What are the 3 types of dispositions? - ✔✔ Discharge, Admit, Transfer
What does HPI stand for? - ✔✔ history of present illness
What does ... [Show More] ROS stand for? - ✔✔ review of systems
The HPI and ROS are considered what type of information? - ✔✔ subjective
The physical exam is what type of information? - ✔✔ objective
If a physician told you a patient's abdomen was non tender, where would you document this? - ✔✔ PE
What section focuses directly on the chief complaint? - ✔✔ HPI
If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? - ✔✔ CAD
Name an example of something you may write in the Social Hx portion of the chart. - ✔✔ smokes 1 pack/day
Name an example of something you may write in the Family Hx portion of the chart. - ✔✔ Mother had Hx of CAD at age 46
What are the abbreviations for the following past medical history terms?
Hypertension
Stroke
Diabetes
Heart Attack
High Cholesterol - ✔✔ HTN
CVA (cerebrovascular accident)
DM
MI
HLD
What are the medical terms for the following past surgical terms?
Removal of the appendix
Removal of the gallbladder
Removal of the uterus
Removal of a fallopian tube
Removal of the tonsils
Removal of the breast - ✔✔ appendectomy
cholecystectomy
hysterectomy
Salpingo-oophorectomy
tonsillectomy
mastectomy
What are the five vital signs? - ✔✔ Blood pressure (BP), heart rate (HR), oxygen saturation (SaO2), respiratory rate (RR), temperature (C or F)
What does NKDA stand for? - ✔✔ no known drug allergies
What does LNMP stand for? - ✔✔ Last Normal Menstrual Period
If the doctor said the exam was "benign", what does this mean? - ✔✔ this means that the exam was normal and of no concern
Explain acute vs chronic. - ✔✔ acute: serious, new condition, that could potentially be life-threatening
chronic: not of much concern, long-lasting condition, typically not a death threat
What are the medical terms for the following pathophysiology abbreviations?
CAD
AAA
COPD
PNA
URI - ✔✔ coronary artery disease
abdominal aortic aneurysm
chronic obstructive pulmonary disease
pneumonia
upper respiratory disease
How are the following diseases diagnosed?
-CHF (two answers)
-PE (three answers)
-Cholecystitis
-Pancreatitis
-Appendicitis
-Hemorrhagic CVA (two answers)
-DVT - ✔✔ -chest x-ray, bnp (b-type natriuretic peptide)
-CT chest with IV contrast (CTA chest), VQ scan, D-dimer
-abdominal ultrasound (US) of RUQ
-elevated lipase lab test
-CT AP w/ PO
-CTA w/ IV contrast, LP (lumbar puncture)
-ultrasound (US)
What are the two types of heart attacks and how are they diagnosed? - ✔✔ STEMI (ST elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction)
STEMI: EKG
NSTEMI: troponin
What are three cardiac risk factors? - ✔✔ HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o
What are four associated symptoms of an MI other than CP? (Hint: catch phrase) - ✔✔ Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB
What are three symptoms a patient with an Ischemic CVA might present with? - ✔✔ Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or changes in speech/vision
What are the only three symptoms of a true allergic reaction? - ✔✔ SOB (difficulty breathing), rash, itching/swelling
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is this disease diagnosed? - ✔✔ an irregularly irregular rhythm, this is diagnosed by and EKG
What physical exam finding is associated with asthma? - ✔✔ wheezes (while inspiring or expiring)
How is altered mental status different from a focal neurological deficit? - ✔✔ AMS is very different than a focal neurological deficit. AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain. The most common cause of AMS for patients without a Hx of dementia is from infection, most often caused by a UTI.
What is the major cause of AMS in the elderly? - ✔✔ UTI
Name one medication associated with seizures. - ✔✔ Dilantin, Tegretol, Keppra, Depakote, Neurontin
What question is every patient asked who comes in with a chief complaint of syncope? - ✔✔ Document what happened prior, during, and after the syncopal episode, as well as how the patient currently feels
What is the medication administered for CVAs and when is it used vs when would it not be indicated? - ✔✔ Ischemic CVA: tPA or another anticoagulant (not used for a hemorrhagic CVA because it breaks down blood clots and if there is a brain bleed, this would not be helpful in this case)
Hemorrhagic CVA: anticonvulsants
What is "layman's name" for GERD? - ✔✔ Acid Reflux/Heartburn
What is the most common cause for seizures in children? - ✔✔ fever
In your own words, describe the significance of an HPI. - ✔✔ The HPI is the beginning of every chart summarizing the reason for the visit and this describes the CC
*The HPI should ONLY include information directly related to the CHIEF COMPLAINT and IMPORTANT CONTEXT for that patient.
Name three people who will read the HPI other than the physician. - ✔✔ Nurses, Coders, and admitting doctors
Name six elements of the HPI - ✔✔ quality, location, timing, onset, duration, associated symptoms, severity, modifying factors, context
How many elements of the HPI do you need to document for a complete chart? - ✔✔ 4 elements
True or False: The patient's entire ED visit is based on their answers to the questions asked during the HPI. - ✔✔ true
True or False: Accurate chronology is not important in an HPI. - ✔✔ false- accurate chronology is very important
What is the main difference between an HPI and an ROS? - ✔✔ HPI contains the CC and anything directly related to why the patient is there, whereas the ROS is a checklist of symptoms that the patient does or does not have.
How many elements of the ROS do you need to document for a complete chart? - ✔✔ 10 elements
List five body systems found in the ROS and provide two symptoms for each system. - ✔✔ Genitourinary: dysuria, Frequency, urgency, Hematuria
Neurological: HA, Syncope, Seizure, Numbness, Focal weakness
Cardiovascular: CP, palpitations, leg swelling (edema)
Gastrointestinal: Abdominal pain, N/V/D, Black or bloody stools
Constitutional: Fever, weight loss, diaphoresis [Show Less]
