Workbook Flashcards
1
Q
High blood pressure
A
Hypertension (HTN)
2
Q
High cholesterol
A
Hyperlipidemia (HLD)
3
Q
Thyroid problem
A
Usually hypothyroidism, sometimes hyperthyroid
4
Q
Heart disease
A
Coronary Artery disease (CAD)
5
Q
Heart attack
A
MI and CAD
6
Q
Heart failure
A
Congestive heart failure
7
Q
Irregular heart beat
A
A fib
8
Q
Murmur
A
Heart murmur
9
Q
Episodes of abnormally fast/racing heartbeat
A
Supraventricular tachycardia
10
Q
Asthma
A
Reactive airway (RAP)
11
Q
Emphysema/chronic bronchitis
A
COPD
12
Q
Blood clotting in the lungs
A
Pulmonary embolism
13
Q
Pneumonia
A
PNA
14
Q
Acid reflux
A
GERD
15
Q
Ulcer
A
Gastric ulcer or peptic ulcer disease
16
Q
Ulcerative cholitis
A
UC
17
Q
Bladder infection
A
UTI
18
Q
Kidney infection
A
Pyelonephritis
19
Q
Kidney stones
A
Renal calculi
20
Q
On dialysis
A
Chronic renal failure (CRF) or end stage renal failure (ESRF) on dialysis
21
Q
Enlarged prostate
A
Benign prostate hypertrophy
22
Q
Gravid/Para/Abortus
A
G: total time pregnant
P: number of lives birth
A: miscarriage or elective abortions
23
Q
Stroke
A
CVA
24
Q
Mini-stroke
A
TIA
25
Seizure
Sz
26
Brain bleed
Hemorrhagic CVA
27
Blood clot in the leg
Lower extremity deep vain thrombosis (DVT)
28
Bulge in aorta
Abdominal aortic aneurysm (AAA)
29
Bad blood flow to my legs
Peripheral vascular disease (PVD)
30
Numbness in my legs
Peripheral neuropathy
31
Low back pain
Chronic low back pain
32
Bulging/herniated disc
Degenerative disc disease (DDD)
33
Arthritis
Usually osteoarthritis (OA) sometime rheumatoid arthritis (RA)
34
Joint pain
Degenerative joint disease (DJD)
35
Weak/fragile bones
Osteoporosis
36
Cancer
CA
37
Spread to my...
With metastases to the
38
They cut it out
Status-post surgical resection
39
It's gone
In remission
40
Tonsils removed
Tonsillectomy
41
Adenoids removed
Adenoidectomy
42
Ear tubes
Pressure equalizer (P.E.) tubes
43
Heart bypass
Coronary Artery Bypass Graft (CABG) - PMHx CAD
44
Stents
Coronary stents
45
Heart cath
Cardiac catheterization
46
Balloon
Angioplasty - PMHx CAD
47
Valve surgery
Valve repair or replacement (Bovine vs. mechanical)
48
Defibrillator
Automatic Implanted Cardiac defibrillator (AICD)
49
Surgery for a fib
Afib s/p cardiac ablation
50
Breast removal
Mastectomy
51
Hole in my neck
Tracheostomy
52
Part of my lung removed
Partial lobectomy
53
Appendix removed
Appendectomy
54
Gallbladder removed
Cholecystectomy
55
Hernia repair
Herniorrhaphy
56
Part of Colon removed
Partial colectomy
57
Bag to collect stool
Colostomy
58
Spleen removed
Splenectomy
59
Stomach stapled
Gastric bypass
60
Kidney removed
Nephrectomy
61
Uterus removed
Hysterectomy
62
Ovary removed
Oophorectomy
63
Ovary and fallopian tunes removed
Salpingo-oophorectomy
64
Tubes tied
Tubal litigation or vasectomy
65
C-section
Cesarean section
66
Prostate removed
Prostatectomy (TURP)
67
Uterine product removed
Dilation and curettage (D&C)
68
Neck Artery cleaned
Carotid endarterectomy
69
Brain surgery
Craniotomy
70
Shunt
Ventriculoperitoneal (VP) shunt
71
Dialysis fistula
AV (ateriovenous) fistula
72
Dialysis Graft
AV Graft
73
PICC line
Peripherally inserted central catheter (PICC)
74
Port
Port-a-cath or medi-port
75
Clot filter
IVC (inferior vena cava) filter
76
Clot filer
Greenfield filter (leg)
77
Leg amputated
Above knee amputation (AKA)
Below knee amputation (BKA)
78
Joint repair
Arthroplasty
79
Meal plates/pins
Hardware
80
Neck fused
Cervical spine fusion
81
Back fused
Lumbar spinal fusion
82
Hip surgery
Open reduction with internal fixation (ORIF)
83
True allergic reaction
Rash, itching, swelling, difficulty breathing
84
FHx
Age of onset is important. Younger onset means higher genetic risk.
85
SHx
Tobacco use, alcohol use, illicit drug use, occupation, living circumstances
86
Tobacco use
Smoking status, ppd, years, second exposure (pediatrics)
Chewing
87
Alcohol use
Frequency and type of alcohol
88
Illicit drug use
Which drug, route administered
89
Occupation
Employed, unemployed, disability, retired. Type of work.
90
Living circumstances
With who, where.
91
SHx pediatrics
Caretaker, attends daycare, school, Siblings, second hand exposure, immunizations.
92
HPI
Subjective story of CC
93
ROS
Subjective head to toe
94
Past history
Medical, surgery, social, family
95
PE
Initial objective finds
96
ED course
Results, re-evals, consultations, events
97
ED flow
Walk-in, triage, bed placement, physician assessment, labs/Rad/meds, results, MDM,diagnosis, consults, dispo.
98
Five vital signs
Heart rate, blood pressure, respiratory rate, temp, oxygen sat
99
Coronary Artery Disease
CAD
Etiology: narrowing of the coronary arteries limits blood supply to the heart muscle causing angina.
CC: chest pain or pressure. Worsened with exertion improved with rest or NTG
Diagnosed: cardiac catheterization (not in ED)
100
Myocardial Infarction
MI
Etiology: acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle.
CC: chest pain, diaphoresis, Nausea, vomiting, SOB
Diagnosed: EKG (STEMI) troponin (NSTEMI)
101
Congestive heart failure
CHF
Etiology: the heart becomes enlarged, inefficient, and congested with excess fluid
CC: SOB, worse with lying down (Orthopnea), DOE
Diagnosed: CXR or elevated BNP (B-type natriuretic peptide)
102
Atrial fibrillation
AFIB
Etiology: atria quiver abnormally
CC: palpitations
Diagnosed: EKG
103
Non-cardiac chest pain
Pericarditis - inflammation of the pericardium
Pleurisy - inflammation of pleura causing pleuritic chest pain
Costochondritis - irritation of the ribs
Chest wall pain - irritation of the chest wall
Pleural effusion - fluid collecting around the lungs causing SOB or CP
104
Pulmonary Embolism
PE
Etiology: clot in pulmonary artery that is restricting blood flow to the lungs
CC: SOB or pleuritic chest pain
Diagnosed: CTA chest (CT of chest with IV contrast) or VQ scan. D-dimer aids in detecting clots but cannot diagnose.
105
Pneumonia
PNA
Etiology: infiltrate (bacterial infection) and inflammation inside the lung
CC: SOB productive cough
Diagnosed: CXR
106
Pneumothorax
PTX
Etiology: collapsed lung due to trauma or a spontaneous small rupture of the lung
CC: SOB and one sided chest pain
Diagnosed: CXR
107
Chronic obstructive pulmonary disease
COPD
Etiology: long-term damage to the lung alveoli along with inflammation and mucous production
CC: SOB
Dx: CXR and Hx of smoking
108
Reactive airway disease
RAD
Etiology: constructing of the airways due to inflammation and muscular contraction of the bronchioles
CC: SOB/wheezing
Dx: clinically
109
Ischemic vascular accident
CVA
Etiology: blockage of the arteries supplying blood to the brain resulting in permanent brain damage
CC: unilateral Focal Neurological deficits, one sided weakness/numbness or changes in speech/vision
Dx: clinically, potentially normal CT head
110
Hemorrhagic CVA
Brain Bleed
Etiology: traumatic or spontaneous rupture of blood vessels
CC: headache
Dx: CT head, LP (lumbar puncture)
111
Transient Ischemic Attack
TIA
Etiology: vascular changes temporarily deprive a part of the brain of oxygen
CC: transient Focal neurological deficit
Dx: clinically
112
Meningitis
Etiology: Inflammation and infection of the meninges; the sac surrounding the brain and spine
CC: headache and neck pain
Dx: LP (lumbar puncture)
113
Spinal cord injury
Etiology: injury to the spinal cord may create weakness and numbness in the extremities past the site of injury
CC: CT if the cervical, thoracic and lumbar spine
114
Seizure
SZ
Etiology: abnormal electrical activity in the brain
CC: seizure activity, syncope
Dx: clinically
115
Bell's Palsy
Etiology: inflammation or infection of the facial nerve causing one-sided weakness of the entire face
CC: facial droop
Dx: clinically
116
Headache
HA
Etiology: various causes
CC: headache of gradual onset
Dx: clinically
117
Altered mental status
AMS
Etiology: multiple causes: most common are hyperglycemia, infection, intoxication and neurological
CC: confusion, decreased responsiveness, unresponsive
Dx: case dependent
118
Syncope
Etiology: temporary loss of blood supply to the brain causing LOC
CC: passing out
Dx: clinically
119
Vertigo
Etiology: harmless problem of inner ear or caused by damage in a specific center of the brain
CC: room spinning, feeling off balance
Dx: clinically
120
Appendicitis
APPY
Etiology: infection of the appendix causing inflammation and blockage
CC: RLQ pain
Dx: CT A/P with PO contrast
121
Small bowel obstruction
SBO
Etiology: physical blockage of the small intestine
CC: abdominal pain, vomiting, constipation, abd distention
Dx: CT A/P with PO contrast Acute Abdominal series (AAS)
122
Gallstones
Cholelithiasis, cholecystitis
Etiology: minerals from the livers bike condense to form gallstones
CC: RUQ pain after eating fatty foods
Dx: abdominal US, RUQ
123
Gastrointestinal bleed
GI Bleed
Etiology: hemorrhage in the upper or lower gastrointestinal tract
CC: hematemesis, coffee ground emesis, hematochezia, melena
Dx: Heme positive stool during recital exam.
124
Diverticulitis
Etiology: acute inflammation and infection of abnormal pockets of the large intestine
CC: LLQ pain
Dx: CT A/P with PO contrast
125
Pancreatitis
Etiology: inflammation of the pancreas
CC: LUQ, epigastric pain
Dx: elevates lipase lab test
126
Gastroesophageal reflux disease
GERD
Etiology: stomach acid regurgitating into the esophagus
CC: epigastric pain
Dx: clinically
127
Other causes of abdominal pain
C Diff Colitis - persistent diarrhea
Gastroenteritis - vomiting and diarrhea
Crohn's disease - immune disorder V/D
IBS - chronically sensitive vowels prone to diarrhea
Gastritis - irritated stomach with vomiting
128
Urinary tract infection
UTI
Etiology - infection
CC: dysuria
Dx: urine drip or urinalysis (nitrite, WBC, bacteria in urine)
129
Pyelonephritis
Etiology: invention of the kidneys
CC: flank pain with dysuria
Dx: CT Abd/Pel w/o contrast or confirmed UTI with CVA tenderness
130
Kidney Stones
Nephrolithiasis, Renal calculi, urolithiasis
Etiology: stone from kidney lodged in ureter
CC: flank pain
Dx: CT Abd/Pel
131
Ectopic pregnancy
Tubal pregnancy
Etiology: fertilized egg develops outside the uterus, usually in the Fallopian tube.
CC: lower abdominal pain or vaginal bleeding while pregnant
Dx: US pelvis
132
Ovarian torsion
Etiology: twisting of the ovarian Artery
CC: lower abdominal pain
Dx: US pelvis
133
Testicular Torsion
Etiology: twisting of the spermatic cord
CC: testicular pain
Dx: US scrotum
134
Upper respiratory infection
URI
Etiology: most often viral infection causing congestion
CC: cough/congestion
Dx: clinically
135
Otitis media
Middle ear infection
Etiology: viral or bacterial infection of the tympanic membrane
CC: ear pain, ear pulling
Dx: clinically
136
Streptococcal pharyngitis
Strep throat
Etiology: bacterial infection of the tonsils and pharynx
CC: sore throat
Dx: rapid strep
137
Conjunctivitis
Pink eye
Etiology: infection of the outer lining of the eye, the conjunctiva
CC: eye redness, irritation or pain
Dx: clinically
138
Epistaxis
Nosebleed
Etiology: rupture JD a blood vessel inside the nose
CC: nose bleed
Dx: clinically
139
Musculoskeletal back pain
Etiology: deterioration or strain of the back creates pain
CC: back pain
DX: clinically
140
Extremity Injury
Etiology: trauma creates pain it swelling
CC: extremity pain
141
Abdominal aortic aneurysm
AAA
Etiology: widened and weakened arterial wall at risk of rupture
CC: midline abdominal pain, midline pulsatile abdominal mass, abdominal bruit
Dx: CR A/P with IV contrast
142
Aortic dissection
Etiology: separation of the muscular wall from the membrane of the artery
CC: chest pain radiating to back, unequal brachial or radial pulses
Dx: CT of chest with IV contrast
143
Deep vein thrombosis
DVT
Etiology: clot in the extremities
CC: extremity pain, calf tenderness, swelling
Dx: US/Doppler of the extremity
144
Cellulitis
Etiology: infection of the skin cells
CC: erythema, edema, increased warmth (calor), induration
Dx: clinically
145
Abscess
Cellulitis with fluctuant
Etiology: skin infection with an underlying collection of pus
CC: red, swollen and painful bulk. Fluctuance pocket, induration, purulent drainage
Dx: clinically
146
Rash
Etiology: changes in the skin appearance due to systemic or localized reaction.
CC: urticaria, macules (flat) papules (raised bumps), vesicles (small blisters)
Dx: clinically
147
Allergic reaction
Etiology: immune response causing an inflammatory reaction consisting of swelling
CC: rash, swelling, itching, SOB
Dx: clinically
148
Diabetic ketoacidosis
DKA
Etiology: shortage of insulin resulting in hyperglycemia and production of ketones
CC: persistent vomiting m, Ketotic odor, tachypnea
Dx: arterial blood gas (ABG) showing low pH, or positive serum ketones
149
Mechanism of injury
MOI
Refers to the way damage was caused.
Rapid forward deceleration
Rapid vertical decel
Penetrating trauma
150
How many elements does the HPI require for level 5 billing?
4
151
What are 9 HPI elements?
Element, onset, timing, location, quality, severity, modifying factors, associated Sx, context
152
How many elements does the ROS need for level 5 billing?
10 or 2 if all other system negative. Could also document that the ROS is limited due to ______
153
Constitutional
Fever, weight loss, sweats
154
Eyes
Changes in vision, eye pain, double vision
155
Ear/nose/throat
Ear ache, nose bleed, congestion, sore throat
156
Cardiovascular
Chest pain, palpitations, leg swelling
157
Respiratory
SOB, cough, sputum, wheezing
158
Gastrointestinal
Abd pain, N/V/D, black tarry stool
159
Genitourinary
Dysuria, frequency, urgency, hematuria
160
Musculoskeletal
Joint pain, muscle pain
161
Integumentary
Rash, itching, abrasion, laceration
162
Neurological
Headache, syncope, seizure, numbness, focal weakness
163
Psychiatric
Depression, anxiety
164
Endocrine
Polyuria, polydipsia
165
Hematologic
Bleeding gums, easy bruising, swollen lymph nodes
166
Immunological
HIV/AIDS, splenectomy
167
Waxing and waning
Always present but changing in intensity
168
MI risk factors
CAD, HTN, HLD, DM, smoking, FHx < 55 y/o
169
PE risk factors
Hx DVT/PE, known DVT, recent surgery, immobilization, A-fib, cancer, pregnancy/birth control
170
Worse with physical exertion
MI
171
Worse with deep breaths
PE
172
Radiation to the back
Aortic dissection
173
Recent trauma
PTX
174
Shortness of breath
MI, PE, PTX
175
Diaphoresis, nausea, vomiting
MI
176
Pleuritic pain
PE and PTX
177
Calf pain
DVT
178
Productive cough
PNA
179
Orthopnea/dyspnea on exertion
CHF
180
Bilateral leg swelling
CHF
181
Hemoptysis
PE
182
Unilateral leg swelling
DVT causing PE
183
Wheezing
Asthma
184
Hx of tobacco use
COPD
185
Chest pain
MI, PE, PNA
186
How many PMHX elements do you need?
2 but it needs to be a mixture can't just be PMHx and PSHx
187
How many elements do you need in the physical exam?
8 elements
188
H&H
Hgb and Hct if they are low this indicates anemia
189
CBC
Complete blood count
If WBC is high this indicates an infection
190
BMP
Basic metabolic panel
Na, K, Creat (creatinine), gluc
191
CMP
Comprehensive metabolic panel
BNP with a LFT
192
LFT
Liver function test
AST, ALT, ALK
193
CEP
Cardiac enzyme panel
Troponin, CK (creatine), CK-MB (creatine kinase-muscle breakdown)
If high this indicates heart damage
194
D-dimer
If it is high this raises the suspicion for PE but can't diagnose. If it is negative it can r/o PE.
195
Cardiac Orders
CBC, BMP, CK, CK-MB, trop, EKG, CXR
196
CSF Analysis
Four tubes
CSF prot - meningitis
CSF RBC - brain bleed (subarachnoid hemorrhage)
197
INR
International Normalized Ratio
Normal INR = 1.0
This tells you if you have too much or too little Coumadin
198
Thyroid Labs
TSH, T3, T4
199
Inflammation labs
CRP - C-reactive protein
ESR - erythrocyte sedimentation Rate
If high this indicates an active inflammation in the body
200
OB/GYN labs
HCG - pregnant
Serum HCG - quantitative pregnant
201
Urine Drip
Leuks, Nit, Gluc, Blo
202
Urinalysis
WBC, RBC, Bact, Epi
203
Sepsis lab
CBC, Lactate (diagnostic), blood CXR
204
Three key labs for efficiency
D-dimer (PE)
Trop (NSTEMI)
Creat (PE)
205
EKG leads and documentation
I, II, III, aVR, aVF, aVL, V1-6
Documentation must have the rate, rhythm, and at least two other findings
206
Critical care time
Any care that the provider provides to prevent permanent bodily harm or death.
Ask, does this patient qualify for critical care and how much time?
