notes
Use only if instructed
DOB
Meaning
Date of Birth
Location in Note
Patient information
DP
Meaning
Dorsalis Pedis
Location in Note
Physical exam
DTR
Meaning
Deep Tendon Reflexes
Location in Note
Physical exam
DVT
Meaning
Deep Vein Thrombosis
Location in Note
Past medical history, diagnosis, assessment
Dx
Meaning
Diagnosis/ assessment
Location in Note
Disposition, assessment and plan
Notes
Do NOT use in note - spell it out
ECHO
Meaning
Echocardiogram
Location in Note
Imaging
E. coli
Meaning
Escherichia coli
Location in Note
Past medical history, labs
ED
Meaning
Emergency Department or Erectile Dysfunction
Location in Note
HPI
Past medical history, diagnosis, assessment
EDD
Meaning
Expected Date of Delivery
Location in Note
HPI, past medical history, pregnancy details
EENT
Meaning
Eyes, Ears, Nose, and Throat
Location in Note
Physical exam
EF
Meaning
Ejection Fraction
Location in Note
Past medical history
EGD
Meaning
Esophagogastro-duodenoscopy
Location in Note
Imaging
EJ
Meaning
External Jugular
Location in Note
Physical exam, procedures
EKG/ECG
Meaning
Electrocardiogram
Location in Note
MDM, imaging
EMR/EHR
Electronic Medical Record or Electronic Hospital Record
Location in Note
This is where the note is written
EMS
Meaning
Emergency Medical Services
Location in Note
HPI
EMT
Meaning
Emergency Medical Technician
Location in Note
Mentioned in HPI
EMTALA
Meaning
Emergency Medical Treatment and Active Labor Act
Location in Note
N/A
ENT
Meaning
Ears, Nose, and Throat
Location in Note
Physical exam, consultations, referral
ENT is both..
a body system and a specialty practice.
EOM
Meaning: Extraocular Movements
Location in Note
Physical exam
EOMI
Meaning
Extraocular Movements Intact
Location in Note
Physical exam
Epi
Meaning
Epinephrine
Location in Note
HPI, procedures
ERCP
Meaning
Endoscopic Retrograde Cholangio-
pancreatography
Location in Note
Imaging
ESR
Meaning
Erythrocyte Sedimentation Rate
Location in Note
Labs
ESR and the term “sed rate” are used…
ESR and the term “sed rate” are used interchangeably for the same meaning.
ESRD
Meaning
End Stage Renal Disease
Location in Note
Past medical history, diagnosis, assessment
ESRD is often followed by “on dialysis” and the days of the week the patient has dialysis.
EtOH
Meaning
Ethanol (alcohol)
Location in Note
Past social history, labs
ET tube
Meaning
Endotracheal tube
Location in Note
Procedures
FB
Meaning
Foreign Body
Location in Note
HPI, physical exam, procedure
Notes
Do NOT use in note - spell it out
FHx
Meaning
Family History
Location in Note
Past histories
Notes
Do NOT use in note - spell it out
FHT
Meaning
Fetal Heart Tones
Location in Note
Procedures, pregnancy details
FROM
Meaning
Full Range Of Motion
Location in Note
Physical exam
Notes
Only use if instructed by provider - otherwise spell it out
Fx
Meaning
Fracture
Location in Note
Past medical history, imaging
Notes
Do NOT use in note - spell it out
GC
Meaning
Gonorrhea
Location in Note
Past medical history, labs, diagnosis, assessment
Notes
Do NOT use in note - spell it out
GCS
Meaning
Glasgow Coma Score
Location in Note
Physical exam
GERD
Meaning
Gastroesophageal Reflux Disease
Location in Note
Past medical history, diagnosis, assessment
GFR
Meaning
Glomerular Filtration Rate
Location in Note
Labs
GI
Meaning
Gastrointestinal
Location in Note
Physical exam
G/P/A
Meaning
Gravida/Para/
Abortus
Location in Note
HPI, past histories
GSW
Meaning
Gunshot Wound
Location in Note
Past medical history, physical exam, diagnosis, assessment
G-tube
Meaning
Gastric tube
Location in Note
Past medical history, physical exam, procedures
GJ-tube
Meaning
Gastro-Jejunal tube
Location in Note
Past medical history, physical exam, procedures
GU
Meaning
Genitourinary
Location in Note
Physical exam
GYN
Meaning
Gynecology
Location in Note
Consultations, referral, patient education
Notes
Spell it out unless instructed by provider
H & H
Meaning
Hemoglobin and Hematocrit
Location in Note
Labs
H & P
Meaning
History and Physical
Location in Note
HPI and physical exam
HA
Meaning
Headache
Location in Note
HPI
Notes
Do NOT use in note - spell it out
Hct
Meaning
Hematocrit
Location in Note
Labs
HD
Meaning
Hemodialysis
Location in Note
Past medical history, diagnosis, assessment
Notes
Do NOT use in note - spell it out unless otherwise instructed
how is Hemodialysis is often written
Hemodialysis is often written following ESRD and is then followed by the days the patient gets dialysis. For example, “history of ESRd on dialysis M/W/F”.
HDL
Meaning
High Density Lipoprotein
Location in Note
Labs
HEENT
Meaning
Head, Eyes, Ears, Nose, and Throat
Location in Note
Physical exam
Hep A/B/C
Meaning
Hepatitis A, B, or C
Location in Note
Past medical history, diagnosis, assessment
HFpEF
Meaning
Heart Failure with Preserved Ejection Fraction
Location in Note
Past medical history, diagnosis, assessment
Notes
This term replaced CHF
what did CHF get replaced by
The old term, CHF or congestive heart failure, was a broad, general term which was replaced by HFpEF, HFrEF, and HFrecEF. HFpEF is most commonly used in documentation.
Hgb
Meaning
Hemoglobin
Location in Note
Labs
HI
Meaning
Homicidal Ideation
Location in Note
HPI, physical exam, diagnosis, assessment
Notes
Do NOT use in note - spell it out
HIV
Meaning
Human Immunodeficiency Virus
Location in Note
Past medical history, diagnosis, assessment
HLD
Meaning
Hyperlipidemia
Location in Note
Past medical history, diagnosis, assessment
HPI
Meaning
History of Present Illness
Location in Note
HPI
HPV
Meaning
Human Papillomavirus
Location in Note
Past medical history, diagnosis, assessment
HR
Meaning
Heart Rate
Location in Note
Vital signs
Notes
Do NOT use in note - spell it out
HSV
Meaning
Herpes Simplex Virus
Location in Note
Past medical history, diagnosis, assessment
HTN
Meaning
Hypertension
Location in Note
Past medical history, diagnosis, assessment
Hx
Meaning
History
Location in Note
Past histories
Notes
Do NOT use in note - spell out out
I & D
Meaning
Incision and Drainage
Location in Note
Procedures
IBS
Meaning
Irritable Bowel Syndrome
Location in Note
Past medical history, diagnosis, assessment
ICD - 10
Meaning
International Classification of Diseases - 10th Revision
Location in Note
Diagnoses
how are diagnoses classified
ICD-10 codes are how diagnoses are classified and there are thousands of different codes.
ICU
Meaning
Intensive Care Unit
Location in Note
Disposition
ID
Meaning
Infectious Disease
Location in Note
Consultations, assessment and plan, referral
IM
Meaning
Intramuscular
Location in Note
Medications
INR
Meaning
International Normalized Ratio
Location in Note
Labs
IP
Meaning
Interphalangeal joint
Location in Note
Physical exam
IUP
Meaning
Intrauterine Pregnancy
Location in Note
Past medical history, diagnosis, assessment
IV
Meaning
Intravenous
Location in Note
Medications
IVC
Meaning
Inferior Vena Cava
Location in Note
Past medical history, physical exam, diagnosis, assessment
IVCD
Meaning
Intraventricular Conduction Delay
Location in Note
EKG in the MDM
JVD
Meaning
Jugular Vein Distention
Location in Note
Physical exam
KUB
Meaning
Kidneys, Ureter, Bladder x-ray
Location in Note
Imaging
L & D
Meaning
Labor and Delivery
Location in Note
Consultations, disposition
Lac
Meaning
Laceration
Location in Note
HPI, physical exam, procedures
Notes
Do NOT use in note - spell it out
LAD
Meaning
Left Axis Deviation
Location in Note
EKG in MDM
LBBB
Meaning
Left Bundle Branch Block
Location in Note
EKG in MDM
LAFB
Meaning
Left Anterior Fascicular Block
Location in Note
EKG in MDM
Lab
Meaning
Laboratory
Location in Note
MDM
LDL
Meaning
Low Density Lipoprotein
Location in Note
Labs
LFT
Meaning
Liver Function Tests
Location in Note
Labs
LLE
Meaning
Left Lower Extremity
Location in Note
Physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
LLQ
Meaning
Left Lower Quadrant
Location in Note
Physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
LMP
Meaning
Last Menstrual Period
Location in Note
HPI, past history
Notes
This is the most recent period, normal or otherwise
LNMP
Meaning
Last Normal Menstrual Period
Location in Note
HPI, past history
Notes
This is the last “normal” period, meaning unchanged from typical
LOC
Meaning
Loss Of Consciousness
Location in Note
HPI
Notes
Do NOT use in note - spell it out
Note that in this abbreviation the “L” stands for “Loss” not “Level” as in the abbreviation “ALOC”. Be careful not to confuse the two.
LP
Meaning
Lumbar Puncture
Location in Note
Procedures
LUE
Meaning
Left Upper Extremity
Location in Note
HPI, physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
LUQ
Meaning
Left Upper Quadrant
Location in Note
HPI, physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
LVH
Meaning
Left Ventricular Hypertrophy
Location in Note
EKG in MDM
LWBS
Meaning
Left Without Being Seen
Location in Note
Disposition
Notes
Typically this is included in a nursing note, not the provider note
L-spine
Meaning
Lumbar Spine
Location in Note
Physical exam
mcg
Meaning
Micrograms
Location in Note
Medications
MCP
Meaning
Metacarpo-
phalangeal joint
Location in Note
Physical exam
Meds
Meaning
Medications
Location in Note
HPI, disposition
Notes
Do NOT use in note - spell it out unless otherwise told by provider
Mets
Meaning
Metastases
Location in Note
HPI, past medical history, diagnosis, assessment
mg
Meaning
Milligrams
Location in Note
Medications
MI
Meaning
Myocardial Infarction
Location in Note
Past medical history, diagnosis, assessment
mL
Meaning
Milliliters
Location in Note
Medications
MMR
Meaning
Measles, Mumps, and Rubella vaccine
Location in Note
Past history
MRA
Meaning
Magnetic Resonance Angiography
Location in Note
Imaging
MRI
Meaning
Magnetic Resonance Imaging
Location in Note
Imaging
MRSA
Meaning
Methicillin-
Resistant Staphylococcus aureus
Location in Note
Past medical history, diagnosis, assessment
MS
Meaning
Multiple Sclerosis
Location in Note
Past medical history, diagnosis, assessment
MSK
Meaning
Musculoskeletal
Location in Note
Physical exam
Notes
Do NOT use in note - spell it out
MTP
Meaning
Metatarso-phalangeal joint
Location in Note
Physical exam
MVA/MVC
Meaning
Motor Vehicle Accident/
Motor Vehicle Collision
Location in Note
HPI, past medical history, diagnosis, assessment
NAD
Meaning
No Acute Disease
Location in Note
Physical exam, imaging
Notes
Do NOT use in note - spell it out
NG tube
Meaning
Nasogastric tube
Location in Note
Physical exam, procedure
NKA
Meaning
No Known Allergies
Location in Note
Patient information, HPI, past history
Notes
Do NOT use in note - spell it out
NKDA
Meaning
No Known Drug Allergies
Location in Note
Patient information, HPI, past history
Notes
Do NOT use in note - spell it out
Nml
Meaning
Normal
Location in Note
All sections
Notes
Do NOT use in note- spell it out
NPO
Meaning
Nil Per Os (Nothing by mouth)
Location in Note
HPI, orders
NSAID
Meaning
Nonsteroidal Anti-Inflammatory Drug
Location in Note
Medications
NSR
Meaning
Normal Sinus Rhythm
Location in Note
Vital signs, physical exam, EKG in MDM
nSTEMI
Meaning
Non-ST Elevation Myocardial Infarction
Location in Note
Past medical history, diagnosis, assessment
NTG
Meaning
Nitroglycerin
Location in Note
Medications
N/V
Meaning
Nausea and Vomiting
Location in Note
HPI
Notes
Do NOT use in note - spell it out
NVD
Meaning
Nausea, Vomiting, and Diarrhea
Location in Note
HPI
Notes
Do NOT use in note - spell it out
O2 Sat
Meaning
Oxygen Saturation
Location in Note
Vital signs
OA
Meaning
Osteoarthritis
Location in Note
Past medical history, diagnosis, assessment
(Degenerative joint disease is another name for osteoarthritis.)
OB/GYN
Meaning
Obstetrics and Gynecology
Location in Note
Consultations, assessment and plan, referral
OD
Meaning
Overdose or Oculus Dexter (right eye)
Location in Note
HPI, diagnosis, assessment
Medications
Notes
Do NOT use in note for overdose - spell it out
OG tube
Meaning
Orogastric tube
Location in Note
Physical exam, procedures
OR
Meaning
Operating Room
Location in Note
Disposition
ORIF
Meaning
Open Reduction with Internal Fixation
Location in Note
Past surgical history, physical exam
Ortho
Meaning
Orthopedics
Location in Note
Consultations, assessment and plan, referral
OS
Meaning Oculus Sinister (left eye)
Location in Note
Medications
OSHA
Meaning
Occupational Health and Safety Administration
Location in Note
N/A
OTC
Meaning
Over - The -
Counter
Location in Note
Medications
PAC
Meaning
Premature Atrial Contraction
Location in Note
Physical exam, EKG in MDM
PCOS
Meaning
Polycystic Ovarian Syndrome
Location in Note
Past medical history, diagnosis, assessment
PCP
Meaning
Primary Care Provider
Location in Note
Patient information
(PCP is also an acronym for an illicit substance tested for in a UDS.)
PE
Meaning
Pulmonary Embolism
Location in Note
Past medical history, diagnosis, assessment
Peds
Meaning
Pediatrics
Location in Note
Consultation, assessment and plan, referral
PEG tube
Meaning
Percutaneous Endoscopic Gastrostomy tube
Location in Note
Past medical history, physical exam, procedures
PERRL
Meaning
Pupils are Equal, Round, and Reactive to Light
Location in Note
Physical exam
PICC
Meaning
Peripherally Inserted Central Catheter
Location in Note
HPI, physical exam, procedures
PID
Meaning
Pelvic Inflammatory Disease
Location in Note
Past medical history, diagnosis, assessment
PIP
Meaning
Proximal Interphalangeal joint
Location in Note
Physical exam
PNA
Meaning
Pneumonia
Location in Note
Past medical history, diagnosis, assessment
Notes
Do NOT use in note - spell it out
PO
Meaning Per Os (by mouth)
Location in Note
Medications
POC
Meaning
Products of Conception
Location in Note
Physical exam, imaging
Post-op
Meaning
Postoperative
Location in Note
HPI
PPE
Meaning
Personal Protective Equipment
Location in Note
N/A
ppd
Meaning
Packs Per Day
Location in Note
Past history
Pre-op
Meaning
Preoperative
Location in Note
HPI
PRN
Meaning
As needed
Location in Note
Medications
PSVT
Meaning
Paroxysmal Supraventricular Tachycardia
Location in Note
EKG in MDM
Psych
Meaning
Psychiatry or Psychiatric
Location in Note
Consultations, assessment and plan, referral
pt
Meaning
Patient
Location in Note
All sections
Notes
Do NOT use in note - spell it out
PT
Meaning
Physical Therapy or Prothrombin Time or Posterior Tibialis
Location in Note
Consultation, assessment and plan, referral
Labs
Physical exam
PTA
Meaning
Prior To Arrival
Location in Note
HPI
PTSD
Meaning
Post-
Traumatic Stress Disorder
Location in Note
Past medical history, diagnosis, assessment
PTT
Meaning
Partial Thromboplastin Time
Location in Note
Labs
PUD
Meaning
Peptic Ulcer Disease
Location in Note
Past medical history, diagnosis, assessment
PVC
Meaning
Premature Ventricular Contraction
Location in Note
Physical exam, EKG in MDM
PVD
Meaning
Peripheral Vascular Disease
Location in Note
Past medical history, diagnosis, assessment
Q#H
Meaning
Every # Hours
Location in Note
Medications
Most common dosing time frames used in this way are Q4H, Q6H, and Q8H. These translate to “every 4 hours”, “every 6 hours”, and “every 8 hours” respectively.
QAM
Meaning
Every morning
Location in Note
Medications
QD
Meaning
Every day
Location in Note
Medications
QHS
Meaning
At bedtime
Location in Note
Medications
QID
Meaning
4 times a day
Location in Note
Medications
QPM
Meaning
Every evening
Location in Note
Medications
RA
Meaning
Rheumatoid Arthritis
Location in Note
Past medical history, diagnosis, assessment
RAD
Meaning
Reactive Airway Disease
Location in Note
Past medical history, diagnosis, assessment
RBBB
Meaning
Right Bundle Branch Block
Location in Note
EKG in MDM
RBC
Meaning
Red Blood Cell
Location in Note
Labs
RICE
Meaning
Rest, Ice, Compression, and Elevation
Location in Note
Care instructions
RLE
Meaning
Right Lower Extremity
Location in Note
Physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
RLQ
Meaning
Right Lower Quadrant
Location in Note
Physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
r/o
Meaning
Rule Out
Location in Note
Assessment and plan, disposition
ROM
Meaning
Range of Motion
Location in Note
Physical exam
ROS
Meaning
Review of Systems
Location in Note
ROS
RRR
Meaning
Regular Rate and Rhythm
Location in Note
Physical exam
RSV
Meaning
Respiratory Syncytial Virus
Location in Note
Past medical history, labs, diagnosis, assessment
RUE
Meaning
Right Upper Extremity
Location in Note
HPI, physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
RUQ
Meaning
Right Upper Quadrant
Location in Note
HPI, physical exam
Notes
Do NOT use in note - spell it out unless otherwise told by provider
Rx
Meaning
Prescription
Location in Note
Medications
Notes
Do NOT use in note - spell it out
SAH
Meaning
Subarachnoid Hemorrhage
Location in Note
Past medical history, diagnosis, assessment
SARS
Meaning
Severe Acute Respiratory Syndrome
Location in Note
Past medical history, diagnosis, assessment
SBO
Meaning
Small Bowel Obstruction
Location in Note
Past medical history, diagnosis, assessment
Sed Rate
Meaning
Erythrocyte Sedimentation Rate
Location in Note
Labs
Sed rate and the term “ESR” are used interchangeably for the same meaning.
SI
Meaning
Suicidal Ideation
Location in Note
HPI
Notes
Do NOT use in note - spell it out
SL
Meaning
Sublingual
Location in Note
Medications
SLE
Meaning
Systemic Lupus Erythematosus
Location in Note
Past medical history, diagnosis, assessment
SLR
Meaning
Straight Leg Raise
Location in Note
Physical exam
SNF
Meaning
Skilled Nursing Facility
Location in Note
Disposition
SOAP
Meaning
Subjective, Objective, Assessment, Plan
Location in Note
Note layout in clinic
SOB
Meaning
Shortness of breath
Location in Note
HPI
Notes
Do NOT use in note - spell it out
s/p
Meaning
Status Post
Location in Note
HPI
STD/STI
Meaning
Sexually Transmitted Disease/
Sexually Transmitted Infection
Location in Note
HPI, past medical history
STEMI
Meaning
ST-Elevated Myocardial Infarction
Location in Note
Past medical history, diagnosis, assessment
Strep
Meaning Streptococcus (type of bacteria)
Location in Note
Labs
Sub Q
Meaning
Subcutaneous
Location in Note
Medications
SVT
Meaning
Supraventricular Tachycardia
Location in Note
Vital signs, EKG in MDM
Sx
Meaning
Symptoms
Location in Note
N/A
Sz
Meaning
Seizure
Location in Note
HPI
Notes
Do NOT use in note - spell it out
T3
Meaning
Triiodothyronine
Location in Note
Labs
T4
Meaning
Thyroxine
Location in Note
Labs
TB
Meaning
Tuberculosis
Location in Note
Past medical history, diagnosis, assessment
TBI
Meaning
Traumatic Brain Injury
Location in Note
Past medical history, diagnosis, assessment
Tdap
Meaning
Tetanus, Diphtheria, And Pertussis vaccine
Location in Note
Past history
Temp
Meaning
Temperature
Location in Note
Vital signs
TIA
Meaning
Transient Ischemic Attack
Location in Note
Past medical history, diagnosis, assessment
TID
Meaning
3 times a day
Location in Note
Medications
TM
Meaning
Tympanic Membrane
Location in Note
Physical exam
Tmax
Meaning
Tympanic Membrane
Location in Note
Physical exam
Tmax
Meaning
Maximum Temperature
Location in Note
HPI
TJ
Meaning
Temporo-mandibular Joint
Location in Note
Physical exam
tPA
Meaning
Tissue Plasminogen Activator
Location in Note
Medications
Trach
Meaning
Tracheostomy
Location in Note
Past surgical history, physical exam
TSH
Meaning
Thyroid Stimulating Hormone
Location in Note
Labs
TTP
Meaning
Tenderness To Palpation
Location in Note
Physical exam
Notes
Only use when told to by provider
T-spine
Meaning
Thoracic Spine
Location in Note
Physical exam
UA
Meaning
Urinalysis
Location in Note
Labs
UDS
Meaning
Urinary Drug Screen
Location in Note
Labs
URI
Meaning
Upper Respiratory Infection
Location in Note
diagnosis, assessment
US
Meaning
Ultrasound
Location in Note
Imaging
Notes
Do NOT use in note - spell it out
UTD
Meaning
Up To Date
Location in Note
Past history
UTI
Meaning
Urinary Tract Infection
Location in Note
Past medical history, diagnosis, assessment
V fib
Meaning
Ventricular Fibrillation
Location in Note
EKG in MDM
VP shunt
Meaning
Ventriculo-peritoneal shunt
Location in Note
Past medical history
VQ scan
Meaning
Ventilation Perfusion Scan
Location in Note
Imaging
V tach
Meaning
Ventricular Tachycardia
Location in Note
EKG in MDM
WBC
Meaning
White Blood Cell
Location in Note
Labs
wnl
Meaning
Within Normal Limits
Location in Note
Imaging
Notes
Do NOT use in note - spell it out
WPW
Meaning
Wolff-
Parkinson White syndrome
Location in Note
Past medical history, EKG in MDM, diagnosis, assessment
XR
Meaning
X-Ray
Location in Note
Imaging
Notes
Do NOT use in note - spell it out
y/o
Meaning
Year(s) old
Location in Note
HPI
How are Orders or prescriptions for medications written?
[MEDICATION NAME] dose administration route and finally, dose timing.
What is an example of how Orders or prescriptions for medications are written?
TORADOL 30 mg IM
IBUPROFEN 600 mg PO Q4H PRN
Prescriptions will include a number indicating how much of the medication the patient needs.
ZOFRAN ODT 4 mg PO #10
PO -
Per os
SL
- Sublingual
ODT
- Oral dissolving tablets
SQ
- Subcutaneous
IM
- Intramuscular
IV
- Intravenous
PO -
Per os, meaning “by mouth”. Medications are taken by mouth and chewed or swallowed.
SL -
Sublingual, meaning “under the tongue”. Medications are placed under the tongue where they dissolve.
ODT -
Oral dissolvable tablet, held in the mouth until it dissolves.
SQ -
Subcutaneous. Medications are injected under the skin in the subcutaneous layer.
IM -
Intramuscular. Medications are injected directly into the muscle.
IV
- Intravenous. Medications are injected directly into the veins.
Medications given in the ED or urgent care are ordered and given only…..
Medications given in the ED or urgent care are ordered and given only while in the facility.
Whats the difference between medications given in the ED
or urgent care vs home medications?
Medications given in the ED or urgent care are ordered and given only while in the facility.
Home medications may be taken on a regular or as needed basis.
What are schedule medications and when are they taken?
Scheduled medications are taken on a regular basis once or multiple times per day.
What are as needed medications
and when are they taken?
As needed medications are only taken when the patient is symptomatic.
QD
- Every day/daily
BID -
Twice a day
TID
- Three times a day
QID
- Four times a day
Q4H
- Every 4 hours
Q6H
- Every 6 hours
Q8H -
Every 8 hours
QAM -
Every morning
QPM -
Every evening
QHS
- At bedtime
PRN
- As needed
Full list of at home dosing periods:
QD - Every day/daily BID - Twice a day TID - Three times a day QID - Four times a day Q4H - Every 4 hours Q6H - Every 6 hours Q8H - Every 8 hours QAM - Every morning QPM - Every evening QHS - At bedtime PRN - As needed
What are the diff types of medications?
Cardiovascular Dermatologic Endocrine ENT Gastrointestinal Genitourinary Hematologic Musculoskeletal Neurologic Psychiatric Respiratory Systemic
What are Cardiovascular medications used for?
Cardiovascular medications are used to treat conditions and diseases of the heart and vasculature.
Generic Name
lisinopril
Zestril
Condition Being Treated
Hypertension
Cardio Vascular Med
Catapres
Generic Name
clonidine
Condition Being Treated
Hypertension/anxiety
Cardiovascular MED
(This medication is often given for hypertension in the ED, but is prescribed for anxiety more often in an outpatient setting.
Generic Name
amiodarone
Nexterone
Condition Being Treated
Arrhythmias
Tip Box: This drug is used often to chemically cardiovert patients in SVT or atrial fibrillation.
Generic Name
losartan
Cozaar
Condition Being Treated
Hypertension
Cardiovascular Med
Diovan
Generic Name
valsartan
Condition Being Treated
Hypertension
Cardiovascular Med
Generic Name
metoprolol
Lopressor
Condition Being Treated
Hypertension
Cardiovascular Med
Tenomin
Generic Name
atenolol
Condition Being Treated
Hypertension
Coreg
Generic Name
carvedilol
Condition Being Treated
Hypertension
Cardiovascular Med
Inderal
Generic Name
propranolol
Condition Being Treated
Hypertension
Cardiovascular med
Digox
Generic Name
digoxin
Condition Being Treated
CHF, arrhythmias
Generic Name
amlodipine
Norvasc
Condition Being Treated
Hypertension
Cardiovascular Med
Cardizem
Generic Name
diltiazem
Condition Being Treated
Angina, arrhythmias
Cardiovascular Med
Lasix
Generic Name
furosemide
Condition Being Treated
Fluid retention, hypertension
Cardiovascular Med
Aldactone
Generic Name
spironolactone
Condition Being Treated
Fluid retention, hypertension
Cardiovascular Med
Tip Box: This drug is also sometimes prescribed to women who struggle with acne.
Microzide
Generic Name
Hydrochlorothiazide (HCTZ)
Condition Being Treated
Fluid retention, hypertension
Cardiovascular Med
Generic Name Acetylsalicylic acid (ASA)
Aspirin
Condition Being Treated
Fever, pain, MI/blood clot prevention
Cardiovascular Med
Tip Box: Aspirin is often referred to as an anticoagulant - this is actually incorrect, as it is an antiplatelet drug. It specifically targets platelets instead of targeting coagulation factors.
Lipitor
Generic Name
atorvastatin
Condition Being Treated
Hyperlipidemia
Cardiovascular Med
Generic Name
simvastatin
Zocor
Condition Being Treated
Hyperlipidemia
Cardiovascular Med
Generic Name
pravastatin
Pravachol
Condition Being Treated
Hyperlipidemia
Cardiovascular Med
Crestor
Generic Name
rosuvastatin
Condition Being Treated
Hyperlipidemia
Cardiovascular Med
Generic Name
lovastatin
Brand Name:
Altoprev
Condition Being Treated
Hyperlipidemia
Cardiovascular Med
Brand Name
Nitrostat/
Nitropaste
Generic Name
Nitroglycerin (NTG)
Condition Being Treated
Angina
Cardiovascular Med
Tip Box: Nitroglycerin can be given topically (on the skin) or orally and is sometimes referred to simply as ‘nitro’.
Brand Name Apresoline
Generic Name
hydralazine
Condition Being Treated
Hypertension
Cardiovascular Med
What are Dermatologic medications used for?
Dermatologic medications are used to treat conditions and diseases of the skin.
Brand Name
Hydrocort
Generic Name
hydrocortisone
Condition Being Treated
Inflammation/
itching
Dermatologic Medications
Generic Name
triamcinolone
Brand Name
Kenalog
Condition Being Treated
Inflammation/itching
Dermatologic Medications
What are Endocrine medications used for?
Endocrine medications are used to treat conditions and diseases of the endocrine system which is responsible for hormone secretion and regulation.
Generic Name
Metformin
Brand Name
Glucophage
Condition Being Treated
Diabetes
Endocrine Medications
Generic Name
pioglitazone
Brand Name
Actos
Condition Being Treated
Diabetes
Endocrine Medications
Lantus/Levemir
Generic Name
insulin
Condition Being Treated
Diabetes
Tip Box: There are many different brands of long-acting insulin.
Endocrine Medications
Tip Box: There are many different brands of long-acting insulin.
Generic Name
insulin
Brand Name
Novolog/
Humalog
Condition Being Treated
Diabetes
Endocrine Medications
Tip Box: There are many different brands of rapid-acting insulin.
Generic Name
glipizide
Brand Name
Glucotrol
Condition Being Treated
Diabetes
Endocrine Medications
Generic Name
levothyroxine
Brand Name
Synthroid
Condition Being Treated
Hypothyroidism
Endocrine Medications
What are ENT medications used
for?
ENT medications are used to treat conditions and diseases of the ears, nose, and throat.
Brand Name
Flonase
Generic Name
fluticasone
Condition Being Treated
Allergies/
inflammation
ENT Medications
Brand Name
Claritin
Generic Name
loratadine
Condition Being Treated
Allergies
ENT Medications
Generic Name
cetirizine
Brand Name
Zyrtec
Condition Being Treated
Allergies
ENT Medications
Brand Name
Vistaril
Generic Name
hydroxyzine
Condition Being Treated
Allergies/
anxiety
ENT Medications
Brand Name
Singulair
Generic Name
montelukast
Condition Being Treated
Allergies
ENT Medications
What are Gastrointestinal medications used for?
Gastrointestinal medications are used to treat conditions and diseases of the stomach and intestines.
Brand Name
Zofran
Generic Name
ondansetron
Condition Being Treated
Nausea
Gastrointestinal Medications
Generic Name
promethazine
Brand Name
Phenergan
Condition Being Treated
Nausea
Gastrointestinal Medications
Brand Name
Reglan
Generic Name
metoclopramide
Condition Being Treated
Nausea, GERD, gastroparesis
Gastrointestinal Medications
Brand Name
Compazine
Generic Name
prochlorperazine
Condition Being Treated
Nausea, anxiety, schizophrenia
Gastrointestinal Medications
Generic Name
ranitidine
Brand Name
Zantac
Condition Being Treated
GERD
Gastrointestinal Medications
Recently, new evidence has come out that shows a correlation between a patient taking certain types of ranitidine and developing cancer, causing the FDA to order a recall of those batches.
Brand Name
Pepcid
Generic Name
famotidine
Condition Being Treated
GERD
Gastrointestinal Medications
Tip Box: Though normally prescribed for GERD, famotidine can also treat allergic reactions involving itching since it is an H2 blocker.
Brand Name
Colace
Generic Name
docusate
Condition Being Treated
Constipation
Gastrointestinal Medications
Generic Name
polyethylene glycol
Brand Name
Miralax
Condition Being Treated
Constipation
Gastrointestinal Medications
Generic Name
omeprazole
Brand Name
Prilosec
Condition Being Treated
GERD
Gastrointestinal
Brand Name
Protonix
Generic Name
pantoprazole
Condition Being Treated
GERD
Gastrointestinal Medications
Brand Name
“GI cocktail”
Generic Name
Maalox/Mylanta, benadryl, and viscous lidocaine
Condition Being Treated
GERD, gastritis, stomach upset
Gastrointestinal Medications
A GI cocktail may include slightly different blends of medications from practice to practice.
What are genitourinary medications used for?
Genitourinary medications are used to treat conditions and diseases of the urinary tract and genitalia.
Brand Name
Propecia
Generic Name
finasteride
Condition Being Treated
Urinary retention
Genitourinary Medications
Tip Box: This medication is only prescribed to men, specifically to decrease complications of BPH which are a direct result of testosterone.
Generic Name
tamsulosin
Brand Name
Flomax
Condition Being Treated
BPH, urinary retention
Genitourinary Medications
Tip Box: This drug is also given to help patients pass kidney stones with less pain.
Brand Name
Macrobid
Generic Name
nitrofurantoin
Condition Being Treated
UTI
Genitourinary Medications
Tip Box: Macrobid is one of the few antibiotics that is used as a specific treatment - in this case it is considered the first-line treatment for uncomplicated UTIs.
Brand Name
Oxytrol
Generic Name
oxybutynin
Condition Being Treated
Urinary incontinence
Genitourinary Medications
Generic Name
estradiol
Brand Name
Estrace
Condition Being Treated
Menopause
Genitourinary Medications
Generic Name
sildenafil
Brand Name
Viagra
Condition Being Treated
Erectile dysfunction
Genitourinary Medications
What are Hematologic medications used for?
Hematologic medications are used to treat conditions and diseases of the blood.
Generic Name
warfarin
Brand Name
Coumadin
Condition Being Treated
DVT/PE
Hematologic Medications
Brand Name
Xarelto
Generic Name
rivaroxaban
Condition Being Treated
DVT/PE/Afib, MI/CVA prevention
Hematologic Medications
Brand Name
Eliquis
Generic Name
apixaban
Condition Being Treated
DVT/PE/Afib, MI/CVA prevention
Hematologic
Generic Name
clopidogrel
Brand Name
Plavix
Condition Being Treated
MI/CVA prevention
Endocrine
Tip Box: Plavix is often referred to as an anticoagulant - this is actually incorrect, as it is an antiplatelet drug. It specifically targets platelets instead of targeting coagulation factors.
What are Musculoskeletal medications used
to treat?
Musculoskeletal medications are used to treat conditions and diseases of the muscles and bones.
Brand Name
Zanaflex
Generic Name
tizanidine
Condition Being Treated
Muscle spasms
Musculoskeletal Medications
Generic Name
acetaminophen
Brand Name
Tylenol
Condition Being Treated
Pain, fever
Musculoskeletal Medications
Brand Name
Colcrys
Generic Name
colchicine
Condition Being Treated
Gout prevention
Musculoskeletal Medications
Generic Name
allopurinol
Brand Name
Alloprim
Condition Being Treated
Gout
Musculoskeletal Medications
Generic Name
cyclobenzaprine
Condition Being Treated
Muscle spasms
Musculoskeletal Medications
Brand Name
Flexeril
Generic Name
methocarbamol
Brand Name
Robaxin
Condition Being Treated
Muscle spasms
Musculoskeletal Medications
Generic Name
baclofen
Brand Name
Gablofen
Condition Being Treated
Muscle spasms
Musculoskeletal Medications
Generic Name
carisoprodol
Brand Name
Soma
Condition Being Treated
Muscle spasms
Musculoskeletal Medications
Generic Name
naproxen
Brand Name
Aleve/
Naprosyn
Condition Being Treated
Inflammation, pain
Musculoskeletal Medications
Brand Name
Aleve/
Naprosyn
Generic Name
naproxen
Condition Being Treated
Inflammation, pain
Musculoskeletal Medications
Generic Name
diclofenac
Brand Name
Voltaren
Condition Being Treated
Inflammation, pain
Musculoskeletal Medications
Generic Name
ibuprofen
Brand Name
Motrin
Condition Being Treated
Inflammation, pain
Musculoskeletal Medications
Generic Name
ketorolac
Brand Name
Toradol
Condition Being Treated
Inflammation, pain
Musculoskeletal Medications
Generic Name
hydrocodone &
acetaminophen
Brand Name
Vicodin/Norco
Condition Being Treated
Pain
Musculoskeletal Medications
Tip Box: Vicodin and Norco are different names for the same medication: “hydrocodone with acetaminophen”; however, the different names correspond to different doses of hydrocodone.
Brand Name
Ultram
Generic Name
tramadol
Condition Being Treated
Pain
Musculoskeletal Medications
Brand Name
Percocet
Generic Name
oxycodone/
acetaminophen
Condition Being Treated
Pain
Musculoskeletal Medications
Generic Name
morphine
Brand Name
MS-Contin
Condition Being Treated
Pain
Musculoskeletal Medications
What are Neurologic medications used for?
Neurologic medications are used to treat conditions and diseases of the brain and nerves.
Generic Name
phenytoin
Brand Name
Dilantin
Condition Being Treated
Seizures
Neurologic Medications
Brand Name
Trileptal
Generic Name
oxcarbazepine
Condition Being Treated
Seizures
Neurologic Medications
Generic Name
levetiracetam
Brand Name
Keppra
Condition Being Treated
Seizures
Neurologic Medications
Brand Name
Topamax
Generic Name
topiramate
Condition Being Treated
Seizures, headaches
Neurologic Medications
Generic Name
divalproex
Brand Name
Depakote
Condition Being Treated
Seizures
Neurologic Medications
Generic Name
Carbidopa/
Levodopa
Brand Name
Duopa
Condition Being Treated
Parkinson’s disease
Neurologic Medications
Brand Name
Lyrica
Generic Name
pregabalin
Condition Being Treated
Nerve pain, seizures
Neurologic Medications
Brand Name
Neurontin
Generic Name
gabapentin
Condition Being Treated
Nerve pain, seizures
Neurologic Medications
Brand Name
Antivert
Generic Name
meclizine
Condition Being Treated
Vertigo
Neurologic Medications
Brand Name
Imitrex
Generic Name
sumatriptan
Condition Being Treated
Headaches/
Chronic migraines
Neurologic Medications
Brand Name
Maxalt
Generic Name
rizatriptan
Condition Being Treated
Headaches/
Chronic migraines
Neurologic Medications
What are Psychiatric medications used for?
Psychiatric medications are used to treat conditions and diseases of behavior and mood.
Brand Name
Seroquel
Generic Name
quetiapine
Condition Being Treated
Schizophrenia, bipolar disorder
Psychiatric Medications
Generic Name
aripiprazole
Brand Name
Abilify
Condition Being Treated
Schizophrenia, bipolar disorder
Psychiatric Medications
Generic Name
risperidone
Brand Name
Risperdal
Condition Being Treated
Schizophrenia, bipolar disorder
Psychiatric Medications
Brand Name
Buspar
Generic Name
buspirone
Condition Being Treated
Anxiety
Psychiatric Medications
Brand Name
Xanax
Generic Name
alprazolam
Condition Being Treated
Anxiety
Psychiatric Medications
Generic Name
clonazepam
Brand Name
Klonopin
Condition Being Treated
Anxiety
Psychiatric Medications
Generic Name
lorazepam
Brand Name
Ativan
Condition Being Treated
Anxiety
Psychiatric Medications
Generic Name
diazepam
Brand Name
Valium
Condition Being Treated
Anxiety, seizures
Psychiatric Medications
Generic Name
zolpidem
Brand Name
Ambien
Condition Being Treated
Insomnia
Psychiatric Medications
Brand Name
Cymbalta
Generic Name
duloxetine
Condition Being Treated
Depression
Psychiatric Medications
Brand Name
Desyrel
Generic Name
trazodone
Condition Being Treated
Insomnia, depression
Psychiatric Medications
Brand Name
Zoloft
Generic Name
sertraline
Condition Being Treated
Depression
Psychiatric Medications
Brand Name
Prozac
Generic Name
fluoxetine
Condition Being Treated
Depression
Psychiatric Medications
Generic Name
citalopram
Brand Name
Celexa
Condition Being Treated
Depression
Psychiatric Medications
Brand Name
Wellbutrin
Generic Name
bupropion
Condition Being Treated
Depression
Psychiatric Medications
Brand Name
Lexapro
Generic Name
escitalopram
Condition Being Treated
Depression
Psychiatric Medications
Generic Name
mirtazapine
Brand Name
Remeron
Condition Being Treated
Depression
Psychiatric Medications
Brand Name
Elavil
Generic Name
amitriptyline
Condition Being Treated
Depression, chronic migraines
Psychiatric Medications
Generic Name
nortriptyline
Brand Name
Pamelor
Condition Being Treated
Depression, chronic migraines
Psychiatric Medications
What are Respiratory medications used for?
Respiratory medications are used to treat conditions and diseases of the lungs and upper respiratory tract.
Generic Name
tiotropium
Brand Name
Spiriva
Condition Being Treated
Asthma, COPD
Respiratory Medications
Generic Name
benzonatate
Brand Name
Tessalon Perles
Condition Being Treated
Cough
Respiratory Medications
Brand Name
Advair Diskus
Generic Name
fluticasone/
salmeterol
Condition Being Treated
Asthma, COPD
Generic Name
albuterol
Brand Name
ProAir/
Ventolin
Condition Being Treated
Dyspnea
Respiratory Medications
Tip Box: This is most commonly prescribed as a rescue inhaler, but albuterol is also prescribed as a nebulizer treatment.
Brand Name
Robitussin DM
Generic Name
dextromethorphan
Condition Being Treated
Cough
Respiratory Medications
Tip Box: This medication is considered over-the-counter, but is still controlled when purchased due to abuse risk.
Generic Name
guaifenesin
Brand Name
Mucinex
Condition Being Treated
Congestion
Respiratory Medications
What are Systemic medications used for?
Systemic medications are used to treat conditions and diseases of the whole body.
Brand Name
Xylocaine
Generic Name
lidocaine
Condition Being Treated
Pain
Systemic Medications
Tip Box: This is the most commonly used topical anesthetic in most EDs and clinics.
Brand Name
Marcaine
Generic Name
bupivacaine
Condition Being Treated
Pain
Systemic Medications
Brand Name
Amidate
Generic Name
etomidate
Condition Being Treated
Conscious sedation
Systemic Medications
Generic Name
Propofol
Brand Name: Diprivan
Condition Being Treated
Conscious sedation
Systemic Medications
Generic Name
fluconazole
Brand Name
Diflucan
Condition Being Treated
Yeast infections, Valley Fever
Class
Antifungal
Systemic Medications
Generic Name
Amoxicillin
Brand Name
Amoxil
Condition Being Treated
Pneumonia, strep, cellulitis, otitis
Class
Antibiotic
Systemic Medications
Brand Name
Augmentin
Generic Name
amoxicillin/ clavulanate
Condition Being Treated
Pneumonia, impetigo, cellulitis, otitis
Class
Antibiotic
Systemic Medications
Generic Name
azithromycin
Brand Name
Z-pak/
Zithromax
Condition Being Treated
Pneumonia, chlamydia, multiple other infections
Class
Antibiotic
Systemic Medications
Generic Name
sulfamethoxazole & trimethoprim
Brand Name
Bactrim
Condition Being Treated
UTI, cellulitis
Class
Antibiotic
Systemic Medications
Brand Name
Cipro
Generic Name
ciprofloxacin
Condition Being Treated
UTI, pyelonephritis, multiple other infections
Class
Antibiotic
Systemic Medications
Cleocin
Generic Name
clindamycin
Condition Being Treated
Strep, acne, multiple other infections
Class
Antibiotic
Systemic Medications
Brand Name
Levaquin
Generic Name
levofloxacin
Brand Name
Levaquin
Condition Being Treated
UTI, pyelonephritis, multiple other infections
Class
Antibiotic
Systemic Medications
Generic Name
metronidazole
Brand Name
Flagyl
Condition Being Treated
Bacterial vaginosis, C. diff, trichomoniasis
Class
Antibiotic
Systemic Medications
Brand Name
Keflex
Generic Name
cephalexin
Condition Being Treated
UTI, cellulitis
Class
Antibiotic
Systemic Medications
Generic Name
penicillin
Brand Name
Penicillin VK
Condition Being Treated
ENT, respiratory tract, and multiple other infections
Class
Antibiotic
Systemic Medications
Generic Name
doxycycline
Condition Being Treated Brand Name
Multiple resistant infections
Class
Antibiotic
Systemic Medications
Brand Name
Benadryl
Generic Name
diphenhydramine
Condition Being Treated
Allergic reactions, sleeplessness
Systemic Medications
Generic Name
acyclovir
Condition Being Treated
Herpes, shingles
Systemic Medications
Generic Name
valacyclovir
Brand Name
Valtrex
Condition Being Treated
Herpes, shingles
Systemic Medications
Brand Name
Valtrex
Generic Name
valacyclovir
Condition Being Treated
Herpes, shingles
Systemic Medications
Brand Name
Tamiflu
Condition Being Treated
Influenza
Systemic Medications
Generic Name
cyanocobalamin
Brand Name
Vitamin B12
Condition Being Treated
Vitamin B12 deficiency
Systemic
Generic Name
prednisone
Condition Being Treated
Inflammation
Systemic Medications
Generic Name
methylprednisolone
Brand Name
Medrol
Condition Being Treated
Inflammation
Systemic Medications
Generic Name
rocuronium (“roc”)
Condition Being Treated
Conscious sedation
Systemic Medications
Generic Name
epinephrine
Brand Name
EpiPen
Condition Being Treated
Anaphylaxis
Systemic Medications
Which of the following are considered diagnostic studies? (Check all that apply).
1 point
Differential diagnosis Consultations Labs Procedures Imaging Reevaluations
Which of the following would be included in a Plan? (Check all that apply).
3 points
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.
Generic Name
succinylcholine (“sux”)
Condition Being Treated
Conscious sedation
Systemic Medications
Subjective fever
ROS or exam?
ROS
Measured fever
ROS or Exam?
ROS
Chills
ROS or Exam?
ROS
Sweating
ROS or Exam?
ROS
Diaphoresis
ROS or Exam?
ROS
Generalized weakness
ROS OR EXAM
ROS
Fatigue
ROS OR EXAM
ROS
Malaise
ROS OR EXAM
ROS
Decreased appetite
ROS OR EXAM
ROS
Decreased oral intake
ROS OR EXAM
ROS
Weight gain
ROS OR EXAM
ROS
Weight loss
ROS OR EXAM
ROS
Urticaria
ROS OR EXAM
ROS
Rash
ROS OR EXAM
ROS
Itching
ROS OR EXAM
ROS
Redness
ROS OR EXAM
ROS
Ecchymosis
ROS OR EXAM
ROS
Abrasion
ROS OR EXAM
ROS
Laceration
ROS OR EXAM
ROS
Burn
ROS OR EXAM
ROS
Dryness
ROS OR EXAM
ROS
Lesion
ROS OR EXAM
ROS
Jaundice
ROS OR EXAM
ROS
Cyanosis
ROS OR EXAM
ROS
Dog bite/Human bite
ROS OR EXAM
ROS
Blurred vision
ROS OR EXAM
ROS
Diplopia
ROS OR EXAM
ROS
Visual changes
ROS OR EXAM
ROS
Eye pain
ROS OR EXAM
ROS
Eye discharge
ROS OR Exam?
ROS
Mattering
ROS OR EXAM
ROS
Eye discoloration
ROS OR EXAM
ROS
Eye foreign body
ROS OR EXAM
ROS
Excessive tearing
ROS OR EXAM
ROS
Eyelid swelling
ROS OR EXAM
ROS
Ear pain
ROS OR EXAM
ROS
Ear discharge
ROS OR EXAM
ROS
Tinnitus
ROS OR EXAM
ROS
Decreased hearing
ROS OR EXAM
ROS
Hearing loss
ROS OR EXAM
ROS
Nasal congestion
ROS OR EXAM
ROS
Rhinorrhea
ROS OR EXAM
ROS
Epistaxis
ROS OR EXAM
ROS
Mouth pain
ROS OR EXAM
ROS
Dental pain
ROS OR EXAM
ROS
Tongue swelling
ROS OR EXAM
ROS
Oral lesions
ROS OR EXAM
ROS
Bleeding gums
ROS OR EXAM
ROS
Dry mouth
ROS OR EXAM
ROS
Sore throat/throat pain
ROS OR EXAM
ROS
Difficulty swallowing
ROS OR EXAM
ROS
Throat swelling
ROS OR EXAM
ROS
Chest pain
ROS OR EXAM
ROS
Palpitations
ROS OR EXAM
ROS
Syncope
ROS OR EXAM
ROS
Diaphoresis
ROS OR EXAM
ROS
Peripheral edema
ROS OR EXAM
ROS
Abdominal pain
ROS OR EXAM
ROS
Pelvic pain
ROS
Flank pain
ROS OR EXAM
ROS
Nausea
ROS OR EXAM
ROS
Vomiting
ROS OR EXAM
ROS
Post-tussive emesis
ROS OR EXAM
ROS
Hematemesis
ROS OR EXAM
ROS
Diarrhea
ROS OR EXAM
ROS
Hematochezia
ROS OR EXAM
ROS
Melena
ROS OR EXAM
ROS
Constipation
ROS OR EXAM
ROS
Dysphagia
ROS OR EXAM
ROS
Rectal bleeding
ROS OR EXAM
ROS
Rectal pain
ROS OR EXAM
ROS
Dysuria
ROS OR EXAM
ROS
Hematuria
ROS OR EXAM
ROS
Urinary incontinence
ROS OR EXAM
ROS
Urinary frequency
ROS OR EXAM
ROS
Urinary urgency
ROS OR EXAM
ROS
Urinary retention
ROS OR EXAM
ROS
Nocturia
ROS OR EXAM
ROS
Vaginal bleeding
ROS OR EXAM
ROS
Vaginal discharge
ROS OR EXAM
ROS
Metrorrhagia
ROS OR EXAM
ROS
Genital lesions
ROS OR EXAM
ROS
Testicular pain
ROS OR EXAM
ROS
Scrotal swelling
ROS OR EXAM
ROS
Penile pain
ROS OR EXAM
ROS
Penile discharge
ROS OR EXAM
ROS
Back pain
ROS OR EXAM
ROS
Back pain
ROS OR EXAM
ROS
Neck pain
ROS OR EXAM
ROS
Myalgias
ROS OR EXAM
ROS
Arthralgias
ROS OR EXAM
ROS
Extremity pain
ROS OR EXAM
ROS
Headache
ROS OR EXAM
ROS
Photophobia
ROS OR EXAM
ROS
Phonophobia
ROS OR EXAM
ROS
Dizziness
ROS OR EXAM
ROS
Lightheadedness
ROS OR EXAM
ROS
Rotational
ROS OR EXAM
ROS
Altered level of consciousness
ROS OR EXAM
ROS
Numbness
ROS OR EXAM
ROS
Tingling
ROS OR EXAM
ROS
Weakness
ROS OR EXAM
ROS
Seizure
ROS OR EXAM
ROS
Dysarthria
ROS OR EXAM
ROS
Dysphasia
ROS OR EXAM
ROS
Bowel/bladder incontinence
ROS OR EXAM
ROS
Saddle anesthesia
ROS OR EXAM
ROS
Anxiety
ROS OR EXAM
ROS
Depression
ROS OR EXAM
ROS
Mania
ROS OR EXAM
ROS
Suicidal ideation
ROS OR EXAM
ROS
Homicidal ideation
ROS OR EXAM
ROS
Auditory or Visual Hallucinations
ROS OR EXAM
ROS
Insomnia
ROS OR EXAM
ROS
Substance abuse
ROS OR EXAM
ROS
Eating disorders
ROS OR EXAM
ROS
Polyuria
ROS OR EXAM
ROS
Polydipsia
ROS OR EXAM
ROS
Polyphagia
ROS OR EXAM
ROS
Hypoglycemia
Heat/Cold intolerance
Hirsutism
ROS OR EXAM
ROS
Alopecia
Hot flashes
ROS OR EXAM
ROS
Bleeding tendency
Bruising tendency
ROS OR EXAM
ROS
Petechiae
Swollen lymph nodes
ROS OR EXAM
ROS
Seasonal allergies
Food allergies
ROS OR EXAM
ROS
Recurrent infections
Impaired immunity
Immunosuppressive therapy
ROS OR EXAM
ROS
ROS OR EXAM? Why?
Constitutional Skin Eyes ENMT (Ears, Nose, Mouth, and Throat) ***** Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurologic Psychiatric Endocrine ***** Heme/Lymph (Hematologic/Lymphatic) ***** Allergy/Immunologic ******
Constitutional
The above = ROS, bottom exam Skin Head/Neck ******** Eyes ENT ****** Lymphatics Cardiovascular Respiratory/Chest Wall ******* Gastrointestinal Genitourinary Musculoskeletal/Back/Extremities ***** Neurological Psychiatric
Some physical exam findings may fit in more than one body system. These may also contradict a finding in another system, so always be cognizant when recording exams.
T/F??
True
Alert
No acute distress
Well-developed, well-nourished
ROS OR EXAM?
Exam
Body System: Constitutional
Somnolent
Obtunded
Unresponsive
ROS OR EXAM
Exam
Body System: Constitutional
Mild distress
Moderate distress
Severe distress
ROS OR EXAM
Exam
Body System: Constitutional
Cachectic
Ill-appearing
Obese/grossly overweight
ROS OR EXAM
Exam
Body System: Constitutional
Cachectic
Ill-appearing
Obese/grossly overweight
ROS OR EXAM
Exam
Body System: Constitutional
Warm
Dry
Pink
ROS OR EXAM
Exam
Body System: Skin
Intact
ROS OR EXAM
Exam
Body System: Skin
No signs of infection
ROS OR EXAM
Exam
Body System: Skin
No rashes
ROS OR EXAM
Exam
Body System: Skin
No signs of trauma
ROS OR EXAM
Exam
Body System: Skin
Cool
ROS OR EXAM
Exam
Body System: Skin
Moist
Clammy
Diaphoretic
ROS OR EXAM
Exam
Body System: Skin
Jaundiced
Cyanotic
Pale
ROS OR EXAM
Exam
Body System: Skin
Laceration
Abrasion
ROS OR EXAM
Exam
Body System: Skin
Avulsion
Lesion
ROS OR EXAM
Exam
Body System: Skin
Fluctuance
Induration
ROS OR EXAM
Exam
Body System: Skin
Erythema
Purulent drainage
ROS OR EXAM
Exam
Body System: Skin
Lymphangitis
ROS OR EXAM
Exam
Body System: Skin
Urticaria
Petechiae
Vesicles
ROS OR EXAM
Exam
Body System: Skin
Hematoma
Ecchymosis
ROS OR EXAM
Exam
Body System: Skin
Normocephalic
Atraumatic
No head tenderness
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Supple
Trachea midline
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No JVD
No cervical lymphadenopathy
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No JVD
No cervical lymphadenopathy
ROS OR EXAM
Body System: Head/Neck DIFF
No carotid bruit
No neck tenderness
ROS OR EXAM
Body System: Head/Neck DIFF
No neck tenderness
No deformity
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Craniectomy
Skull malformations
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Battle sign
Contusions
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Lacerations
Hematomas
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Ecchymosis
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Skull tenderness
Sinus tenderness
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Supple
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Nuchal rigidity
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Trachea midline
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Deviation
Tracheal deviation
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No JVD
JVD
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No cervical lymphadenopathy
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Cervical lymphadenopathy
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No carotid bruit
Carotid bruit
ROS OR EXAM
Body System: Head/Neck DIFF
No tenderness
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
C-spine tenderness
Paraspinal muscle tenderness
Trapezius tenderness
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
C-spine tenderness
Paraspinal muscle tenderness
Trapezius tenderness
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
No deformity
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
Bony crepitus
Step-offs
ROS OR EXAM
Exam
Body System: Head/Neck DIFF
PERRLA
EOMI
ROS OR EXAM
Exam
Body System: Eyes
Normal conjunctiva
Anicteric sclera
ROS OR EXAM
Exam
Body System: Eyes
Sluggish pupils
Blown pupil
ROS OR EXAM
Exam
Body System: Eyes
Dilated pupils
Fixed pupils
ROS OR EXAM
Exam
Body System: Eyes
Nystagmus
Entrapment
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Body System: Eyes
Injected conjunctiva
Pale conjunctiva
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Body System: Eyes
Scleral Icterus
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Body System: Eyes
TMs clear
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Body System: ENMT
Retracted TM
Bulging TM
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Body System: ENMT
Erythematous TM
Dull TM
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Body System: ENMT
Hemotympanum
TM obscured by cerumen
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Body System: ENMT
Normal nares (nostrils)
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Body System: ENMT
Epistaxis
Rhinorrhea
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Body System: ENMT
Septal hematoma
Boggy turbinates
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Body System: ENMT
Nasal deformity
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Body System: ENMT
Moist mucous membranes
Dry mucous membranes
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Body System: ENMT
Dental caries
Edentulous
Gingival abscess
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Body System: ENMT
Tonsillar hypertrophy
Pharyngeal erythema
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Body System: ENMT
Pharyngeal exudates
Cobblestoning
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Body System: ENMT
No lymphadenopathy
Lymphadenopathy
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Body System: ENMT
Regular rate
Regular rhythm
No edema
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Body System: Cardiovascular
Good capillary refill
Strong, equal distal pulses
Normal heart sounds
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Body System: Cardiovascular
Tachycardia
Bradycardia
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Body System: Cardiovascular
Arrhythmia
Atrial fibrillation
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Body System: Cardiovascular
Peripheral edema
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Body System: Cardiovascular
Delayed cap(illary) refill
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Body System: Cardiovascular
Absent pulse (0+) - Bounding (4+) ROS OR EXAM
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Body System: Cardiovascular
Rubs
Gallops
Murmurs
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Body System: Cardiovascular
Lungs CTA
Equal breath sounds
Non-labored respirations
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Body System: Respiratory/ Chest Wall**
No chest wall tenderness
No chest wall deformity
Normal breast exam
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Body System: Respiratory/ Chest Wall**
Wheezes
Crackles
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Body System: Respiratory/ Chest Wall**
Rales
Rhonchi
Stridor
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Body System: Respiratory/ Chest Wall**
Diminished breath sounds
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Body System: Respiratory/ Chest Wall**
Tachypnea
Bradypnea
Apnea
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Body System: Respiratory/ Chest Wall**
Tenderness
Exam
Body System: Respiratory/ Chest Wall**
Crepitus
Seat belt sign
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Body System: Respiratory/ Chest Wall**
Ecchymosis
Emphysema
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Body System: Respiratory/ Chest Wall**
Masses
Nipple discharge
Tenderness
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Body System: Respiratory/ Chest Wall**
Soft
Nontender
Nondistended
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Body System: Gastrointestinal**
Normal bowel sounds
No palpable masses
Normal rectal exam
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Body System: Gastrointestinal**
Rigid (involuntary guarding)
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Body System: Gastrointestinal**
Mild tenderness
Moderate tenderness
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Body System: Gastrointestinal**
Severe tenderness
Rebound tenderness
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Body System: Gastrointestinal**
Voluntary guarding
Murphy’s sign
Mcburney’s point tenderness
ROS OR EXAM
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Body System: Gastrointestinal**
Psoas sign
Obturator sign
Rovsing’s sign
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Body System: Gastrointestinal**
Distended
ROS OR EXAM
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Body System: Gastrointestinal**
Absent
Hyperactive
Hypoactive
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Body System: Gastrointestinal**
Hernia (umbilical, inguinal, etc/reducible, unable to reduce, etc)
ROS OR EXAM
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Body System: Gastrointestinal**
Rectal exam: Normal tone Brown stool Guaiac negative No hemorrhoids
ROS OR EXAM
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Body System: Gastrointestinal**
Rectal exam:
Decreased tone
Black (melanotic), red, white stool
Guaiac positive
ROS OR EXAM
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Body System: Gastrointestinal**
Internal/external/ thrombosed hemorrhoids
ROS OR EXAM
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Body System: Gastrointestinal**
Normal external female genitalia
Normal bimanual exam
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Body System: Genitourinary**
Normal speculum exam
Normal external male genitalia
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Body System: Genitourinary**
Sores
Lesions
Rashes
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Body System: Genitourinary**
Cervical motion tenderness
Adnexal tenderness
ROS OR EXAM
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Body System: Genitourinary**
Cervical os open
Blood or malodorous/
discolored discharge in the vault
ROS OR EXAM
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Body System: Genitourinary**
Penile lesions
Penile sores
Urethral discharge
ROS OR EXAM
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Body System: Genitourinary**
Normal external male genitalia
Circumcised/uncircumcised
ROS OR EXAM
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Body System: Genitourinary**
Scrotal swelling
Testicular mass
Inguinal hernia
ROS OR EXAM
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Body System: Genitourinary**
Nontender bones/muscles
Full range of motion (extremities)
Normal muscle strength
ROS OR EXAM
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Body System: Musculoskeletal/Back/Extremities**
Distal neurovascular intact
No bony deformity
Nontender back
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Exam
Body System: Muskuloskeletal/Back/Extremities**
No back deformity
Full range of motion (back)
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Bony tenderness
Soft tissue tenderness
Calf tenderness
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Decreased/limited range of motion
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Muscle weakness
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Capillary refill delay
Poor distal pulses
Edema
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Joint laxity
Bony crepitus
Obvious deformity
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Malalignment
Palpable cords
Homan’s sign
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
T/L- spine tenderness
CVA tenderness
Paraspinal muscle tenderness
ROS OR EXAM
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Body System: Musculoskeletal/Back/Extremities**
Crepitus
Step-offs
Kyphosis
ROS OR EXAM
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Body System: Muskuloskeletal/Back/Extremities**
Decreased/limited range of motion
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Body System: Muskuloskeletal/Back/Extremities**
A/O x4
Normal speech
No focal neuro deficits
ROS OR EXAM
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Body System: Neurological**
Normal sensation
Normal deep tendon reflexes
Cranial nerves II - XII intact
ROS OR EXAM
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Body System: Neurological**
Cranial nerves II - XII intact
Normal gait
Normal finger-to-nose, heel-to-shin
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Body System: Neurological**
Negative Romberg’s
No meningismus
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Body System: Neurological**
Disoriented to 1 or more
Somnolent
Obtunded
ROS OR EXAM
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Body System: Neurological**
Responsive only to voice/painful stimuli
Unresponsive
Does not follow commands
ROS OR EXAM
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Body System: Neurological**
Dysarthria
Dysphasia
Aphasia
ROS OR EXAM
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Body System: Neurological**
Extremity weakness
Pronator drift
Decreased grip strength (< 5/5)
Tremors
ROS OR EXAM
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Body System: Neurological**
Paresthesias/
decreased sensation
ROS OR EXAM
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Body System: Neurological**
Abnormally fast or slow reflexes
ROS OR EXAM
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Body System: Neurological**
Changes in neuro functions that affect eyes to upper shoulders, including the face
ROS OR EXAM
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Body System: Neurological**
Ataxia
ROS OR EXAM
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Body System: Neurological**
Dysmetria
ROS OR EXAM
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Body System: Neurological**
Positive Romberg’s sign
ROS OR EXAM
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Body System: Neurological**
Meningismus
ROS OR EXAM
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Body System: Neurological**
Cooperative behavior
Appropriate mood and affect
ROS OR EXAM
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Body System: Psychiatric**
Normal judgement
Non-suicidal
ROS OR EXAM
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Body System: Psychiatric**
Uncooperative
Belligerent
Relaxed
ROS OR EXAM
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Body System: Psychiatric**
Anxious
Depressed
Tearful
ROS OR EXAM
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Body System: Psychiatric**
Hostile
Flat
Paranoid
ROS OR EXAM
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Body System: Psychiatric**
Appears intoxicated
ROS OR EXAM
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Body System: Psychiatric**
Abnormal psychotic thoughts:
Suicidal
Homicidal
ROS OR EXAM
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Body System: Psychiatric**
Hallucinations
Tangential
Flight of ideas
ROS OR EXAM
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Body System: Psychiatric**
