These 2 lab test,which are part of the 7 basic chemistries, will be high in someone with renal failure. Urea and creatinine AAA Abdominal Aortic Aneurysm Abd Abdomen, Abdominal Abx Antibiotics Acute blockage of artery that provides blood to brain CVA (Cerebrovascular Accident) Adenoids removed Adenoidectomy AKA Above The Knee Amputation AMA Against Medical Advice AMS Altered Mental Status Appendix removed Appendectomy Are cough and fever related? Yes, when it could go either way, definitely put it in HPI Arthritis Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) ASA Acetylsalicylic Acid (Aspirin) Asthma Asthma Back fused Lumbar spinal fusion "Bad blood flow in my legs" Peripheral Vascular Disease (PVD) Bag to collect stool Colostomy Balloon Angioplasty --> PMHx CAD BCP Birth Control Pill BID Twice Daily Bilat LE Bilateral Lower Extremities Bipolar Bipolar disorder Black tarry stools Melena Bladder infection Urinary Tract Infection (UTI) Blood clot in lung Pulmonary Embolism (PE) "Blood clot in my leg" Lower Extremity Deep Vein Thrombosis Blood is the urine is called what? Hematuria BM Bowel Movement BP Blood Pressure Brain bleed Hemorrhagic CVA Brain surgery Craniotomy Breast removal Mastectomy "Bulge in my aorta" Abdominal Aortic Aneurysm (AAA) Bulging/herniated disc Degenerative Disc Disease (DDD) CA Cancer, Carcinoma CABG Coronary Artery Bypass Graft, "open heart surgery" CAD Coronary Artery Disease, "heart disease" Cancer Cancer or Carcinoma (CA) Chemo Chemotherapy CHF Congestive Heart Failure Clot filter (leg) Greenfield Filter Clot filter (lower abdomen) IVC (inferior vena cava) Filter c/o complains of Collapse lung due to trauma or a spontaneous small rupture of the lung Pneumothorax COPD Chronic Obstructive Pulmonary Disease CP Chest Pain CPR Cardiopulmonary Resuscitation Crohn's/UC Crohn's Disease or Ulcerative Colitis C-section Caesarean Section CSF Cerebrospinal Fluid C-spine Cervical Spine (neck) CT or CAT Computerized Assisted Tomography CT w/ PO CT Abd/Pel with PO contract CV Cardiovascular CVA Cerebrovascular Accident -orCostovertebral Angle CVA is used medically as an abbreviation for a cerebral vascular accident, as well as this location of the body. Costovertebral Angle CXR Chest X-Ray DC'd Discharged Home Defibrillator Automatic Implanted Cardiac Defibrillator (AICD) DFP Dorsal Fetal Pulse Diabetes Diabetes Mellitus (DM) Dialysis fistula AV (arteriovenous) Fistula Dialysis graft AV Graft Diverticulitis Diverticulitis DKA Diabetic Ketoacidosis DM Diabetes Mellitus DNR Do Not Resuscitate DOE Dyspnea On Exertion Drip Intravenous Drip DVT Deep Venous Thrombosis Dx Diagnosis Dz Disease Ear tubes Pressure Equalizer (P.E.) Tubes EKG/ECG Electrocardiogram Emphysema/Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD) Enlarged prostate Benign Prostate Hypertrophy (BPH) Episodes of abnormally fast/racing heartbeat Supraventricular Tachycardia (SVT) An erythematous TM would be abnormal for this body part. Ear --> indicates ear infection EtOH Alcohol Fast breathing rate Tachypnea FHx Family History A Fib Atrial Fibrillation Fx Fracture Gallbladder removed Cholecystectomy GERD Gastro-Esophageal Reflux Disease, "acid reflux" GI Gastrointestinal G/P/Ab Gravida/Para/Abortion GSW Gun Shot Wound gtt Drops GU Genitourinary HA Headache Heart attack Myocardial Infarction (MI) and CAD Heart bypass Coronary Artery Bypass Graft (CABG) --> PMHx CAD Heart cath Cardiac catheterization Heart disease Usually Coronary Artery Disease (CAD) Heart failure Congestive Heart Failure (CHF) HEENT Head, Eyes, Ears, Nose, Throat Hepatitis Hepatitis A, Hepatitis B, or Hepatitis C Hernia repair Herniorrhaphy H&H Hemoglobin & Hematocrit The "H&H" comes back with this lab test. If low it would indicate the patient is anemic. Hemoglobin and hematocrit. hemoglobin would be low if the patient is anemic. High blood pressure Hypertension (HTN) High cholesterol Hyperlipidemia (HLD) h/o history of hole in my neck Tracheostomy (commonly called a "trach") How do you diagnose a hemorrhagic CVA? CT of the head How do you diagnose appendicitis? CT Abdomen/Pelvis How do you diagnose gallstones? Ultrasound of RUQ How do you diagnose meningitis? Lumbar puncture How do you document a neck pulse/carotid pulse? Right carotid pulse 2+ How do you document a normal radial pulse? Right radial pulse 2+ How do you document a pulse on the heal? Posterior Tibialis Pulse 2+ How do you document a pulse on top of the foot? Dorsal pedis pulse 2+ H&P History of Present Illness & Physical Exam HPI History of Present Illness HTN Hypertension Hx History I&D Incision & Drainage IDDM Insulin Dependent Diabetes Mellitus "I drink a lot" Alcoholism or EtOH abuse If someone comes in complaining about dyspnea, what are the 2 major diseases to worry about? PE and PNA IM Intramuscular "I'm on dialysis" Chronic Renal Failure (CRF) on dialysis "I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM) Irregular heartbeat Atrial Fibrillation (A-Fib) Irritable bowel Irritable Bowel Syndrome (IBS) Ischemic and infarct of the interior lateral myocardium MI "I take shots (insulin) for my diabetes" Insulin Dependent Diabetes Mellitus (IDDM) It's gone In remission IUP Intrauterine Pregnancy IV Intravenous IVDA IV Drug Abuse IVP Intravenous Push IVPB Intravenous Piggy-Back Join pain (chronic) Degenerative Joint Disease (DJD) Joint repair Arthroplasty JVD Jugular Vein Distension Kidney infection Pyelonephritis (Pyelo) Kidney removal Nephrectomy Kidney stones Renal calculi LAD Left Axis Deviation Leg amputated Above Knee Amputation (AKA) Below Knee Amputation (BKA) LLE Left Lower Extremity LLQ Left Lower Quadrant LNMP Last Normal Menstrual Period LOC Loss of Consciousness Low back pain Chronic Low Back Pain LP Lumbar Puncture L-Spine Lumbar Spine LUE Left Upper Extremity LUQ Left Upper Quadrant MCA Motorcycle Accident Metal plates/pins Hardware MI Myocardial Infarction Mini-stroke Transient Ischemic Attack (TIA) Murmur Heart murmur MVA/MVC Motor Vehicle Accident/Motor Vehicle Collision N/A Not Applicable NAD No Acute Disease, No Acute Distress Name the vital signs blood pressure, respiratory rate, heart rate, oxygen saturation, temperature Neb Inhaled Nebulizer Neck artery cleaned Carotid Endarterectomy Neck fused Cervical spinal fusion NIDDM Non-Insulin Dependent Diabetes Mellitus NKDA No Known Drug Allergies Nml -or- nl Normal No rebound, no guard Abdominal NSAID Non-Steroidal Anti-Inflammatory Drug NSR Normal Sinus Rhythm NTG Nitroglycerin Number of HPI elements needed for Level 5 4 elements Number of physical exam elements needed for Level 5 8 elements (at least 1 finding in 8 different organ systems) Number of PMSFH (past medical and surgical; either social or family history) elements for Level 5 2 elements Number of ROS elements needed for Level 5 10 elements N/V/D Nausea/Vomiting/Diarrhea O2 Sat Oxygen Saturation (a.k.a. SaO2) OD Overdose Ovary and fallopian tubes removed Salpingo-oophorectomy Ovary removed Oophorectomy Pacer Pacemaker Pain with urination Dysuria Pancreatitis Pancreatitis Part of my colon removed Partial colectomy Part of my lung removed Partial lobectomy Patch Transdermal PCN Penicillin PCP Primary Care Physician (a.k.a. PMD) PE Pulmonary Embolism -or- Physical Exam Pedal edema is used to describe what? CHF PERRL Pupils are equal, round, and reactive to light PICC Line Peripherally Inserted Central Catheter (PICC) PNA Pneumonia Pneumonia Pneumonia (PNA) PO Per Os (by mouth) Port Port-a-cath or Medi-Port PR Per Rectum The presence of fluctuance would indicate this body tissue and would likely require I&D. Abscess prn As needed Prostate removed Prostatectomy (most often TransUrethral Removal of the Prostate, or TURP) pt patient PTA Prior To Arrival PTX Pneumothorax PUD Peptic Ulcer Disease q2h Every 2 Hours qd Every Day qh Every Hour qhs At Every Bedtime QID Four Times a Day Radiation Radiation therapy RBBB is the abbreviation used to describe this medical term, which would indicate an abnormal EKG finding. Right Bundle Branch Block Reflux Gastroesophageal Reflux Disease (GERD) RLE Right Lower Extremity RLQ Right Lower Quadrant r/o Rule Out ROM Range of Motion ROS Review of Systems RUE Right Upper Extremity Runny noise Rhinorrhea RUQ Right Upper Quadrant Rx Prescription SBO Small Bowel Obstruction Schizophrenia Schizophrenia Seizures Seizure disorder/Epilepsy Shunt Ventriculoperitoneal (VP) Shunt SL Sub-lingual SOB Shortness of Breath s/p Status Post (after) Spleen removed Splenectomy Spread to my... With metastases to the... SQ Subcutaneous STEMI ST Elevation Myocardial Infarction Stents Coronary Stents --> PMHx CAD Stomach stapled Gastric bypass Stroke Cerebrovascular Accident (CVA) Surgery for Afib Afib s/p cardiac ablation SVT Super Ventricular Tachycardia Sweating Diaphoresis Sx Symptoms They cut it out Status-post surgical resection This abbreviation is used to describe a heart attack. MI This abbreviation is used to describe a normal heart rhythm. NSR This abbreviation is used to describe diabetes. DM This hyphenated surgery would indicate the patient is missing both an ovary and a fallopian tube. Salpingo-Oophorectomy This is the medical term used to describe redness. Erythema; injection This lab test is used to help physicians rule out PE and DVT. D-dimer This lab test will be elevated in patients with CHF. BNP This lab test will be high in patient with pancreatitis. Lipase This surgery is performed to remove a portion of the intestines Colectomy This surgery is performed to remove the appendix. Appendectomy Thyroid problem Usually Hypothyroidism, sometimes Hyperthyroidism TIA Transient Ischemic Attack TID Three Times a Day TM Tympanic Membrane To check for JVD, what would be examined? Neck Tonsils removed Tonsillectomy T-Spine Thoracic Spine Tubes tied Tubal ligation (female) or Vasectomy (male) Tx Treatment UA Urinalysis Ulcer Gastric Ulcer or Peptic Ulcer Disease URI Upper Respiratory Infection US Ultrasound UTD Up To Date Uterus removed Hysterectomy UTI Urinary Tract Infection Valve surgery Valve repair or replacement (Bovine vs. Mechanical) Weak/fragile bones Osteoporosis What are 4 things that must be documented in HPI after a syncope episode? What happened prior to episode, during episode, after episode, and their current status in the ED What are all of the possible elements of an HPI? Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity What are examples of PHI? date of birth, social security number, diagnosis, what tests were run, what the results of the tests were What are the 4 types of focal neurological deficits? Changes in speech, vision, strength, and sensation What are the 6 rules of HIPAA? Rule #1: if a patient is not assigned to your doctor, DO NOT tough the chart. Rule #2: There is always someone watching. Rule #3: Never share your username or password. Rule #4: No cell phones or pictures. Rule #5: Your job does not belong on social media. Rule #6: Ask yourself, "Do I need to access this for my job?" What are the main differences between HPI and ROS? HPI focuses on chief complaint; ROS is a check from head to toe What does HIPAA stand for? Health Insurance Portability and Accountability Act What does HITECH stand for? The Health Information Technology for Economic and Clinical Health Act --> PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption. What does PHI stand for? Protected Health Information What do you do if someone asks for your help with a patient? We cannot touch patients. Find a nurse, a tech, etc. who can help. What is diagnosed when elevated Troponin is present? MI What is GPA? G = the total number of times the patient has been pregnant P = the number of live births (viable children) that the patient has had A = the total number of miscarriages or elective abortions What is likely the diagnosis of lower abdomen pain? Appendicitis, ectopic pregnancy What is syncope? Fainting; passing out What is the medical term for a bloody nose? Epistaxis What is the medical term for bruise? Ecchymosis Who would read your HPI other than your doctor? PCP, lawyers, coders, insurance companies, etc. WNL Within Normal Limits
