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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

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2
Q

CP body systems

A

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

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3
Q

CP DDx

A

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

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4
Q

CP necessary HPI components

A

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

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5
Q

CP necessary HPI components: location

A

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

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6
Q

CP necessary HPI components: severity and quality

A

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

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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

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8
Q

CP necessary HPI components: context

A

what pt was doing: exercising, resting, alwwpinf

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9
Q

CP necessary HPI components: modifying factors

A

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

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10
Q

CP necessary HPI components: relevant hx

A

medical, surgical, social and family histories.

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11
Q

CP drugs are…

A

aspirin (ASA) and nitroglycerin

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12
Q

CP drugs: aspirin

A

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

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13
Q

CP drugs: nitroglycerin

A

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

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14
Q

CP PEx

A

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

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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

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16
Q

SOB body systems

A

lungs/respiratory system, heart/CV system

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17
Q

SOB DDx

A

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

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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

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19
Q

SOB necessary HPI components: timing

A

timing (onset)is very important

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20
Q

SOB necessary HPI components: duration

A

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

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21
Q

SOB necessary HPI components: associated signs and symptoms

A

cough, congestion, fever, chest pain

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22
Q

SOB necessary HPI components: context

A

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

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23
Q

SOB HPI components: relevant histories

A

CHF, COPD, asthma, PE, MI

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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)

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25
Q

common tests for SOB

A

heart enzymes: CK, CK-MB, troponin EKG: MI, arrhythmia CXR: pneumonia, pneumothorax, CHF, rib fx D-Dimer: PE and DVT

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26
Q

Abd pain body systems

A

appendix, stomach, small intestine, colon, gallbladder (GB), spleen, liver

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27
Q

Abd pain DDx

A

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

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28
Q

Abd pain necessary HPI components

A

location, PMH and PSH, assoc sx,

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29
Q

Abd pain necessary HPI components: location

A

4 quad + epigastric + suprapubic appendix is RLQ gallbladder is RUQ

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30
Q

Abd pain necessary HPI components: PMH

A

any similar sx in the past and # of episodes. eaten recently? what and when (fatty food assoc with GB)

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31
Q

Abd pain necessary HPI components: PSH

A

past surgical histories of -ectomies can rule out dx. appendectomy (appendix) and cholecystectomy (GB). Hysterectomy (uterus). hermia repair

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32
Q

Abd pain necessary HPI components: associated signs and symptoms

A

n/v, n/v/d, constipation, fever, dysuria

33
Q

Abd pain PEx

A

abd tenderness? where? rebound (pain on taking the hands off) and guarding distention bowl sound: normal, hyperactive, hypoactive?

34
Q

common tests for abd pain

A

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
Q

HA body system

A

head/brain

36
Q

HA DDx

A

meningitis, migraine, stroke, aneurysm, intercranial hemorrhage

37
Q

Stroke

A

ischemic stroke: blood clot or plaque hemorrhagic stroke: bleeding into brain tissue transient ischemic attack (TIA): temporary and no permanent damage

38
Q

HA drug: blood thinners

A

need to check if pt already taking blood thinners. common meds: Plavix, Coumadin (Warfarin), aspirin

39
Q

Aneurysm

A

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
Q

HA necessary HPI components

A

severity, quality, timing and duration, assoc sx

41
Q

HA necessary HPI components: severity and quality

A

description of headache mild, moderate, severe sharp, throbbing is it the worst they ever experienced? meningitis?

42
Q

HA necessary HPI components: timing and duration

A

when? gradual or sudden?

43
Q

HA necessary HPI components: associated signs and symptoms

A

vision changes, fever, stiff neck, focal weakness in any of the extremities, dysphasia

44
Q

HA PEx

A

neurologic findings A&E x3 facial droop slurred speech CN II-XII intact? facial muscle movement DTR (deep tendon reflexes) normal sensations?

45
Q

Common tests for HA

A

CT head: tumor, CVA (cardiovascular accident), ICH (intercranial hemorrhage) and aneurysm lumber puncture (LP): meningitis

46
Q

AMS body system

A

head/brain

47
Q

AMS definition

A

general changes in brain function such as confusion, memory loss and loss of alertness

48
Q

AMS DDx

A

stroke, aneurysm, drug OD, chronic dementia, UTI (can be a tipping pt for triggering AMS)

49
Q

AMS necessary HPI components

A

timing, duration, assoc sx, what is “normal” for the pt?

50
Q

AMS and intravenous tissue plasminogen activator (TPA)

A

“clot buster”: for acute ischemic stroke. need to be administered within 3 hours of onset and also need other eligibilities

51
Q

AMS necessary HPI components: associated signs and symptoms

A

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
Q

AMS PEx

A

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
Q

common tests for AMS

A

CT head: tumor, CVA, ICH and aneurysm UDS (urine drug screen): drug OD urinalysis (UA): UTI

54
Q

Flank pain body system

A

GU, especially kidney, ureter or bladder

55
Q

Flank pain DDx

A

nephrolithiasis (kidney stones), pyelonephritis (UTI moved up to kidney), UTI, hydronephrosis (fluid buildup in kidney)

56
Q

Flank pain necessary HPI components

A

severity, quality, assoc sx (radiation), PMH

57
Q

Flank pain necessary HPI components: severity

A

kidney stones often accompanied by severe pain

58
Q

Flank pain necessary HPI components: quality

A

if dull and achy - pyelonephiritis if severe - nephrolithiasis

59
Q

Flank pain necessary HPI components: associated signs and symptoms

A

radiation: kidney stone travels to ureter and bladder and pain radiates to suprapubic region. hematuria, dysuria, hesitancy, fever, nausea, vomitting

60
Q

Flank pain necessary HPI components: PMH

A

history of UTI or nephrolithiasis (removed surgically or passed spontaneously?)

61
Q

Flank pain PEx

A

CVAT (costovertebral angle tenderness)

62
Q

common tests for flank pain

A

urinalysis: UTI and hematuria CT scan of abd/pel without contrast: kidney stones

63
Q

Back pain body system

A

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
Q

Back pain DDx

A

lumber or thoracic strain chronic back pain herniated disc fractures degenerative discs

65
Q

Back pain necessary HPI components

A

location and radiation (assoc sx), timing and duration, context, modifying factors, PMH

66
Q

Back pain necessary HPI components: location and radiation

A

upper vs. lower left vs. right vs. on the spine pain may spread into the hip, legs or neck

67
Q

Back pain necessary HPI components: timing and duration

A

sudden onset? chronic pain? exacerbated recently?

68
Q

Back pain necessary HPI components: associated signs and symptoms

A

radiation of pain bilateral lower extremity (BLE) weakness or pain bowl/fecal or urinary incontinence (losing control) numbness or tingling to any extremities

69
Q

Back pain necessary HPI components: PMH

A

multiple presentation to ED? with the same cc?

70
Q

Back pain necessary HPI components: modifying factors

A

heat, ice, NSAIDs (non-steroidal anti-inflammatory drugs; e.g., tylenol), narcotics (which one?)

71
Q

Back pain PEx

A

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
Q

common tests for back pain

A

x-ray (C-, L-, T-spine): fx, dislocation CT scans: fx, dislocation MRI: herniated disc, pinched nerve (not done too much in ER)

73
Q

Motor vehicle collision

A

is not a cc, technically documentation of facts of the collision is important.

74
Q

MVC necessary HPI components

A

location, context

75
Q

MVC necessary HPI components: location

A

this is not the location of accident or pt’s seat or etc. where it hurts

76
Q

MVC necessary HPI components: context

A

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
Q

MVC PEx

A

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
Q

common lab tests for MVC

A

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
Q

common radiology tests for MVC

A

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

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