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AAA ✔✔Abdominal Aortic Aneurysm A Fib ✔✔Atrial Fibrillation Abd ✔✔Abdomen, Abdominal Abx ✔✔Antibiotics AMA ✔✔Against Medical Advice AMS ✔✔Altered Mental Status ASA ✔✔Acetylsalicylic Acid (Aspirin) BID ✔✔Twice Daily Bilat LE ✔✔Bilateral Lower Extremities BM ✔✔Bowel M
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AAA ✔✔Abdominal Aortic Aneurysm A Fib ✔✔Atrial Fibrillation Abd ✔✔Abdomen, Abdominal Abx ✔✔Antibiotics AMA ✔✔Against Medical Advice AMS ✔✔Altered Mental Status ASA ✔✔Acetylsalicylic Acid (Aspirin) BID ✔✔Twice Daily Bilat LE ✔✔Bilateral Lower Extremities BM ✔✔Bowel Movement BP ✔✔Blood Pressure CA ✔✔Cancer, Carcinoma CABG ✔✔Coronary Artery Bypass Graft, "open heart surgery"
CAD ✔✔Coronary Artery Disease, "heart disease" CT or CAT ✔✔Computerized Assisted Tomography CHF ✔✔Congestive Heart Failure COPD ✔✔Chronic Obstructive Pulmonary Disease CP ✔✔Chest Pain CPR ✔✔Cardiopulmonary Resuscitation C-section ✔✔Caesarean Section C-spine ✔✔Cervical Spine (neck) CSF ✔✔Cerebrospinal Fluid CVA ✔✔Cerebrovascular Accident - or- Costovertebral Angle CXR ✔✔Chest X-Ray c/o ✔✔complains of DKA ✔✔Diabetic Ketoacidosis DM ✔✔Diabetes Mellitus
HPI ✔✔History of Present Illness HTN ✔✔Hypertension Hx ✔✔History H&H ✔✔Hemoglobin & Hematocrit H&P ✔✔History of Present Illness & Physical Exam I&D ✔✔Incision & Drainage IDDM ✔✔Insulin Dependent Diabetes Mellitus IUP ✔✔Intrauterine Pregnancy IVDA ✔✔IV Drug Abuse JVD ✔✔Jugular Vein Distension LLE ✔✔Left Lower Extremity LLQ ✔✔Left Lower Quadrant LNMP ✔✔Last Normal Menstrual Period LOC ✔✔Loss of Consciousness
LP ✔✔Lumbar Puncture L-Spine ✔✔Lumbar Spine LUE ✔✔Left Upper Extremity LUQ ✔✔Left Upper Quadrant MCA ✔✔Motorcycle Accident MI ✔✔Myocardial Infarction MVA/MVC ✔✔Motor Vehicle Accident/Motor Vehicle Collision N/A ✔✔Not Applicable NAD ✔✔No Acute Disease, No Acute Distress NIDDM ✔✔Non-Insulin Dependent Diabetes Mellitus NKDA ✔✔No Known Drug Allergies Nml - or- nl ✔✔Normal NSAID ✔✔Non-Steroidal Anti-Inflammatory Drug NSR ✔✔Normal Sinus Rhythm NTG ✔✔Nitroglycerin
q2h ✔✔Every 2 Hours QID ✔✔Four Times a Day RLE ✔✔Right Lower Extremity RLQ ✔✔Right Lower Quadrant ROM ✔✔Range of Motion ROS ✔✔Review of Systems RUE ✔✔Right Upper Extremity RUQ ✔✔Right Upper Quadrant Rx ✔✔Prescription r/o ✔✔Rule Out SOB ✔✔Shortness of Breath s/p ✔✔Status Post (after) Sx ✔✔Symptoms TIA ✔✔Transient Ischemic Attack TID ✔✔Three Times a Day
TM ✔✔Tympanic Membrane T-Spine ✔✔Thoracic Spine Tx ✔✔Treatment UA ✔✔Urinalysis URI ✔✔Upper Respiratory Infection US ✔✔Ultrasound UTD ✔✔Up To Date UTI ✔✔Urinary Tract Infection WNL ✔✔Within Normal Limits AKA ✔✔Above The Knee Amputation SBO ✔✔Small Bowel Obstruction h/o ✔✔history of DFP ✔✔Dorsal Fetal Pulse PCN ✔✔Penicillin
The "H&H" comes back with this lab test. If low it would indicate the patient is anemic. ✔✔Hemoglobin and hematocrit. hemoglobin would be low if the patient is anemic. This lab test will be high in patient with pancreatitis. ✔✔Lipase This lab test is used to help physicians rule out PE and DVT. ✔✔D-dimer This lab test will be elevated in patients with CHF. ✔✔BNP This abbreviation is used to describe a heart attack. ✔✔MI This abbreviation is used to describe diabetes. ✔✔DM This abbreviation is used to describe a normal heart rhythm. ✔✔NSR RBBB is the abbreviation used to describe this medical term, which would indicate an abnormal EKG finding. ✔✔Right Bundle Branch Block CVA is used medically as an abbreviation for a cerebral vascular accident, as well as this location of the body. ✔✔Costovertebral Angle This surgery is performed to remove the appendix. ✔✔Appendectomy STEMI ✔✔ST Elevation Myocardial Infarction BCP ✔✔Birth Control Pill PTX ✔✔Pneumothorax
PNA ✔✔Pneumonia CV ✔✔Cardiovascular GERD ✔✔Gastro-Esophageal Reflux Disease, "acid reflux" What is GPA? ✔✔G = the total number of times the patient has been pregnant P = the number of live births (viable children) that the patient has had A = the total number of miscarriages or elective abortions No rebound, no guard ✔✔Abdominal CT w/ PO ✔✔CT Abd/Pel with PO contract DC'd ✔✔Discharged Home Number of physical exam elements needed for Level 5 ✔✔ 8 elements (at least 1 finding in 8 different organ systems) Number of HPI elements needed for Level 5 ✔✔4 elements Number of ROS elements needed for Level 5 ✔✔ 10 elements Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5 ✔✔2 elements Name the vital signs ✔✔blood pressure, respiratory rate, heart rate, oxygen saturation, temperature
Heart attack ✔✔Myocardial Infarction (MI) and CAD Heart failure ✔✔Congestive Heart Failure (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 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, or 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) on dialysis Enlarged prostate ✔✔Benign Prostate Hypertrophy (BPH) Stroke ✔✔Cerebrovascular Accident (CVA) Mini-stroke ✔✔Transient Ischemic Attack (TIA) Seizures ✔✔Seizure disorder/Epilepsy Brain bleed ✔✔Hemorrhagic CVA Bipolar ✔✔Bipolar disorder Schizophrenia ✔✔Schizophrenia "I drink a lot" ✔✔Alcoholism or EtOH abuse "Blood clot in my leg" ✔✔Lower Extremity Deep Vein Thrombosis
Adenoids removed ✔✔Adenoidectomy Ear tubes ✔✔Pressure Equalizer (P.E.) 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 vs. Mechanical) Pacer ✔✔Pacemaker Defibrillator ✔✔Automatic Implanted Cardiac Defibrillator (AICD) Surgery for Afib ✔✔Afib 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 Bag to collect stool ✔✔Colostomy Spleen removed ✔✔Splenectomy Stomach stapled ✔✔Gastric bypass Uterus removed ✔✔Hysterectomy Ovary removed ✔✔Oophorectomy Ovary and fallopian tubes removed ✔✔Salpingo-oophorectomy Tubes tied ✔✔Tubal ligation (female) or Vasectomy (male) Prostate removed ✔✔Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) Neck artery cleaned ✔✔Carotid Endarterectomy Brain surgery ✔✔Craniotomy Shunt ✔✔Ventriculoperitoneal (VP) Shunt Dialysis fistula ✔✔AV (arteriovenous) Fistula
To check for JVD, what would be examined? ✔✔Neck The presence of fluctuance would indicate this body tissue and would likely require I&D. ✔✔Abscess This is the medical term used to describe redness. ✔✔Erythema; injection Pedal edema is used to describe what? ✔✔CHF Blood is the urine is called what? ✔✔Hematuria What is the medical term for bruise? ✔✔Ecchymosis What is the medical term for a bloody nose? ✔✔Epistaxis Kidney removal ✔✔Nephrectomy Fast breathing rate ✔✔Tachypnea Black tarry stools ✔✔Melena Runny noise ✔✔Rhinorrhea Sweating ✔✔Diaphoresis Pain with urination ✔✔Dysuria Acute blockage of artery that provides blood to brain ✔✔CVA (Cerebrovascular Accident)
Collapse lung due to trauma or a spontaneous small rupture of the lung ✔✔Pneumothorax Ischemic and infarct of the interior lateral myocardium ✔✔MI How do you diagnose a hemorrhagic CVA? ✔✔CT of the head How do you diagnose appendicitis? ✔✔CT Abdomen/Pelvis How do you diagnose gallstones? ✔✔Ultrasound of RUQ How do you diagnose meningitis? ✔✔Lumbar puncture What are the 4 types of focal neurological deficits? ✔✔Changes in speech, vision, strength, and sensation What are the main differences between HPI and ROS? ✔✔HPI focuses on chief complaint; ROS is a check from head to toe Who would read your HPI other than your doctor? ✔✔PCP, lawyers, coders, insurance companies, etc. Are cough and fever related? ✔✔Yes, when it could go either way, definitely put it in HPI What are 4 things that must be documented in HPI after a syncope episode? ✔✔What happened prior to episode, during episode, after episode, and their current status in the ED What is syncope? ✔✔Fainting; passing out How do you document a normal radial pulse? ✔✔Right radial pulse 2+
