Ed Scribe - Final Exam Questions And Answers Already Passed

Medical Decision Making (MDM) The physician's thought process Pain vs. Tenderness Patient's feeling vs. physician's assessment What does distress mean? The doctor's judgment of discomfort Baseline An individual's normal state of being What does Auscultation mean? 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 What is the ED flow (overview)? 1. Check in and Chief Complaint 2. Physician assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition What is the ED flow before orders are made? 1. Arrival 2. Triage 3. Vital Signs / Bed Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE What is the ED flow after orders are made? 1. Differential Dx 2. Physician orders labs, imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition What is the general documentation template? HPI ROS PHx PE ED course Disposition Thyroid problem means.. Usually Hypothyroidism, sometimes hyperthyroidism "I only take pills for my diabetes" means.. Non-Insulin Dependent Diabetes Mellitus - NIDDM "I take shots (insulin) for my diabetes" means.. Insulin Dependent Diabetes Mellitus - IDDM Heart disease means.. Usually Coronary Artery Disease - CAD Heart attack means.. Myocardial Infarction - MI and CAD Irregular heartbeat means.. Atrial Fibrillation (A-Fib) Murmur means.. Heart murmur Episodes of abnormally fast/racing heartbeat means.. Supraventricular Tachycardia - SVT Emphysema/Chronic Bronchitis means.. Chronic Obstructive Pulmonary Disease - COPD Blood clot in lung means.. Pulmonary Embolism - PE Reflux means.. Gastroesophageal Reflux Disease - GERD Ulcer means.. Gastric Ulcer or Peptic Ulcer Disease Hepatitis means.. Hepatitis A, Hepatitis B, or Hepatitis C Crohn's/UC means.. Crohn's Disease or Ulcerative Colitis Kidney infection means.. Pyelonephritis - Pyelo Kidney stones means.. Renal calculi "I'm on dialysis" means.. Chronic Renal Failure - CRF or End Stage Renal Disease - ESRD on dialysis Enlarged prostate means.. Benign Prostate Hypertrophy - BPH What is the convention for documenting gynecological PMHx? G: P: A: Stroke means.. Ischemic Cerebrovascular Accident - CVA Mini-stroke means.. Transient Ischemic Attack - TIA Seizures means.. Seizure disorder/Epilepsy Brain bleed means.. Hemorrhagic CVA "I drink a lot" means.. ETOH abuse or Alcoholism "I do drugs" means.. Substance abuse "Blood clot in my leg" means.. DVT "Bulge in my aorta" or "Triple A" Abdominal Aortic Aneurysm "Bad blood flow to my legs" means.. Peripheral Vascular Disease - PVD "Numbness in my legs" means.. Peripheral Neuropathy Bulging/Herniated disc means.. Degenerative Disc Disease - DDD What does Arthritis mean? Osteoarthritis, Rheumatoid Arthritis Joint pain (chronic) means.. Degenerative Joint Disease -DJD Weak/fragile bones means.. Osteoporosis Spread to my means.. With metastases to the.. "They cut it out" (in regards to cancer) means.. Status-post surgical resection "It's gone" (in regards to cancer) means.. In remission Tonsils removed means.. Tonsillectomy Adenoids removed means.. Adenoidectomy Ear tubes means.. Pressure Equalizer Tubes Heart bypass means.. Coronary Artery Bypass Graft - CABG PMHx CAD Stents means.. Coronary Stents Heart Cath means.. Cardiac Catheterization Balloon means.. Angioplasty PMHx CAD Valve surgery means.. Valve repair or replacement - Bovine vs. Mechanical Pacer means.. Pacemaker Defibrillator means.. Automatic Implanted Cardiac Defibrillator - AICD Surgery for A Fib means.. Afib s/p cardiac ablation Breast removal means.. Mastectomy Hole in my neck means.. Tracheostomy - commonly called "trach" Part of lung removed means.. Partial lobectomy Gallbladder removed means.. Cholecystectomy Hernia repair means.. Herniorrhaphy Part of my colon removed means.. Partial colectomy Bag to collect stool means.. Colostomy Spleen removed means.. Splenectomy Stomach stapled means.. Gastric bypass Exploratory means.. Exploratory Laparoscopy - ExLap Kidney removed means.. Nephrectomy