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ScribeUSA Final > Lectures > Flashcards

Lectures Flashcards

1
Q

The main reason for the patient’s ED visit

A

Chief Complaint

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2
Q

The physician’s thought process

A

Medical Decision Making

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3
Q

Normal, nothing of concern

A

Benign

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4
Q

The doctor’s judgment of discomfort

A

Distress

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5
Q

The state of having a fever, concerning for infection

A

Febrile

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6
Q

New onset, likely concerning

A

Acute

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7
Q

Long-standing, not of direct concern

A

Chronic

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8
Q

An individual’s normal state of being

A

Baseline

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9
Q

Listening with a stethoscope

A

Auscultation

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10
Q

The act of pressing on an area (by the doctor)

A

Palpation

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11
Q

Admitted to the hospital overnight

A

Inpatient

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12
Q

Seen and sent home the same day

A

Outpatient

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13
Q

Subjective vs. Objective

A

Feeling vs. Fact

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14
Q

Chief Complaint

A

The main reason for the patient’s ED visit

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15
Q

Medical Decision Making

A

The physician’s thought process

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16
Q

Pain vs. Tenderness

A

Patient’s feeling vs. Physician’s assessment

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17
Q

Benign

A

Normal, nothing of concern

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18
Q

Distress

A

The doctor’s judgment of discomfort

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19
Q

Acute

A

New onset, likely concerning

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20
Q

Chronic

A

Long-standing, not of direct concern

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21
Q

Baseline

A

An individual’s normal state of being

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22
Q

Auscultation

A

Listening with a stethoscope

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23
Q

Palpation

A

The act of pressing on an area (by the doctor)

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24
Q

Inpatient

A

Admitted to the hospital overnight

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25
Q

Outpatient

A

Seen and sent home the same day

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26
Q

5 vital signs

A

HR, BP, RR, T, SaO2

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27
Q

HPI

A

History of Present Illness

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28
Q

ROS

A

Review of Systems

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29
Q

H&P

A

History and Physical

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30
Q

Hx

A

Past History

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31
Q

PMHx

A

Past Medical History

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32
Q

PSHx

A

Past Surgical History

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33
Q

FHx

A

Family History

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34
Q

SHx

A

Social History

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35
Q

2 Parts of Subjective Exam

A

HPI, ROS

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36
Q

MDM

A

Medical Decision Making

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37
Q

DDx

A

Differential Diagnoses

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38
Q

2 Parts of Objective Exam

A

PE, ED Course

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39
Q

6 parts of template

A

HPI, ROS, Hx, PE, ED Course, Dx/Dispo

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40
Q

Name of hospital documentation system

A

Cerner

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41
Q

“High blood pressure”

A

Hypertension (HTN)

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42
Q

“High cholesterol”

A

Hyperlipidemia (HLD)

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43
Q

“Thyroid problem”

A

Hypothyroidism (or Hyper)

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44
Q

“Diabetes”

A

Diabetes Mellitus (DM)

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45
Q

“Take pills for my diabetes”

A

Non-Insulin Dependent Diabetes Mellitus

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46
Q

“Take shots for my diabetes”

A

Insulin Dependent Diabetes Mellitus

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47
Q

“Heart disease”

A

Coronary Artery Disease (CAD)

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48
Q

“Heart attack”

A

Myocardial Infarction (MI) and Coronary Artery Disease (CAD)

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49
Q

“Heart failure”

A

Congestive Heart Failure (CHF)

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50
Q

“Irregular heartbeat”

A

Atrial Fibrillation (A Fib)

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51
Q

“Murmur”

A

Heart murmur

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52
Q

“Episodes of abnormally fast/racing heartbeat”

A

Supraventricular Tachycardia (SVT)

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53
Q

“Emphysema/Chronic Bronchitis”

A

Chronic Obstructive Pulmonary Disease (COPD)

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54
Q

“Blood clot in lung”

A

Pulmonary Embolism (PE)

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55
Q

“Reflux”

A

Gastroesophageal Reflux Disease (GERD)

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56
Q

“Ulcer” (2)

A

Gastric Ulcer, Peptic Ulcer Disease (PUD)

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57
Q

“Krones/UC”

A

Crohn’s Disease, Ulcerative Colitis

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58
Q

“Bladder infection”

A

Urinary Tract Infection (UTI)

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59
Q

“Kidney infection”

A

Pyelonephritis (Pyelo)

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60
Q

“Kidney stones”

A

Renal calculi

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61
Q

“I’m on dialysis” (2)

A

Chronic Renal Failure (CRF), End Stage Renal Disease (ESRD) on dialysis

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62
Q

“Enlarged prostate”

A

Benign Prostate Hypertrophy (BPH)

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63
Q

GPA: G?

A

G = total number of times pt has been pregnant

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64
Q

GPA: P?

A

P = Number of live births (viable children)

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65
Q

GPA: A?

A

A = number of miscarriages or elective abortions

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66
Q

“Stroke”

A

Cerebrovascular Accident (CVA)

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67
Q

“Mini-stroke”

A

Transient Ischemic Attack (TIA)

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68
Q

“See-jzers” (2)

A

Seizure disorder, Epilepsy

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69
Q

“Brain bleed”

A

Hemorrhagic CVA

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70
Q

“Bipolar”

A

Bipolar disorder

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71
Q

“Skit-zoe-fren-ee-uh”

A

Schizophrenia

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72
Q

“I drink a lot” (2)

A

EtOH abuse, Alcoholism

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73
Q

“I do drugs”

A

Substance Abuse

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74
Q

“Blood clot in my leg”

A

Lower Extremity Deep Vein Thrombosis (DVT)

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75
Q

“Bulge in my aorta”

A

Abdominal Aortic Aneurysm (AAA)

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76
Q

“Bad blood flow to my legs”

A

Peripheral Vascular Disease (PVD)

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77
Q

“Numbness in my legs”

A

Peripheral Neuropathy

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78
Q

“Low back pain”

A

Chronic Low Back Pain

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79
Q

“Bulging/Herniated disc”

A

Degenerative Disc Disease (DDD)

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80
Q

“Arthritis” (2)

A

Osteoarthritis (OA), Rheumatoid Arthritis (RA)

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81
Q

“Joint pain (chronic)”

A

Degenerative Joint Disease (DJD)

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82
Q

“Weak/fragile bones”

A

Osteoporosis

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83
Q

“Spread to my…”

A

With metastases to the…

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84
Q

“Chemo”

A

Chemotherapy

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85
Q

“Radiation”

A

Radiation therapy

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86
Q

“They cut it out”

A

s/p surgical resection

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87
Q

“It’s (the cancer) gone”

A

In remission

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88
Q

“Tonsils” removed”

A

Tonsillectomy

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89
Q

“Adenoids removed”

A

Adenoidectomy

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90
Q

“Ear tubes”

A

Pressure Equalizer (P.E.) Tubes

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91
Q

“Heart bypass”

A

Coronary Artery Bypass Graft (CABG), PMHx CAD

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92
Q

“Stents”

A

Coronary Stents, PMHx CAD

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93
Q

“Heart Cath”

A

Cardiac catheterization

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94
Q

“Balloon”

A

Angioplasty, PMHx CAD

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95
Q

“Valve surgery”

A

Valve repair/replacement (Bovine vs. Mechanical)

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96
Q

“Pacer”

A

Pacemaker

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97
Q

“Defibrillator”

A

Automatic Implanted Cardiac Defibrillator (AICD)

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98
Q

“Surgery for Afib”

A

Afib s/p cardiac ablation

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99
Q

“Breast removal”

A

Mastectomy

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100
Q

“Hole in my neck”

A

Tracheostomy

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101
Q

“Part of my lung removed”

A

Partial lobectomy

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102
Q

“Appendix removed”

A

Appendectomy

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103
Q

“Gallbladder removed”

A

Cholecystectomy

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104
Q

“Hernia repair”

A

Herniorrhaphy

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105
Q

“Part of my colon removed”

A

Partial colectomy

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106
Q

“Bag to collect stool”

A

Colostomy

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107
Q

“Spleen removed”

A

Splenectomy

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108
Q

“Stomach stapled”

A

Gastric bypass

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109
Q

“Exploratory”

A

Exploratory Laproscopy

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110
Q

“Kidney removed”

A

Nephrectromy

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111
Q

“Uterus removed”

A

Hysterectomy (partial vs. total)

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112
Q

“Ovary removed”

A

Oophorectomy

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113
Q

“Ovary and fallopian tubes removed”

A

Salpingo-oophorectomy

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114
Q

“Tubes tied” (female)

A

Tubal ligation

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115
Q

“Tubes tied” (male)

A

Vasectomy

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116
Q

“C-Section”

A

Caesarean Section

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117
Q

“Prostate removed”

A

Prostatectomy (often Trans-Urethral Removal of the Prostate, or TURP)

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118
Q

“Uterine product removed”

A

Dilation and Curettage (D&C)

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119
Q

“Neck artery cleaned”

A

Carotid Endarterectomy

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120
Q

“Brain surgery”

A

Craniotomy (brain bleed vs. brain CA)

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121
Q

“Shunt”

A

Ventriculoperitoneal (VP) Shunt

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122
Q

“Dialysis fistula”

A

AV (arteriovenous) Fistula

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123
Q

“Dialysis graft”

A

AV (arteriovenous) Graft

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124
Q

“PICC Line”

A

Peripherally Inserted Central Catheter (PICC)

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125
Q

“Port” (2)

A

Port-a-cath or Medi-port

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126
Q

“Clot filter (lower abdomen)”

A

IVC (inferior vena cava) Filter

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127
Q

“Clot filter (leg)”

A

Greenfield Filter

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128
Q

“Leg amputated” (2)

A

Above Knee Amputation (AKA), Below Knee Amputation (BKA)

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129
Q

“Joint repair”

A

Arthroplasty

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130
Q

“Metal plates/pins”

A

Hardware

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131
Q

“Neck fused”

A

Cervical spinal fusion

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132
Q

“Back fused”

A

Lumbar spinal fusion

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133
Q

“Hip surgery”

A

Open Reduction with Internal Fixation (ORIF)

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134
Q

HTN

A

Hypertension

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135
Q

HLD

A

Hyperlipidemia

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136
Q

DM

A

Diabetes Mellitus

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137
Q

NIDDM

A

Non-Insulin Dependent Diabetes Mellitus

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138
Q

CAD

A

Coronary Artery Disease

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139
Q

MI

A

Myocardial Infarction

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140
Q

CHF

A

Congestive Heart Failure

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141
Q

A-Fib

A

Atrial Fibrillation

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142
Q

SVT

A

Supraventricular Tachycardia

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143
Q

COPD

A

Chronic Obstructive Pulmonary Disease

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144
Q

PE

A

Pulmonary Embolism

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145
Q

PNA

A

Pneumonia

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146
Q

GERD

A

Gastroesophageal Reflux Disease

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147
Q

PUD

A

Peptic Ulcer Disease

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148
Q

IBS

A

Irritable Bowel Syndrome

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149
Q

UTI

A

Urinary Tract Infection

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150
Q

Pyelo

A

Pyelonephritis

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151
Q

CRF

A

Chronic Renal Failure

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152
Q

ESRD

A

End Stage Renal Disease

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153
Q

BPH

A

Benign Prostate Hypertrophy

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154
Q

CVA

A

Cerebrovascular Accident

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155
Q

TIA

A

Transient Ischemic Attack

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156
Q

“Skit-zoe-fren-ee-uh”

A

Schizophrenia

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157
Q

DVT

A

Deep Vein Thrombosis

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158
Q

AAA

A

Abdominal Aortic Aneurysm

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159
Q

PVD

A

Peripheral Vascular Disease

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160
Q

DDD

A

Degenerative Disc Disease

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161
Q

OA

A

Osteoarthritis

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162
Q

RA

A

Rheumatoid Arthritis

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163
Q

DJD

A

Degeneratie Joint Disease

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164
Q

“Ton-sals”

A

Tonsils

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165
Q

“Add-uh-noids”

A

Adenoids

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166
Q

P.E. Tubes

A

Pressure Equalizer Tubes

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167
Q

Trach

A

Tracheostomy

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168
Q

“Uh-pin-dics”

A

Appendix

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169
Q

ExLap

A

Exploratory Laproscopy

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170
Q

TURP

A

Trans-Urethral Removal of the Prostate

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171
Q

D&C

A

Dilation and Curettage

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172
Q

VP

A

Ventriculoperitoneal

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173
Q

AV

A

Arteriovenous

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174
Q

PICC

A

Peripherally Inserted Central Catheter

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175
Q

IVC

A

Inferior Vena Cava

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176
Q

AKA

A

Above Knee Amputation

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177
Q

BKA

A

Below Knee Amputation

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178
Q

ORIF

A

Open Reduction with Internal Fixation

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179
Q

Diagnosed by: MI (STEMI)

A

EKG

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180
Q

Diagnosed by: MI (non-STEMI)

A

elevated Troponin

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181
Q

Diagnosed by: AFIB

A

EKG

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182
Q

Diagnosed by: CHF

A

CXR, elevated BNP

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183
Q

Diagnosed by: CAD

A

Positive cardiac catheterization (not in ED)

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184
Q

Diagnosed by: Angina

A

Exertional CP with Hx of CAD

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185
Q

Diagnosed by: PE

A

CTA Chest

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186
Q

Diagnosed by: PTX

A

CXR

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187
Q

Diagnosed by: PNA

A

CXR

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188
Q

Diagnosed by: COPD

A

CXR with Hx of Smoking

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189
Q

Diagnosed by: Asthma/Reactive Airway Disease (RAD)

A

Clinically

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190
Q

Diagnosed by: Ischemic CVA

A

Clinically

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191
Q

Diagnosed by: Hemorrhagic CVA (“brain bleed”)

A

CT Head, LP

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192
Q

Diagnosed by: TIA

A

Clinically

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193
Q

Diagnosed by: Meningitis

A

LP

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194
Q

Diagnosed by: Spinal Cord Injury

A

CT Cervical/Thoracic/Lumbar Spine

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195
Q

Cervical Spine

A

Neck

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196
Q

Thoracic Spine

A

Upper back

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197
Q

Lumbar Spine

A

Lower back

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198
Q

Diagnosed by: Bells Palsy

A

Clinically

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199
Q

Medical term for HA

A

Cephalgia

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200
Q

Condition when eye makes repetitive, uncontrolled eye movements

A

Nystagmus

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201
Q

Associated Diseases: Epigastric

A

GERD, MI

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202
Q

Associated Diseases: RUQ

A

Cholecystitis

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203
Q

Associated Diseases: LUQ

A

Pancreatitis

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204
Q

Associated Diseases: Periumbillical

A

SBO

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205
Q

Associated Diseases: RLQ

A

Appendicitis

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206
Q

Associated Diseases: LLQ

A

Diverticulitis

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207
Q

Associated Diseases: Suprapubic

A

Ovarian Torsion, Ovarian Cyst, UTI

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208
Q

Associated Diseases: Flanks

A

Pyelonephritis, Renal Calculi

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209
Q

Abdominal Region: Appendicitis

A

RLQ

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210
Q

Abdominal Region: SBO

A

Periumbillical

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211
Q

Abdominal Region: Cholecystitis

A

RUQ

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212
Q

Abdominal Region: GI Bleed

A

Any

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213
Q

Abdominal Region: Diverticulitis

A

LLQ

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214
Q

Abdominal Region: Pancreatitis (2)

A

Epigastric, LUQ

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215
Q

Abdominal Region: GERD

A

Epigastric

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216
Q

Diagnosed by: Appendicitis

A

CT A/P with PO

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217
Q

Diagnosed by: SBO (2)

A

CT A/P with PO, Acute Abdominal Series (AAS)

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218
Q

Diagnosed by: Cholecystitis

A

US RUQ

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219
Q

Diagnosed by: GI Bleed

A

Guaiac (Heme) Positive

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220
Q

Diagnosed by: Diverticulitis

A

CT A/P with PO

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221
Q

Diagnosed by: Pancreatitis

A

Elevated Lipase

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222
Q

Diagnosed by: GERD

A

Endoscopy (not in ED)

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223
Q

Diagnosed by: UTI

A

Urinalysis (WBC, Nitrite, or Bacteria)

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224
Q

Diagnosed by: Pyelo (2)

A

CT A/P, UTI with CVA tenderness on exam

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225
Q

Diagnosed by: Kidney Stone (and clue)

A

CT A/P, RBC in UA may be a clue

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226
Q

Diagnosed by: Ectopic Pregnancy

A

US Pelvis

227
Q

Diagnosed by: Ovarian Torsion

A

US Pelvis

228
Q

Diagnosed by: Testicular Torsion

A

US Scrotum

229
Q

Diagnosed by: Upper Respiratory Infection (URI)

A

Clinically

230
Q

Diagnosed by: Otitis Media

A

Clinically

231
Q

Diagnosed by: Streptococcal Pharyngitis

A

Rapid Strep

232
Q

Diagnosed by: Conjunctivitis

A

Clinically

233
Q

Diagnosed by: Epistaxis

A

Clinically

234
Q

Diagnosed by: Abdominal Aortic Aneurysm (AAA)

A

CTA A/P

235
Q

Diagnosed by: Aortic Dissection

A

CTA Chest

236
Q

Diagnosed by: Deep Vein Thrombosis (DVT)

A

US/Doppler of the extremity

237
Q

Diagnosed by: Cellulitis

A

Clinically

238
Q

Diagnosed by: Abscess

A

Clinically

239
Q

Diagnosed by: Rash

A

Clinically

240
Q

Diagnosed by: Allergic Reaction

A

Clinically

241
Q

Diagnosed by: Diabetic Ketoacidosis (DKA) (2)

A

Arterial Blood Gas (ABG) showing low pH (acidosis), Positive Serum ketones

242
Q

Diagnosed by: Trauma (2)

A

CT, XR

243
Q

CAD

A

Coronary Artery Disease

244
Q

ASA

A

Aspirin

245
Q

NTG

A

Nitroglycerin

246
Q

CHF

A

Congestive Heart Failure

247
Q

PND

A

Paroxysmal Nocturnal Dyspnea

248
Q

DOE

A

Dyspnea on Exertion

249
Q

JVD

A

Jugular Vein Distention

250
Q

BNP

A

B-type Natriuretic Peptide

251
Q

AFIB

A

Atrial Fibrillation

252
Q

RVR

A

Rapid Ventricular Response

253
Q

NSR

A

Normal Sinus Rhythm

254
Q

CP

A

Chest Pain

255
Q

SOB

A

Shortness of Breath

256
Q

BCP

A

Birth Control Pills

257
Q

PNA

A

Pneumonia

258
Q

CAP

A

Community Acquired Pneumonia

259
Q

Abx

A

Antibiotics

260
Q

PTX

A

Pneumothorax

261
Q

RAD

A

Reactive Airway Disease

262
Q

LP

A

Lumbar Puncture

263
Q

TIA

A

Transient Ischemic Attack

264
Q

Sz

A

Seizure

265
Q

HA

A

Headache

266
Q

FND

A

Focal Neurological Deficits

267
Q

AMS

A

Altered Mental Status

268
Q

APPY

A

Appendicitis

269
Q

SBO

A

Small Bowel Obstruction

270
Q

AAS

A

Acute Abdominal Series

271
Q

BM

A

Bowel Movement

272
Q

N/V/D

A

Nausea/Vomiting/Diarrhea

273
Q

US

A

Ultrasound

274
Q

GERD

A

Gastroesophageal Reflux Disease

275
Q

CVA

A

Costovertebral Angle

276
Q

RBC

A

Red Blood Cells

277
Q

A/P

A

Abdomen/Pelvis

278
Q

UA

A

Urinalysis

279
Q

URI

A

Upper Respiratory Infection

280
Q

TM

A

Tympanic Membrane

281
Q

PTA (not prior to arrival)

A

Peri-Tonsillar Abscess

282
Q

SLR

A

Straight Leg Raise

283
Q

CSMT

A

Circulation, Sensory, Motor, Tendon

284
Q

ROM

A

Range of Motion

285
Q

I&D

A

Incision and Drainage

286
Q

DM

A

Diabetes Mellitus

287
Q

DKA

A

Diabetic Ketoacidosis

288
Q

ABG

A

Arterial Blood Gas

289
Q

SI

A

Suicidal Ideation

290
Q

HI

A

Homicidal Ideation

291
Q

GCS

A

Glasgow Coma Scale

292
Q

MVA

A

Motor Vehicle Accident

293
Q

GSW

A

Gun Shot Wound

294
Q

MOI

A

Mechanism of Injury

295
Q

Congestive Heart Failure

A

Fluid traffic jam

296
Q

Sudden attack or increase in symptoms

A

Paroxysmal

297
Q

Paroxysmal

A

Sudden attack or increase in symptoms

298
Q

Inflammation of sac surrounding the heart causing CP

A

Pericarditis

299
Q

Inflammation of the sac surrounding the lungs causing CP

A

Pleurisy

300
Q

Irritation of the ribs causing CP worsened by pressing on the sternum

A

Costochondritis

301
Q

Irritation of the chest wall causing pain with palpation of the chest

A

Chest Wall Pain

302
Q

Fluid collecting around the lungs causing SOB or CP

A

Pleural Effusion

303
Q

“lung infection and inflammation”

A

Pneumonia (PNA)

304
Q

“collapsed lung”

A

Pneumothorax (PNA)

305
Q

“damage to alveoli”

A

Emphysema

306
Q

“long term lung inflammation and mucus production”

A

chronic bronchitis

307
Q

“constricting of airway and muscular contraction in lungs”

A

bronchospasm

308
Q

“nebulizer breathing treatment for RAD”

A

bronchodilators

309
Q

“weakness of half of the body”

A

Hemiparesis

310
Q

“one-sided numbness”

A

Unilateral Paresthesias

311
Q

“cannot generate or understand language”

A

Aphasia

312
Q

“stiff neck”

A

Nuchal rigidity

313
Q

“cannot control urination”

A

Incontinence

314
Q

“inflammation or viral infection of facial nerve causing one-sided weakness”

A

Bells Palsy

315
Q

“about to pass out”

A

near-syncope

316
Q

“relating to sudden drop in blood pressure”

A

Vasovagal

317
Q

“feeling off balance”

A

Disequilibrium

318
Q

“ringing in ears”

A

Tinnitus

319
Q

“production of gallstones”

A

Cholelithiasis

320
Q

“inflammation of the gallbladder”

A

Cholecystitis

321
Q

GI

A

Gastrointestinal

322
Q

“vomiting blood”

A

Hematemesis

323
Q

“bright red blood in stool”

A

Hematochezia

324
Q

“black tarry stool”

A

Melena

325
Q

“abdominal pockets of the large intestine”

A

Diverticuli

326
Q

“immune disorder causing diarrhea and abdominal pain”

A

Crohn’s Disease

327
Q

“GI Bug”

A

Gastroenteritis

328
Q

“Stomach ache with vomiting”

A

Gastritis

329
Q

“painful urination”

A

Dysuria

330
Q

“spread from a UTI”

A

Pyelonephritis

331
Q

“kidney stones”

A

Renal Calculi

332
Q

“kidney stone in kidney”

A

Nephrolithiasis

333
Q

“kidney stone in ureter”

A

Urolithiasis

334
Q

“tubal pregnancy”

A

Ectopic pregnancy

335
Q

“twisting of ovarian artery”

A

Ovarian Torsion

336
Q

“twisting of spermatic cord”

A

Testicular Torsion

337
Q

“middle ear infection”

A

Otitis Media

338
Q

“red throat”

A

Pharyngeal Erythema

339
Q

“enlargement”

A

hypertrophy

340
Q

“pus”

A

exudates

341
Q

“back pain that radiates down legs”

A

Sciatica

342
Q

“separation of muscular wall from membrane of artery”

A

Aortic Dissection

343
Q

“widened and weakened arterial wall”

A

Abdominal Aortic Aneurysm

344
Q

“skin system”

A

Integumentary System

345
Q

“infection of skin cells”

A

Cellulitis

346
Q

“skin infection with collection of pus”

A

Abscess

347
Q

“pus-pocket”

A

Fluctuance

348
Q

“skin hardening”

A

Induration

349
Q

“pus-like”

A

Purulent

350
Q

“itchy”

A

Pruritic

351
Q

“hives or wheals”

A

Urticaria

352
Q

“flat rash”

A

Macules

353
Q

“rash with raised bumps”

A

Papules

354
Q

“small blisters”

A

Vesicles

355
Q

“face swelling”

A

Facial Angioedema

356
Q

3 symptoms from allergic reaction

A

Rash, Itching, Swelling

357
Q

“dry mouth”

A

Dry Mucous Membranes

358
Q

“increased thirst”

A

Polydipsia

359
Q

“increased urination”

A

Polyuria

360
Q

“low blood pH”

A

acidosis

361
Q

A short list of diseases the doctor considers when diagnosing a patient

A

Differential Diagnosis

362
Q

Specific symptoms that raise the physician’s concern for that particular disease

A

Pertinent Positives

363
Q

Specific symptoms that are not present which cause the physician to doubt certain diagnoses

A

Pertinent Negatives

364
Q

“Red flags” that would put a patient at risk for that particular disease

A

Risk Factors

365
Q

The study of the causes of diseases

A

Etiology

366
Q

Membrane lining the thoracic cavity

A

Parietal Pleura

367
Q

Membrane covering the lungs

A

Visceral Pleura

368
Q

Differential Diagnosis

A

A short list of diseases the doctor considers when diagnosing a patient

369
Q

Pertinent Positives

A

Specific symptoms that raise the physician’s concern for that particular disease

370
Q

Pertinent Negatives

A

Specific symptoms that are not present which cause the physician to doubt certain diagnoses

371
Q

Risk Factors

A

“Red flags” that would put a patient at risk for that particular disease

372
Q

Etiology

A

The study of the causes of diseases

373
Q

Parietal Pleura

A

Membrane lining the thoracic cavity

374
Q

Visceral Pleura

A

Membrane covering the lungs

375
Q

Description: Onset

A

When did the complaint begin?

376
Q

Description: Timing

A

Has it been constant, intermittent, or waxing and waning?

377
Q

Description: Location

A

Where is the discomfort?

378
Q

Description: Quality

A

Does it feel sharp, dull, aching, cramping… ?

379
Q

Description: Severity

A

How bad is it? Mild, mod, sever, or 0-10

380
Q

Description: Modifying Factors

A

What makes it better? What makes it worse?

381
Q

Description: Associated Sx

A

Do any other symptoms accompany the complaint?

382
Q

Description: Context

A

Is there anything else that’s important?

383
Q

HPI Element: When did the complaint begin?

A

Onset

384
Q

HPI Element: Has it been constant, intermittent, or waxing and waning?

A

Timing

385
Q

HPI Element: Where is the discomfort?

A

Location

386
Q

HPI Element: Does it feel sharp, dull, aching, cramping… ?

A

Quality

387
Q

HPI Element: How bad is it? Mild, mod, severe, or 1-10?

A

Severity

388
Q

HPI Element: What makes it better? What makes it worse?

A

Modifying Factors

389
Q

HPI Element: Do any other symptoms accompany the complaint?

A

Associated Sx

390
Q

HPI Element: Is there anything else that’s important?

A

Context

391
Q

Body System: Fever, weight loss, sweats

A

Constitutional

392
Q

Body System: Change in vision, Eye pain, Double vision

A

Eyes

393
Q

Body System: Ear ache, Nose bleed, Congestion, Sore throat

A

Ear/Nose/Throat

394
Q

Body System: Chest pain, Palpitations, Leg swelling

A

Cardiovascular

395
Q

Body System: SOB, Cough, Sputum, Wheezing

A

Respiratory

396
Q

Body System: Abdominal pain, N/V/D, Black or bloody stools

A

Gastrointestinal

397
Q

Body System: Dysuria, Frequency, Urgency, Hematuria

A

Genitourinary

398
Q

Body System: Joint pain, Muscle pain

A

Musculoskeletal

399
Q

Body System: Rash, Itching, Abrasion, Laceration

A

Integumentary/Skin

400
Q

Body System: Headache, Syncope, Seizure, Numbness, Focal weakness

A

Neurological

401
Q

Body System: Depression, Anxiety

A

Psychiatric

402
Q

Body System: Polyuria, Polydipsia

A

Endocrine

403
Q

Body System: Bleeding gums, easy bruising, swollen lymph nodes

A

Hematologic/Lymph

404
Q

Body System: HIV/AIDS, Splenectomy

A

Immunologic

405
Q

Based on the patient’s feeling (HPI, ROS)

A

Subjective

406
Q

Factual information from the provider (PE)

A

Objective

407
Q

The story of the patient’s chief complaint

A

History of Present Illness

408
Q

Head-to-toe checklist of patient’s symptoms

A

Review of Systems

409
Q

“Comes and goes”

A

Intermittent

410
Q

Always present but changing in intensity

A

Waxing and waning

411
Q

Something that makes a symptom better or worse

A

Modifying factor

412
Q

To make worse

A

Exacerbate

413
Q

Review of Systems

A

Head-to-toe checklist of patient’s symptoms

414
Q

Waxing and waning

A

Always present but changing in intensity

415
Q

Modifying factor

A

Something that makes a symptom better or worse

416
Q

AT/NC

A

Atraumatic/Normocephalic

417
Q

“drowsy”

A

Somnolent

418
Q

“deadened”

A

Obtunded

419
Q

PERRL

A

Pupils are Equal, Round, and Reactive to Light

420
Q

EOMI

A

Extra Ocular Movements Intact

421
Q

“sclera are white”

A

Sclera are anicteric

422
Q

“yellowing of sclera”

A

Scleral icterus

423
Q

“redness of eye”

A

Conjunctival injection

424
Q

“swelling behind eye”

A

Papilledema

425
Q

“blood behind front lens”

A

Hyphema

426
Q

Internal Eye Exam

A

Fundoscopic Exam

427
Q

Instrument for Fundoscopic Exam

A

Ophthalmoscope

428
Q

Used for external eye exam (2)

A

Wood’s lamp, Fluorescein

429
Q

“earwax”

A

Cerumen

430
Q

“Nostrils”

A

Nares

431
Q

“Nostril”

A

Naris

432
Q

“nose swelling due to trauma”

A

Septal Hematoma

433
Q

“runny nose”

A

Rhinorrhea

434
Q

“nose bleed”

A

Epistaxis

435
Q

“swollen inner nose”

A

Boggy turbinates

436
Q

DMM

A

Dry Mucous Membranes

437
Q

OP

A

Oropharynx

438
Q

“cavities”

A

Dental Caries

439
Q

“missing teeth”

A

Edentulous

440
Q

“white plaque on back of tonsils”

A

Tonsillar Exudate

441
Q

“swooshing sound in neck artery”

A

Carotid Bruit

442
Q

2 types of spine tenderness

A

Vertebral Point, Paraspinal

443
Q

“enlargement of thyroid”

A

Thyromegaly

444
Q

Description of AFIB

A

Irregularly Irregular Rhythm

445
Q

“extra beats”

A

Extra systoles

446
Q

5 pulse types

A

Radial, Carotid, Femoral, Dorsalis Pedis (DP), Posterior Tibialis (PT)

447
Q

DP

A

Dorsalis Pedis

448
Q

PT (not physical therapy)

A

Posterior Tibialis

449
Q

CTAB

A

Clear to auscultation bilaterally

450
Q

“signs of a surgical abdomen”

A

Peritoneal Signs

451
Q

3 Peritoneal Signs

A

Voluntary Guarding, Rebound Tenderness, Rigidity

452
Q

TTP

A

Tender To Palpation

453
Q

S, NT

A

Soft and Non-tender

454
Q

“enlarged organ”

A

Organomegaly

455
Q

“enlarged liver”

A

Hepatomegaly

456
Q

“enlarged spleen”

A

Splenomegaly

457
Q

HSM

A

Hepatosplenomegaly

458
Q

Appendicitis Sign

A

McBurney’s point tenderness

459
Q

Cholecystitis Sign

A

Murphy’s sign

460
Q

CMT

A

Cervical Motion Tenderness

461
Q

FROM

A

Full Range of Motion

462
Q

“tender raised area of tissue”

A

Contusion

463
Q

“blue”

A

Cyanotic

464
Q

“yellow”

A

Jaundice

465
Q

“sweaty or clammy”

A

Diaphoretic

466
Q

“increased warmth”

A

Calor

467
Q

Skin trauma seen in elderly

A

Skin Tear

468
Q

“flap of skin”

A

Avulsion

469
Q

“difficulty speaking”

A

Dysarthria

470
Q

“decreased sensation”

A

Hypoesthesia

471
Q

“absent sensation”

A

Numbness

472
Q

“off balance walking”

A

Ataxia

473
Q

“painful walking”

A

Antalgic

474
Q

A frame of reference used to describe anatomy and movement

A

Anatomical Position

475
Q

Pain felt on palpation

A

Tenderness

476
Q

Without trauma

A

Atraumatic

477
Q

Yellowing, also known as jaundice

A

Icterus

478
Q

Pus-like

A

Purulent

479
Q

Redness

A

Erythema

480
Q

Organ enlargement

A

Organomegaly

481
Q

The flow of blood through the body’s blood vessels

A

Perfusion

482
Q

Feeling and emotion

A

Affect

483
Q

Able to be comforted

A

Consolable

484
Q

Used to access level of consciousness in trauma patients

A

GCS

485
Q

Anatomical Position

A

A frame of reference used to describe anatomy and movement

486
Q

Icterus

A

Yellowing, also known as jaundice

487
Q

Perfusion

A

The flow of blood through the body’s blood vessels

488
Q

Affect

A

Feeling and emotion

489
Q

Consolable

A

Able to be comforted

490
Q

CBC

A

Complete Blood Count

491
Q

WBC

A

White Blood Cells

492
Q

BMP

A

Basic Metabolic Panel

493
Q

CMP

A

Comprehensive Metabolic Panel

494
Q

LFT

A

Liver function test

495
Q

BUN

A

Blood Urea Nitrogen

496
Q

CK

A

Creatine Kinase

497
Q

CEP

A

Cardiac Enzyme Panel

498
Q

CK-MB

A

Creatine Kinase - Muscle Breakdown

499
Q

CK-RI

A

Creatine Kinase - Relative Index

500
Q

BNP

A

B-type Natriuretic Peptide

501
Q

ABG

A

Arterial Blood Gas

502
Q

VBG

A

Venous Blood Gas

503
Q

CSF

A

Cerebrospinal Fluid

504
Q

2 tests for coagulation studies

A

PT/INR

505
Q

NSR

A

Normal Sinus Rhythm

506
Q

SB

A

Sinus Bradycardia

507
Q

ST

A

Sinus Tachycardia

508
Q

A fib

A

Atrial Fibrillation

509
Q

A flutter

A

Atrial Flutter

510
Q

Paced

A

Pacemaker is functioning

511
Q

SVT

A

Supraventricular Tachycardia

512
Q

PVC

A

Premature Ventricular Contraction

513
Q

PAC

A

Premature Atrial Contraction

514
Q

LAD

A

Left Axis Deviation

515
Q

RAD (ekg interpretation)

A

Right Axis Deviation

516
Q

LAFB

A

Left anterior fascicular block

517
Q

LBBB

A

Left Bundle Branch Block

518
Q

RBBB

A

Right Bundle Branch Block

519
Q

1° AVB

A

First Degree AV Block

520
Q

LVH

A

Left Ventricular Hypertrophy

521
Q

PRWP

A

Poor R wave Progression

522
Q

ST ↑

A

Acute ST Elevation

523
Q

ST ↓

A

Acute ST Depression

524
Q

NSSTΔ’s

A

Non-specific ST/T changes

525
Q

Inferior leads

A

II, III, aVF

526
Q

Lateral leads

A

I, aVL, V5, V6

527
Q

Anterior leads

A

V3, V4

528
Q

Septal leads

A

V1, V2

529
Q

CCT

A

Critical Care Time

530
Q

ACS

A

Acute Coronary Syndrome

531
Q

Blood taken from an artery

A

Arterial Blood Gas

532
Q

The clear liquid separated from clotted blood

A

Serum

533
Q

The change of blood from liquid to solid

A

Coagulation

534
Q

Medication that suppresses the central nervous system that results in unconsciousness and lack of sensation

A

Anesthesia

535
Q

The propagation of microorganisms or of living tissue cells in media conductive to their growth

A

Cultures

536
Q

Care provided to any patient that is at serious risk for deterioration that may lead to permanent bodily harm or death

A

Critical Care Time

537
Q

Serum

A

The clear liquid separated from clotted blood

538
Q

Coagulation

A

The change of blood from liquid to solid

539
Q

Anesthesia

A

Medication that suppresses the CNS that results in unconsciousness and lack of sensation

540
Q

POC

A

Point of Care

541
Q

elements for level 5 HPI

A

4

542
Q

elements for level 5 ROS

A

10, 2 + “All systems negative”

543
Q

elements for level 5 PMH/SH/FH

A

2

544
Q

elements for level 5 PE

A

8

545
Q

8 elements of HPI

A

Location, Quality, Timing, Severity, Duration, Associated Symptoms, Modifying Factors, Context

546
Q

14 elements of ROS or PE

A

Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurological, Integumentary, Hematological, Lymphatic, Immunological, Psychological

547
Q

3 elements of PMHx

A

PMHx/PSHx, SHx, FHx

548
Q

RA (not arthritis)

A

Room Air

549
Q

NC

A

Nasal Cannula

550
Q

FM

A

Facial Mask

551
Q

NRM

A

Non-Rebreather Mask

552
Q

CPAP

A

Continuous Positive Airway Pressure

553
Q

BiPAP

A

Biphasic Positive Airway Pressure

554
Q

BVM

A

Bag-valve-mask

555
Q

ETT

A

Endotracheal Tube

556
Q

R/B/A

A

Risks/Benefits/Alternatives

557
Q

HIPAA

A

Health Insurance Portability and Accountability Act

558
Q

HITECH

A

Health Information for Economic and Clinical Health Act

559
Q

PHI

A

Protected Health Information

560
Q

Disposition

A

The patient’s destination after they leave the ED

561
Q

Diagnosis

A

The process of determining which disease or condition explains a person’s symptoms and signs

562
Q

HIPPA definition

A

A body of laws designed to protect private health information of patients

563
Q

HITECH definition

A

Privacy laws related to electronic transmission of health information

564
Q

Protected Health Information

A

Any information that can be tied to a particular patient

ScribeUSA Final (3 decks)

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