Course 1: ED Flow

Question 1

Objective

Answer 1

Fact

Question 2

Chief complaint

Answer 2

The main reason for the patient’s ED visit

Question 3

Medical decision making

Answer 3

The physician’s thought process

Question 4

Pain

Answer 4

Patient’s feeling

Question 5

Tenderness

Answer 5

Physician’s assessment

Question 6

Benign

Answer 6

Normal, nothing of concern

Question 7

Distress

Answer 7

The doctor’s judgment of discomfort

Question 8

Febrile

Answer 8

The state of having a fever, concerning for infection

Question 9

Acute

Answer 9

New onset, likely concerning

Question 10

Chronic

Answer 10

Long-standing, not of direct concern

Question 11

Baseline

Answer 11

An individual’s normal state of being

Question 12

Auscultation

Answer 12

Listening with a stethoscope

Question 13

Palpation

Answer 13

The act of pressing on an area by the doctor

Question 14

Inpatient

Answer 14

Admitted to th hospital overnight

Question 15

Outpatient

Answer 15

Seen and sent home the same day

Question 16

What is a scribe?

Answer 16

An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner

Question 17

Scribes can….

Answer 17

• document history, physical exam, results, procedures, and physician consults
• access and document lab results and radiology findings
• access and display X-rays for the physician to review
• locate and obtain PMHx, previous charts, past results, and recent studies
• record physician interpretations of X-Rays and ECG’s

Question 18

Scribes cannot….

Answer 18

• touch patients
• write orders or prescriptions
• give verbal orders
• partake in any activity that may affect patient health or outcome
• sign or authenticate any chart or record
• handle bodily fluids or specimens

Question 19

Charge nurse

Answer 19

Manages the ED patient flow

Question 20

Mid-level provider

Answer 20

Nurse practitioner (LNP) or Physician assistant (PA) that works under the supervision of a physician to diagnose and treat patients

Question 21

ED Nurse

Answer 21

Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures

Question 22

Respiratory therapist

Answer 22

Administers “breathing treatments” and assists with managing a patient’s airway

Question 23

ED Tech

Answer 23

Helps the nurse and assists with procedures

Question 24

Unit secretary

Answer 24

Places physician’s orders, answers phone calls, pages other specialists/doctors, and organize the patient’s paperwork

Question 25

Scribe

Answer 25

Documents the patient's visit on behalf of the physician

Question 26

ED Flow

Answer 26

* Check in and chief complaint * physician assessment * objective orders and results * medical decision making * Disposition

Question 27

Two ways to enter a hospital

Answer 27

* walk-in | * EMS (ambulance)

Question 28

What happens at the triage?

Answer 28

* chief complaint * vital signs * level of acuity (5 low to 1 high)9

Question 29

What are the vital signs?

Answer 29

Heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (T), oxygen saturation SAO2

Question 30

What happens in a nurse assessment?

Answer 30

* Confirm chief complaint * review allergies * brief past medical history

Question 31

What happens at history and physical?

Answer 31

Subjective: HPI and ROS Past history: PMHx, PSHx FHx, SHx Objective: PE

Question 32

Differential Dx:

Answer 32

Based on History and physical, the physician generates a list of things that may be causing the pt's subjective symptoms. Then the doctor places orders to "rule out" each differential

Question 33

Subjective

Answer 33

Feeling

Question 34

Physician orders

Answer 34

* lab studies * imaging studies * procedures * medications

Question 35

Final Dx

Answer 35

The physician uses MDM and reviews specific results that can rule out differential diagnoses (DDx) to reach the Final Diagnosis

Question 36

3 options for disposition

Answer 36

* discharge * admittance * transfer

Question 37

General documentation template and which ones are subjective and objective

Answer 37

* HPI (sub) * ROS (sub) * past history * PE (ob) * Ed course (ob) * disposition

Question 38

Where to document patient complaint?

Answer 38

HPI or ROS

Question 39

Where to document past Dx or surgery?

Answer 39

Past history

Question 40

Where to document physician's observation?

Answer 40

PE

Question 41

Where to document objective study?

Answer 41

Results/ED course

Question 42

Where to document re-evaluation?

Answer 42

ED course

Question 43

Where to document where the pt will go?

Answer 43

Diagnosis and disposition

Question 44

High blood pressure

Answer 44

Hypertension (HTN)

Question 45

High cholesterol

Answer 45

Hyperlipidemia (HLD)

Question 46

Thyroid problem

Answer 46

Hypothyroidism or hyperthyroidism

Question 47

Diabetes

Answer 47

Diabetes mellitus (DM)

Question 48

"I only take pills for my diabetes"

Answer 48

Non-insulin dependent diabetes mellitus (NIDDM)

Question 49

"I take shots (insulin) for my diabetes"

Answer 49

Insulin dependent diabetes mellitus (IDDM)

Question 50

Heart disease

Answer 50

Usually coronary artery disease (CAD)

Question 51

Heart attack

Answer 51

Myocardial infarction (MI) and CAD

Question 52

Heart failure

Answer 52

Congestive heart failure (CHF)

Question 53

Irregular heartbeat

Answer 53

Atrial Fibrillation (A-Fib)

Question 54

Murmur

Answer 54

Heart murmur

Question 55

Episodes of abnormally fast/racing heartbeat

Answer 55

Supraventricle tachycardia (SVT)

Question 56

Asthma

Answer 56

Asthma

Question 57

Emphysema/ Chronic Bronchitis

Answer 57

Chronic obstructive pulmonary disease (COPD)

Question 58

Blood clot in lung

Answer 58

Pulmonary Embolism (PE)

Question 59

Pneumonia

Answer 59

Pneumonia (PNA)

Question 60

Reflux

Answer 60

Gastroesophageal reflux disease (GERD)

Question 61

Ulcer

Answer 61

Gastric ulcer or peptic ulcer disease

Question 62

Pancreatitis

Answer 62

Pancreatitis

Question 63

Hepatitis

Answer 63

Hepatitis (A,B or C)

Question 64

Diverticulitis

Answer 64

Diverticulitis

Question 65

Crohn's/UC

Answer 65

Crohn's disease or ulcerative colitis

Question 66

Irritable bowel

Answer 66

Irritable bowel syndrome (IBS)

Question 67

Bladder infection

Answer 67

Urinary tract infection (UTI)

Question 68

Kidney infection

Answer 68

Pyelonephritis (Pyelo)

Question 69

Kidney stones

Answer 69

Renal calculi

Question 70

"I'm on dialysis"

Answer 70

Chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis

Question 71

Enlarged prostate

Answer 71

Benign prostate hypertrophy (BPH)

Question 72

G.P.A. (Gynecology)

Answer 72

G: number of pregnancies P: number of live births (viable children) A: number of miscarriages or abortions

Question 73

Stroke

Answer 73

Cerebrovascular Accident (CVA)

Question 74

Mini-Stroke

Answer 74

Transient Ischemic attack (TIA)

Question 75

Seizures

Answer 75

Seizure disorder/epilepsy

Question 76

Brain bleed

Answer 76

Hemorrhagic (CVA)

Question 77

Bipolar

Answer 77

Bipolar disorder

Question 78

Schizophrenia

Answer 78

Schizophrenia

Question 79

"I drink a lot"

Answer 79

ETOH abuse or alcoholism

Question 80

"I do drugs"

Answer 80

Substance abuse

Question 81

"Blood clot in my leg"

Answer 81

Lower extremity deep vein thrombosis (DVT)

Question 82

"Bulge in my aorta" or "Triple A"

Answer 82

Abdominal aortic aneurysm (AAA)

Question 83

"Bad blood flow to my legs"

Answer 83

Peripheral vascular disease (PVD)

Question 84

"Numbness in my legs"

Answer 84

Peripheral neuropathy

Question 85

Low back pain

Answer 85

Chronic low back pain

Question 86

Bulging/herniated disc

Answer 86

Degenerative Disc disease (DDD)

Question 87

Arthritis

Answer 87

Osteoarthritis (OA) or Rheumatoid Arthritis (RA)

Question 88

Joint pain (chronic)

Answer 88

Degenerate joint disease (DJD)

Question 89

Weak/fragile bones

Answer 89

Often Osteoporosis

Question 90

Cancer that spread to my...

Answer 90

Type/ cancer/ with metastases to the...

Question 91

Chemo

Answer 91

Chemotherapy

Question 92

Radiation

Answer 92

Radiation therapy

Question 93

They cut it out

Answer 93

Status-post surgical resection

Question 94

It's gone

Answer 94

In remission

Question 95

-ectomy

Answer 95

Removal surgery

Question 96

-itis

Answer 96

Inflammation

Question 97

-pathy

Answer 97

Disease

Question 98

-osis

Answer 98

Disease/condition

Question 99

Tonsils removed

Answer 99

Tonsillectomy

Question 100

Adenoids removed

Answer 100

Adenoidectomy

Question 101

Ear tubes

Answer 101

Pressure equalizer (P.E.) Tubes

Question 102

Heart bypass

Answer 102

Coronary artery bypass graft (CABG) ➡️ PMHx CAD

Question 103

Stents

Answer 103

Coronary stents ➡️ PMHx CAD

Question 104

Heart cath

Answer 104

Cardiac catheterization

Question 105

Balloon

Answer 105

Angioplasty ➡️ PMHx CAD

Question 106

Valve surgery

Answer 106

Valve repair or replacement (Bovine vs. Mechanical)

Question 107

Pacer

Answer 107

Pacemaker

Question 108

Defibrillator

Answer 108

Automatic implanted cardiac defibrillator (AICD)

Question 109

Surgery for Afib

Answer 109

Afib s/p cardiac ablation

Question 110

Breast removal

Answer 110

Mastectomy

Question 111

Hole in my neck

Answer 111

Tracheostomy ("trach")

Question 112

Part of my lung removed

Answer 112

Partial lobectomy

Question 113

Appendix removed

Answer 113

Appendectomy

Question 114

Gallbladder removed

Answer 114

Cholecystectomy

Question 115

Hernia repair

Answer 115

Herniorrhaphy

Question 116

Part of my colon removed

Answer 116

Partial colectomy

Question 117

Bag to collect stool

Answer 117

Colostomy

Question 118

Spleen removed

Answer 118

Splenectomy

Question 119

Stomach stapled

Answer 119

Gastric bypass

Question 120

Exploratory

Answer 120

Exploratory laproscopy (ExLap)

Question 121

Kidney removed

Answer 121

Nephrectomy

Question 122

Uterus removed

Answer 122

Hysterectomy (partial vs. total)

Question 123

Ovary removed

Answer 123

Oophorectomy

Question 124

Ovary and Fallopian tubes removed

Answer 124

Salpingo-oophorectomy

Question 125

Tubes tied

Answer 125

Tubal ligation (female) or vasectomy (male)

Question 126

C-Section

Answer 126

Cesarean section

Question 127

Prostate removed

Answer 127

Prostatectomy (TURP)

Question 128

Uterine product removed

Answer 128

Dilation and curettage (D and C)

Question 129

Neck artery cleaned

Answer 129

Carotid endarterectomy

Question 130

Brain surgery

Answer 130

Craniotomy (brain bleed vs. brain CA)

Question 131

Shunt

Answer 131

Ventriculoperitoneal (VP) shunt

Question 132

Dialysis fistula

Answer 132

AV (arteriovenous) fistula

Question 133

Dialysis graft

Answer 133

AV graft

Question 134

PICC line

Answer 134

Peripherally inserted central catheter (PICC)

Question 135

Port

Answer 135

Port-a-cath or Medi-Port

Question 136

Clot filter (lower abdomen)

Answer 136

IVC (inferior vena cava) Filter

Question 137

Clot filter (leg)

Answer 137

Greenfield filter

Question 138

Leg amputated

Answer 138

Above knee amputation (AKA) | Below knee amputation (BKA)

Question 139

Joint repair

Answer 139

Arthroplasty

Question 140

Metal plates/pins

Answer 140

Hardware

Question 141

Neck fused

Answer 141

Cervical spinal fusion

Question 142

Back fused

Answer 142

Lumbar spinal fusion

Question 143

Hip surgery

Answer 143

Open reduction with internal fixation (ORIF)

Question 144

True allergy

Answer 144

Rash, itching, swelling, difficulty breathing

Question 145

Adverse reaction

Answer 145

Anything that is not a true allergy

Question 146

FHx General

Answer 146

* HTN * DM * CA

Question 147

FHx cardiac

Answer 147

MI/CAD less than 55 y/o

Question 148

NKDA

Answer 148

No known drug allergies

Question 149

Bruising

Answer 149

Ecchymosis

Question 150

Redness

Answer 150

Erythema