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ScribeAmerica ED Classroom Training > Course 2: Diseases > Flashcards

Course 2: Diseases Flashcards

1
Q

Course of diagnosis

A
  1. Subjective complaints and risk factors
  2. Differential diagnoses
  3. Objective evaluation
  4. Final diagnosis
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2
Q

Associated symptoms

A

Specific symptoms that raise the physician’s suspicion for a particular differential diagnosis

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3
Q

Pertinent negatives

A

Specific symptoms that are not present which lower the physician’s suspicion for a particular differential diagnosis

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4
Q

The Triple Threat

A

Hypertension (HTN), Hyperlipidemia (HLD), Diabetes Mellitus (DM)

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5
Q

Effects of chronically high blood glucose

A

Cerebrovascular accident, diabetic retinopathy, cardiac disease, renal failure, peripheral vascular disease, neuropathy

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6
Q

Effects of chronically high blood pressure

A

Cerebrovascular accident, retinopathy, cardiac disease, congestive heart failure, renal failure

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7
Q

Effects of chronically high cholesterol

A

Cerebrovascular accident, cardiac disease, pancreatitis

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8
Q

Coronary Artery Disease (CAD) Etiology

A

Narrowing of the coronary arteries causing reduced blood flow to the heart muscle

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9
Q

Coronary Artery Disease (CAD) Risk Factors

A

HTN, HLD, DM, Smoking, Family history of CAD/MI < 55 years old

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10
Q

Coronary Artery Disease (CAD) Chief Complaint

A

Angina: Exertional chest pain or chest pressure

Modifying Factors: Worse with exertion, Improved with rest and/or nitroglycerin

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11
Q

Coronary Artery Disease (CAD) Associated Symptoms

A

Shortness of breath

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12
Q

Coronary Artery Disease (CAD) Medications

A

Nitroglycerin (NTG) to manage angina; Acetylsalicylic acid (ASA) to decrease the chance of a blockage

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13
Q

Coronary Artery Disease (CAD) Method of Diagnosis

A

Cardiac catheterization (CAD cannot be diagnosed in the ED)

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14
Q

Coronary Artery Disease (CAD) Pertinent Scribe Information

A

A patient has CAD if they have a past medical history of angina, MI, CABG, cardiac stents, or angioplasty

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15
Q

Myocardial Infarction (MI) Etiology

A

Acute blockage of the coronary arteries causing ischemia or infarct to the heart muscle

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16
Q

Myocardial Infarction (MI) Risk Factors

A

CAD, HTN, HLD, DM, Smoking, Family history of CAD < 55 years old

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17
Q

Myocardial Infarction (MI) Chief Complaint

A

Chest pain or chest pressure

Modifying Factors: Worse with exertion, Improved with rest and/or nitroglycerin

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18
Q

Myocardial Infarction (MI) Associated Symptoms

A

Diaphoresis, nausea/vomiting, shortness of breath

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19
Q

Myocardial Infarction (MI) Medications

A

Acetylsalicylic acid (ASA), Nitroglycerin (NTG), Thrombolytic (Heparin)

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20
Q

Myocardial Infarction (MI) Method of Diagnosis

A

STEMI: Diagnosed by EKG (may also have elevated troponin)

Non-STEMI: Diagnosed by elevated troponin

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21
Q

Myocardial Infarction (MI) Pertinent Scribe Information

A

Document ED arrival time, EKG time, ASA time, cath lab departure time; STEMI patients must get to the cath lab within 90 minutes of arrival

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22
Q

Congestive Heart Failure (CHF) Etiology

A

The heart becomes enlarged, inefficient, and congested with excess fluid

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23
Q

Congestive Heart Failure (CHF) Risk Factors

A

History of CHF, HTN, HLD, DM, Kidney disease, Smoking

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24
Q

Congestive Heart Failure (CHF) Chief Complaint

A

Shortness of breath

Modifying Factors: Worse with lying flat (orthopnea), Worse with exertion - Dyspnea on Exertion (DOE), Episodically worse at night - Paroxysmal Nocturnal Dyspnea (PND)

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25
Q

Congestive Heart Failure (CHF) Associated Symptoms

A

Bilateral lower extremity swelling, fatigue, cough

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26
Q

Congestive Heart Failure (CHF) Medications

A

Diuretics (Lasix, Furosemide) → Intended to cause urination of excess fluid

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27
Q

Congestive Heart Failure (CHF) Physical Exam Findings

A

Rales (crackles) in lungs, Jugular Vein Distention (JVD), Pedal edema

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28
Q

Congestive Heart Failure (CHF) Method of Diagnosis

A

CXR and elevated B-type Natriuretic Peptide (BNP)

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29
Q

Congestive Heart Failure (CHF) Pertinent Scribe Information

A

If patient has CHF history, document their current dosage of Lasix; search echocardiograms and document the cardiac output (EF or ejection fraction) and cardiac valve function

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30
Q

Atrial Fibrillation (A Fib) Etiology

A

Electrical abnormalities in the “wiring” of the heart causes the top of the heart (atria) to quiver abnormally

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31
Q

Atrial Fibrillation (A Fib) Risk Factors

A

Paroxysmal A Fib, Chronic A Fib, Alcoholism

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32
Q

Atrial Fibrillation (A Fib) Chief Complaint

A

Palpitations (fast, pounding, irregular)

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33
Q

Atrial Fibrillation (A Fib) Associated Symptoms

A

Global weakness, fatigue, lightheadedness

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34
Q

Atrial Fibrillation (A Fib) Medications

A

Coumadin/Warfarin (blood thinner), Digoxin (slows down heart rate)

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35
Q

Atrial Fibrillation (A Fib) Physical Exam Findings

A

Irregularly irregular rhythm

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36
Q

Atrial Fibrillation (A Fib) Method of Diagnosis

A

EKG

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37
Q

Atrial Fibrillation (A Fib) Pertinent Scribe Information

A

ED concern is Rapid Ventricular Response (RVR) which is A Fib with a rate greater than 100 bpm; patients who have A Fib are at increased risk for developing blood clots and often take a blood thinner

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38
Q

Pulmonary Embolism (PE) Etiology

A

A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs

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39
Q

Pulmonary Embolism (PE) Risk Factors

A

Known DVT, Past medical history of DVT/PE, Family history of DVT/PE, Recent surgery, Cancer, A Fib, Immobility, Pregnancy, Birth control pills (BCPs), Smoking

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40
Q

Pulmonary Embolism (PE) Chief Complaint

A

Chest pain

Modifying Factors: Worse with deep breaths (pleuritic)

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41
Q

Pulmonary Embolism (PE) Associated Symptoms

A

Shortness of breath, Hypoxia (low oxygen saturation), Tachycardia (elevated heart rate)

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42
Q

Pulmonary Embolism (PE) Method of Diagnosis

A

Screening tool: D-Dimer

Diagnostic tool: CTA chest (CT with IV contrast)

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43
Q

Pulmonary Embolism (PE) Pertinent Scribe Information

A

A deep vein thrombosis (DVT) is a blood clot in an extremity (not in the lungs); symptoms of a DVT include extremity pain and swelling and has the same risk factors as a PE; a DVT is diagnosed by an ultrasound of that extremity

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44
Q

Pneumonia (PNA) Etiology

A

Infiltrate (bacterial infection) and inflammation inside the lung

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45
Q

Pneumonia (PNA) Risk Factors

A

Elderly, Bedridden, Immunocompromised, Recent chest injury, Recent surgery

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46
Q

Pneumonia (PNA) Chief Complaint

A

Productive cough

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47
Q

Pneumonia (PNA) Associated Symptoms

A

Shortness of breath, fever, chest pain

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48
Q

Pneumonia (PNA) Medications

A

Rocephin and Zithromax (antibiotics)

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49
Q

Pneumonia (PNA) Physical Exam Findings

A

Rhonchi

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50
Q

Pneumonia (PNA) Method of Diagnosis

A

CXR

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51
Q

Pneumonia (PNA) Pertinent Scribe Information

A

Community Acquired Pneumonia (CAP) protocol requires documenting antibiotics (abx), vital signs, SaO2, mental status, and blood cultures

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52
Q

Chronic Obstructive Pulmonary Disease (COPD) Etiology

A

Long-term damage to the lungs’ alveoli (emphysema) along with inflammation and mucus production (chronic bronchitis)

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53
Q

Chronic Obstructive Pulmonary Disease (COPD) Risk Factors

A

Smoking

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54
Q

Chronic Obstructive Pulmonary Disease (COPD) Chief Complaint

A

Shortness of breath

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55
Q

Chronic Obstructive Pulmonary Disease (COPD) Associated Symptoms

A

Wheezing, cough, chest tightness

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56
Q

Chronic Obstructive Pulmonary Disease (COPD) Treatment

A

Bronchodilators, supplemental oxygen, corticosteroids, ventilatory support

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57
Q

Chronic Obstructive Pulmonary Disease (COPD) Physical Exam Findings

A

Decreased breath sounds, wheezes

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58
Q

Chronic Obstructive Pulmonary Disease (COPD) Method of Diagnosis

A

COPD not diagnosed in ED; CXR ordered to check for pneumonia in ED due to acute exacerbation of COPD due to infection

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59
Q

Chronic Obstructive Pulmonary Disease (COPD) Pertinent Scribe Information

A

Document the patient’s baseline O2 requirement

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60
Q

Asthma Etiology

A

Constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a “bronchospasm”

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61
Q

Asthma Risk Factors

A

Personal or family history of asthma, Smoking, Occupational exposures, Obesity, Allergies

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62
Q

Asthma Chief Complaint

A

Shortness of breath

Modifying Factors: Improved with “breathing treatments”, Exacerbated by certain triggers

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63
Q

Asthma Associated Symptoms

A

Wheezing

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64
Q

Asthma Treatment

A

Bronchodilators, corticosteroids, inhalers (inhaled corticosteroids) or nebulizers

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65
Q

Asthma Physical Exam Findings

A

Wheezes (inspiratory or expiratory)

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66
Q

Asthma Pertinent Scribe Information

A

Be sure to document the patient’s oxygen saturation; if the patient becomes hypoxic, they may require supplemental oxygen or additional interventions

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67
Q

Cerebrovascular accident (CVA) vs Transient Ischemic Attack (TIA)

A

CVA and TIA both involve abnormal blood flow in the brain; CVA causes permanent brain damage, while TIA does not

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68
Q

Ischemic CVA Etiology

A

Blockage of the arteries supplying blood to the brain resulting in permanent brain damage

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69
Q

Ischemic CVA Risk Factors

A

HTN, HLD, DM, Smoking, History of TIA/CVA, Family history of TIA/CVA, A Fib

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70
Q

Ischemic CVA Chief Complaint

A

Unilateral focal neurological deficits: One-sided weakness/numbness or changes in speech/vision

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71
Q

Ischemic CVA Medications

A

tPA (thrombolytic) will be administered if the patient meets the criteria

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72
Q

Ischemic CVA Physical Exam Findings

A

Unilateral neurological deficits

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73
Q

Ischemic CVA Method of Diagnosis

A

Clinically, following a CT head in order to rule out hemorrhagic CVA

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74
Q

Ischemic CVA Pertinent Scribe Information

A

Document the date and time they were “last known well” (at baseline) as well as the source of this information; this is used to assess eligibility for tPA; Also, document tPA considered and if it was not indicated due to:

  • Onset greater than 3 hours or unknown/unreliable time of onset
  • Symptoms are rapidly improving
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75
Q

Hemorrhagic CVA Etiology

A

Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain

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76
Q

Hemorrhagic CVA Risk Factors

A

HTN, Anticoagulant use, Recent head trauma

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77
Q

Hemorrhagic CVA Chief Complaint

A

Severe, sudden onset (“thunderclap”) headache

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78
Q

Hemorrhagic CVA Associated Symptoms

A

Nausea, AMS, Focal neurological deficits (unilateral weakness, numbness, tingling, changes in speech/vision)

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79
Q

Hemorrhagic CVA Physical Exam Findings

A

Unilateral neurological deficits

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80
Q

Hemorrhagic CVA Method of Diagnosis

A

Combination of CT head, clinical presentation, and in rare cases lumbar puncture

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81
Q

Hemorrhagic CVA Pertinent Scribe Information

A

Document “tPA not administered due to hemorrhage”

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82
Q

Transient Ischemic Attack (TIA) Etiology

A

Vascular changes temporarily deprive a part of the brain of oxygen (symptoms usually last less than 1 hour)

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83
Q

Transient Ischemic Attack (TIA) Risk Factors

A

HTN, HLD, DM, Smoking, History of TIA/CVA, Family history of TIA/CVA, A Fib

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84
Q

Transient Ischemic Attack (TIA) Chief Complaint

A

Transient focal neurological deficits (changes in speech, vision, strength, or sensation)

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85
Q

Transient Ischemic Attack (TIA) Method of Diagnosis

A

Clinically

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86
Q

Transient Ischemic Attack (TIA) Pertinent Scribe Information

A

TIA’s are also known as “mini strokes” because symptoms usually last < 1 hour and there is no permanent brain damage; document TPA considered and not indicated due to the fact that symptoms are resolved

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87
Q

Meningitis Etiology

A

Inflammation and infection of the meninges (the sac surrounding the brain and spinal cord)

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88
Q

Meningitis Risk Factors

A

Recent international travel, Recent exposure to a sick contact

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89
Q

Meningitis Chief Complaint

A

Headache, neck pain or stiffness, fever, AMS

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90
Q

Meningitis Physical Exam Findings

A

Meningismus, Nuchal rigidity

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91
Q

Meningitis Method of Diagnosis

A

Lumbar puncture (LP)

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92
Q

Meningitis Pertinent Scribe Information

A

Meningitis is notoriously hard to diagnose; any person with a headache or fever will likely be asked if they have headache, neck pain, or fever; be sure to document all of the symptoms that the patient has and does not have

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93
Q

Altered Mental Status (AMS) Etiology

A

Globalized confusion, caused by things that affect the entire brain; most common are hypoglycemia, infection, intoxication, and neurological

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94
Q

Altered Mental Status (AMS) Risk Factors

A

Known infection (commonly UTI in elderly patients), Diabetic, Elderly, Dementia, Alcohol use, Drug use

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95
Q

Altered Mental Status (AMS) Chief Complaint

A

Confusion, Decreased responsiveness, Unresponsive

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96
Q

Altered Mental Status (AMS) Method of Diagnosis

A

Case-dependent

97
Q

Altered Mental Status (AMS) Pertinent Scribe Information

A

AMS is very different compared to a focal neurological deficit (FND); AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar); focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain

98
Q

Syncope (Passing Out) Etiology

A

Temporary loss of blood supply to the brain leading to loss of consciousness; there are a variety of causes, with the most common being vasovagal and low blood volume (dehydration/hypovolemia); occasionally syncope occurs due to cardiac/neurological issues

99
Q

Syncope (Passing Out) Chief Complaint

A

Loss of consciousness (LOC), Fainting or passing out

100
Q

Syncope (Passing Out) Pertinent Scribe Information

A

Document what happened:

  1. Before the episode
  2. During the episode
  3. After the episode (were they sleepy, groggy, confused, or had slurred speech?; may be postictal)
  4. How the patient is currently feeling

Were they near-syncopal? Did they almost pass out or have lightheadedness?

Patients who have had a syncopal episode may have also had a seizure so document any seizure-like activity

101
Q

Appendicitis Etiology

A

Infection of the appendix causes inflammation and blockage, possibly leading to rupture

102
Q

Appendicitis Chief Complaint

A

Abdominal pain

Location: RLQ

Modifying Factors: Worse with movement

103
Q

Appendicitis Associated Symptoms

A

Nausea, vomiting, fever, decreased appetite

104
Q

Appendicitis Physical Exam Findings

A

RLQ tenderness, McBurney’s point tenderness

105
Q

Appendicitis Method of Diagnosis

A

CT abdomen/pelvis with PO contrast

106
Q

Cholelithiasis Etiology

A

Minerals from the liver’s bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder

107
Q

Cholelithiasis Risk Factors

A

Female 40 and older, Native American or Hispanic or Mexican origin, Being overweight or obese, Being sedentary, Being pregnant, Eating a high-fat diet

108
Q

Cholelithiasis Chief Complaint

A

Abdominal pain

Location: RUQ

Quality: Typically sharp

Modifying Factors: Worse with eating fatty foods, deep breaths, and palpation

109
Q

Cholelithiasis Physical Exam Findings

A

RUQ tenderness, Murphy’s sign (sign of acute cholecystitis)

110
Q

Cholelithiasis Method of Diagnosis

A

Abdominal ultrasound (RUQ)

111
Q

Cholelithiasis Pertinent Scribe Information

A

As a complication, patients can develop acute cholecystitis; this can be indication for an emergent cholecystectomy

112
Q

Urinary Tract Infection (UTI) Etiology

A

Infection of the urinary tract (bladder and/or urethra)

113
Q

Urinary Tract Infection (UTI) Risk Factors

114
Q

Urinary Tract Infection (UTI) Chief Complaint

A

Painful urination (dysuria)

115
Q

Urinary Tract Infection (UTI) Associated Symptoms

A

Urinary frequency, urgency, malodorous urine, AMS (elderly)

116
Q

Urinary Tract Infection (UTI) Physical Exam Findings

A

Suprapubic tenderness

117
Q

Urinary Tract Infection (UTI) Method of Diagnosis

A

Urine dip or urinalysis (UA)

118
Q

Urinary Tract Infection (UTI) Pertinent Scribe Information

A

A UTI left untreated can migrate to the kidneys via the ureters causing pyelonephritis; in these patients, their urinary symptoms may be similar but also include flank pain, with fever, malaise, and nausea/vomiting; a PE finding of costovertebral angle (CVA) tenderness and a positive urine can diagnose this condition but may be further evaluated with a CT A/P; in most cases, these patients require admission and more aggressive treatment with IV antibiotics

119
Q

Kidney Stones Etiology

A

A kidney stone dislodged from the kidney and begins traveling down the ureter; the stone scrapes and irritates the ureter, causing severe flank pain and bloody urine

120
Q

Kidney Stones Chief Complaint

A

Flank pain

121
Q

Kidney Stones Associated Symptoms

A

Blood in the urine (hematuria), Nausea/vomiting, Unable to void

122
Q

Kidney Stones Physical Exam Findings

A

Costovertebral angle (CVA) tenderness

123
Q

Kidney Stones Method of Diagnosis

A

CT abdomen/pelvis, Red blood cells in the UA may be a clue

124
Q

Kidney Stones Pertinent Scribe Information

A

Common naming: Nephrolithiasis, Renal calculi, Urolithiasis

125
Q

Ectopic Pregnancy Etiology

A

Fertilized egg develops outside the uterus, usually in the fallopian tube; high risk for rupture and death

126
Q

Ectopic Pregnancy Risk Factors

A

Pregnant female (HCG positive), STD (PID)

127
Q

Ectopic Pregnancy Chief Complaint

A

Lower abdominal pain, Vaginal bleeding while pregnant

128
Q

Ectopic Pregnancy Method of Diagnosis

A

Ultrasound pelvis (determine location of fetus; intrauterine is a normal finding)

129
Q

Ectopic Pregnancy Pertinent Scribe Information

A

Any female with a positive pregnancy test who is complaining of lower abdominal pain or vaginal bleeding will always receive an US pelvis to rule out a possible ectopic pregnancy

130
Q

Spinal Cord Injury Etiology

A

Bruise, partial tear, or complete tear of the spinal cord

131
Q

Spinal Cord Injury Chief Complaint

A

Neck or back pain, Bilateral extremity weakness

132
Q

Spinal Cord Injury Method of Diagnosis

A

CT C-spine, T-spine, and/or L-spine

133
Q

Pneumothorax Etiology

A

Collapsed lung

134
Q

Pneumothorax Chief Complaint

A

Shortness of breath, One-sided chest pain

135
Q

Pneumothorax Method of Diagnosis

136
Q

Internal Organ Injury Etiology

A

Rupture leading to hemorrhage/bleeding

137
Q

Internal Organ Injury Chief Complaint

A

Abdominal pain, Abdominal distension

138
Q

Internal Organ Injury Method of Diagnosis

A

CT abdomen

139
Q

Fracture Etiology

A

Trauma creates pain/swelling

140
Q

Fracture Chief Complaint

A

Pain, Swelling, Bruising, Use limitation

141
Q

Fracture Method of Diagnosis

142
Q

Trauma Documentation Requirements

A
  1. Mechanism of Injury → HPI
  2. Patient on blood thinners? → HPI
  3. Glasgow Coma Scale (GCS) → PE
143
Q

Concerning symptoms s/p trauma

A

LOC, Confusion, Numbness, Weakness, Headache, Neck/back pain, Shortness of breath, Chest pain, Abdominal pain

Be sure to document positive and negative for each symptom

144
Q

Back Pain Etiology

A

Deterioration or strain of the back creates pain that is worse with movement

145
Q

Back Pain Risk Factors

A

Chronic back pain, Age, Physically demanding job

146
Q

Back Pain Chief Complaint

A

Back pain (mostly lumbar)

147
Q

Back Pain Physical Exam Findings

A

Paraspinal tenderness, Positive straight leg raise (+ SLR diagnoses Sciatica, which is back pain that radiates down the legs)

148
Q

Back Pain Pertinent Scribe Information

A

Remember to document if there is any recent trauma related to the back pain; trauma increases the physician’s concern about possible spinal injury; concerning symptoms include lower extremity weakness/numbness and bowel or bladder incontinence

149
Q

Abdominal Aortic Aneurysm (AAA) Etiology

A

Widened and weakened arterial wall at risk of rupture

150
Q

Abdominal Aortic Aneurysm (AAA) Risk Factors

A

Age, HTN, Smoking, CAD

151
Q

Abdominal Aortic Aneurysm (AAA) Chief Complaint

A

Midline abdominal pain

152
Q

Abdominal Aortic Aneurysm (AAA) Physical Exam Findings

A

Midline pulsatile abdominal mass, Abdominal bruit, Unequal femoral pulses, Hypotension

153
Q

Abdominal Aortic Aneurysm (AAA) Method of Diagnosis

A

CT abdomen/pelvis with IV contrast

154
Q

Aortic Dissection Etiology

A

Separation of the muscular wall from the membrane of the artery, putting the patient at risk of aortic rupture and death

155
Q

Aortic Dissection Risk Factors

A

Age, HTN, Connective Tissue Disorder

156
Q

Aortic Dissection Chief Complaint

A

Ripping or tearing chest pain radiating to the back

157
Q

Aortic Dissection Physical Exam Findings

A

Unequal brachial or radial pulses, hypotension

158
Q

Aortic Dissection Method of Diagnosis

A

CT chest with IV contrast

159
Q

Sepsis Etiology

A

An infection that gets into the bloodstream; in response to a systemic infection, chemicals released from the immune system cause inflammation throughout the entire body, potentially leading to shock and death

160
Q

Sepsis Risk Factors

A

Current infection: viral, bacterial, or fungal; Compromised immune system; Open wounds; Chronically ill; Young/old; Having an intense invasive device such as an IVC or breathing tube

161
Q

Sepsis Chief Complaint

A

Fever, AMS

162
Q

Sepsis Associated Symptoms

A

Symptoms vary, depending on the source of the infection

163
Q

Sepsis Pertinent Scribe Information

A

Given that sepsis is a time-sensitive, life-threatening condition, healthcare providers must act quickly when trying to diagnose and treat this infection; think of the investigation and treatment as a series of four stages

164
Q

Sepsis Protocol

A
  1. Stage 1: Trending Vital Signs
  2. Stage 2: Monitoring Labs
  3. Stage 3: Preliminary Management
  4. Stage 4: Finalized Management
165
Q

Sepsis Protocol Stage 1: Trending Vital Signs

A

Looking for tachycardia (HR > 100 bpm), fever (temp > 100.4 °F), hypotension, and tachypnea

166
Q

Sepsis Protocol Stage 2: Monitoring Labs

A

Physician will carefully monitor the patient’s CBC to look for leukocytosis (elevated WBC) in addition to checking lactate, which indicates large amounts of dying cells

167
Q

Sepsis Protocol Stage 3: Preliminary Management

A

Order a blood culture, start broad spectrum antibiotics (Zosyn, Vancomycin, Rocephin), and obtain broad infectious workup to look for source

168
Q

Sepsis Protocol Stage 4: Finalized Management

A

Once the blood cultures return in a few days, there will likely be a shift in the antibiotic regimen based on the identity of the pathogen(s)

169
Q

Cellulitis Etiology

A

Infection of the skin cells

170
Q

Cellulitis Chief Complaint

A

Red, swollen, painful, and sometimes warm area of the skin

171
Q

Cellulitis Medications

A

Antibiotics

172
Q

Cellulitis Physical Exam Findings

A

Erythema, Edema, Increased warmth (calor), Induration

173
Q

Cellulitis Method of Diagnosis

A

Clinically

174
Q

Cellulitis Pertinent Scribe Information

A

If the patient has evidence of quickly spreading cellulitis, they may require a hospitalization for IV antibiotics

175
Q

Abscess Etiology

A

Infection of skin with an underlying collection of pus

176
Q

Abscess Chief Complaint

A

Red, swollen, painful lump

177
Q

Abscess Medications

A

Antibiotics

178
Q

Abscess Physical Exam Findings

A

Erythema, Edema, Increased warmth (calor), Induration, Fluctuance (pus-pocket)

179
Q

Abscess Method of Diagnosis

A

Clinically

180
Q

Abscess Pertinent Scribe Information

A

Abscesses must have the pus-pocket drained; remember to always document incision and drainage (I&D) procedure notes for abscesses

181
Q

Headache Etiology

A

Pain in any region of the head

182
Q

Headache Chief Complaint

183
Q

Seizure Etiology

A

Abnormal electrical activity in the brain

184
Q

Seizure Chief Complaint

A

Seizure activity or syncope

185
Q

Bell’s Palsy Etiology

A

Inflammation or viral infection of the facial nerve causes one-sided weakness of the entire face

186
Q

Bell’s Palsy Chief Complaint

A

Facial droop

187
Q

Vertigo Etiology

A

The sensation that you, or the environment around you, is spinning

188
Q

Vertigo Chief Complaint

A

Room spinning

189
Q

Diabetic Ketoacidosis (DKA) Etiology

A

Shortage of insulin resulting in hyperglycemia and production of ketones

190
Q

Diabetic Ketoacidosis (DKA) Chief Complaint

191
Q

Suicidal Ideation Etiology

A

Thinking about suicide

192
Q

Suicidal Ideation Chief Complaint

A

Suicidal thoughts

193
Q

Ovarian Torsion Etiology

A

Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in infarct of the ovary

194
Q

Ovarian Torsion Chief Complaint

A

Abdominal pain

195
Q

Allergic Reaction Etiology

A

Immune response causing an inflammatory reaction consisting of swelling, itching (pruritus), and rash

196
Q

Allergic Reaction Chief Complaint

197
Q

Bronchitis Etiology

A

Inflammation of the lining of the bronchial tubes

198
Q

Bronchitis Chief Complaint

199
Q

Covid Etiology

A

Coronaviruses are a family of viruses that can cause illnesses such as the common cold and severe acute respiratory syndrome

200
Q

Covid Chief Complaint

A

Fever, Cough, Tiredness

201
Q

Otitis Media (OM) Etiology

A

Viral or bacterial infection of the tympanic membrane (TM) causing ear pain and pressure

202
Q

Otitis Media (OM) Chief Complaint

203
Q

Rash Etiology

A

Changes in the skin’s appearance due to systemic or localized reaction; may be from medication, virus, bacteria, fungus, insect, etc.

204
Q

Rash Chief Complaint

205
Q

Upper Respiratory Infection (URI) Etiology

A

Most often viral infection causes congestion, cough, and inflammation of the upper airway

206
Q

Upper Respiratory Infection (URI) Chief Complaint

A

Cough, Runny nose, Sore throat

207
Q

C. Diff Colitis Etiology

A

Opportunistic bacteria that causes persistent diarrhea

208
Q

C. Diff Colitis Chief Complaint

209
Q

Diverticulitis Etiology

A

Acute inflammation and infection of abnormal pockets of the large intestine, known as diverticula

210
Q

Diverticulitis Chief Complaint

211
Q

Gastroesophageal Reflux Disease (GERD) Etiology

A

Stomach acid regurgitating into the esophagus

212
Q

Gastroesophageal Reflux Disease (GERD) Chief Complaint

A

Epigastric pain

213
Q

GI Bleed Etiology

A

Hemorrhage in the upper or lower GI tract that can lead to anemia

214
Q

GI Bleed Chief Complaint

A

Hematemesis, Coffee ground emesis, Hematochezia, Melena

215
Q

Gastritis Etiology

A

Irritated stomach with vomiting; “stomach ache”

216
Q

Gastritis Chief Complaint

A

Abdominal pain

217
Q

Gastroenteritis Etiology

A

Vomiting and diarrhea; “GI bug” often viral or bacterial

218
Q

Gastroenteritis Chief Complaint

A

Vomiting and diarrhea

219
Q

Pancreatitis Etiology

A

Inflammation of the pancreas

220
Q

Pancreatitis Chief Complaint

A

LUQ and epigastric pain

221
Q

Small Bowel Obstruction (SBO) Etiology

A

Physical blockage of the small intestine

222
Q

Small Bowel Obstruction (SBO) Chief Complaint

A

Abdominal pain, Vomiting, Constipation

223
Q

Diabetes Mellitus (DM) Etiology

A

The inadequacy of insulin in controlling the blood glucose level (insulin resistance)

224
Q

Diabetes Mellitus (DM) Risk Factors

A

Family history of DM, Obesity, High carb diet, Lack of exercise

225
Q

Diabetes Mellitus (DM) Chief Complaint

A

Unusual weight loss or gain, Polyuria, Polydipsia, Blurred vision, Nausea/vomiting

226
Q

Diabetes Mellitus (DM) Medications

A

Insulin Dependent: Humalog, Lantus

Non-Insulin Dependent: Oral meds like metformin, glyburide

227
Q

Diabetes Mellitus (DM) Method of Diagnosis

A

Fasting blood glucose, Hemoglobin A1C

228
Q

Hypertension (HTN) Etiology

A

Higher than normal pressure of blood pushing against the walls of your arteries

229
Q

Hypertension (HTN) Risk Factors

A

DM, Obesity, Age, Smoking, Alcohol use, Family history of HTN

230
Q

Hypertension (HTN) Chief Complaint

A

Usually has no warning signs or symptoms

231
Q

Hypertension (HTN) Medications

A

Different blood pressure medicines can work in different ways to keep blood pressure at a healthy level:

  • Causing the body to get rid of water, which decreases the amount of water and salt in the body to a healthy level
  • Relaxing the blood vessels
  • Making the heart beat with less force
  • Blocking nerve activity that can restrict the blood vessels
232
Q

Hypertension (HTN) Method of Diagnosis

A

Having blood pressure measures consistently above normal may result in a diagnosis of high blood pressure (or hypertension)

233
Q

Hypertension (HTN) Pertinent Scribe Information

A

Hypertension puts people at a higher risk for many diseases because of blood vessel damage throughout the body

234
Q

Hyperlipidemia (HLD) Etiology

A

An elevated level of lipid in the blood causes plaque buildup along arterial walls

235
Q

Hyperlipidemia (HLD) Risk Factors

A

Family history of HLD, Obesity, High lipid diet (high in saturated fats), Alcohol use, Physical inactivity

236
Q

Hyperlipidemia (HLD) Chief Complaint

A

Usually has no warning signs or symptoms

237
Q

Hyperlipidemia (HLD) Medications

238
Q

Hyperlipidemia (HLD) Method of Diagnosis

A

Not often done in the ED, more relevant in the setting of being a risk factor for other emergent diseases

ScribeAmerica ED Classroom Training (5 decks)

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