Lectures Flashcards
The main reason for the patient’s ED visit
Chief Complaint
The physician’s thought process
Medical Decision Making
Normal, nothing of concern
Benign
The doctor’s judgment of discomfort
Distress
The state of having a fever, concerning for infection
Febrile
New onset, likely concerning
Acute
Long-standing, not of direct concern
Chronic
An individual’s normal state of being
Baseline
Listening with a stethoscope
Auscultation
The act of pressing on an area (by the doctor)
Palpation
Admitted to the hospital overnight
Inpatient
Seen and sent home the same day
Outpatient
Subjective vs. Objective
Feeling vs. Fact
Chief Complaint
The main reason for the patient’s ED visit
Medical Decision Making
The physician’s thought process
Pain vs. Tenderness
Patient’s feeling vs. Physician’s assessment
Benign
Normal, nothing of concern
Distress
The doctor’s judgment of discomfort
Acute
New onset, likely concerning
Chronic
Long-standing, not of direct concern
Baseline
An individual’s normal state of being
Auscultation
Listening with a stethoscope
Palpation
The act of pressing on an area (by the doctor)
Inpatient
Admitted to the hospital overnight
Outpatient
Seen and sent home the same day
5 vital signs
HR, BP, RR, T, SaO2
HPI
History of Present Illness
ROS
Review of Systems
H&P
History and Physical
Hx
Past History
PMHx
Past Medical History
PSHx
Past Surgical History
FHx
Family History
SHx
Social History
2 Parts of Subjective Exam
HPI, ROS
MDM
Medical Decision Making
DDx
Differential Diagnoses
2 Parts of Objective Exam
PE, ED Course
6 parts of template
HPI, ROS, Hx, PE, ED Course, Dx/Dispo
Name of hospital documentation system
Cerner
“High blood pressure”
Hypertension (HTN)
“High cholesterol”
Hyperlipidemia (HLD)
“Thyroid problem”
Hypothyroidism (or Hyper)
“Diabetes”
Diabetes Mellitus (DM)
“Take pills for my diabetes”
Non-Insulin Dependent Diabetes Mellitus
“Take shots for my diabetes”
Insulin Dependent Diabetes Mellitus
“Heart disease”
Coronary Artery Disease (CAD)
“Heart attack”
Myocardial Infarction (MI) and Coronary Artery Disease (CAD)
“Heart failure”
Congestive Heart Failure (CHF)
“Irregular heartbeat”
Atrial Fibrillation (A Fib)
“Murmur”
Heart murmur
“Episodes of abnormally fast/racing heartbeat”
Supraventricular Tachycardia (SVT)
“Emphysema/Chronic Bronchitis”
Chronic Obstructive Pulmonary Disease (COPD)
“Blood clot in lung”
Pulmonary Embolism (PE)
“Reflux”
Gastroesophageal Reflux Disease (GERD)
“Ulcer” (2)
Gastric Ulcer, Peptic Ulcer Disease (PUD)
“Krones/UC”
Crohn’s Disease, Ulcerative Colitis
“Bladder infection”
Urinary Tract Infection (UTI)
“Kidney infection”
Pyelonephritis (Pyelo)
“Kidney stones”
Renal calculi
“I’m on dialysis” (2)
Chronic Renal Failure (CRF), End Stage Renal Disease (ESRD) on dialysis
“Enlarged prostate”
Benign Prostate Hypertrophy (BPH)
GPA: G?
G = total number of times pt has been pregnant
GPA: P?
P = Number of live births (viable children)
GPA: A?
A = number of miscarriages or elective abortions
“Stroke”
Cerebrovascular Accident (CVA)
“Mini-stroke”
Transient Ischemic Attack (TIA)
“See-jzers” (2)
Seizure disorder, Epilepsy
“Brain bleed”
Hemorrhagic CVA
“Bipolar”
Bipolar disorder
“Skit-zoe-fren-ee-uh”
Schizophrenia
“I drink a lot” (2)
EtOH abuse, Alcoholism
“I do drugs”
Substance Abuse
“Blood clot in my leg”
Lower Extremity Deep Vein Thrombosis (DVT)
“Bulge in my aorta”
Abdominal Aortic Aneurysm (AAA)
“Bad blood flow to my legs”
Peripheral Vascular Disease (PVD)
“Numbness in my legs”
Peripheral Neuropathy
“Low back pain”
Chronic Low Back Pain
“Bulging/Herniated disc”
Degenerative Disc Disease (DDD)
“Arthritis” (2)
Osteoarthritis (OA), Rheumatoid Arthritis (RA)
“Joint pain (chronic)”
Degenerative Joint Disease (DJD)
“Weak/fragile bones”
Osteoporosis
“Spread to my…”
With metastases to the…
“Chemo”
Chemotherapy
“Radiation”
Radiation therapy
“They cut it out”
s/p surgical resection
“It’s (the cancer) gone”
In remission
“Tonsils” removed”
Tonsillectomy
“Adenoids removed”
Adenoidectomy
“Ear tubes”
Pressure Equalizer (P.E.) Tubes
“Heart bypass”
Coronary Artery Bypass Graft (CABG), PMHx CAD
“Stents”
Coronary Stents, PMHx CAD
“Heart Cath”
Cardiac catheterization
“Balloon”
Angioplasty, PMHx CAD
“Valve surgery”
Valve repair/replacement (Bovine vs. Mechanical)
“Pacer”
Pacemaker
“Defibrillator”
Automatic Implanted Cardiac Defibrillator (AICD)
“Surgery for Afib”
Afib s/p cardiac ablation
“Breast removal”
Mastectomy
“Hole in my neck”
Tracheostomy
“Part of my lung removed”
Partial lobectomy
“Appendix removed”
Appendectomy
“Gallbladder removed”
Cholecystectomy
“Hernia repair”
Herniorrhaphy
“Part of my colon removed”
Partial colectomy
“Bag to collect stool”
Colostomy
“Spleen removed”
Splenectomy
“Stomach stapled”
Gastric bypass
“Exploratory”
Exploratory Laproscopy
“Kidney removed”
Nephrectromy
“Uterus removed”
Hysterectomy (partial vs. total)
“Ovary removed”
Oophorectomy
“Ovary and fallopian tubes removed”
Salpingo-oophorectomy
“Tubes tied” (female)
Tubal ligation
“Tubes tied” (male)
Vasectomy
“C-Section”
Caesarean Section
“Prostate removed”
Prostatectomy (often Trans-Urethral Removal of the Prostate, or TURP)
“Uterine product removed”
Dilation and Curettage (D&C)
“Neck artery cleaned”
Carotid Endarterectomy
“Brain surgery”
Craniotomy (brain bleed vs. brain CA)
“Shunt”
Ventriculoperitoneal (VP) Shunt
“Dialysis fistula”
AV (arteriovenous) Fistula
“Dialysis graft”
AV (arteriovenous) Graft
“PICC Line”
Peripherally Inserted Central Catheter (PICC)
“Port” (2)
Port-a-cath or Medi-port
“Clot filter (lower abdomen)”
IVC (inferior vena cava) Filter
“Clot filter (leg)”
Greenfield Filter
“Leg amputated” (2)
Above Knee Amputation (AKA), Below Knee Amputation (BKA)
“Joint repair”
Arthroplasty
“Metal plates/pins”
Hardware
“Neck fused”
Cervical spinal fusion
“Back fused”
Lumbar spinal fusion
“Hip surgery”
Open Reduction with Internal Fixation (ORIF)
HTN
Hypertension
HLD
Hyperlipidemia
DM
Diabetes Mellitus
NIDDM
Non-Insulin Dependent Diabetes Mellitus
CAD
Coronary Artery Disease
MI
Myocardial Infarction
CHF
Congestive Heart Failure
A-Fib
Atrial Fibrillation
SVT
Supraventricular Tachycardia
COPD
Chronic Obstructive Pulmonary Disease
PE
Pulmonary Embolism
PNA
Pneumonia
GERD
Gastroesophageal Reflux Disease
PUD
Peptic Ulcer Disease
IBS
Irritable Bowel Syndrome
UTI
Urinary Tract Infection
Pyelo
Pyelonephritis
CRF
Chronic Renal Failure
ESRD
End Stage Renal Disease
BPH
Benign Prostate Hypertrophy
CVA
Cerebrovascular Accident
TIA
Transient Ischemic Attack
“Skit-zoe-fren-ee-uh”
Schizophrenia
DVT
Deep Vein Thrombosis
AAA
Abdominal Aortic Aneurysm
PVD
Peripheral Vascular Disease
DDD
Degenerative Disc Disease
OA
Osteoarthritis
RA
Rheumatoid Arthritis
DJD
Degeneratie Joint Disease
“Ton-sals”
Tonsils
“Add-uh-noids”
Adenoids
P.E. Tubes
Pressure Equalizer Tubes
Trach
Tracheostomy
“Uh-pin-dics”
Appendix
ExLap
Exploratory Laproscopy
TURP
Trans-Urethral Removal of the Prostate
D&C
Dilation and Curettage
VP
Ventriculoperitoneal
AV
Arteriovenous
PICC
Peripherally Inserted Central Catheter
IVC
Inferior Vena Cava
AKA
Above Knee Amputation
BKA
Below Knee Amputation
ORIF
Open Reduction with Internal Fixation
Diagnosed by: MI (STEMI)
EKG
Diagnosed by: MI (non-STEMI)
elevated Troponin
Diagnosed by: AFIB
EKG
Diagnosed by: CHF
CXR, elevated BNP
Diagnosed by: CAD
Positive cardiac catheterization (not in ED)
Diagnosed by: Angina
Exertional CP with Hx of CAD
Diagnosed by: PE
CTA Chest
Diagnosed by: PTX
CXR
Diagnosed by: PNA
CXR
Diagnosed by: COPD
CXR with Hx of Smoking
Diagnosed by: Asthma/Reactive Airway Disease (RAD)
Clinically
Diagnosed by: Ischemic CVA
Clinically
Diagnosed by: Hemorrhagic CVA (“brain bleed”)
CT Head, LP
Diagnosed by: TIA
Clinically
Diagnosed by: Meningitis
LP
Diagnosed by: Spinal Cord Injury
CT Cervical/Thoracic/Lumbar Spine
Cervical Spine
Neck
Thoracic Spine
Upper back
Lumbar Spine
Lower back
Diagnosed by: Bells Palsy
Clinically
Medical term for HA
Cephalgia
Condition when eye makes repetitive, uncontrolled eye movements
Nystagmus
Associated Diseases: Epigastric
GERD, MI
Associated Diseases: RUQ
Cholecystitis
Associated Diseases: LUQ
Pancreatitis
Associated Diseases: Periumbillical
SBO
Associated Diseases: RLQ
Appendicitis
Associated Diseases: LLQ
Diverticulitis
Associated Diseases: Suprapubic
Ovarian Torsion, Ovarian Cyst, UTI
Associated Diseases: Flanks
Pyelonephritis, Renal Calculi
Abdominal Region: Appendicitis
RLQ
Abdominal Region: SBO
Periumbillical
Abdominal Region: Cholecystitis
RUQ
Abdominal Region: GI Bleed
Any
Abdominal Region: Diverticulitis
LLQ
Abdominal Region: Pancreatitis (2)
Epigastric, LUQ
Abdominal Region: GERD
Epigastric
Diagnosed by: Appendicitis
CT A/P with PO
Diagnosed by: SBO (2)
CT A/P with PO, Acute Abdominal Series (AAS)
Diagnosed by: Cholecystitis
US RUQ
Diagnosed by: GI Bleed
Guaiac (Heme) Positive
Diagnosed by: Diverticulitis
CT A/P with PO
Diagnosed by: Pancreatitis
Elevated Lipase
Diagnosed by: GERD
Endoscopy (not in ED)
Diagnosed by: UTI
Urinalysis (WBC, Nitrite, or Bacteria)
Diagnosed by: Pyelo (2)
CT A/P, UTI with CVA tenderness on exam
Diagnosed by: Kidney Stone (and clue)
CT A/P, RBC in UA may be a clue
Diagnosed by: Ectopic Pregnancy
US Pelvis
Diagnosed by: Ovarian Torsion
US Pelvis
Diagnosed by: Testicular Torsion
US Scrotum
Diagnosed by: Upper Respiratory Infection (URI)
Clinically
Diagnosed by: Otitis Media
Clinically
Diagnosed by: Streptococcal Pharyngitis
Rapid Strep
Diagnosed by: Conjunctivitis
Clinically
Diagnosed by: Epistaxis
Clinically
Diagnosed by: Abdominal Aortic Aneurysm (AAA)
CTA A/P
Diagnosed by: Aortic Dissection
CTA Chest
Diagnosed by: Deep Vein Thrombosis (DVT)
US/Doppler of the extremity
Diagnosed by: Cellulitis
Clinically
Diagnosed by: Abscess
Clinically
Diagnosed by: Rash
Clinically
Diagnosed by: Allergic Reaction
Clinically
Diagnosed by: Diabetic Ketoacidosis (DKA) (2)
Arterial Blood Gas (ABG) showing low pH (acidosis), Positive Serum ketones
Diagnosed by: Trauma (2)
CT, XR
CAD
Coronary Artery Disease
ASA
Aspirin
NTG
Nitroglycerin
CHF
Congestive Heart Failure
PND
Paroxysmal Nocturnal Dyspnea
DOE
Dyspnea on Exertion
JVD
Jugular Vein Distention
BNP
B-type Natriuretic Peptide
AFIB
Atrial Fibrillation
RVR
Rapid Ventricular Response
NSR
Normal Sinus Rhythm
CP
Chest Pain
SOB
Shortness of Breath
BCP
Birth Control Pills
PNA
Pneumonia
CAP
Community Acquired Pneumonia
Abx
Antibiotics
PTX
Pneumothorax
RAD
Reactive Airway Disease
LP
Lumbar Puncture
TIA
Transient Ischemic Attack
Sz
Seizure
HA
Headache
FND
Focal Neurological Deficits
AMS
Altered Mental Status
APPY
Appendicitis
SBO
Small Bowel Obstruction
AAS
Acute Abdominal Series
BM
Bowel Movement
N/V/D
Nausea/Vomiting/Diarrhea
US
Ultrasound
GERD
Gastroesophageal Reflux Disease
CVA
Costovertebral Angle
RBC
Red Blood Cells
A/P
Abdomen/Pelvis
UA
Urinalysis
URI
Upper Respiratory Infection
TM
Tympanic Membrane
PTA (not prior to arrival)
Peri-Tonsillar Abscess
SLR
Straight Leg Raise
CSMT
Circulation, Sensory, Motor, Tendon
ROM
Range of Motion
I&D
Incision and Drainage
DM
Diabetes Mellitus
DKA
Diabetic Ketoacidosis
ABG
Arterial Blood Gas
SI
Suicidal Ideation
HI
Homicidal Ideation
GCS
Glasgow Coma Scale
MVA
Motor Vehicle Accident
GSW
Gun Shot Wound
MOI
Mechanism of Injury
Congestive Heart Failure
Fluid traffic jam
Sudden attack or increase in symptoms
Paroxysmal
Paroxysmal
Sudden attack or increase in symptoms
Inflammation of sac surrounding the heart causing CP
Pericarditis
Inflammation of the sac surrounding the lungs causing CP
Pleurisy
Irritation of the ribs causing CP worsened by pressing on the sternum
Costochondritis
Irritation of the chest wall causing pain with palpation of the chest
Chest Wall Pain
Fluid collecting around the lungs causing SOB or CP
Pleural Effusion
“lung infection and inflammation”
Pneumonia (PNA)
“collapsed lung”
Pneumothorax (PNA)
“damage to alveoli”
Emphysema
“long term lung inflammation and mucus production”
chronic bronchitis
“constricting of airway and muscular contraction in lungs”
bronchospasm
“nebulizer breathing treatment for RAD”
bronchodilators
“weakness of half of the body”
Hemiparesis
“one-sided numbness”
Unilateral Paresthesias
“cannot generate or understand language”
Aphasia
“stiff neck”
Nuchal rigidity
“cannot control urination”
Incontinence
“inflammation or viral infection of facial nerve causing one-sided weakness”
Bells Palsy
“about to pass out”
near-syncope
“relating to sudden drop in blood pressure”
Vasovagal
“feeling off balance”
Disequilibrium
“ringing in ears”
Tinnitus
“production of gallstones”
Cholelithiasis
“inflammation of the gallbladder”
Cholecystitis
GI
Gastrointestinal
“vomiting blood”
Hematemesis
“bright red blood in stool”
Hematochezia
“black tarry stool”
Melena
“abdominal pockets of the large intestine”
Diverticuli
“immune disorder causing diarrhea and abdominal pain”
Crohn’s Disease
“GI Bug”
Gastroenteritis
“Stomach ache with vomiting”
Gastritis
“painful urination”
Dysuria
“spread from a UTI”
Pyelonephritis
“kidney stones”
Renal Calculi
“kidney stone in kidney”
Nephrolithiasis
“kidney stone in ureter”
Urolithiasis
“tubal pregnancy”
Ectopic pregnancy
“twisting of ovarian artery”
Ovarian Torsion
“twisting of spermatic cord”
Testicular Torsion
“middle ear infection”
Otitis Media
“red throat”
Pharyngeal Erythema
“enlargement”
hypertrophy
“pus”
exudates
“back pain that radiates down legs”
Sciatica
“separation of muscular wall from membrane of artery”
Aortic Dissection
“widened and weakened arterial wall”
Abdominal Aortic Aneurysm
“skin system”
Integumentary System
“infection of skin cells”
Cellulitis
“skin infection with collection of pus”
Abscess
“pus-pocket”
Fluctuance
“skin hardening”
Induration
“pus-like”
Purulent
“itchy”
Pruritic
“hives or wheals”
Urticaria
“flat rash”
Macules
“rash with raised bumps”
Papules
“small blisters”
Vesicles
“face swelling”
Facial Angioedema
3 symptoms from allergic reaction
Rash, Itching, Swelling
“dry mouth”
Dry Mucous Membranes
“increased thirst”
Polydipsia
“increased urination”
Polyuria
“low blood pH”
acidosis
A short list of diseases the doctor considers when diagnosing a patient
Differential Diagnosis
Specific symptoms that raise the physician’s concern for that particular disease
Pertinent Positives
Specific symptoms that are not present which cause the physician to doubt certain diagnoses
Pertinent Negatives
“Red flags” that would put a patient at risk for that particular disease
Risk Factors
The study of the causes of diseases
Etiology
Membrane lining the thoracic cavity
Parietal Pleura
Membrane covering the lungs
Visceral Pleura
Differential Diagnosis
A short list of diseases the doctor considers when diagnosing a patient
Pertinent Positives
Specific symptoms that raise the physician’s concern for that particular disease
Pertinent Negatives
Specific symptoms that are not present which cause the physician to doubt certain diagnoses
Risk Factors
“Red flags” that would put a patient at risk for that particular disease
Etiology
The study of the causes of diseases
Parietal Pleura
Membrane lining the thoracic cavity
Visceral Pleura
Membrane covering the lungs
Description: Onset
When did the complaint begin?
Description: Timing
Has it been constant, intermittent, or waxing and waning?
Description: Location
Where is the discomfort?
Description: Quality
Does it feel sharp, dull, aching, cramping… ?
Description: Severity
How bad is it? Mild, mod, sever, or 0-10
Description: Modifying Factors
What makes it better? What makes it worse?
Description: Associated Sx
Do any other symptoms accompany the complaint?
Description: Context
Is there anything else that’s important?
HPI Element: When did the complaint begin?
Onset
HPI Element: Has it been constant, intermittent, or waxing and waning?
Timing
HPI Element: Where is the discomfort?
Location
HPI Element: Does it feel sharp, dull, aching, cramping… ?
Quality
HPI Element: How bad is it? Mild, mod, severe, or 1-10?
Severity
HPI Element: What makes it better? What makes it worse?
Modifying Factors
HPI Element: Do any other symptoms accompany the complaint?
Associated Sx
HPI Element: Is there anything else that’s important?
Context
Body System: Fever, weight loss, sweats
Constitutional
Body System: Change in vision, Eye pain, Double vision
Eyes
Body System: Ear ache, Nose bleed, Congestion, Sore throat
Ear/Nose/Throat
Body System: Chest pain, Palpitations, Leg swelling
Cardiovascular
Body System: SOB, Cough, Sputum, Wheezing
Respiratory
Body System: Abdominal pain, N/V/D, Black or bloody stools
Gastrointestinal
Body System: Dysuria, Frequency, Urgency, Hematuria
Genitourinary
Body System: Joint pain, Muscle pain
Musculoskeletal
Body System: Rash, Itching, Abrasion, Laceration
Integumentary/Skin
Body System: Headache, Syncope, Seizure, Numbness, Focal weakness
Neurological
Body System: Depression, Anxiety
Psychiatric
Body System: Polyuria, Polydipsia
Endocrine
Body System: Bleeding gums, easy bruising, swollen lymph nodes
Hematologic/Lymph
Body System: HIV/AIDS, Splenectomy
Immunologic
Based on the patient’s feeling (HPI, ROS)
Subjective
Factual information from the provider (PE)
Objective
The story of the patient’s chief complaint
History of Present Illness
Head-to-toe checklist of patient’s symptoms
Review of Systems
“Comes and goes”
Intermittent
Always present but changing in intensity
Waxing and waning
Something that makes a symptom better or worse
Modifying factor
To make worse
Exacerbate
Review of Systems
Head-to-toe checklist of patient’s symptoms
Waxing and waning
Always present but changing in intensity
Modifying factor
Something that makes a symptom better or worse
AT/NC
Atraumatic/Normocephalic
“drowsy”
Somnolent
“deadened”
Obtunded
PERRL
Pupils are Equal, Round, and Reactive to Light
EOMI
Extra Ocular Movements Intact
“sclera are white”
Sclera are anicteric
“yellowing of sclera”
Scleral icterus
“redness of eye”
Conjunctival injection
“swelling behind eye”
Papilledema
“blood behind front lens”
Hyphema
Internal Eye Exam
Fundoscopic Exam
Instrument for Fundoscopic Exam
Ophthalmoscope
Used for external eye exam (2)
Wood’s lamp, Fluorescein
“earwax”
Cerumen
“Nostrils”
Nares
“Nostril”
Naris
“nose swelling due to trauma”
Septal Hematoma
“runny nose”
Rhinorrhea
“nose bleed”
Epistaxis
“swollen inner nose”
Boggy turbinates
DMM
Dry Mucous Membranes
OP
Oropharynx
“cavities”
Dental Caries
“missing teeth”
Edentulous
“white plaque on back of tonsils”
Tonsillar Exudate
“swooshing sound in neck artery”
Carotid Bruit
2 types of spine tenderness
Vertebral Point, Paraspinal
“enlargement of thyroid”
Thyromegaly
Description of AFIB
Irregularly Irregular Rhythm
“extra beats”
Extra systoles
5 pulse types
Radial, Carotid, Femoral, Dorsalis Pedis (DP), Posterior Tibialis (PT)
DP
Dorsalis Pedis
PT (not physical therapy)
Posterior Tibialis
CTAB
Clear to auscultation bilaterally
“signs of a surgical abdomen”
Peritoneal Signs
3 Peritoneal Signs
Voluntary Guarding, Rebound Tenderness, Rigidity
TTP
Tender To Palpation
S, NT
Soft and Non-tender
“enlarged organ”
Organomegaly
“enlarged liver”
Hepatomegaly
“enlarged spleen”
Splenomegaly
HSM
Hepatosplenomegaly
Appendicitis Sign
McBurney’s point tenderness
Cholecystitis Sign
Murphy’s sign
CMT
Cervical Motion Tenderness
FROM
Full Range of Motion
“tender raised area of tissue”
Contusion
“blue”
Cyanotic
“yellow”
Jaundice
“sweaty or clammy”
Diaphoretic
“increased warmth”
Calor
Skin trauma seen in elderly
Skin Tear
“flap of skin”
Avulsion
“difficulty speaking”
Dysarthria
“decreased sensation”
Hypoesthesia
“absent sensation”
Numbness
“off balance walking”
Ataxia
“painful walking”
Antalgic
A frame of reference used to describe anatomy and movement
Anatomical Position
Pain felt on palpation
Tenderness
Without trauma
Atraumatic
Yellowing, also known as jaundice
Icterus
Pus-like
Purulent
Redness
Erythema
Organ enlargement
Organomegaly
The flow of blood through the body’s blood vessels
Perfusion
Feeling and emotion
Affect
Able to be comforted
Consolable
Used to access level of consciousness in trauma patients
GCS
Anatomical Position
A frame of reference used to describe anatomy and movement
Icterus
Yellowing, also known as jaundice
Perfusion
The flow of blood through the body’s blood vessels
Affect
Feeling and emotion
Consolable
Able to be comforted
CBC
Complete Blood Count
WBC
White Blood Cells
BMP
Basic Metabolic Panel
CMP
Comprehensive Metabolic Panel
LFT
Liver function test
BUN
Blood Urea Nitrogen
CK
Creatine Kinase
CEP
Cardiac Enzyme Panel
CK-MB
Creatine Kinase - Muscle Breakdown
CK-RI
Creatine Kinase - Relative Index
BNP
B-type Natriuretic Peptide
ABG
Arterial Blood Gas
VBG
Venous Blood Gas
CSF
Cerebrospinal Fluid
2 tests for coagulation studies
PT/INR
NSR
Normal Sinus Rhythm
SB
Sinus Bradycardia
ST
Sinus Tachycardia
A fib
Atrial Fibrillation
A flutter
Atrial Flutter
Paced
Pacemaker is functioning
SVT
Supraventricular Tachycardia
PVC
Premature Ventricular Contraction
PAC
Premature Atrial Contraction
LAD
Left Axis Deviation
RAD (ekg interpretation)
Right Axis Deviation
LAFB
Left anterior fascicular block
LBBB
Left Bundle Branch Block
RBBB
Right Bundle Branch Block
1° AVB
First Degree AV Block
LVH
Left Ventricular Hypertrophy
PRWP
Poor R wave Progression
ST ↑
Acute ST Elevation
ST ↓
Acute ST Depression
NSSTΔ’s
Non-specific ST/T changes
Inferior leads
II, III, aVF
Lateral leads
I, aVL, V5, V6
Anterior leads
V3, V4
Septal leads
V1, V2
CCT
Critical Care Time
ACS
Acute Coronary Syndrome
Blood taken from an artery
Arterial Blood Gas
The clear liquid separated from clotted blood
Serum
The change of blood from liquid to solid
Coagulation
Medication that suppresses the central nervous system that results in unconsciousness and lack of sensation
Anesthesia
The propagation of microorganisms or of living tissue cells in media conductive to their growth
Cultures
Care provided to any patient that is at serious risk for deterioration that may lead to permanent bodily harm or death
Critical Care Time
Serum
The clear liquid separated from clotted blood
Coagulation
The change of blood from liquid to solid
Anesthesia
Medication that suppresses the CNS that results in unconsciousness and lack of sensation
POC
Point of Care
elements for level 5 HPI
4
elements for level 5 ROS
10, 2 + “All systems negative”
elements for level 5 PMH/SH/FH
2
elements for level 5 PE
8
8 elements of HPI
Location, Quality, Timing, Severity, Duration, Associated Symptoms, Modifying Factors, Context
14 elements of ROS or PE
Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurological, Integumentary, Hematological, Lymphatic, Immunological, Psychological
3 elements of PMHx
PMHx/PSHx, SHx, FHx
RA (not arthritis)
Room Air
NC
Nasal Cannula
FM
Facial Mask
NRM
Non-Rebreather Mask
CPAP
Continuous Positive Airway Pressure
BiPAP
Biphasic Positive Airway Pressure
BVM
Bag-valve-mask
ETT
Endotracheal Tube
R/B/A
Risks/Benefits/Alternatives
HIPAA
Health Insurance Portability and Accountability Act
HITECH
Health Information for Economic and Clinical Health Act
PHI
Protected Health Information
Disposition
The patient’s destination after they leave the ED
Diagnosis
The process of determining which disease or condition explains a person’s symptoms and signs
HIPPA definition
A body of laws designed to protect private health information of patients
HITECH definition
Privacy laws related to electronic transmission of health information
Protected Health Information
Any information that can be tied to a particular patient
