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(Select the best option. Now that the results are back, the physician will be ready to discharge the patient home. (Select all that apply.). T/F. Expand the following medical abbreviation. Calculate the G, P and A, respectively. (select the best option. CT A/P or confirmed UTI with CVA tenderness on exam. What is the benign "no touch" exam for the eyes system? Name some procedures that qualify the patient for critical care. (choose one. What is the benign "no touch" exam for the Neurological system? What does "CVA" stand for in the PE section? If a doctor says "Lead one, Lead two, or Lead three" what do you write? What are the 6 different types of pulses? Name some diagnoses that would qualify the patient for critical care time. Peritonsillar Abscess, forms in the tissues of the throat next to one of the tonsils. Inflammation of the walls of the lymphatic vessels, The separation of any part of the body from the whole. What is the benign "no touch" exam for the Neck system? How would you document GPA for a patient who has previously been pregnant four times in the past, has three children at home, and is NOT currently pregnant? What must you document for a "code exam"? (select all that apply.). Vital Signs / Bed Placement 4. What needs to happen with patients who have both cardiac risk factors and epigastric pain? What does "Fluorescein uptake" during a physical exam mean? How is CHF (fluid traffic jam) diagnosed? No, the PHx does not meet Level 5 billing criteria. Mechanical, Automatic Implanted Cardiac Defibrillator - AICD. What does it mean when a chart is "Down-coded"? CT does not use IV contrast but may or may not use PO contrast. AMS is generalized and typically caused by something and typically caused by something that can affect the whole brain - drugs, low BS. What general area of the body does Cranial Nerves (CN) control? He has a history of Type II DM and is s/p right BKA. RUQ pain; sharp, worsened with eating, deep breaths, and palpation. What does BNP stand for and what does it test for? Why or why not? Non-tender. 1. What are we worried about for someone with a GI bleed? Match the location with the appropriate pulse that you would document in the physical exam? In a physical exam, what does "TTP" mean? How many minutes of Critical Care Time were provided? What is the difference between an allergic reaction and an adverse reaction? Chronic Obstructive Pulmonary Disease - COPD, Chronic Renal Failure - CRF or End Stage Renal Disease - ESRD on dialysis. What usually happens during the initial physical exam of a pt c/o a spinal cord injury? (select all that apply), You've just caught up on all of your charting. Abdominal pain, bright green emesis, constipation. Medical terminology. What is the medical term for "high chloride"? combination of (+) EKG and (+) blood work : STEMI. How many tubes of CSF are typically obtained during a Lumbar Puncture? Which is the first item in the formula for writing an HPI? Does this patient qualify for Critical Care? What does tPA stand for and what does it do? Because it is less likely that their current Sx are life threatening if they have survived similar Sx in the past, What should you focus on when writing an HPI? What section of the neurological exam would you document "Normal Finger-Nose-Finger test" and "Normal Heel-to-Shin"? If the doctor takes 1 finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating? "They cut it out" (in regards to cancer) means.. "It's gone" (in regards to cancer) means.. Coronary Artery Bypass Graft - CABG > PMHx CAD, Valve repair or replacement - Bovine vs. What is the general documentation template? What are you looking for when double checking your chart? How to make sure the HPI is coded at a "level 5"? Which of the following would belong in a psychiatric exam? Line that divides the body into right and left halves. (Select all that apply.). What is the ED flow before orders are made? (Select all that apply.). What is a special type of life saving care that some patients receive? What is the benign "touch" exam for the Eyes system? What are the associated diseases of the Periumbilical region? What is the core measure for Ischemic CVA? A 43-year-old male presents to the ED with vomiting that began 5 hours ago. What is an important thing to document for Bell's Palsy? How would you diagnose AFIB? George is employed with SA as a scribe. Nurse Assessment 5. Medical terminology. FND are localized - weakness, numbness, speech, vision - to one specific area and corresponds with damage to a specific spot in the brain. If a doctor says "Sinus at 114 (greater than 100bpm)" what do you write? FEMALE LOWER ABD PAIN: "Fever, RLQ pain" is a red flag for.. LOW BACK PAIN: "Weakness/Numbness in lower extremities" is a red flag for.. LOW BACK PAIN: "Numbness of the groin" is a red flag for.. LOW BACK PAIN: "Loss of bowel or bladder control" is a red flag for.. LOW BACK PAIN: "Hx of IVDA" is a red flag for.. LOW BACK PAIN: "Fever" is a red flag for.. LOW BACK PAIN: "Abd pain" is a red flag for.. DIZZINESS/HEADACHE: "Weakness/Numbness/Tingling" is a red flag for.. DIZZINESS/HEADACHE: "Changes in speech or vision" is a red flag for.. Cerebral Vascular Accident - CVA, Subarachnoid Hemorrhage - SAH. How is CAD (major risk factor for MI) diagnosed? What are the causes of orthostatic syncope. "Unable to obtain a complete ___ due to ___" in each section independently. Costo-Vertebral Angle tenderness; flank tenderness - tenderness over kidneys, Alert and Oriented to Person, Place, and Time. What is the medical term for "bright red blood in stools"? Both test for inflammation. Expand the following PMHx abbreviation into the full medical term. What procedure would be used to diagnose Meningitis? What PE finding is important for your provider to assess and include in the procedure note before the patient can be discharged home? What is the core measure for Acute Pulmonary Embolism? Topical therapy. Chest pains when taking a deep breath: PTX. Read through the PE and decide if this meets Level 5 billing criteria. CT A/P with PO Contrast, Acute Abdominal Series (AAS). Other than McBurney's Point Tenderness, what is another sign to check for Appendicitis? Clear to auscultation bilaterally. What is the medical term for "enlarged thyroid"? 1. An ED technician informs the provider that they have just finished applying a splint and sling for the patient with the wrist fracture. What is an Abdominal Aortic Aneurysm (AAA)? What emergency conditions (ideally from what you have learned in CRT) from the following list may explain the patient's symptoms? Final Dx 5. What are the associated diseases of the Flanks? Use the abbreviation to answer the question. What is the normal INR for patients NOT on blood thinners? In a Differential (includes CBC), what does "High Segs / Segmented Neutrophils" tell us? In a Differential (includes CBC), what does "High Monos / Monocytes" tell us? What additional documental may the physician be reimbursed for? Situated below or further away from the head. What is/are the chief complaints of a patient with Altered Mental Status (AMS)? No, because George accessed his own medical record using his EMR login. What is the medical term for "low bicarbonate"? DIZZINESS/HEADACHE: "Difficulty with balance" is a red flag for.. DIZZINESS/HEADACHE: "Fever" is a red flag for.. DIZZINESS/HEADACHE: "Neck pain" is a red flag for.. DIZZINESS/HEADACHE: "Altered Mental Status" is a red flag for.. DIZZINESS/HEADACHE: "Worst headache of life/ Thunderclap onset" is a red flag for.. DIZZINESS/HEADACHE: "Syncope or seizure" is a red flag for.. SYNCOPE: "Tongue bite wound" is a red flag for.. SYNCOPE: "Numbness/Weakness/Tingling" is a red flag for.. SYNCOPE: "Changes in speech or vision" is a red flag for.. SYNCOPE: "Chest pain" is a red flag for.. SYNCOPE: "Shortness of Breath - SOB" is a red flag for.. SYNCOPE: "Palpitations" is a red flag for.. AMS: "Numbness/Weakness/Tingling" is a red flag for.. AMS: "Changes in speech or vision" is a red flag for.. AMS: "Hx of depression or drug abuse" is a red flag for.. AMS: "Hx of Diabetes" is a red flag for.. TRAUMA: "Loss of Consciousness - LOC" is a red flag for.. TRAUMA: "Unilateral Numbness/Weakness/Tingling" is a red flag for.. TRAUMA: "Bilateral Numbness/Weakness/Tingling" is a red flag for.. TRAUMA: "Neck pain or back pain" is a red flag for.. TRAUMA: "Shortness of Breath - SOB or Chest Pain - CP" is a red flag for.. TRAUMA: "Abdominal pain" is a red flag for.. GERD, AAA, Pancreatitis, Hepatitis, Deveticulitis, Kidney stones, UTI, Renal insufficiency/failure, CVA, TIA, Epilepsy/Seizure, Migraines, Dementia, Alzheimer's, Depression, Anxiety, Bipolar, Schizophrenia, Tonsillectomy, Adenoidectomy, Pressure Equalization tubes, CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement, Automatic Implantable Cardioverter Defibrillator, Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy, Nephrectomy, Hysterectomy, C-section, Oophorectomy, Salpingo-oophorectomy, Tubal ligation, TURP, AKA - Above the Knee Amputation, BKA - Below the Knee Amputation, Carotid Endarterectomy, Craniotomy, VP shunt, a surgical procedure used to reduce the risk of stroke by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery, Peripherally Inserted Central Catheter - is a thin, soft, flexible tube - an IV line, The flow of blood through the body's blood vessels, Glasgow Coma Scale, used to assess level of consciousness in trauma patients. What is the medical term for infection of the gall bladder? What is the medical term for "high sodium"? No, the PE does not meet Level 5 billing criteria. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs, deep vein thrombosis-blood clot develops in the vein, pulmonary embolism-blood clot that forms in a vein, travels through your bloodstream, and lodges in your lungs, Widening of a blood vessel due to pressure on weakened tissues causing formation of a sac of blood, Medical procedure by which an abnormally fast heart rate or cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs, sonogram of the heart, also called cardiac ultrasound, inflammation of the pericardium (fluid filled sac that surrounds the heart), airway that connects the lungs and the layrnx/pharynx, chronic obstructive pulmonary disorder-chronic emphysema and bronchitis (which usually occur together) that causes narrowing of the airway, tuberculosis-bacterial infection caused by various strains of mycobacteria, usually mycobacterium tuberculosis, that involves the lungs, but may spread to other organs, upper respiratory infection-illnesses caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx, harsh, high pitched sound caused by obstruction of air passages, whistling sound resulting from the narrowing of air passages, swelling around the vocal cords leading to a "barking" cough; common among children, collection of blood in the pleural cavity, collection of air in the space around the lungs, swelling of the conjuctiva (the thin membrane that covers the surface of the eyelid and the sclera), inability to express oneself through speech, situation of tingling, numbness, or prickling, a particular type of dizziness characterized by a spinning sensation when stationary, involuntary contraction and relaxation of the muscle, characteristic of some neurologic disorders, tympanic membrane-cone-shaped membrane that separates the internal ear from the middle ear; aka the ear drum, cerebral vascular accident-aka stroke; blood flow to a part of the brain stops; ischemic or hemorrhagic, deep tendon reflexes-reflexes elicited and measured on a scale of 0-5+; often patellar reflex tested (Normal: 2+ patellar reflexes), Glascow coma scale: test that assesses mental and motor function on a scale of 3-15 with 15 indicating the patient is functioning properly, dye used in eye exam to observe corneal abnormalities, loss of global cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging, type of seizure that affects the entire brain, thin membrane that covers the inner surface of the eyelid and the sclera, speech condition that occurs making it difficult to pronounce words due to weakness, paralysis or lack of muscle coordination, loss of sensation restricted to the area of the buttocks and perineum, inflammation of the membranes of the spinal cord or brain (viral or bacterial), Reflex elicited when the sole of the foot is stimulated wit ha blunt instrument based upon what the big toe does when the sole of the foot is stimulated, patient is unable to flex his or her head forward due to an unnatural rigidity of the neck muscles, determines the smallest thing a person can see, ability to store, retain, and recall information and experience, emergency containment order-patient can be held against his will if the physician deems him a threat, temporary detaining order-court-ordered, necessary if a physician deems a patient threatening, but that patient refuses to be admitted, bowel sounds-gurgling, rumbling, or growling noises from the abdomen caused by the muscular contraction of peristalsis , the process that moves the contents of the stomach and intestines downward; describes as active, hyperactive, hypoactive, diminished or absent, rapid though patterns that often occur in manic episodes, form of hallucination that involves perceiving sounds without auditory stimulus, Feeling of pain, burning, or discomfort upon urination, area between the anus and the scrotum in the male and the anus and the vulva in the female, site of extreme sensitivity in acute appendicitis, situated in the normal area of the appendix midway between the umbilicus and the anterior iliac crest in the right lower quadrant of the abdomen, Finding associated w/ acute cholecystitis, which causes pain on inspiration when the examiner's fingers are placed on teh right upper quadrant at the location of the gallbladder, psychological and physiological state characterized by somatic, eomtional, cognitive, and behavioral components, post traumatic stress disorder-type of axiety disorder that can occur after seeing or experiencing a traumatic event that involved the threat of injury or death, described as feeling sad, blue, unhappy, miserable, or down in the dumps, mental disorder characterized by a breakdown of though processes and by poor emotional responsiveness which makes it difficult to tell the difference between real and unreal experiences, think logically, have normal emotional responses and behave normally in social situations, termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability, twisting of the spermatic cor, which cuts off the blood supply to the testicle and surrounding structures within the scrotum, accumulation of fluid in the peritoneal cavity, consequence of chronic liver disease characterized by scarring leading to loss of liver function, Small, bulging sacs or pouches of the inner lining of the intestine (diverticulosis) that become inflamed or infected, swelling of kidney due to a backup of urine; often detected by renal ultrasound, dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis, acute renal failure-failure of the kidneys in a short time (hours or days), bilateral tubal ligation-severing and sealing or clamping and blocking of fallopian tubes to prevent implantation of egg in the uterus, chronic kidney disease-failure of the kidneys over a long period of time, dilation and cutterage-surgery to scrape away the endometrium, hemadialysis- extracorporeal way of ridding the blood of wastes when a patient has renal failure, social service board of Charlottesville responsible for mental health services, crackling, popping, or grating sound heard and experienced beneath the skin or at the the joints, slow leg raise-a potential sign of a herniated disc; when a patient is lying on her back with knees extended, an examiner raises the patient's leg to see if pain is elicited, presence of blood in the tympanic cavity of the middle ear, an injury in which a body structure is forcibly detached, layer of skin between the epidermis and subcutaneous tissues, catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein) for central venous access, flexible plastic tube that is inserted through the side of the chest into the pleural space used to remove air (pneumothorax), fluid (pleural effusion, blood, chyle) or pus (empyema) from the intrathoracic space, removal of foreign matter or dead tissue from a wound, common syndrome in which a person has long-term, body-wide pain and tenderness in the joints, muscles, tendons, and other soft tissues, focuses assessment with sonography for trauma. A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on an uneven patch of sidewalk. What section of the physical exam would you document "RUE strength 3/5" under? ", Which section of the chart would you find AKA? (select all that apply.). CHEST PAIN: "Pleuritic pain" is a red flag for.. Disposition. Triage 3. 1) 10 elements (organ systems) checked off. PMHx DVT or PE, FHx DVT or PE, recent surgery, cancer, immobility, pregnancy, BCP, smoking, LE trauma, LE casts, Cellulitis with fluctuance; skin infection with an underlying collection of pus, The pus-pocket is drained - Incision and Drainage - I&D. How to make sure the ROS is coded at a "level 5"? Constitutional, eyes, ENT, CV, Res, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological. Hematemesis, coffee ground emesis, hematochezia, melena, Guaiac positive or Heme + stool, gastroccult. Hypoglycemia, infection, intoxication, neurological. NSR at a rate of 80bpm, no acute ST/T changes. What must happen on ALL EKG documentation in order for the physician to be reimbursed for their interpretation? What is the difference between a CTA and a CT? Name 3 past surgical histories that indicate that the patient has a history of CAD. What is the chief complaint of a Hemorrhagic CVA (Brain Bleed)? Nephrolithiasis, Renal Calculi, Urolithiasis. How is AMS different from Focal Neuro Deficit (FND)? Turning the hand so that the palm faces upward. What are the associated diseases of the Epigastric region? What is/are the chief complaint(s) of Cholelithiasis and Cholecystitis? What ROS system would include Dyspepsia, the medical term for indigestion? ), A consultation note indicating the admitting physician. PMHx and PSHx count as 1 element. Make sure the HPI has at least 4 elements. Allergic reaction can only be these 3 things: rash, itching, swelling. Which of the following would be ordered to investigate thyroid disease? What is the normal INR for a patient that is on blood thinners? What does "PE" stand for in the Diagnosis section of the chart? What is the name of the state after a seizure? What is the most common primary lipid disorder. Results and ED course 4. A patient has the following history: breast CA s/p chemoradiation therapy and mastectomy. Pertaining to the palm of the hand or the sole of the foot. That all final diagnoses are based off of documentation somewhere else in your chart. Swelling of the head of the optic nerve, a sign of increased intracranial pressure. What tests will almost always be placed for every adult patient complaining of chest pain? Instead, we would count back the number of days and document this numerically. What is the ED flow after orders are made? If a doctor says "Sinus at 72 (between 60 and 100bpm)" what do you write? You quickly look up the information on your laptop and tell the physician that the labs came back normal except for a blood glucose level of 356, so your provider subsequently asks you to tell the nurse to start that patient on an insulin drip. What is all included in the Cardiac Enzyme Panel (CEP)? If a doctor says "Left Axis" for an EKG, what do you write? What is its function. CTA- CT Angiogram looks at the arteries and uses IV contrast. Which of the following are NOT valid DDx for a patient with CC of HA? A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. What are the associated diseases of the RUQ? What are three different names for "kidney stone"? What is the benign "touch" exam for the Respiratory system? What is a STEMI (ST Elevation Myocardial Infarction)? What is the normal Oxygen Saturation range? What is the benign "no touch" exam for the GI system? ABD PAIN: "Blood in vomit or stool" is a red flag for.. ABD PAIN: "Dizziness" is a red flag for.. GI bleed, Abdominal Aortic Aneurysm - AAA. What is the core measure for Abd pain - female patient? In the psychiatric exam, what do SI and HI stand for? Soft. What cardiac enzyme is more specific to heart damage? What element is constant? What condition correctly describes "translocation of a thrombus leading to dyspnea and hypoxia"? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation. No guarding, rebound, or rigidity. DNR. What is the benign "no touch" exam for the Cardiovascular system? What are the findings "Battle's sign" and "Raccoon eyes" a sign of? RLQ pain, gradual onset, constant, worsened with movement. ), Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? a systolic sound (abnormal) heard over the carotid artery area during auscultation. Which of the following would need to go into a consult note for a patient that will be admitted to the hospital for treatment of bacterial meningitis? What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician? What is a medical term for "sweating heavily"? - Scribe: Documents the patient's visit on behalf of the physician, What FHx/SHx information is usually asked for pediatric patients? In what body system would you document "TM erythema and bulging"? Name the rhythm that the physician would hear if the patient was A Fib. It's the middle of the day. What is the benign "touch" exam for the Skin system? How is Small Bowel Obstruction (SBO) diagnosed? What must acute MI patients receive as soon as possible? FEMALE LOWER ABD PAIN: "Pregnancy" is a red flag for.. Cholelithiasis, Cholecystitis, Gallbladder wall thickening, bile sludge, bile duct obstruction. Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. What is a pre-existing condition you must have before you can get diverticulitis? What is the medical term for "middle ear infection"? A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. "I only take pills for my diabetes" means.. Non-Insulin Dependent Diabetes Mellitus - NIDDM. Positive cardiac catheterization - not done in the ED. Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine, A body of laws designed to protect private health information of patients, Privacy laws related to electronic transmission of health information, Major Sx, Chest Pain/SOB, Discussed Risks/Benefits/Alternatives, Procedures, Consent, Female/Male Chaperone Present, Unique Physical Exam Identifiers, Times, Orders per Consults, General, Organic, and Biological Chemistry, Fundamentals of General Organic and Biological Chemistry, Carl A. Hoeger, David S. Ballantine, John E. McMurry, Virginia E. Peterson.