BIOL 261 > SCRIBE FINAL > Flashcards

SCRIBE FINAL Flashcards

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1
Q

The critical care time is between:

A

30-74 min (1st level)

75-105 (2nd level)

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2
Q

How long is the core measure for smoking?

A

3-10 min

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3
Q

How long is the core measure for alcohol?

A

15-30 min

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4
Q

Are all ortho joint reductions performed under general anathesia: T or F

A

False

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5
Q

Name 5 elements of the HPI

A 
Onset 
Location
Duration 
Character 
Aggravating factors 
Radiation 
Timing 
Severity
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6
Q

List 3 acceptable caveats

A

Intoxicated, dementia, intubated

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7
Q

Name 5 organ systems in the physical exam section of the chart.

A

Head, eyes, ears, nose, throat, neck

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8
Q

What is Dr. Azmoon’s specialty?

A

Cardiology

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9
Q

What is Dr. Channell’s specialty?

A

Gynecology

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10
Q

Name a physician that works in surgery?

A

Dr.Garg

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11
Q

What is the brand name for the medication Odansetron?

A

Zofran

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12
Q

Brand name for Metronidazole

A

Flagyl

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13
Q

Brand name for hydrocodone

A

Norco

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14
Q

Brand name for Hydromorphone

A

Dilaudid

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15
Q

Brand name for cerfriaxone

A

Rocephin

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16
Q

Define the term laceration

A

A cut

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17
Q

Why would a patient receive antibiotics during an emergency department?

A

To treat bacterial infection

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18
Q

What is meant by the term mid level provider?

A

Nurse practitioner and physician assistant

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19
Q

What are three medications that signify the pt is likely receiving critical care?

A

TPA, narcan, NTG drip

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20
Q

What should be included for every procedure?

A

Date, time, who performed the procedure.

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21
Q

Where do you document associated symptoms?

A

In the free text narrative and the drop down boxes

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22
Q

Is accurate chronology important in an HPI

A

Yes

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23
Q

How many elements need to be included in the HPI focused chart?

A

4 elements as well as chief complaint

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24
Q

True or false: lacerations are billed based on length

A

True

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25
Why would our hospital receive a trauma patient?
Because we’re the closest hospital
26
What template do you use for the review of systems (ROS)?
...ROSQUICK
27
``` ‘Pedsexam ‘Fullneuro ‘Iimitedexam ‘Universal Are all templates that would be documented under what? ```
Physical exam
28
What do you document under core measure?
Dr counsels pt, gave pt resources, and included it in DCI
29
Paced EKG’s do not include what?
ST segments, T-wave abnormalities, axis, or conduction
30
Why do we use “EKG” and not “ECG”
Medical tradition is important
31
Where in the EKG do you include BPM?
After normal sinus
32
What are the billing requirements for EKG?
1. Interpreter 2. 3 positive-negative findings 3. Rate/ rhythm
33
Murphy's sign
cholecystitis
34
McBurney's sign
acute appendicitis
35
Brudzinski's Sign
meningitis
36
kernig's sign
meningitis/ subarachnoid hemorrhage
37
6 reasons for reevaluation notes
1. provider greets patient 2. Vitals signs rechecked 3. exam findings need to be rechecked 4. determine if particular treatment is effective 5. admission 6. discharge
38
3 procedures that include the risk/ benefit
blood transfusion, lumbar puncture, sedation
39
LFT
liver function
40
BUN
blood, urea, nitrogen
41
kidney function
BUN + creatine+ eGFR
42
BNP
B type natriuretic peptide
43
coags
PT/INR/PTT
44
CBC
complete blood count
45
CMP
complete metabolic panel
46
BMP
basic metabolic panel
47
ABG
arterial blood gas
48
UA
urinalysis
49
when to ask about Critical Care patients?
after seeing critical patients midway through shift end of shift
50
define critical care patient
in danger of losing life or limb
51
how to tell if provider is doing a limited exam
not using stethoscope
52
Sclera
White of the eye
53
Conjunctiva
Mucous membrane covering the skin of the eye
54
What does NML stand for?
Normal
55
What is Ecchymosis
Bruising
56
What is ortho joint reduction?
Reducing dislocation
57
Ortho FX care:
Fixing long bone
58
In what three words describe a patient status?
Improved, expired, stabilized
59
Name 2 doctors in pediatrics:
Dagher | Jain
60
Name 2 doctors in cardiology:
Choudhary | Azmoon
61
Name 2 doctors in family medicine:
Barag | Gabrillo
62
Name 1 doctor in neurology:
Altamimi
63
Worth 2 points in medical decision making?
- Independent interpretation of radiology results | - Review and summary of old records
64
When is the only time you don't write the date "5 days ago" and write "15 January 2018" instead?
Lab results or in comparison to an old EKG
65
2 ways to test cerebellar function?
Finger to nose | Heel to shin
66
4 possible causes of facial droop?
1. CVA 2. Bell's Palsy 3. Complex migraines 4. Todd's paralysis
67
How many components do you need for PMSFH?
2 components 1 finding per component per system
68
HPI components:
OLD CARTS, primary doctor, and associate symptoms
69
How many points needed for comprehensive billing in a medical decision making?
4 points
70
How many systems needed for comprehensive billing in ROS?
10 systems
71
2 types of aphasia:
1. receptive: word salad | 2. expressive: know what they're saying but can't put it into words
72
Where in the EKG section of the chart do you document the following? LBBB
Conduction
73
Define antiemetic:
Medication used to treat nausea and vomiting
74
Define analgesic:
Medications used to treat pain
75
What is normal heart rate?
60-100 BPM
76
What is bradycardic?
Heart rate equal to or less than 59 BPM
77
What is tachycardic?
Heart rate equal to or greater than 101 BPM
78
What template do you use for HPI?
`gentem
79
Emergency labs: (9)
``` CBC w/ differential BMP BNP CMP Troponin uDip COAGS ABG D-Dimer ```
80
Unit of EKG?
BPM
81
Name 3 core measures:
1. Council the pt. in the room 2. Provide printed resources at time of DC 3. Print alcohol cessation instruction in DCI
82
List 3 common CC diagnoses:
CPR (cardiac arrest) AFIB MI
83
Which diagnoses would CT scans be used for? (4)
Appendice Masses Tumor TAA
84
What diagnosis would LP be used for?
Meningitis
85
Specialist don't admit, they only consult except for which exceptions:
OBGYN or surgery
86
Colle's fracture:
Breaking hands by falling forwards
87
List 2 analgesics:
Ketorolac | Acetaminophen (safest)
88
List 2 antibiotics:
Ceftriaxone | Ciprofloxacin
89
List 2 antiemetics:
Ondansetron (most used) | Promethazine
90
How many elements need to be included in the HPI for a comprehensive/level 5 chart?
4 elements = chief complaint
91
Where in the EKG section of the chart do you document the following? Multifocal PVC's
Arrhythmia, rhythm
92
Where in the EKG section of the chart do you document the following? Right superior axis deviation
Axis
93
Where in the EKG section of the chart do you document the following? Low voltage QRS
Conduction
94
Where in the EKG section of the chart do you document the following? T wave abnormality, consider lateral ischemia
T-wave
95
Where in the EKG section of the chart do you document the following? Early repolarization
Rhythm
96
Where in the EKG section of the chart do you document the following? Atrial flutter
Dysrhythmia
97
NSAID:
Nonsteroidal antiinflammatory drug
98
PNA
Pneumonia
99
NTG
Nitroglycerin
100
TIA
Transient ischemic attack
101
PVC
Premature ventricular contraction
102
TAA
Thoracic aortic aneurism
103
What are the 3 requirements for critical care time?
Critical illness Critical Intervention Critical Time
104
3 common critical care procedures:
BIPAP/CPAP Central line Pacemaker placed
BIOL 261
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