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122 Cards in this Set

  • Front
  • Back

Subjective vs objective

Feeling vs fact

Chief complaint

The main reason for the pt's ED visit

MDM

The physician's thought process

Pain vs tenderness

Pt's feelings vs physician's assessment

Benign

Normal, nothing of concern

Distress

Doctor's judgement of discomfort

Febrile

State of having fever, concerning for infection

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

Charge nurse

Manages the ED patient flow

Mid-level provider

Nurse practitioner or physician assistant that works under the supervision of a physician to diagnose and treat patients

ED nurse

Records medical histories symptoms monitors the patient start IVs administers medications and assist with procedures

Respiratory therapist

Administers breathing treatments and assist with managing a patient's airway

ED tech

Helps the nurse and assist with procedures

Unit secretary

Places physicians orders answer his phone calls pages other specialist doctors and organizes the patient paperwork

Scribe

Documents the patient's visit on behalf of the physician

High blood pressure

Hypertension HTN

High cholesterol

Hyperlipidemia HLD

Thyroid problem

Usually hypothyroidism sometimes hyperthyroidism

Diabetes

Diabetes mellitus DM

I only take pills for my diabetes

Non-insulin-dependent diabetes mellitus NIDDM

I take shots for my diabetes

Insulin-dependent diabetes mellitus IDDM

Heart disease

Usually coronary artery disease CAD

Heart attack

Myocardial infarction MI and CAD

Heart failure

Congestive heart failure or CHF

Irregular heartbeat

Atrial fibrillation A-fib

Murmur

Heart murmur

Episodes of abnormally fast racing heartbeat

Supraventricular tachycardia SVT

Asthma

Asthma

Emphysema chronic bronchitis

Chronic obstructive pulmonary disease COPD

Blood clot in the lung

Pulmonary embolism PE

Pneumonia

Pneumonia PNA

Reflux

Gastroesophageal reflux disease GERD

Ulcer

Gastric ulcer or peptic ulcer disease

Pancreatitis

Pancreatitis

Hepatitis

Hepatitis A hepatitis B hepatitis C

Diverticulitis

Diverticulitis

Crohn's/UC

Crohn's disease or ulcerative colitis

Irritable bowel

Irritable bowel syndrome IBS

Bladder infection

Urinary tract infection UTI

Kidney infection

Pyelonephritis Pyelo

Kidney stones

Renal calculi

I'm on dialysis

Chronic renal failure CRF or end stage renal disease ESRD on dialysis

Enlarged prostate

Benign prostate hypertrophy BPH

Gravida

The total number of times the patient has been pregnant

Para

The number of live births the patient has had

Abortion

The total number of miscarriages or elective abortions

Stroke

Ischemic cerebrovascular accident CVA

Mini stroke

Transient ischemic attack TIA

Seizure

Seizure disorder epilepsy

Brain bleed

Hemorrhagic CVA

Bipolar

Bipolar disorder

Schizophrenia

Schizophrenia

I drink a lot

EtOH abuse or alcoholism

I do drugs

Substance abuse

Blood clot in my leg

Lower extremity deep vein thrombosis DVT

Bulge in my aorta or triple AAA

Abdominal aortic aneurysm AAA

Add 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

Usually osteoarthritis OA sometimes rheumatoid arthritis RA

Joint pain chronic

Degenerative joint disease DJD

Weak/fragile bones

Often osteoporosis

Cancer

Cancer or carcinoma CA: brain breast long: prostate ovarian skin bone leukemia lymphoma

Spread to my

With metastases to the

Chemo

Chemotherapy

Radiation

Radiation therapy

They cut it out

Status post surgical resection

It's Gone

In remission

Tonsils removed

Tonsillectomy

Adenoids removed

Adenoidectomy

Ear tubes

Pressure equalizer PE 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 or replacement bovine versus mechanical

Pacer

Pacemaker

Defibrillator

Automatic implanted cardiac defibrillator AICD

Surgery for a fib

A fib S/P cardiac ablation

Breast removal

Mastectomy

Hole in my neck

Tracheostomy commonly called a trach

Part of my lung removed

Partial lobectomy

Appendix removed

Appendectomy

Gallbladder removed

Cholecystectomy

Hernia repair

Herniorrhaphy

Part of my colon removed

Partial colectomy

Back to collect stool

Colostomy

Spleen removed

Splenectomy

Stomach stapled

Gastric bypass

Exploratory

Exploratory laparoscopy ex lap

Kidney removed

Nephrectomy

Uterus removed

Hysterectomy partial versus total

Ovary removed

Oophorectomy

Ovary and fallopian tubes removed

Salpingo-oophorectomy

Tubes tied

Tubal ligation female or Vasectomy male

C-section

Caesarean section

Prostate removed

Prostate ectomy transurethral removal of the prostate TURP

Uterine product removed

Dilation in curettage D&C

Neck artery cleaned

Carotid endarterectomy

Brain surgery

Craniotomy brain bleed verse brain CA

Shunt

Ventriculoperitoneal shunt VP

Dialysis fistula

AV arteriovenous fistula

Dialysis graft

AV graft

PICC line

Peripherally inserted central catheter PICC

Port

Port-a-cath or medi-port

Clot filter lower abdomen

IVC inferior vena cava filter

Clot filter leg

Greenfield filter

Leg amputated

Above knee amputation AKA below knee amputation BKA

Arthroplasty

Arthroplasty

Metal plates/pins

Hardware

Neck fused

Cervical spine fusion

Back fused

Lumbar spinal fusion

Hip surgery

Open reduction with internal fixation ORIF

Fx

Family history

Social history SHx

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