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69 Cards in this Set
- Front
- Back
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CBC |
Complete Blood Count |
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High WBC |
Leukocytosis Infection |
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Low Hgb + Hct (H+H) |
Hgb: is RBC capacity to O2 carry Hct: RBC count Anemia |
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Low Plt |
Platelet Thrombocytopenia Prone to bleeding |
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Dx and Lab Values |
Some Dx can be made directly from lab values Like leukocytosis and thrombocytopenia |
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Differential |
CBC w/ Diff Test that also counts different WBC to see type of infection |
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Left Shift |
Left immature, right mature Left indicates lots of new WBC pumped meaning there's an acute infection |
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BMP |
Basic Metabolic Panel, Chem-7 Test of body chemicals |
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High/Low Na |
Hypernatremia Hyponatremia Both indicate dehydration |
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High/Low Potassium |
Hyperkalemia (Poor Kidney Function) Hypokalemia (May cause arrythmias) |
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High BUN |
Blood Urea Nitrogen (Renal failure) |
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High/Low HCO3 Buffer System |
Hypercarbia (Possible Respiratory Disease) Hypocarbia (Hyperventilation) |
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High Cl- |
Hypercholeremia (Possible dehydration) |
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LFT |
Liver Function Test Test amino acid transaminase/phosphatase High level indicate liver damage |
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CEP |
Cardiac Enzyme Panel |
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High Trop |
Troponin Specific to heart damage, the gold standard! |
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High CK |
Creatine Kinase: released w/ heart or other muscle damage Indicates rhabdomyolysis |
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High CK-MB |
Creatine Kinase - Muscle Breakdown More specific to heart but not 100% |
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High CK-RI |
Creatine Kinase - Relative Index Just index of CK-MB |
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Cardiac Order Set |
3 pairs: CBC, BMP (Blood) CK/CK-MB, Troponin (Levels) EKG, CXR (Scans) |
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What's an order? |
Standard of care w/ patient of certain symptoms. The cardiac order is done when someone reports chest pain. |
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High D-Dimer |
Blood clots release dimer (not specific to anywhere in body) Can also indicate pregnancy or tumor |
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Negative D-Dimer |
No Pulmonary Embolism |
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Positive D-Dimer |
Unsure of source, may be PE. Must go further to rule out PE w/ CTA Chest or VQ |
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High BNP |
B-Type Natriuretic Peptide CHF |
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VBG |
Venous Blood Gas Tests pH of blood |
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ABG |
Arterial Blood Gas Tests pO2,pCO2, and pH of blood More difficult to do as arteries are deeper |
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CSF Analysis |
Microanalysis of glucose, WBC, RBC, bacteria in Cerebral Spinal Fluid |
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What indicates meningitis in CSF? |
No glucose High protein WBC/RBC Bacteria |
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Coags |
Coagulation Studies, indicate coumadin level |
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High PT |
High prothrombin time Blood too thin |
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INR |
International Normalized Ratio Ratio determining acceptable clotting time. 1.0 Normal, no coumadin 2.0-3.0 with Coumadin treatment, don't go above or below |
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ENT Labs |
Ear, nose, throat Test for strep/flu |
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High Lip |
Lipase (pancreatic enzyme) Specific to pancreatitis |
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High Amy |
Amylase (pancreatic enzyme) Possible pancreatitis |
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High/Low TSH |
Hypothyroidism/Hyperthyroidism Remember it's opposite because TSH being pumped out by Pituitary gland to fix the condition |
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Low T3/T4 |
Hypothyroidism |
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High CRP |
C-Reactive Protein Indicates non-specific inflammation |
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High ESR |
Erythrocyte sedimentation rate Clumped RBC that fall to bottom. Indicates inflammation |
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HCG |
Present ONLY during pregnancy More sensitive with serum test |
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Quantitative Serum HCG |
Quantitative test, if serum HCG goes down it indicates miscarriage |
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T+S/ABORh Rh Negative |
Type and Screen/Blood Type. Rh negative will see Rh positive baby as antigen, her antibodies will attack baby blood. Need RhoGAM shot |
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Microscopic Urinalysis |
Usual urine test for UTI/Kidney stone Quantitative test for WBC/RBC/Bact |
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Problem of epithelial cells in urinalysis |
Indicates contaminated sample b/c epithelial cells easily hold bacteria Can't tell if UTI |
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Blood Cx |
Blood Culture Test if blood sample has bact growth Definitive sepsis |
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Sepsis Labs |
CBC as well, high WBC can indicate sepsis |
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Cx and the Four Types and caveat |
Cultures Blood, urine, wound, stool Time consuming |
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Toxicology Labs |
Check levels of ASA, APAP (acetominophen), EtOH |
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Utox and Rules Regarding it |
Urine drug screen Qualitative, not quantitative drug screen Make sure to document if intentional or unintentional |
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Accu-check |
Finger check lab for diabetes Most common, easiest to conduct |
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High Ketone |
Indicate Diabetic Ketoacidosis (DKA) |
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High HgbA1C |
Test that tells average blood sugar in past 3 months High indicates poor DM control |
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Labs for Medication Level are Mostly for What Dx and Why? |
Seizures Need to know if seizure b/c low medication level or seizure in spite of medication |
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Low Digoxin |
Risk for Afib |
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When documenting imaging studies... |
Radiologist will give a report as well as your physician. Look at both opinions |
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CXR Description |
No soft tissue info Good for chest/abd Chest: PNA/PTX Abd: Gas patterns that indicate rupture/blockage |
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CT Scan Description |
Show soft tissue Can look through slices Lot more radiation Can use contrast |
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3 Types of CT Scan and Where They're Used |
CT w/o contrast: Bones, lungs, kidney stone CTA (CT w/IV contrast): Blood CT A/P w/PO contrast: Gastro/GI |
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US Description |
Ultrasound Movie: good for blood flow, heart No radiation |
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AAS |
Acute Abdominal Series 3 shots of abdomen taken with x-ray |
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US Uses |
Blood flow in vein for DVT Gallbladder scan Reproductive organs |
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TTE |
Transthoracic echo Directly over chest, typical |
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TEE |
Transesophageal echo Down throat, behind heart, for better image Need anesthesia |
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EF < 50% |
Systolic ejection fraction |
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EF >50% |
Diastolic ejection fraction |
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MRI/MRA Scan Description |
Highest quality, soft tissue shown Expensive and time consuming No radiation |
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Everything about Consultation |
Document in A/P: "spoke with Dr.X, [specialty], about [treatment], he recommends X and Y" Make sure to scribe it If there's question about consultation, ask the specialist |
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What if the specialist comes in? |
He does his own H+P, A/P and leaves note Note her eval, dx, and recommend |
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Everything about Total Time Spent |
Record time enter/time left if doc spends extra time Must document what doc was doing 30 min conversation = 5 sentences |
