Medical Terminology
Inflammation of the pancreas
Pancreatitis
Etiology: Infiltrate (bacterial infection) and inflammation inside the lung
Catch Phrase: Productive cough with fever
Risk Factors: Elderly, Bedridden, Recent chest injury, Recent surgery
Chief Complaint: SOB or Productive cough
Assoc. Sx: Cough with sputum, Fever, Chest pain
Assoc. Med: Rocephin and Zithromax (Antibiotics)
Physical Exam: Rhonchi
Diagnosed by: CXR
Pneumonia
What section of the ED chart contains subjective information?
HPI and ROS
What does "PERRL" stand for in an eye exam?
Pupils Equally Round and Reacting to Light
Period. (except its so fast you can barely understand it, so its more like "prt")
MBM
ear ache
Otalgia
Etiology: Abnormal electrical activity in the brain leading to abnormal physical manifestations. Often caused by epilepsy, ETOH withdrawals, or febrile [] in pediatric pts
Chief Complaint: [] activity, Syncope
Assoc. Sx: Injuries (tongue bite), Confusion, Headache, Incontinence (urinary or fecal)
Physical Exam: Somnolent, Confused (Postictal)
Seizure
Name three associated symptoms that should be documented for a patient presenting with shortness of breath.
Cough, CP, Wheezing
What are the two main physical exam findings that may indicate an inner ear infection?
TM erythema, TM bulging
"Patient at risk for polypharmacy"
PRF
Described as grating, scratching sound of the heart indicative of pericarditis.
Friction Rub (heart sound)
Etiology :Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina (chest pain specifically due to heart-muscle ischemia)
Catch Phrase: Chest pain with physical exertion
Chief Complaint: Chest pain or Chest pressure
Worse with exertion
Improved by rest or NTG
Assoc. Med
Acetylsalicylic Acid (Aspirin or ASA) 324 mg PO
Nitroglycerin (NTG) 0.4mg SL
Diagnosed By: Cardiac catheterization (Not diagnosed in the ED)
CAD
The four most important symptoms to document for a trauma patient are LOC, ___________, ___________, and ___________.
Head injury, Neck pain, Back pain,
* also will take headache, n/v, vision changes, focal deficits
If a provider performs a full neurological exam, name three areas they will assess.
Motor function, sensation, reflexes
"uhhhh I think Hester has a dot phrase for that."
TB
Tensing of abdominal wall muscles indicative of true abdominal disease
Guarding
Etiology: Injury to the [ ] may create weakness or numbness in the extremities past the site of the injury
Chief Complaint: Neck pain or Back pain, Bilateral extremity weakness
Physical Exam: Midline bony tenderness, deformities, or step-offs, Bilateral extremity weakness, Numbness, Decreased rectal tone
Diagnosed by
CT Cervical Spine (Neck)
CT Thoracic Spine (Upper back)
CT Lumbar Spine (Lower back)
Spinal cord injury
A patient states they had a similar headache 2 months ago. What three questions should you ask to further explore this past episode?
How long did it last? Did they seek medical attention? What treatment was given?
A patient presents with abdominal pain. List three physical exam findings that might indicate appendicitis.
McBurney’s point tenderness, rebound tenderness, psoas sign
"That's not how you spell that."
RC
Triangular indentation of the radial dorsal aspect of the hand
Snuff Box
Etiology: Electrical abnormalities in the “wiring” of the heart causes the top of the heart (atria) to quiver abnormally
Chief Complaint: Palpitations (Fast, Pounding, Irregular)
Risk Factors: Paroxysmal [], Chronic []
Physical Exam: Irregularly irregular rhythm, Tachycardia
Diagnosed by :EKG (ECG)
Assoc. Med: Coumadin (Warfarin): Blood thinner, prevents blood clots in atria. Digoxin: Slows down heart rate
A-fib
If a patient was involved in a motor vehicle accident, what three questions should be asked to assess the severity of the accident?
Seat belt use, Airbag deployment, Loss of consciousness
If a patient arrives after a motor vehicle accident, what three physical exam findings might suggest head trauma?
Battle’s sign, hemotympanum, periorbital ecchymosis
"how long have you been a scribe for?"
AP