Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

I Am Scribe University > Common Chief Complaints > Flashcards

Common Chief Complaints Flashcards

1
Q

Common chief complaints

A

CP, SOB, abd pain, HA, back pain, flank pain, AMS, MVC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

CP body systems

A

heart/CV, lungs/respiratory, esophagus/GI system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

CP DDx

A

MI, PE, pleurisy and costochondritis, gastroesophageal reflux disease (GERD), angina, atypical chest pain, pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

CP necessary HPI components

A

location, severity, quality, assoc sx (radiation), context, mod factors, relevant PMH, PSH, FHx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

CP necessary HPI components: location

A

Locations: left, right, central. NO lower (it’s epigastric in abd)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

CP necessary HPI components: severity and quality

A

description of the pain, such as “crushing,” “elephant on chest”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

CP necessary HPI components: associated signs and symptoms

A

radiation: if the pain spreads to neck, left arm or abd. n/v/d, SOB, palpitations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

CP necessary HPI components: context

A

what pt was doing: exercising, resting, alwwpinf

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

CP necessary HPI components: modifying factors

A

any medication, position or action that improves, worsens or has no effect on sx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

CP necessary HPI components: relevant hx

A

medical, surgical, social and family histories.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

CP drugs are…

A

aspirin (ASA) and nitroglycerin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

CP drugs: aspirin

A

antiplatelet agent. early tx (w/in 24 hrs of onset) can help

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

CP drugs: nitroglycerin

A

vasodilator. can treat angina. can be tablets, transdermal patches, ointments, IV or sublingual

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

CP PEx

A

chest wall tenderness, HR, heart sound, breath sounds, level of distress, diaphoresis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

common test for CP

A

heart enzymes (blood test): CK, CK-MB, troponin EKG: MI and arrhythmia CXR: pneumonia, pneumothorax, congestive heart failure (CHF), cardiomegaly, rib fx D-Dimer (blood test): pulmonary embolism, DVT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

SOB body systems

A

lungs/respiratory system, heart/CV system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

SOB DDx

A

pnuemonia, bronchitis, upper respiratory infection, pneumothroax, PE, CHF, COPD, asthma, pleurisy In PEDs: croup (barky cough)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

SOB: pneumothorax

A

“collapsed lung.” air between the lung and the spaces around lung. most often after injury to the chest wall. may be spontaneous in tall, skinny young white males

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

SOB necessary HPI components: timing

A

timing (onset)is very important

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

SOB necessary HPI components: duration

A

length of time as well as “sudden” or “gradual”, continuous, intermittent, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

SOB necessary HPI components: associated signs and symptoms

A

cough, congestion, fever, chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

SOB necessary HPI components: context

A

during exertion? birth control pills (BCP) a long car or plane ride?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

SOB HPI components: relevant histories

A

CHF, COPD, asthma, PE, MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

SOB PEx

A

did the pt exhibit chest wall tenderness? heart sounds (murmurs, gallops, rubs) breath sounds (wheezes, rhonchi, rales, stridor) level of respiratory distress is the pt exhibiting retractions? skin color (normal, pale, cyanotic)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
common tests for SOB
heart enzymes: CK, CK-MB, troponin EKG: MI, arrhythmia CXR: pneumonia, pneumothorax, CHF, rib fx D-Dimer: PE and DVT
26
Abd pain body systems
appendix, stomach, small intestine, colon, gallbladder (GB), spleen, liver
27
Abd pain DDx
appendicitis, cholecystitis and cholelithiasis (gall stone), small bowl obstruction, diverticulitis (outcropping of intestine inflammed) and diverticulosis (presence of diverticulum), gastroenteritis (vomit+diarrhea), GERD, AAA, ascites, constipation, UTI
28
Abd pain necessary HPI components
location, PMH and PSH, assoc sx,
29
Abd pain necessary HPI components: location
4 quad + epigastric + suprapubic appendix is RLQ gallbladder is RUQ
30
Abd pain necessary HPI components: PMH
any similar sx in the past and # of episodes. eaten recently? what and when (fatty food assoc with GB)
31
Abd pain necessary HPI components: PSH
past surgical histories of -ectomies can rule out dx. appendectomy (appendix) and cholecystectomy (GB). Hysterectomy (uterus). hermia repair
32
Abd pain necessary HPI components: associated signs and symptoms
n/v, n/v/d, constipation, fever, dysuria
33
Abd pain PEx
abd tenderness? where? rebound (pain on taking the hands off) and guarding distention bowl sound: normal, hyperactive, hypoactive?
34
common tests for abd pain
CT of abd/pelvis: appendicitis, diverticulitis, diverticulosis, kidney stone, small bowl obstruction GB ultrasound: cholelithiasis and cholecystitis KUB (kidney, uterus, bladder): small bowl obstruction and constipation Liver panel (blood test): liver dz or damage amylase (blood test): pancreatitis urinalysis (blood test): UTI
35
HA body system
head/brain
36
HA DDx
meningitis, migraine, stroke, aneurysm, intercranial hemorrhage
37
Stroke
ischemic stroke: blood clot or plaque hemorrhagic stroke: bleeding into brain tissue transient ischemic attack (TIA): temporary and no permanent damage
38
HA drug: blood thinners
need to check if pt already taking blood thinners. common meds: Plavix, Coumadin (Warfarin), aspirin
39
Aneurysm
weak are of blood vessel balloon or bulge out. can burst or put pressure on surrounding tissue. common sx: double vision, loss of vision, HA, eye pain
40
HA necessary HPI components
severity, quality, timing and duration, assoc sx
41
HA necessary HPI components: severity and quality
description of headache mild, moderate, severe sharp, throbbing is it the worst they ever experienced? meningitis?
42
HA necessary HPI components: timing and duration
when? gradual or sudden?
43
HA necessary HPI components: associated signs and symptoms
vision changes, fever, stiff neck, focal weakness in any of the extremities, dysphasia
44
HA PEx
neurologic findings A&E x3 facial droop slurred speech CN II-XII intact? facial muscle movement DTR (deep tendon reflexes) normal sensations?
45
Common tests for HA
CT head: tumor, CVA (cardiovascular accident), ICH (intercranial hemorrhage) and aneurysm lumber puncture (LP): meningitis
46
AMS body system
head/brain
47
AMS definition
general changes in brain function such as confusion, memory loss and loss of alertness
48
AMS DDx
stroke, aneurysm, drug OD, chronic dementia, UTI (can be a tipping pt for triggering AMS)
49
AMS necessary HPI components
timing, duration, assoc sx, what is "normal" for the pt?
50
AMS and intravenous tissue plasminogen activator (TPA)
"clot buster": for acute ischemic stroke. need to be administered within 3 hours of onset and also need other eligibilities
51
AMS necessary HPI components: associated signs and symptoms
slurred speech, confusion, fever (UTI), dysuria (UTI). Need to know pt's baseline (e.g., A&O x1 but baseline for pt per caregiver)
52
AMS PEx
neurologic findings include: A&O x? facial droop slurred speech focal weakness in any of the extremities CN II-XII intact? reflexes (DTR) normal sensation?
53
common tests for AMS
CT head: tumor, CVA, ICH and aneurysm UDS (urine drug screen): drug OD urinalysis (UA): UTI
54
Flank pain body system
GU, especially kidney, ureter or bladder
55
Flank pain DDx
nephrolithiasis (kidney stones), pyelonephritis (UTI moved up to kidney), UTI, hydronephrosis (fluid buildup in kidney)
56
Flank pain necessary HPI components
severity, quality, assoc sx (radiation), PMH
57
Flank pain necessary HPI components: severity
kidney stones often accompanied by severe pain
58
Flank pain necessary HPI components: quality
if dull and achy - pyelonephiritis if severe - nephrolithiasis
59
Flank pain necessary HPI components: associated signs and symptoms
radiation: kidney stone travels to ureter and bladder and pain radiates to suprapubic region. hematuria, dysuria, hesitancy, fever, nausea, vomitting
60
Flank pain necessary HPI components: PMH
history of UTI or nephrolithiasis (removed surgically or passed spontaneously?)
61
Flank pain PEx
CVAT (costovertebral angle tenderness)
62
common tests for flank pain
urinalysis: UTI and hematuria CT scan of abd/pel without contrast: kidney stones
63
Back pain body system
back pain is along the spine or along either side of spine. do not confuse with flank pain. 7 Cervical, 12 thoracic, 5 lumber, sacrum, coccyx
64
Back pain DDx
lumber or thoracic strain chronic back pain herniated disc fractures degenerative discs
65
Back pain necessary HPI components
location and radiation (assoc sx), timing and duration, context, modifying factors, PMH
66
Back pain necessary HPI components: location and radiation
upper vs. lower left vs. right vs. on the spine pain may spread into the hip, legs or neck
67
Back pain necessary HPI components: timing and duration
sudden onset? chronic pain? exacerbated recently?
68
Back pain necessary HPI components: associated signs and symptoms
radiation of pain bilateral lower extremity (BLE) weakness or pain bowl/fecal or urinary incontinence (losing control) numbness or tingling to any extremities
69
Back pain necessary HPI components: PMH
multiple presentation to ED? with the same cc?
70
Back pain necessary HPI components: modifying factors
heat, ice, NSAIDs (non-steroidal anti-inflammatory drugs; e.g., tylenol), narcotics (which one?)
71
Back pain PEx
straight leg raise and the result. Midline tenderness: possible injury to spine paraspinal muscle tenderness reflexes can pt move lower extremities? gait (nl or disrupted)
72
common tests for back pain
x-ray (C-, L-, T-spine): fx, dislocation CT scans: fx, dislocation MRI: herniated disc, pinched nerve (not done too much in ER)
73
Motor vehicle collision
is not a cc, technically documentation of facts of the collision is important.
74
MVC necessary HPI components
location, context
75
MVC necessary HPI components: location
this is not the location of accident or pt's seat or etc. where it hurts
76
MVC necessary HPI components: context
pt's seat, location of impact on car, speed of the cars involved, size/type of vehicle, seat belt (un/restrained), air bag deployment (which one), ambulatory or walking?
77
MVC PEx
wearing C-collar and/or on backboard? \*\*\*then you cannot writeFROM and supple\*\*\* check abd for tenderness from seat belt ("seat belt sign") be very thorough
78
common lab tests for MVC
CBC BMP UA: hematouria EtOH: alcohol intoxication UDS: ilicit drug use BHCG (female pt): pregnancy b/c can't use x-ray on pregnant pt.
79
common radiology tests for MVC
CT head CT C-spine CT chest CT abd/pel CT multiplanar Reconstruction (T&L) C-spine X-ray T-spine X-ray L-spine X-ray CXR other X-rays

I Am Scribe University (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions