What is scleral icterus, and what does it indicate? For any seriously ill patient what 2 questions must the scribe ask the physician? Quality is an important descriptor that can paint a picture for concerning DDx. Make sure the HPI has at least 4 elements. Procedure of using a syringe to collect synovial fluid from a joint capsule. What does the DP stand for in "DP pulse"? CT A/P or confirmed UTI with CVA tenderness on exam. Results and ED course 4. ", Which section of the chart would you find AKA? How does Nitroglycerin (NTG) benefit a potential MI or CAD? What is a pre-existing condition you must have before you can get diverticulitis? Costo-Vertebral Angle tenderness; flank tenderness - tenderness over kidneys, Alert and Oriented to Person, Place, and Time. What is the medical term for infection of the gall bladder? CHEST PAIN: "Recent trauma" is a red flag for.. What is a STEMI (ST Elevation Myocardial Infarction)? How is A Fib (electrical problem) diagnosed? Which of the following would be documented in ED Course? In a Differential (includes CBC), what does "High Monos / Monocytes" tell us? What is a special type of life saving care that some patients receive? What is the core measure for Acute Otitis Externa (Outer Ear Infection)? What is the medical term for "high bicarbonate"? Location is an important element that can paint a picture for concerning DDx. Fill in the blank: Critical care must be at least a minimum of __________. What needs to happen with patients who have both cardiac risk factors and epigastric pain? Differential Dx 2. Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view). This scenario is acceptable and within the bounds of your scribe scope. Name 8 of the body systems included in the ROS. If a doctor says "Sinus at 72 (between 60 and 100bpm)" what do you write? What element is constant? How many tubes of CSF are typically obtained during a Lumbar Puncture? The Emergency Department is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room. How would you document "Aspartate Transaminase"? What is the medical term for "high potassium"? less than full alertness, altered level of consciousness, Physical waisting with loss of weight and muscle mass due to disease, rapid swelling - most commonly eyes or lips. Consent should be documented any time a procedure is performed, but there maybe certain situations in which consent is unobtainable. No, because George accessed his own medical record using his EMR login. What are three different names for "kidney stone"? Room Air, Nasal Cannula, Facial Mask,Non-Rebreather Mask. What are the possible consequences of a HIPAA violation? What are the chief complaints of Congestive Heart Failure (CHF)? What term describes "the patient destination is home"? What is the medical term for stones in the gallbladder? What is the best diagnosis for his complaint? Match the following exam findings with the appropriate organ system. What must acute MI patients receive as soon as possible? Non-tender. What is/are the chief complaints of a patient with Altered Mental Status (AMS)? Confusion, decreased responsiveness, unresponsive. Episodes of abnormally fast/racing heartbeat means.. What are the risk factors associated with a Myocardial Infarction (MI)? Distal pulses intact. Document "last known well" date and time. Topical therapy. What do you need to make sure to document for every admitted patient? What is the medical term for "low glucose"? Match the following description to the appropriate team member. Medical terminology. What cardiac enzyme is more specific to heart damage? What is the benign "no touch" exam for the general system? What medical term describes "noticeable blood in the urine"? T/F. What happened prior, during, and after the syncopal episode, as well as how the pt currently feels. What does "PE" stand for in the Diagnosis section of the chart? HTN, HLD, DM, Hx TIA/CVA, smoking, FHx CVA, A Fib. A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. Inflammation of the walls of the lymphatic vessels, The separation of any part of the body from the whole. What is the normal Oxygen Saturation range? PMHx and PSHx count as 1 element. A full examination is unable to be obtained due to clinical condition. What is the benign "no touch" exam for the eyes system? combination of (+) EKG and (+) blood work : STEMI. Follow up, Time period in which to follow up, Specific conditions for return to ED, Condition: stable for discharge, Time of disposition. Hematemesis, coffee ground emesis, hematochezia, melena, Guaiac positive or Heme + stool, gastroccult. Calculate the G, P and A, respectively. Fat is used for fuel instead and produces ketones. "I take shots (insulin) for my diabetes" means.. Insulin Dependent Diabetes Mellitus - IDDM. What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information? (select all that apply.). What does "hyphema" mean in a physical exam? Elderly, bedridden, recent chest injury, recent surgery, Collapsed lung do to trauma or a spontaneous small rupture of the lung. Peritonsillar Abscess, forms in the tissues of the throat next to one of the tonsils. What is the name of the state after a seizure? Based on this, does the patient meet Level 5 billing criteria for this section of the chart? (select all that apply), You've just caught up on all of your charting. What is the medical term for "high glucose"? What is the medical term for "low potassium"? What are we worried about for someone with a GI bleed? What is its function. Cholelithiasis, Cholecystitis, Gallbladder wall thickening, bile sludge, bile duct obstruction. HPI, ROS, Hx, PE. (select all that apply.). What lab order contains the "H&H" (hemoglobin and hematocrit)? A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What subcategories are included in within the Past History section of the template? What is the normal INR for a patient that is on blood thinners? Clear to auscultation bilaterally. Patient's feeling vs. physician's assessment, The act of pressing on an area by the doctor, 1. Physician assessment 3. (Select all that apply.). Allergic reaction can only be these 3 things: rash, itching, swelling. T/F. What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. CAD, HTN, HLD, DM, Smoker, FHx CAD <55 y/o. What are the findings "Battle's sign" and "Raccoon eyes" a sign of? How to make sure the Physical Exam is coded at a "level 5"? What is the chief complaint of someone with COPD? "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 would dry mucous membranes indicate? Which of these 2 physical exam findings could a physician appreciate without auscultating the patient's lungs? MOI, How it occurred, when it occurred, and what surface did they land on. 1. Yes, because the fever started soon after the cough. An accumulation of blood in the anterior chamber of the eye. Medical terminology. Name some procedures that qualify the patient for critical care. HPI > ROS > PHx > PE > ED course > Disposition, Usually Hypothyroidism, sometimes hyperthyroidism. What is the medical term for "coughing up blood"? ), b) Documenting the answers to every question asked by the doctor. If a doctor says "Nothing acute" for an EKG, what do you write? What are the associated diseases of the LUQ? A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. NSR at a rate of 80bpm, no acute ST/T changes. How to make sure the ROS is coded at a "level 5"? A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. CHEST PAIN: "Diaphoresis, Nausea, Vomiting" is a red flag for.. Check in and Chief Complaint 2. Cholelithiasis = Gallstones, Cholecystitis = Gallbladder infection. Ovary and fallopian tubes removed means.. Tubal ligation - female or Vasectomy - male, Prostatectomy, most often Trans-Urethral Removal of the Prostate - TURP, Peripherally Inserted Central Catheter - PICC, Open Reduction with Internal Fixation - ORIF. How to make sure the PMHx is coded at a "level 5"? What is one test/lab that will never result during a patient's ED visit? FEMALE LOWER ABD PAIN: "Pregnancy" is a red flag for.. The first patient is presenting with a productive cough steadily worsening since onset 4 weeks ago. What are some other associated Sx of an MI other than CP? When documenting the diagnoses, what question must you always ask the physician? What are the clinical signs associated with scrapie? What section of the physical exam would you document "RUE strength 3/5" under? What is the most common types of macrocytic anemia? What is a medical term for "sweating heavily"? Non-specific test used to help rule out PE or DVT. What does LAD stand for as an EKG abbreviation? HPI: 4, ROS: 10 or 2 "All systems negative", PHx: 2, PE: 8. (select all that apply), Which of the following would NOT be considered an example of PHI? turning of the hand so the palm faces downward, situated behind or directed towards the rear, physician taps on a surface to determine the underlying structure, Physician listens to the internal sounds of the body using a stethoscope, Physician feels the different parts of the body, Premature death of cells in living tissue, surgically created opening connecting an internal organ to the surface of the body, Tissue death caused by a local lack of oxygen due to obstruction of the tissue's blood supply, Decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels, Malnutritioned, wasting, or in poor health, vital signs taken sitting, standing, and supine, methycillin resistant staphylococcus aureus; one strain of the staphylococcus bacteria that is resistant to medications conventionally used to treat it. A vascular change that temporarily deprives a part of the brain of oxygen but does not result in any long lasting deficits"? What is the medical term for "middle ear infection"? What is the biggest concern with a "sore throat"? (Select all that apply.). Match each critical care dx with it's associated procedure. Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. Your provider is busy dealing with a crtically ill patient and during this time the ED starts to pick up pace as more patients arrive. In what body system would you document "TM erythema and bulging"? What is the benign "no touch" exam for the Psychiatric system? What is the medical term/system for "skin"? You are starting your shift and your physician immediately picks up 3 patients. (Select all that apply.). 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. What is the benign "no touch" exam for the Extremities system? What is the difference between BMP and CMP? CHEST PAIN: "Pleuritic pain" is a red flag for.. It is stored in the gallbladder and made in the liver. ), Yes, because the phone is not an approved hospital device and it is not encrypted. All symptoms documented in the ROS are also documented in the HPI. What is the benign "touch" exam for the Skin system? How does Aspirin (ASA) benefit a potential MI or CAD? All symptoms documented in the HPI are also documented in the ROS. 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. ), A consultation note indicating the admitting physician. RLQ pain, gradual onset, constant, worsened with movement. What is the core measure for Ischemic CVA? What is the benign "touch" exam for the Neck system? What is the medical term for "high chloride"? Which of the following would be the best diagnosis? No, the PHx does not meet Level 5 billing criteria. (select all that apply.). In a physical exam, what does "TTP" mean? What is the medical term for "extra beats"? The patient also appears to be lethargic with obvious lacerations above her right eyebrow, left hand, and left thigh. 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. Match the following results with the corresponding diagnosis. What are the associated diseases of the LLQ? What medical term would you use to describe a "runny nose"? What is the most common primary lipid disorder. In the neurological exam, what does "normal gait" mean? While your provider is prepping the critical patient for a procedure, she asks you to look up the CBC result on another patient. RUQ pain; sharp, worsened with eating, deep breaths, and palpation. Name 4 causes of Altered Mental Status (AMS)? diabetic ketoacidosis-occurs when the body cannot use sugar (glucose) as a fuel sources because there is no insulin or not enough insulin. Name a type of Orthopedic procedure that may be performed by the EP? Given the information, what might the most likely diagnoses' end up being for these patients?