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122 Cards in this Set
- Front
- Back
Subjective vs objective |
Feeling vs fact |
|
Chief complaint |
The main reason for the pt's ED visit |
|
MDM |
The physician's thought process |
|
Pain vs tenderness |
Pt's feelings vs physician's assessment |
|
Benign |
Normal, nothing of concern |
|
Distress |
Doctor's judgement of discomfort |
|
Febrile |
State of having fever, concerning for infection |
|
Acute |
New onset, likely concerning |
|
Chronic |
Long standing not of direct concern |
|
Baseline |
An individual's normal state of being |
|
Auscultation |
Listening with a stethoscope |
|
Palpation |
The act of pressing on an area by the doctor |
|
Inpatient |
Admitted to the hospital overnight |
|
Outpatient |
Seen and sent home the same day |
|
Charge nurse |
Manages the ED patient flow |
|
Mid-level provider |
Nurse practitioner or physician assistant that works under the supervision of a physician to diagnose and treat patients |
|
ED nurse |
Records medical histories symptoms monitors the patient start IVs administers medications and assist with procedures |
|
Respiratory therapist |
Administers breathing treatments and assist with managing a patient's airway |
|
ED tech |
Helps the nurse and assist with procedures |
|
Unit secretary |
Places physicians orders answer his phone calls pages other specialist doctors and organizes the patient paperwork |
|
Scribe |
Documents the patient's visit on behalf of the physician |
|
High blood pressure |
Hypertension HTN |
|
High cholesterol |
Hyperlipidemia HLD |
|
Thyroid problem |
Usually hypothyroidism sometimes hyperthyroidism |
|
Diabetes |
Diabetes mellitus DM |
|
I only take pills for my diabetes |
Non-insulin-dependent diabetes mellitus NIDDM |
|
I take shots for my diabetes |
Insulin-dependent diabetes mellitus IDDM |
|
Heart disease |
Usually coronary artery disease CAD |
|
Heart attack |
Myocardial infarction MI and CAD |
|
Heart failure |
Congestive heart failure or 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 the 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 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 or end stage renal disease ESRD on dialysis |
|
Enlarged prostate |
Benign prostate hypertrophy BPH |
|
Gravida |
The total number of times the patient has been pregnant |
|
Para |
The number of live births the patient has had |
|
Abortion |
The total number of miscarriages or elective abortions |
|
Stroke |
Ischemic cerebrovascular accident CVA |
|
Mini stroke |
Transient ischemic attack TIA |
|
Seizure |
Seizure disorder epilepsy |
|
Brain bleed |
Hemorrhagic CVA |
|
Bipolar |
Bipolar disorder |
|
Schizophrenia |
Schizophrenia |
|
I drink a lot |
EtOH abuse or alcoholism |
|
I do drugs |
Substance abuse |
|
Blood clot in my leg |
Lower extremity deep vein thrombosis DVT |
|
Bulge in my aorta or triple AAA |
Abdominal aortic aneurysm AAA |
|
Add blood flow to my legs |
Peripheral vascular disease PVD |
|
Numbness in my legs |
Peripheral neuropathy |
|
Low back pain |
Chronic low back pain |
|
Bulging herniated disc |
Degenerative disc disease DDD |
|
Arthritis |
Usually osteoarthritis OA sometimes rheumatoid arthritis RA |
|
Joint pain chronic |
Degenerative joint disease DJD |
|
Weak/fragile bones |
Often osteoporosis |
|
Cancer |
Cancer or carcinoma CA: brain breast long: prostate ovarian skin bone leukemia lymphoma |
|
Spread to my |
With metastases to the |
|
Chemo |
Chemotherapy |
|
Radiation |
Radiation therapy |
|
They cut it out |
Status post surgical resection |
|
It's Gone |
In remission |
|
Tonsils removed |
Tonsillectomy |
|
Adenoids removed |
Adenoidectomy |
|
Ear tubes |
Pressure equalizer PE 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 versus mechanical |
|
Pacer |
Pacemaker |
|
Defibrillator |
Automatic implanted cardiac defibrillator AICD |
|
Surgery for a fib |
A fib 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 |
|
Back to collect stool |
Colostomy |
|
Spleen removed |
Splenectomy |
|
Stomach stapled |
Gastric bypass |
|
Exploratory |
Exploratory laparoscopy ex lap |
|
Kidney removed |
Nephrectomy |
|
Uterus removed |
Hysterectomy partial versus total |
|
Ovary removed |
Oophorectomy |
|
Ovary and fallopian tubes removed |
Salpingo-oophorectomy |
|
Tubes tied |
Tubal ligation female or Vasectomy male |
|
C-section |
Caesarean section |
|
Prostate removed |
Prostate ectomy transurethral removal of the prostate TURP |
|
Uterine product removed |
Dilation in curettage D&C |
|
Neck artery cleaned |
Carotid endarterectomy |
|
Brain surgery |
Craniotomy brain bleed verse brain CA |
|
Shunt |
Ventriculoperitoneal shunt VP |
|
Dialysis fistula |
AV arteriovenous fistula |
|
Dialysis graft |
AV graft |
|
PICC line |
Peripherally inserted central catheter PICC |
|
Port |
Port-a-cath or medi-port |
|
Clot filter lower abdomen |
IVC inferior vena cava filter |
|
Clot filter leg |
Greenfield filter |
|
Leg amputated |
Above knee amputation AKA below knee amputation BKA |
|
Arthroplasty |
Arthroplasty |
|
Metal plates/pins |
Hardware |
|
Neck fused |
Cervical spine fusion |
|
Back fused |
Lumbar spinal fusion |
|
Hip surgery |
Open reduction with internal fixation ORIF |
|
Fx |
Family history |
|
Social history SHx |
Tobacco use, alcohol use, illicit drug use, occupation, living circumstances |