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173 Cards in this Set
- Front
- Back
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subjective |
feeing; includes history of present illness and reviw of systems |
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objective |
fact; includes physical exam, ed course, disposition |
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cheif complaint |
the main reason for the patient's ED visit |
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medical decision making |
the physician's thought process |
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pain vs tenderness |
patient's feelings vs physician's assessment |
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benign |
normal, notihng of concern |
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febrile |
the state of having a fever, concerning for infection |
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acute |
new onset, likely concerning |
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chronic |
long-standing, not of direct concern |
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baseline |
an individual's nomral state of being |
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ausculataion |
lsitening with a stehtoscope |
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palpation |
the act of pressing on an area (by the doctor) |
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inpatient |
admitted to the hospital overnight |
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outpatient |
seen and sent home the same day |
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scribe's job |
documents the patient's visit on behalf of the physician |
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Vital signs |
HR: heart rate (bpm) BP : blood pressure (mmHg) RR: respiratory rate T: temperature SaO2 : oxygen saturation (%) |
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Disposition |
Discharge home Admit for further care Transfer to another facility |
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High blood pressure |
Hypertension (HTN) |
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High cholesterol |
Hyperlipidemia ( HLD) |
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Thyroid problem |
Usually hypothyroidism or hyperthyroidism |
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Diabetes |
Diabetes mellitus (DM) |
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"I only take pills for my diabetes " |
Non-insulin dependent diabetes mellitus (NIDDM) |
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"I take shots (insulin) for my diabetes." |
Insulin dependent diabetes mellitus (IDDM) |
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Heart Disease |
Usually coronary artery disease (CAD) |
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Heart attack |
Myocardial infarction (MI) and CAD |
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Heart failure |
Congestive heart failure (CHF) |
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Irregular heartbeat |
Atrial fibrillation (A-Fib) Seen on EKG |
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Murmur |
Heart murmur |
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Episodes of abnormally fast/ racing heartbeat |
Supra ventricular tachycardia (SVT) |
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Asthma |
Asthma (wheezing) |
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Emphysema / chronic bronchitis |
Chronic obstructive pulmonary disease (COPD) usually found in life long smokers |
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Blood clot in lungs |
Pulmonary embolism (PE) |
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Pneumonia |
Pneumonia (PNA) |
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Reflux |
Gastroesophageal reflux disease (GERD) |
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Ulcer |
Gastric ulcer or peptic ulcer disease |
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Pancreatitis |
Pancreatitis |
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Hepatitis |
Hepatitis A, Hepatitis B, Hepatitis C |
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Diverticulitis |
Diverticulitis, inflammation of large intestine |
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Crohn's/ UC |
Crohn's disease or ulcerative colitis |
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Irritable bowel |
Irritable bowel syndrome (IBS) |
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Bladder infection |
Urinary tract infection (UTI) |
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Kidney Infection |
Pyelonephritis (pyelo) |
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Kidney stone |
Renal calculi |
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"I'm on dialysis" |
Chronic renal failure (CRF) or End Stage renal disease (ESRD) |
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Enlarged prostate |
Benign prostate hypertrophy (BPH) |
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Stroke |
Cerebrovascular accident (CVA) |
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Mini-stroke |
Transient Ischemic Attack (TIA) |
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Seizures |
Seizure disorder/ epilepsy |
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Brain bleed |
Hemorrhagic CVA |
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Bipolar |
Bipolar disorder |
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"I drink a lot" |
ETOH abuse or alcoholism |
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"I do drugs" |
Substance abuse |
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"Blood clot in my leg" |
Lower extremity deep vein thrombosis (DVT) |
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"Bulge in my aorta" or "Triple A" |
Abdominal aortic aneurysm (AAA) |
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"Bad blood flow to my legs" |
Peripheral vascular disease (PVD) |
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"Numbness in my legs" |
Peripheral neuropathy |
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"Low back pain" |
Chronic low back pain |
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"Bulging /herniated disc" |
Degenerative disc disease (DDD) |
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"Arthritis" |
Usually osteoarthritis (OA) |
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Joint pain (chronic ) |
Degenerative joint disease (DJD) |
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Joint pain (chronic ) |
Degenerative joint disease (DJD) |
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Weak/fragile bones |
Often osteoporosis |
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"They cut it out " |
Status post surgical resection |
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Tonsils removed |
Tonsillectomy |
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Adenoids removed |
Adenoidectomy |
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Ear tubes |
Pressure equalizer (P.E.) tubes |
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Heart bypass |
Coronary artery bypass graft (CABG) Goes in PMHx |
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Stents |
Coronary stents Put in PMHx> CAD |
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Heart cath |
Cardiac catheterization |
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Ballon |
Angioplasty Put in PMHX > CAD |
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Valve surgery |
Valve repair or replacement (bovine vs. Mechanical ) |
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Defibrillator |
Automatic implanted cardiac defibrillator (AICD) |
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Surgery for Afib |
Afib s/p cardiac ablation |
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Breast removal |
Mastectomy |
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Hole in my neck |
Tracheostomy (commonly alley a "trach") |
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Part of my lung removed |
Partial lobectomy |
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Appendix removal |
Appendectomy |
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Gallbladder removal |
Cholecystectomy |
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Hernia repair |
Herniorrhaphy |
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Part of colon removed |
Partial colectomy |
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Bag to collect stool |
Colostomy |
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Spleen removed |
Splenectomy |
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Stomach stapled |
Gastric bypass |
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Kidney removed |
Nephrectomy |
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Uterus removed |
Hysterectomy (partial vs. Total) |
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Ovary removed |
Oophorectomy |
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Ovary and fallopian tubes removed |
Salpingo-oophorectomy |
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Tubes tied |
Tubal ligation (female) or vasectomy (male) |
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Prostate removed |
Prostatectomy |
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Uterine product removed |
Dilation and curettage (D&C) |
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Neck artery cleaned |
Carotid endarterectomy |
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Brain surgery |
Craniotomy (bring beer vs. Brain CA) |
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Shunt |
Ventriculoperitoneal (VP) shunt |
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Dialysis fistula |
AV (arteriovenous) fistula |
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Dialysis graft |
AV graft |
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PICC line |
Peripherally Inserted central catheter (PICC) |
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Port |
Port-a-cath or Medi-port |
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Clot filter (lower abdomen) |
IVC (inferior vena cava) filter |
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Clot filter (leg) |
Greenfield filter |
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Joint repair |
Anthroplasty |
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Neck fused |
Cervical spinal fusion |
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Back fused |
Lumbar spinal fusion |
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Hip surgery |
Open reduction with internal fixation (ORIF) |
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What are the five vital signs? |
HR - heart rate BP- blood pressure RR - respiratory rate T - temperature O2 Sat - O2 saturation |
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Is the HPI and ROS objective or subjective? |
Subjective |
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Is the Physical Exam objective or subjective? |
Objective |
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What is the abbreviation for cardiac bypass? |
CABG - coronary artery bypass graft |
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What is the abbreviation for high blood pressure? |
HTN - hypertension |
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What is the medical term for acid reflux? |
GERD - gastroesophageal reflux disease |
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What is the medical term for stroke? |
CVA - cerebrovascular accident |
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What is the term for gallbladder removal? |
Cholecystectomy |
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What does NKDA stand for? |
No known drug allergies |
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What is the medical term for redness? |
Erythema |
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What is the medical term for bruising? |
Ecchymosis |
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If the doctor says the exam was "benign", what does that mean? |
Normal, no danger to health |
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Differential diagnosis |
What could possibly be wrong with the patient |
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Pertinent positives |
Specific symptoms that raise the physician's suspicion for a particular disease |
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Pertinent negative |
Specific symptoms that are not present which cause a physician to doubt certain diagnoses |
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Coronary artery disease (CAD) |
Narrowing of the coronary arteries limits blood supply to the heart muscle Chief complaint : chest pain or chest pressure; worse with exertion; improved with rest and NTG Diagnosed by : cardiac catheterization |
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Myocardial infarction (MI) |
Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle Chief complaint : chest pain or chest pressure Diagnosed by : EKG (STEMI) or elevated troponin (non- STEMI) Acute MI patients must receive Aspirin 324mg as soon as possible. STEMI patients must get to the Cath-lab within 90 minutes of arrival. Document ED arrival, depart time, and when symptoms started. |
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Congestive heart failure (CHF) |
The heart becomes enlarged, inefficient, and congested with excess fluid Chief complaint: shortness of breath Diagnosed by: CXR or elevated BNP You can think of CHF as fluid traffic jam in the heart; fluid gets backed up the neck (JVD) and down the legs (pedal edema) |
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Atrial fibrillation (AFIB) |
Electrical abnormalities in the 'wiring " of the heart causes the top of the heart (atria ) to quiver abnormally Chief complaint : palpitations (fast,pounding, irregular ) Diagnosed by: EKG
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Pulmonary embolism (PE) |
A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs Chief complaint : SOB or Pleuritic chest pain ( CP due to deep breathes ) Diagnosed by: CTA chest (CT chest w/ IV contrast) or VQ scan |
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Pneumonia (PNA ) |
Infiltrate (bacterial infection) and inflammation inside the lungs Chief complaint: SOB or productive cough Diagnosed by : CXR |
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Pneumothorax (PTX) |
Collapsed lung due to trauma or a spontaneous small rupture of the lungs Chief complaint : SOB and one sided chest pain Diagnosed by: CXR Document the percentage of lung collapsed |
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Chronic obstructive pulmonary disease (COPD ) |
Long term damage to the lung's alveoli (emphysema ) along with inflammation and mucous production (chronic bronchitis ) Chief complaint : SOB Physical Exam: decreased breath sounds wheezes, rales Diagnosed by: CXR and Hx of smoking |
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Reactive airway disease (RAD) |
Constricting of the airway due to inflammation and muscular contraction of the broncholes, known as a "bronchospasm" Chief complaint: SOB/wheezing Diagnosed by: clinically |
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Ischemic cerebral vascular accident (CVA) |
Blockage of the arteries supplying blood to the brain resulting in the permanent brain damage Chief complaint: unilateral focal neurological deficits: one sided weakness/numbness or change in speech/vision Diagnosed by: clinically, potentially normal CT head For stroke patient ALWAYS document the date and time they were last known well |
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Hemorrhagic CVA, brain bleed |
Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding I the brain Chief complaint : headache Diagnosed by: CT head or LP |
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Transient ischemic attack (TIA) |
Vascular changes temporarily deprive a part of the brain oxygen (symptoms usually last less than an hour) Chief complaint : transient focal neurological deficits Diagnosed : clinically |
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Meningitis: bacterial vs. Viral |
Inflammation and infection of the meninges; the sac surrounding the brain and spinal cord Chief complaint : headache and neck pain Diagnosed by: lumbar puncture |
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Bells palsy |
Inflammation or viral infection of the facial nerve causes one-sided weakness of the entire face Chief complaint : facial droop with sudden onset Diagnosed: clinically |
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Syncope |
Fainting or passing out |
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Appendicitis |
Infection of the appendix causes inflammation and blockage, possibly leading to rupture Chief complaint : RLQ pain, gradual onset, constant, worsening with movement Diagnosed by: CT A/P with PO contrast |
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Small bowel obstruction (SBO) |
Physical blockage of the small intestine Chief complaint: abdominal pain, vomiting, constipation Diagnosed by: CT A/P with PO contrast |
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Gallstones (cholelithiasis, cholecystitis) |
Minerals from the liver's bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder Chief complaint : RUQ pain, sharp, worsening with eating, deep breathes, and palpations Diagnosed by: abdominal US, RUQ |
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Gastrointestinal bleed (GI Bleed) |
Hemorrhage in the upper or lower gastrointestinal tract can lead to anemia Chief complaint :hematemesis (upper), coffee ground emesis (lower), hematochezia (lower), melena (upper) Diagnosed by: heme positive stool (Guaiac positive) during rectal exam |
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Diverticulitis |
Acute inflammation and infection of abnormal pockets of the large intestine, known as diverticuli Chief complaint : LLQ pain Diagnosed by: CT A/P with PO contrast |
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Pancreatitis |
Inflammation of the pancreas Chief complaint : LUQ, epigastric pain Diagnosed by: elevated lipase lab tests (or sometimes elevated amylase) |
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Gastroesophageal reflux disease (GERD) |
Stomach acid regurgitating into the esophagus Chief complaint: epigastric pain, burning, improved with antacids |
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Urinary tract infection (UTI) |
Infection in the urinary tract (bladder or urethra) Chief complaint: dysuria Diagnosed by: urine dip or urinalysis |
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Pyelonephritis |
Infection of the tissue in the kidneys, usually spread from UTI chief complaint : flank pain with dysuria Diagnosed by: CT Abd/Pelosi without contrast |
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Kidney stone ( renal calculi) |
A kidney stone dislodged from the kidney and begins to traveling down the ureter Chief complaint: flank pain that radiates to the groin Diagnosed by: CT abd/pelvis |
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Ectopic pregnancy (tubal pregnancy ) |
Fertilized egg develops outside the uterus, usually in the fallopian tube, high risk for rupture or death Chief complaint : lower abdominal pain or vaginal bleeding while pregnant Diagnosed by: US pelvis |
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Ovarian torsion |
Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in infarct of the ovary Chief complaint : lower abdominal pain (RLQ or LLQ) Diagnosed by : US pelvis |
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Testicular torsion |
Twisting of the spermatic cord resulting in the loss of blood flow and nerve function to the testicle Chief complaint : testicular pain Diagnosed by: US scrotum |
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Upper respiratory infection (URI) |
Aka common cold Most often viral infection causes congestion, cough, and inflammation of the upper airway Chief complaint:cough/congestion Diagnosed by: clinically |
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Otitis media (middle ear infection) |
Viral bacteria infection of the tympanic membrane causing ear pain and pressure Chief complaint: ear pain , ears pulling Diagnosed by : clinically |
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Streptococcal pharyngitis (strep throat) |
Bacterial infection of the tonsils and pharynx causing a sore throat and frequently swollen lymph nodes Chief complaint : sore throat Diagnosed by: rapid strep |
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Conjunctivitis (pink eye ) |
Infection of the outer lining of the eye, known as the conjunctivitis Chief complaint: eye redness, irritation, or pain Diagnosed: clinically |
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Epistaxis (nose bleed) |
Rupture of a blood vessel inside the nose causes blood to flow out of the nose and into the throat Diagnosed by: clinically |
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Abdominal aortic aneurysm (AAA ) |
Widened and weakened arterial wall at risk of rupture Diagnosed by: CT A/P with IV contrast dye Cc: midline abdominal pain |
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Aortic dissection |
Separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death Diagnosed by: CT Chest with IV contrast dye |
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Deep vein thrombosis (DVT) |
Diagnosed by: US/Doppler of the extremity |
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Allergic reactions can only cause what? |
Rash Itching Swelling SOB due to airway swelling |
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Diabetic ketoacidosis (DKA) |
Shortage of insulin resulting in hyperglycemia and production of ketone Diagnosed by: arterial blood gas (ABC or VBG) showing low pH (acidosis) or positive serum ketones |
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Etiology |
The study of the cause of diseases |
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What should the HPI include? |
Only information that is directly related to the chief complaint and important context for that patient |
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How many elements does a complete HPI require? |
4 elements |
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What are the elements of the HPI? |
Element:description Onset: when did the complaint begin? Timing: has it been constant, intermittent, or waxing and waning? Location : where is the discomfort? Quality: does it feel sharp, dull, aching, cramping.....? Severity: how bad is it? Mild, moderate, severe or 0-10 Modifying factors : what makes it better? What makes it worse? Associated Sx : do any other symptoms accompany the complaint? Context: is there anything else that's important? |
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What are the four most important symptoms to document for any trauma patients in the HPI? |
LOC Head injury Neck pain Back pain |
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How many elements are needed to have a complete ROS? |
10 elements |
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What are the elements of the ROS? |
Constitutional: fever, weight loss, sweats Eyes: change in vision, eyes pain, double vision Ear/nose/throat : ear ache, nose bleed, congestion, sore throat Cardiovascular: chest pain, palpitations, leg swellings Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary/skin Neurological Psychiatric Endocrine Hematologic/lymph Immunologic |
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CBC - complete blood count |
Includes: WBC white blood count Hgb hemoglobin Hct hematocrit Plt platelets |
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Differential - CBC with DIFF |
CBC complete blood count Bands - bands cells Segs- segmented neutrophils Lymphs- lymphocytes Monos- monocytees Eos- eosinophils |
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BMP- basic metabolic panel |
Na- sodium K-potassium BUN- blood urea nitrogen Creat- creatinine Gluc- glucose HC03- bicarbonate Cl- chloride |
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CEP - Cardiac Enzyme panel |
Trop - troponin CK - creatine kinase CK - MB - creatine kinase- muscle breakdown CK-RI- creatine kinase relative index Myo - myoglobin |
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D-dimer |
Is a protein that is excreted by clots of blood, looking for PE |
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Respiratory labs |
BNP - B-type Natriuretic peptide ABG- arterial blood gas VBG - venous blood gas |
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Cardiac order set |
CBC - r/o infection BMP - Respiratory issues CK, Ck-MB - r/o MI Troponin - r/o MI EKG CXR - enlarged heart |
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How many elements are required for the PE? |
8 elements |
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How many elements are required for the past history? |
2 elements |
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What must be recorded due to a consultation? |
1. Timestamp 2. Name of provider consulted 3. Speciality of provider consulted 4. What was discussed |
