ED Course 1: Past Histories and ED Flow

Flashcards covering medical terminology, past medical and surgical histories, ED workflow, and scribe responsibilities from ED Course 1.

What does the medical abbreviation EHR stand for?

electronic health record

What does the abbreviation cc stand for in medical documentation?

chief complaint

What does the abbreviation PHx stand for?

past history

What does the abbreviation PMHx stand for?

past medical history

What does the abbreviation PSHx stand for?

past surgical history

What does the abbreviation SHx stand for?

social history

What does the abbreviation FHx stand for?

family history

What abbreviation is used for hypertension?

HTN

What abbreviation is used for hyperlipidemia?

HLD

What abbreviation is used for diabetes mellitus?

DM

What does NIDDM stand for?

Non-Insulin Dependent Diabetes Mellitus

What does IDDM stand for?

Insulin Dependent Diabetes Mellitus

What does CAD stand for?

coronary artery disease

What does MI stand for?

myocardial infarction

What does CHF stand for?

congestive heart failure

What does PNA stand for?

pneumonia

What does IBS stand for?

Irritable Bowel Syndrome

What does BPH stand for?

Benign prostatic hyperplasia

What does AAA stand for?

abdominal aortic aneurysm

What does PVD stand for?

peripheral vascular disease

What does COPD stand for?

chronic obstructive pulmonary disease

What does PE stand for?

pulmonary embolism

What does DVT stand for?

deep vein thrombosis

What does GERD stand for?

gastroesophageal reflux disease

What does UTI stand for?

urinary tract infection

What does CKD stand for?

chronic kidney disease

What is the FULL medical term for heart disease?

coronary artery disease

What is the FULL medical term for heart attack?

myocardial infarction

What is the FULL medical term for heart failure?

congestive heart failure

What is the FULL medical term for emphysema?

chronic obstructive pulmonary disease

What is the FULL medical term for blood clot in the lung?

pulmonary embolism

What is the FULL medical term for reflux?

gastroesophageal reflux disease

What is the FULL medical term for bladder infection?

urinary tract infection

What is the FULL medical term for kidney infection?

pyelonephritis

What is the FULL medical term for stroke?

cerebrovascular accident

What is the FULL medical term for blood clot in the brain?

ischemic cerebrovascular accident

What is the FULL medical term for brain bleed?

hemorrhagic cerebrovascular accident

What is the FULL medical term for mini stroke?

transient ischemic attack

What is the FULL medical term for blood clot in my leg?

deep vein thrombosis

What is the FULL medical term for bad blood flow in my legs?

peripheral vascular disease

If a patient states they have an irregular heartbeat, what general term describes their condition?

Arrhythmia

If the patient states they have "emphysema," what will you document in the PMHx?

COPD

Which type of stroke can be described as a "blockage in the brain?"

ischemic cerebrovascular accident

Which type of stroke can be described as a "brain bleed?"

hemorrhagic cerebrovascular accident

What is the FULL medical term for High blood pressure?

hypertension

What is the FULL medical term for High cholesterol?

hyperlipidemia

A patient only takes pills for diabetes. This means they have:

non-insulin dependent diabetes mellitus

A patient takes insulin for their diabetes. This means they have:

insulin-dependent diabetes mellitus

A patient states they've had an infection in their lungs. What is the medical term for this?

pneumonia

What is the FULL medical term for kidney stones?

renal calculi

What is the medical term for tonsils removed?

tonsillectomy

What is the medical term for adenoids removed?

adenoidectomy

What is the medical term for "neck arteries cleaned"?

carotid endarterectomy

What procedure is described as a "balloon in my heart"?

angioplasty

What procedure is described as "stents in my heart"?

coronary stents

What is the medical term for heart bypass?

coronary artery bypass graft

What is the medical term for breast removal?

mastectomy

What is the medical term for part of my lung removed?

partial lobectomy

What is the medical term for appendix removed?

appendectomy

What is the medical term for gallbladder removed?

cholecystectomy

What is the medical term for part of my colon removed?

partial colectomy

What is the medical term for spleen removed?

splenectomy

What is the medical term for ovary and fallopian tube removed?

salpingo-oophorectomy

What is the medical term for kidney removed?

nephrectomy

What is the medical term for uterus removed?

hysterectomy

What is the medical term for ovary removed?

oophorectomy

What is the medical term for ear tubes?

pressure equalizer tubes

What is the medical term for prostate removed?

prostatectomy

What is a scribe?

Scribes share the provider's burden of data gathering & chart documentation (in an EHR). We are present during all data gathering including the patient conversation, physical exam, labs and imaging, and re-evaluations.

Can scribes touch patients?

No

Can scribes access and display X-rays for the provider to review?

Yes!

Can scribes give or pass on verbal orders?

No

Can scribes handle bodily fluids or specimens?

No

In what step of the ED flow do providers make observations about the patient's body using inspection, palpation, and auscultation?

Physical Exam

What are subjective portions of the chart?

HPI, ROS

What are objective portions of the chart?

Physical Exam, ED course

In what step of the ED flow do patients tell us their symptoms?

History

In what step of the ED flow do the Chief complaint and vitals get taken?

Triage

What is a differential diagnosis?

A list of potential diagnoses the provider thinks the patient may have.

What is the medical term for inflammation of the pancreas?

Pancreatitis

What is the medical term for inflammation of the liver?

Hepatitis

What does the suffix -itis mean?

infection and/or inflammation of

What does the suffix -osis mean?

Disease of

What does the suffix -ectomy mean?

Surgical removal of