ED Course 1: Overview of Past Histories and Emergency Department Flow Processes

EHR

electronic health record

cc

chief complaint

PHx

past history

PMHx

past medical history

PSHx

past surgical history

SHx

social history

FHx

family history

HTN

hypertension

HLD

hyperlipidemia

DM

diabetes mellitus

NIDDM

Non-Insulin Dependent Diabetes Mellitus

IDDM

Insulin Dependent Diabetes Mellitus

CAD

coronary artery disease

MI

myocardial infarction

CHF

congestive heart failure

PNA

pneumonia

IBS

Irritable Bowel Syndrome

BPH

Benign prostatic hyperplasia

AAA

abdominal aortic aneurysm

PVD

peripheral vascular disease

COPD

chronic obstructive pulmonary disease

PE

pulmonary embolism

DVT

deep vein thrombosis

GERD

gastroesophageal reflux disease

UTI

urinary tract infection

CKD

chronic kidney disease

FULL medical term for: heart disease

coronary artery disease

FULL medical term for: heart attack

myocardial infarction

FULL medical term for: heart failure

congestive heart failure

FULL medical term for: emphysema

chronic obstructive pulmonary disease

FULL medical term for: blood clot in the lung

pulmonary embolism

FULL medical term for: reflux

gastroesophageal reflux disease

FULL medical term for: bladder infection

urinary tract infection

FULL medical term for: kidney infection

pyelonephritis

FULL medical term for: stroke

cerebrovascular accident

FULL medical term for: blood clot in the brain

ischemic cerebrovascular accident

FULL medical term for: brain bleed

hemorrhagic cerebrovascular accident

FULL medical term for: mini stroke

transient ischemic attack

FULL medical term for: blood clot in my leg

deep vein thrombosis

FULL medical term for: bad blood flow in my legs

peripheral vascular disease

Patient says they have an irregular heartbeat. This means they have an ______ (use general term).

Arrhythmia

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

chronic obstructive pulmonary disease or COPD

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

pulmonary embolism (PE)

What is the medical term for reflux or "acid reflux"

gastroesophageal reflux disease (GERD)

What is the medical term for a bladder infection

urinary tract infection (UTI)

What is the medical term for a kidney infection

pyelonephritis

What is the medical term for a stroke

cerebrovascular accident (CVA)

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 medical term for a mini stroke

transient ischemic attack

FULL medical term for: High blood pressure

hypertension

FULL medical term for: High cholesterol

hyperlipidemia

Patient only takes pills for diabetes. This means they have

non-insulin dependent diabetes mellitus

Patient takes insulin for their diabetes. This means they have

insulin-dependent diabetes mellitus

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

pnuemonia

FULL medical term for: kidney stones

renal calculi

tonsils removed

tonsillectomy

adenoids removed

adenoidectomy

"neck arteries cleaned"

carotid endarterectomy

"balloon in my heart"

angioplasty

"stents in my heart"

coronary stents

heart bypass

coronary artery bypass graft

breast removal

mastectomy

Part of my lung removed

partial lobectomy

appendix removed

appendectomy

gallbladder removed

cholecystectomy

part of my colon removed

partial colectomy

spleen removed

splenectomy

ovary and fallopian tube removed

salpingo-oophorectomy

kidney removed

nephrectomy

uterus removed

hysterectomy

ovary removed

oophorectomy

ear tubes

pressure equalizer tubes

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

What is the difference between Subjective and Objective

Subjective information is based on a feeling. Typically comes from the patient (or other historian).

Objective information is factual information. Typically comes from provider or objective testing (labs, imaging, etc).

Pain vs Tenderness

Pain is a subjective term (comes from the patient)

Tenderness is an objective term (appreciated by the provider)

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

Physical Exam

What are subjective portions of the chart?

HPI, ROS

What are objective portions of the chart?

Physical Exam, ED course

What is the correct order of the ED flow?

Checkin/Triage> History>Physical>DDx> Orders/results>MDM>disposition

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 diganosis

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

A 22 y/o female patient has arrived to the ED with complaints of lower abdominal pain after being 3 weeks post-partum to a healthy baby. The patient says that she has another older child at home and had an elective abortion two years before. What should you document as her GPA?

Gravida: 3, Para: 2, Abortus: 1

Term for inflammation of the pancreas?

Pancreatitis

Term for inflammation of the liver?

Hepatitis

-itis

infection and/or inflammation of

-osis

Disease of

-ectomy

Surgical removal of