Workbook Flashcards

1
Q

High blood pressure

A

Hypertension (HTN)

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2
Q

High cholesterol

A

Hyperlipidemia (HLD)

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3
Q

Thyroid problem

A

Usually hypothyroidism, sometimes hyperthyroid

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4
Q

Heart disease

A

Coronary Artery disease (CAD)

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5
Q

Heart attack

A

MI and CAD

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6
Q

Heart failure

A

Congestive heart failure

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7
Q

Irregular heart beat

A

A fib

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8
Q

Murmur

A

Heart murmur

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9
Q

Episodes of abnormally fast/racing heartbeat

A

Supraventricular tachycardia

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10
Q

Asthma

A

Reactive airway (RAP)

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11
Q

Emphysema/chronic bronchitis

A

COPD

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12
Q

Blood clotting in the lungs

A

Pulmonary embolism

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13
Q

Pneumonia

A

PNA

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14
Q

Acid reflux

A

GERD

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15
Q

Ulcer

A

Gastric ulcer or peptic ulcer disease

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16
Q

Ulcerative cholitis

A

UC

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17
Q

Bladder infection

A

UTI

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18
Q

Kidney infection

A

Pyelonephritis

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19
Q

Kidney stones

A

Renal calculi

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20
Q

On dialysis

A

Chronic renal failure (CRF) or end stage renal failure (ESRF) on dialysis

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21
Q

Enlarged prostate

A

Benign prostate hypertrophy

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22
Q

Gravid/Para/Abortus

A

G: total time pregnant
P: number of lives birth
A: miscarriage or elective abortions

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23
Q

Stroke

A

CVA

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24
Q

Mini-stroke

A

TIA

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25
Q

Seizure

A

Sz

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26
Q

Brain bleed

A

Hemorrhagic CVA

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27
Q

Blood clot in the leg

A

Lower extremity deep vain thrombosis (DVT)

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28
Q

Bulge in aorta

A

Abdominal aortic aneurysm (AAA)

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29
Q

Bad blood flow to my legs

A

Peripheral vascular disease (PVD)

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30
Q

Numbness in my legs

A

Peripheral neuropathy

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31
Q

Low back pain

A

Chronic low back pain

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32
Q

Bulging/herniated disc

A

Degenerative disc disease (DDD)

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33
Q

Arthritis

A

Usually osteoarthritis (OA) sometime rheumatoid arthritis (RA)

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34
Q

Joint pain

A

Degenerative joint disease (DJD)

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35
Q

Weak/fragile bones

A

Osteoporosis

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36
Q

Cancer

A

CA

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37
Q

Spread to my…

A

With metastases to the

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38
Q

They cut it out

A

Status-post surgical resection

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39
Q

It’s gone

A

In remission

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40
Q

Tonsils removed

A

Tonsillectomy

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41
Q

Adenoids removed

A

Adenoidectomy

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42
Q

Ear tubes

A

Pressure equalizer (P.E.) tubes

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43
Q

Heart bypass

A

Coronary Artery Bypass Graft (CABG) - PMHx CAD

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44
Q

Stents

A

Coronary stents

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45
Q

Heart cath

A

Cardiac catheterization

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46
Q

Balloon

A

Angioplasty - PMHx CAD

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47
Q

Valve surgery

A

Valve repair or replacement (Bovine vs. mechanical)

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48
Q

Defibrillator

A

Automatic Implanted Cardiac defibrillator (AICD)

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49
Q

Surgery for a fib

A

Afib s/p cardiac ablation

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50
Q

Breast removal

A

Mastectomy

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51
Q

Hole in my neck

A

Tracheostomy

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52
Q

Part of my lung removed

A

Partial lobectomy

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53
Q

Appendix removed

A

Appendectomy

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54
Q

Gallbladder removed

A

Cholecystectomy

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55
Q

Hernia repair

A

Herniorrhaphy

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56
Q

Part of Colon removed

A

Partial colectomy

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57
Q

Bag to collect stool

A

Colostomy

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58
Q

Spleen removed

A

Splenectomy

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59
Q

Stomach stapled

A

Gastric bypass

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60
Q

Kidney removed

A

Nephrectomy

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61
Q

Uterus removed

A

Hysterectomy

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62
Q

Ovary removed

A

Oophorectomy

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63
Q

Ovary and fallopian tunes removed

A

Salpingo-oophorectomy

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64
Q

Tubes tied

A

Tubal litigation or vasectomy

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65
Q

C-section

A

Cesarean section

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66
Q

Prostate removed

A

Prostatectomy (TURP)

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67
Q

Uterine product removed

A

Dilation and curettage (D&C)

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68
Q

Neck Artery cleaned

A

Carotid endarterectomy

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69
Q

Brain surgery

A

Craniotomy

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70
Q

Shunt

A

Ventriculoperitoneal (VP) shunt

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71
Q

Dialysis fistula

A

AV (ateriovenous) fistula

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72
Q

Dialysis Graft

A

AV Graft

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73
Q

PICC line

A

Peripherally inserted central catheter (PICC)

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74
Q

Port

A

Port-a-cath or medi-port

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75
Q

Clot filter

A

IVC (inferior vena cava) filter

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76
Q

Clot filer

A

Greenfield filter (leg)

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77
Q

Leg amputated

A

Above knee amputation (AKA)

Below knee amputation (BKA)

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78
Q

Joint repair

A

Arthroplasty

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79
Q

Meal plates/pins

A

Hardware

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80
Q

Neck fused

A

Cervical spine fusion

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81
Q

Back fused

A

Lumbar spinal fusion

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82
Q

Hip surgery

A

Open reduction with internal fixation (ORIF)

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83
Q

True allergic reaction

A

Rash, itching, swelling, difficulty breathing

84
Q

FHx

A

Age of onset is important. Younger onset means higher genetic risk.

85
Q

SHx

A

Tobacco use, alcohol use, illicit drug use, occupation, living circumstances

86
Q

Tobacco use

A

Smoking status, ppd, years, second exposure (pediatrics)

Chewing

87
Q

Alcohol use

A

Frequency and type of alcohol

88
Q

Illicit drug use

A

Which drug, route administered

89
Q

Occupation

A

Employed, unemployed, disability, retired. Type of work.

90
Q

Living circumstances

A

With who, where.

91
Q

SHx pediatrics

A

Caretaker, attends daycare, school, Siblings, second hand exposure, immunizations.

92
Q

HPI

A

Subjective story of CC

93
Q

ROS

A

Subjective head to toe

94
Q

Past history

A

Medical, surgery, social, family

95
Q

PE

A

Initial objective finds

96
Q

ED course

A

Results, re-evals, consultations, events

97
Q

ED flow

A

Walk-in, triage, bed placement, physician assessment, labs/Rad/meds, results, MDM,diagnosis, consults, dispo.

98
Q

Five vital signs

A

Heart rate, blood pressure, respiratory rate, temp, oxygen sat

99
Q

Coronary Artery Disease

A

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
Q

Myocardial Infarction

A

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
Q

Congestive heart failure

A

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
Q

Atrial fibrillation

A

AFIB

Etiology: atria quiver abnormally

CC: palpitations

Diagnosed: EKG

103
Q

Non-cardiac chest pain

A

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
Q

Pulmonary Embolism

A

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
Q

Pneumonia

A

PNA

Etiology: infiltrate (bacterial infection) and inflammation inside the lung

CC: SOB productive cough

Diagnosed: CXR

106
Q

Pneumothorax

A

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
Q

Chronic obstructive pulmonary disease

A

COPD

Etiology: long-term damage to the lung alveoli along with inflammation and mucous production

CC: SOB

Dx: CXR and Hx of smoking

108
Q

Reactive airway disease

A

RAD

Etiology: constructing of the airways due to inflammation and muscular contraction of the bronchioles

CC: SOB/wheezing

Dx: clinically

109
Q

Ischemic vascular accident

A

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
Q

Hemorrhagic CVA

A

Brain Bleed

Etiology: traumatic or spontaneous rupture of blood vessels

CC: headache

Dx: CT head, LP (lumbar puncture)

111
Q

Transient Ischemic Attack

A

TIA

Etiology: vascular changes temporarily deprive a part of the brain of oxygen

CC: transient Focal neurological deficit

Dx: clinically

112
Q

Meningitis

A

Etiology: Inflammation and infection of the meninges; the sac surrounding the brain and spine

CC: headache and neck pain

Dx: LP (lumbar puncture)

113
Q

Spinal cord injury

A

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
Q

Seizure

A

SZ

Etiology: abnormal electrical activity in the brain

CC: seizure activity, syncope

Dx: clinically

115
Q

Bell’s Palsy

A

Etiology: inflammation or infection of the facial nerve causing one-sided weakness of the entire face

CC: facial droop

Dx: clinically

116
Q

Headache

A

HA

Etiology: various causes

CC: headache of gradual onset

Dx: clinically

117
Q

Altered mental status

A

AMS

Etiology: multiple causes: most common are hyperglycemia, infection, intoxication and neurological

CC: confusion, decreased responsiveness, unresponsive

Dx: case dependent

118
Q

Syncope

A

Etiology: temporary loss of blood supply to the brain causing LOC

CC: passing out

Dx: clinically

119
Q

Vertigo

A

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
Q

Appendicitis

A

APPY

Etiology: infection of the appendix causing inflammation and blockage

CC: RLQ pain

Dx: CT A/P with PO contrast

121
Q

Small bowel obstruction

A

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
Q

Gallstones

A

Cholelithiasis, cholecystitis

Etiology: minerals from the livers bike condense to form gallstones

CC: RUQ pain after eating fatty foods

Dx: abdominal US, RUQ

123
Q

Gastrointestinal bleed

A

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
Q

Diverticulitis

A

Etiology: acute inflammation and infection of abnormal pockets of the large intestine

CC: LLQ pain

Dx: CT A/P with PO contrast

125
Q

Pancreatitis

A

Etiology: inflammation of the pancreas

CC: LUQ, epigastric pain

Dx: elevates lipase lab test

126
Q

Gastroesophageal reflux disease

A

GERD

Etiology: stomach acid regurgitating into the esophagus

CC: epigastric pain

Dx: clinically

127
Q

Other causes of abdominal pain

A

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
Q

Urinary tract infection

A

UTI

Etiology - infection

CC: dysuria

Dx: urine drip or urinalysis (nitrite, WBC, bacteria in urine)

129
Q

Pyelonephritis

A

Etiology: invention of the kidneys

CC: flank pain with dysuria

Dx: CT Abd/Pel w/o contrast or confirmed UTI with CVA tenderness

130
Q

Kidney Stones

A

Nephrolithiasis, Renal calculi, urolithiasis

Etiology: stone from kidney lodged in ureter

CC: flank pain

Dx: CT Abd/Pel

131
Q

Ectopic pregnancy

A

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
Q

Ovarian torsion

A

Etiology: twisting of the ovarian Artery

CC: lower abdominal pain

Dx: US pelvis

133
Q

Testicular Torsion

A

Etiology: twisting of the spermatic cord

CC: testicular pain

Dx: US scrotum

134
Q

Upper respiratory infection

A

URI

Etiology: most often viral infection causing congestion

CC: cough/congestion

Dx: clinically

135
Q

Otitis media

A

Middle ear infection

Etiology: viral or bacterial infection of the tympanic membrane

CC: ear pain, ear pulling

Dx: clinically

136
Q

Streptococcal pharyngitis

A

Strep throat

Etiology: bacterial infection of the tonsils and pharynx

CC: sore throat

Dx: rapid strep

137
Q

Conjunctivitis

A

Pink eye

Etiology: infection of the outer lining of the eye, the conjunctiva

CC: eye redness, irritation or pain

Dx: clinically

138
Q

Epistaxis

A

Nosebleed

Etiology: rupture JD a blood vessel inside the nose

CC: nose bleed

Dx: clinically

139
Q

Musculoskeletal back pain

A

Etiology: deterioration or strain of the back creates pain

CC: back pain

DX: clinically

140
Q

Extremity Injury

A

Etiology: trauma creates pain it swelling

CC: extremity pain

141
Q

Abdominal aortic aneurysm

A

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
Q

Aortic dissection

A

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
Q

Deep vein thrombosis

A

DVT

Etiology: clot in the extremities

CC: extremity pain, calf tenderness, swelling

Dx: US/Doppler of the extremity

144
Q

Cellulitis

A

Etiology: infection of the skin cells

CC: erythema, edema, increased warmth (calor), induration

Dx: clinically

145
Q

Abscess

A

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
Q

Rash

A

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
Q

Allergic reaction

A

Etiology: immune response causing an inflammatory reaction consisting of swelling

CC: rash, swelling, itching, SOB

Dx: clinically

148
Q

Diabetic ketoacidosis

A

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
Q

Mechanism of injury

A

MOI

Refers to the way damage was caused.

Rapid forward deceleration

Rapid vertical decel

Penetrating trauma

150
Q

How many elements does the HPI require for level 5 billing?

A

4

151
Q

What are 9 HPI elements?

A

Element, onset, timing, location, quality, severity, modifying factors, associated Sx, context

152
Q

How many elements does the ROS need for level 5 billing?

A

10 or 2 if all other system negative. Could also document that the ROS is limited due to ______

153
Q

Constitutional

A

Fever, weight loss, sweats

154
Q

Eyes

A

Changes in vision, eye pain, double vision

155
Q

Ear/nose/throat

A

Ear ache, nose bleed, congestion, sore throat

156
Q

Cardiovascular

A

Chest pain, palpitations, leg swelling

157
Q

Respiratory

A

SOB, cough, sputum, wheezing

158
Q

Gastrointestinal

A

Abd pain, N/V/D, black tarry stool

159
Q

Genitourinary

A

Dysuria, frequency, urgency, hematuria

160
Q

Musculoskeletal

A

Joint pain, muscle pain

161
Q

Integumentary

A

Rash, itching, abrasion, laceration

162
Q

Neurological

A

Headache, syncope, seizure, numbness, focal weakness

163
Q

Psychiatric

A

Depression, anxiety

164
Q

Endocrine

A

Polyuria, polydipsia

165
Q

Hematologic

A

Bleeding gums, easy bruising, swollen lymph nodes

166
Q

Immunological

A

HIV/AIDS, splenectomy

167
Q

Waxing and waning

A

Always present but changing in intensity

168
Q

MI risk factors

A

CAD, HTN, HLD, DM, smoking, FHx < 55 y/o

169
Q

PE risk factors

A

Hx DVT/PE, known DVT, recent surgery, immobilization, A-fib, cancer, pregnancy/birth control

170
Q

Worse with physical exertion

A

MI

171
Q

Worse with deep breaths

A

PE

172
Q

Radiation to the back

A

Aortic dissection

173
Q

Recent trauma

A

PTX

174
Q

Shortness of breath

A

MI, PE, PTX

175
Q

Diaphoresis, nausea, vomiting

A

MI

176
Q

Pleuritic pain

A

PE and PTX

177
Q

Calf pain

A

DVT

178
Q

Productive cough

A

PNA

179
Q

Orthopnea/dyspnea on exertion

A

CHF

180
Q

Bilateral leg swelling

A

CHF

181
Q

Hemoptysis

A

PE

182
Q

Unilateral leg swelling

A

DVT causing PE

183
Q

Wheezing

A

Asthma

184
Q

Hx of tobacco use

A

COPD

185
Q

Chest pain

A

MI, PE, PNA

186
Q

How many PMHX elements do you need?

A

2 but it needs to be a mixture can’t just be PMHx and PSHx

187
Q

How many elements do you need in the physical exam?

A

8 elements

188
Q

H&H

A

Hgb and Hct if they are low this indicates anemia

189
Q

CBC

A

Complete blood count

If WBC is high this indicates an infection

190
Q

BMP

A

Basic metabolic panel

Na, K, Creat (creatinine), gluc

191
Q

CMP

A

Comprehensive metabolic panel

BNP with a LFT

192
Q

LFT

A

Liver function test

AST, ALT, ALK

193
Q

CEP

A

Cardiac enzyme panel

Troponin, CK (creatine), CK-MB (creatine kinase-muscle breakdown)

If high this indicates heart damage

194
Q

D-dimer

A

If it is high this raises the suspicion for PE but can’t diagnose. If it is negative it can r/o PE.

195
Q

Cardiac Orders

A

CBC, BMP, CK, CK-MB, trop, EKG, CXR

196
Q

CSF Analysis

A

Four tubes

CSF prot - meningitis

CSF RBC - brain bleed (subarachnoid hemorrhage)

197
Q

INR

A

International Normalized Ratio

Normal INR = 1.0

This tells you if you have too much or too little Coumadin

198
Q

Thyroid Labs

A

TSH, T3, T4

199
Q

Inflammation labs

A

CRP - C-reactive protein

ESR - erythrocyte sedimentation Rate

If high this indicates an active inflammation in the body

200
Q

OB/GYN labs

A

HCG - pregnant

Serum HCG - quantitative pregnant

201
Q

Urine Drip

A

Leuks, Nit, Gluc, Blo

202
Q

Urinalysis

A

WBC, RBC, Bact, Epi

203
Q

Sepsis lab

A

CBC, Lactate (diagnostic), blood CXR

204
Q

Three key labs for efficiency

A

D-dimer (PE)

Trop (NSTEMI)

Creat (PE)

205
Q

EKG leads and documentation

A

I, II, III, aVR, aVF, aVL, V1-6

Documentation must have the rate, rhythm, and at least two other findings

206
Q

Critical care time

A

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?