Course 2: Pathophysiology Flashcards
Pertinent Positives
Specific symptoms that raise the physician’s suspicion for a particular disease.
Pertinent Negatives
Specific symptoms that are not present which cause the physician to doubt certain diagnoses.
Timing
Constant
Intermittent
Waxing and Waning
CAD: etiology
Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina.
Angina
Chest pain specifically due to heart-muscle ischemia.
CAD: catch phrase
Chest pain with physical exertion.
CAD: chief complaint
Chest pain or Chest pressure: worse with exertion, improved by rest or NTG.
CAD: assoc. med.
ASA 324mg PO
NTG 0.4mg SL
CAD: diagnosed by
Cardiac catheterization (not diagnosed in ED)
CAD: scribe alert
- CAD is the single greatest risk factor for MI.
- Stress tests or Cardiac Catheterization assess the severity of CAD.
- A pt has CAD if they have a PMHx pf Angina, MI, CABG, Cardiac stents, or Angioplasty.
- Every pt complaining of CP should always receive Aspirin 324 mg PO, unless it was given PTA or if it is contraindicated due to bleeding or allergy.
MI (stemi, non-stemi): etiology
Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle.
MI (stemi, non-stemi): catch phrase
Chest pressure with diaphoresis, N/V, and SOB
MI (stemi, non-stemi): risk factors
CAD, HTN, HLD, DM, Smoker, FHx of CA
MI (stemi, non-stemi): CC
Chest pain or chest pressure
MI (stemi, non-stemi): diagnosed by
EKC(stemi) or elevated Troponin (non-stemi)
MI (stemi, non-stemi): assoc. med
ASA
NTG
B-Blocker
Thrombolytic (Heparin)
MI (stemi, non-stemi): scribe alert
- Acute MI pts must receive ASA 324mg as soon as possible.
2. STEMI pts must get to Cath-lab within 90 minutes of arrival. Document ED arrival and depart times.
CHF: etiology
The heart becomes enlarged, inefficient, and congested with excess fluid.
CHF: catch phrase
SOB with pedal edema and orthopnea.
CHF: CC
SOB:
worse when lying flat (orhtopnea)
PND
dyspnea on excertion (DOE)
PND
Paroxysmal nocturnal dyspnea
Orthopnea
SOB when lying flat
CHF: physical exam
Rales in lungs, JVD, in neck, pitting pedal edema.
CHF: assoc. med
diuretics (Lasix, Furosemide) –> Urinate extra fluid.
CHF: Diagnosed by
CXR or elevated BNP
BNP
B-type Natriuretic Peptide
CHF: scribe alert
You can think of CHF as a fluid traffic jam in the heart; fluid gets backed up the neck (JVD) and down the legs (pedal edema).
A Fib: etiology
Electrical abnormalities in the “wiring” of the heart causes the top of the heart (atria) to quiver abnormally.
A Fib: CC
Palpitations (Fast, Pounding, Irregular)
A Fib: risk factors
Paroxysmal A Fib, Chronic A Fib
A Fib: physical exam
Irregularly irregular rhythm, Tachycardia
A Fib: diagnosed by
EKG
A Fib: assoc. med
Coumadin (Warfarin), Digoxin
Coumadin (Warfarin)
Blood thinner, prevents blood clots in atria
Digoxin
Slows down heart rate
A Fib: scribe alert
ED concern is RVR, Theese patients will often be “cardioverted” which means they are put back into a regular rhythm, known as NSR
RVR
Rapid Ventricular Response
Non-cardiac CP: Pericarditis
Inflammation of the sac surrounding the heart causing CP.
Non-cardiac CP: Pleurisy
Inflammation of the sac surrounding the lungs causing pleuritic CP.
Non-cardiac CP: Costochondritis
Irritation of the ribs causing CP worsened by pressing on the sternum.
Non-cardiac CP:
Chest Wall Pain
Irritation of the chest wall causing pain with palpation of the chest.
Non-cardiac CP: Pleural Effusion
Fluid collecting around the lungs causing SOB or CP
MI
Heart attack
Diagnosed by:
EKG (STEMI) or Elevated Troponin (Non- STEMI)
A Fib
Electrical problem
Diagnosed by:
EKG
CHF
Fluid traffic jam
Diagnosed by:
CXR or Elevated BNP
CAD
Major risk factor for MI
Diagnosed by:
Positive cardiac catheterization (not in ED)
Angina
Symptom of CAD
Diagnosed by:
Exertional CP with Hx of CAD
PE: etiology
A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs
PE: catch phrase
Pleuritic chest pain with tachycardia and hypoxia
PE: risk factor
Known DVT, PMHx of DVT or PE, FHx, Recent surgery, Cancer, A Fib, Immobility, Pregnancy, BCP, Smoking
PE: CC
SOB or Pleuritic chest pain (CO worse with deep breaths)
PE: diagnosed by
CTA Chest or VQ scan.
D-dimer
CTA Chest
CT Chest with IV contrast
D-dimer
aids in detecting clots, but cannot diagnose a PE.
PNA: etiology
Infiltrate (bacterial infection) and inflammation inside the lung
PNA: catch phrase
Productive cough with fever
PNA : risk factors
Elderly, bedridden, recent chest injury, recent surgery
PNA: CC
SOB or productive cough
PNA: assoc. med
Rocephin and Zithromax (Abx)
PNA: assoc. Sx
Cough with sputum, fever, CP
PNA: physical exam
Rhonchi
PNA: diagnosed by
CXR
PNA: scribe alert
Core measure: CAP protocol applies to pts with PNA. CAP protocol requires documenting Abx, vital signs, SaO2, mental status and blood cultures
CAP
Community Acquired Pneumonia
PTX
Pneumothorax
PTX: etiology
Collapsed lung due to trauma or a spontaneous small rupture of the lung
PTX: CC
SOB and one-sided chest pain:
Sudden onset
Often trauma pts
PTX: physical exam
Absent breath sounds unilaterally
PTX: diagnosed by
CXR
PTX: scribe alert
Document the percentage of lung collapsed (eg. 20% PTX). These pts will have a chest tube placed to reinflate the lung.
COPD: etiology
Long-term damage to the lung’s alveoli (emphysema) along with inflammation and mucous production (chronic bronchitis)
COPD: risk factors
Smoking
COPD: CC
SOB
COPD: physical exam
Decreases breath sounds, wheezes, rales
COPD: assoc. med
Home O2 (document how much O2 they use at baseline).
COPD: diagnosed by
CXR and hx of smoking
RAD
Reactive Airway Disease
RAD: etiology
Constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as “bronchospasm”.
RAD: CC
SOB/Wheezing:
Improved by nebulizer “breathing treatments” (bronchodilators)
RAD: physical exam
Wheezes (Inspiratory or Expiratory)
RAD: assoc. med
Inhalers, Nebulizers, Corticosteroids
RAD: diagnosed by
Clinically
RAD: scribe alert
The physician will ask the asthma pt:
- Do they have a home nebulizer (machine)?
- Have they been on steroids recently?
- Hx of hospitalization for asthma?
- Hx of intubation (breathing tube)?
- Asthma trigger?
PE
Pleuritic CP with tachycardia and hypoxia
Diagnosed by:
CTA Chest
PTX
Unilateral CP and SOB
Diagnosed by:
CXR
PNA
SOB and productive cough
Diagnosed by:
CXR
COPD
SOB with Hx of smoking
Diagnosed by:
CXR
Asthma
Wheezing with Hx of Asthma
Diagnosed by:
Clinically
Ischemic CVA: etiology
Blockage of the arteries supplying blood to the brain resulting in permanent brain damage
Ischemic CVA: CC
Unilateral focal neurological deficits: One-sided weakness/numbness or changes in speech/vision
Ischemic CVA: risk factors
HTN, HLD, DM, Hx TIA/CVA, smoking, FHx CVA, A Fib
Ischemic CVA: physical exam
Neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits
Ischemic CVA: diagnosed by
Clinically, potentially normal CT Head
Ischemic CVA: scribe alert
For any stroke pt ALWAYS 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, a powerful blood thinner that can reverse a CVA.
Document tPA considered and not indicated due to:
1. Onset greater than 3 hours or Unkown/Unreliable time of onset.
2. Symptoms are rapidly improving.
Hemorrhagic CVA
Brain bleed
Hemorrhagic CVA: etiology
Traumatic or spontaneous rupture of blood vessels int he head leads to bleeding in the brain.
Hemorrhagic CVA: CC
Headache: Sudden onset (Thunderclap)
Hemorrhagic CVA: assoc, Sx
Changes in speech, vision, sensation (numbness), or motor strength (weakness), AMS, Seizure, Headache
Hemorrhagic CVA: physical exam
Unilateral neurological deficits
Hemorrhagic CVA: diagnosed by
CT Head or LP
Hemorrhagic CVA: scribe alert
Document “tPA not indicated due to hemorrhage”
TIA: etiology
Vascular changes temporarily deprive a part of the brain of oxygen (Sx usually last less than 1 hour)
TIA: CC
Transient focal neurological deficit:
Changes in Speech, Vision, Strength, or Snesation
TIA: diagnosed by
Clinically
TIA: scribe alert
TIA’s are also known as “Mini Strokes” because Sx usually last
Meningitis: etiology
Inflammation and infection of the meninges; the sac surrounding the brain and spinal cord.
Meningitis: CC
Headache and neck pain
Headache
Cephalgia
Meningitis: assoc. Sx
Fever, neck pain, neck stiffness, AMS
Meningitis: physical exam
Meningismus, nuchal rigidity
Meningitis: diagnosed by
LP
Spinal Cord Injury: etiology
Injury to the spinal cord may create weakness or numbness in the extremities past the sire of the injury
Spinal Cord Injury: CC
Neck pain or Back pain, bilateral extremity weakness
Spinal Cord Injury: physical exam
Midline bony tenderness, deformities, or step-offs, bilateral extremity weakness, numbness, decreased rectal tone.
Spinal Cord Injury: diagnosed by
CT Cervical Spine (Neck)
CT Thoracic Spine (Upper back)
CT Lumbar Spine (Lower Back)
Spinal Cord Injury: scribe alert
remember that during the initial physical exam the spine is often immobilized with a C-collar and backboard; document accordingly.
Sz
Seizure
Sz: etiology
Abnormal electrical activity in the brain leading to abnormal physical manifestations. Often caused by epilepsy, ETOH withdrawals, or febrile seizure in pediatric pts
Sz: CC
Seizure activity, syncope
Sz: assoc. Sx
Injuries (tongue bite), confusion, headache, incontinence (urinary or fecal)
Sz: physical exam
somnolent, confused (Post-Ictal)
Sz: medications
Dilantin, Tegretol Keppra, Depakote, Neurontin
Sz: scribe alert
The physician will ask:
- Has the pt had a similar sz in the past?
- Does the pt have a hx of seizures?
- What was the date of their last seizure?
- What sz medication do they take?
- Have they missed in medication doses?
Bells palsy: etiology
Inflammation or viral infection of the facial nerve causes one-sided weakness of the entire face.
Bells palsy: CC
Facial droop:
Sudden onset
Bells palsy: assoc. Sx
Jaw or ear pain, increased tear flow of one eye
Bells palsy: Pert. Neg
No extremity weakness, no changes in speech or vision.
Bells palsy: physical exam
Unilateral weakness of the upper and lower face.
Bells palsy: Diagnosed by
Clinically
Bells palsy: scribe alert
Bell’s Palsy is the most common cause of facial droop in young pts who do not have CVA risk factors. Remember to document the absence of other FND.
HA: etiology
Various causes including hypertensive headaches (from high blood pressure), recurrent diagnosed migraines, Sinusitis, etc.
HA: CC
headache (gradual or onset)
Pressure, throbbing
HA: Pert. Neg
No fever, no neck stiffness, no numbness/weakness, no changes in speech or vision
HA: scribe alert
Always remember to document if the HA is similar or dissimilar to any prior HA. Never document “Worst headache of life” or “Thunderclap onset” unless specifically instructed by a physician.
AMS: etiology
Multiple causes: most common are hypoglycemia, infection, intoxication, and neurological.
AMS: risk factors
Diabetic, elderly, demented, EtOH use, drug use
AMS: CC
Confusion, decreased responsiveness, unresponsive
AMS: diagnosed by
Case dependent
AMS: scribe alert
AMS is very different than a focal neurological deficit.
AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar).
Focal neuro deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain.
The most common cause of AMS for patients without a hx of dementia is from infection, most often caused by a UTI.
Syncope: etiology
Temporary loss of blood supply to the brain resulting in loss of consciousness. There are a variety of causes; most common are vasovagal and low blood volume (dehydration/hypovolemia). Occasionally syncope occurs due to cardiac/neurologic causes.
Syncope: CC
Passing-out vs. about to pass-out (near-syncope)
Syncope: scribe alert
Document what happened prior, during, and after the syncopal episode, as well as how the patient currently feels.
Vertigo: etiology
Caused by two etiologies: the vertigo may be from a harmless problem of the inner ear (benign positional vertigo), or it may be caused due to damage in a specific center of the brain (possible CVA).
Vertigo: CC
Room-spinning, feeling off balance (disequilibrium):
worsened with head movement
Vertigo: assoc. Sx
N/V, Tinnitus (ringing in ears)
Vertigo: physical exam
Horizontal Nystagmus, + Romberg, + Dix-Hallpike Test
Vertigo: assoc. med
Meclizine (Antivert)
Vertigo: diagnosed by
Clinically
Hemorrhagic CVA
Document:
tPA ineligibility
Ischemic CVA
Document:
tPA eligibility, last known normal
Meningitis
Document:
HA, fever, neck pain
Spinal Cord Injury
Document:
Bilateral extremity weakness
TIA
Document:
When did Sx resolve?
Sz
Post-Ictal state, missed Sz meds?
Bell’s Palsy
Absence of other FND
HA/Migraine
Similar Sx in past? Gradual onset
AMS
Infection? DM? Drugs? Baseline?
Syncope
Before, during, after, current status
Vertigo
N/V, Nystagmus
Abdominal Quadrants
RUQ, RLQ, LLQ, LUQ R Flank, L Flank Periumbilical (belly button) Suprapubic (on top of pubic hairs) Epigastrium (lower chest)
Epigastric
Associated Diseases
GERD, MI
RUQ
Associated Diseases
Cholecystitis
LUQ
Associated Diseases
Pancreatitis
Periumbilical
Associated Diseases
SOB
RLQ
Associated Diseases
Appendicitis
LLQ
Associated Diseases
Diverticulitis
Suprapubic
Associated Diseases
Ovarian Torsion
Ovarian Cyst
UTI
Flanks
Associated Diseases
Pyelonephritis
Renal Calculi
APPY
Appendicitis
APPY: etiology
Infection of the appendix causes inflammation and blockage, possibly leading to rupture
APPY: CC
RLQ Pain:
Gradial Onset
Constant
Worsened with movement
APPY: assoc. Sx
Decreased appetite (anorexia), fever, N/V
APPY: physical exam
McBurney’s point tenderness, RLQ tenderness
APPY: diagnosed by
CT A/P with PO constrast
SBO
Small Bowel Obstruction
SBO: etiology
Physical blockage of the small intestine
SBO: risk factor
Elderly, infants, abdominal surgery, narcotic pain medication.
SBO: CC
Abdominal pain, vomiting, constipation
SBO: assoc. Sx
Abd distension, bloating, no BMs
SBO: physical exam
Abd tenderness, guarding, rebound, abnormal bowel sounds, abd distension, tympany
SBO: diagnosed by
CT A/P with PO Contrast AAS
AAS
Acute Abdominal Series
Gallstones
Cholelithiasis, Cholecystitis
Gallstones: etiology
Minerals from the liver’s bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder.
Gallstones: catch phrase
RUQ abd pain after eating fatty foods
Gallstones: CC
RUQ Pain:
sharp
worsened with eating, deep breaths and palpation
Gallstones: physical exam
RUQ tenderness, Murphy’s sign
Gallstones: diagnosed by
Abd US, RUQ
GI bleed: etiology
Hemorrhage in the upper or lower GI tract can lead to anemia.
GI bleed: CC
Hematemesis (Upper), coffee ground emesis (Lower), Hematochezia (Lower), Melena (Upper)
GI bleed: assoc. Sx
Generalized weakness, lightheadedness, SOB, abd pain, rectal pain
GI bleed: physical exam
Pale conjunctiva, pallor, Tachycardia Rectal Exam: melena, grossly bloody stool
GI bleed: diagnosed by
Heme positive stool (Guaiac positive) during a rectal exam
GI bleed: scribe alert
ED concern is the need for a possible blood transfusion due to significant blood loss.
Diverticulitis: etiology
Acute inflammation and infection of abnormal pockets of the large intestine, known as diverticuli
Diverticulitis: risk factors
Diverticulosis, advanced age
Diverticulitis: CC
LLQ pain
Diverticulitis: assoc. Sx
Nausea, fever, diarrhea
Diverticulitis: diagnosed by
CT A/P with PO Contrast
Pancreatitis: etiology
Inflammation of the pancreas
Pancreatitis: risk factors
EtOH abuse, Cholecystitis, specific medications
Pancreatitis: CC
LUQ, epigastric pain
Pancreatitis: assoc. Sx
N/V
Pancreatitis: physical exam
epigastric tenderness
Pancreatitis: diagnosed by
Elevated Lipase lab test (or sometimes elevated Amylase)
GERD
Gastroesophageal reflux
GERD: etiology
Stomach acid regurgitating into the esophagus
GERD: CC
Epigastric Pain:
Burning
Improved with antacids
GERD: physical exam
Epigastric tenderness
GERD: assoc. med
GI cocktail (numbs and soothes the esophagus and stomach)
GERD: scribe alert
Due to the proximity of the stomach to the heart, patients with cardiac risk factors and epigastric pain will always get a cardiac workup.
C. Diff Colitis
Opportunistic bacteria that causes persistent diarrhea
Gastroenteritis
Vomiting and diarrhea; “GI bug” often viral or bacterial
Crohn’s Disease
Immune disorder causing diarrhea and abdominal pain
Irritable Bowel Syndrome
Chronically sensitive bowels prone to diarrhea
Gastritis
Irritated stomach with vomiting; “Stomach ache”
Appendicitis
RLQ
Diagnosed by:
CT A/P with PO
SBO
Periumbillical
Diagnosed by:
CT A/P with PO, AAS
Cholecystitis
RUQ
Diagnosed by:
US RUQ
GI bleed
Any quadrant
Diagnosed by:
Guaiac (heme) Positive
Diverticulitis
LLQ
Diagnosed by:
CT A/P with PO
Pancreatitis
Epigastic, LUQ
Diagnosed by:
Elevated Lipase
GERD
Epigastric
Diagnosed by:
Endoscopy (not in ED)
UTI: etiology
Infection in the urinary tract (bladder or urethra)
UTI: CC
Dysuria (painful urination)
UTI: risk factors
Female
UTI: assoc. Sx
Frequency, urgency, malodorous urine, AMS(elderly)
UTI: physical exam
Suprapubic tenderness
UTI: diagnosed by
Urine dip (done in ED) or urinalysis (specimen sent to lab to test for Nitrite, WBC and Bacteria in urine)
Pyelonephritis: etiology
Infection of the tissue in the kidneys, usually spread from a UTI.
Pyelonephritis: risk factors
female, frequent UTI’s
Pyelonephritis: CC
Flank pain with dysuria
Pyelonephritis: assoc. Sx
Fever,N/V
Pyelonephritis: physical exam
Costo-vertebral Angle (CVA) tenderness
Pyelonephritis: diagnosed by
CT Abd/Pel without contrast or confirmed UTI with CVA tenderness on exam
Kidney stones
Nephrolithiasis, Renal Calculi, Urolithiasis
Kidney stones: etiology
A kidney stone dislodges from the kidney and begins traveling down the ureter. The stone scrapes and irritates the ureter, causing severe flank pain and bloody urine.
Kidney stones: CC
Flank pain:
sudden onset
radiating to groin
Kidney stones: assoc. Sx
Hematuria, N/V, unable to void
Kidney stones: exam
CVA tenderness
Kidney stones: diagnosed by
CT Abd/Pelvis
RBC in UA may be a clue.
Ectopic Pregnancy
Tubal pregnancy
Ectopic Pregnancy: etiology
Fertilized egg develops outside the uterus, usually in the Fallopian tube. High risk for rupture and death.
Ectopic pregnancy: risk factors
Pregnant female (HCG positive), STD (PID)
Ectopic pregnancy: CC
Lower abdominal pain or vaginal bleeding while pregnant
Ectopic pregnancy: diagnosed by
US Pelvis–> Determine location of fetus
Ectopic pregnancy: scribe alert
Any female with a positive pregnancy test who is complaining of lower abd pain or vaginal bleeding will always receive an US Pelvis to rule out a possible ectopic pregnancy.
Ovarian torsion: etiology
Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in infarct of the ovary.
Ovarian torsion: CC
Lower abd pain (RLQ, LLQ)
Ovarian torsion: physical exam
Adnexal tenderness (right or left). Tenderness in the RLQ or LLQ
Ovarian torsion: diagnosed by
US Pelvis–> Assesses blood flow to ovaries.
Ovarian torsion: scribe alert
Ovarian and testicular torsion are very time sensitive due to the risk of losing an ovary or testicle. Be sure to document accurate times for the pt arrival, US results, and any physician (surgical) consultations.
Testicular torsion: etiology
Twisting of the spermatic cord resulting in loss of blood flow and nerve function to the testicle
Testicular torsion: CC
testicular pain
Testicular torsion: physical exam
Testicular tenderness and swelling (right or left)
Testicular torsion: diagnosed by
US Scrotum
UIT: diagnosed by
Urinalysis (WBC, Nitrite, or Bacteria)
Pyelo: diagnosed by
CT Abd/Pelvis (A/P) UTI with CVA tenderness on exam
Kidney stone: diagnosed by
CT A/P (RBC in UA may be a clue)
Ectopic pregnancy: diagnosed by
US Pelvis
Ovarian torsion: diagnosed by
US Pelvis
Testicular torsion: diagnosed by
US Scrotum
Upper Respiratory Infection
URI
URI: etiology
Most often viral infection causes congestion, cough, and inflammation of the upper airway.
URI: CC
Cough/congestion
URI: assoc. Sx
Fever, sore throat, headache, myalgias
URI: physical exam
Rhinorrhea, boggy turbinates, pharyngeal erythema
URI: diagnosed by
Clinicallly
URI: scribe alert
Pay special attention to any complaints of CP or SOB for URI pts; always be careful to describe the CP or SOB accurately so as not to accidentally create the impression of symptoms consistent with an MI or PE.
Otitis Media
Middle ear infection
Otitis media: etiology
Viral or bacterial infection of the TM causing ear pain and pressure.
Otitis media: CC
Ear pain, ear pulling
Otitis media: assoc. Sx
Fever, sore throat, dry cough, congestion
Otitis media: physical exam
Erythema, effusion, dullness, or bulging of the TM.
Otitis media: diagnosed by
Clinically
Strep Throat
Streptococcal Pharyngitis
Strep throat: etiology
Bacterial infection of the tonsils and pharynx causing a sore throat and frequently swollen lymph nodes.
Strep throat: CC
Sore throat
Strep throat: physical exam
Pharyngeal erythema tonsillar hypertrophy (enlargement) tonsillar exudates (pus)
Strep throat: diagnosed by
Rapid strep
Strep throat: scribe alert
More sore throats are viral, however Strep throat is bacterial so Abx will help.
The biggest concern about a sore throat is the possibility of a PTA. Signs of PTA include uvular shift or tonsillar asymmetry
PTA
Peri-Tonsillar Abscess
Conjunctivitis: etiology
Infection of the outer lining of the eye, known as the conjunctiva
Conjunctivitis: CC
Eye redness, irritation or pain
Conjunctivitis: assoc. Sx
Eyelid matting, eye discharge, fever
Conjunctivitis: physical exam
Conjunctival injection (redness), edema, and exudates
Injection
Redness
Conjunctivitis: diagnosed by
Clinically
Epistaxis: etiology
Rupture of a blood vessels inside the nose causes blood to flow out the nose and into the throat.
Epistaxis: CC
Nose bleed
Epistaxis: risk factors
Blood thinners (Coumadin/Warfarin, ASA, Plavix) or HTN
Epistaxis: physical exam
Anterior, posterior, or Septal source (of the bleeding)
Epistaxis: diagnosed by
Clinically
Epistaxis: scribe alert
Procedure Epistaxis management: Nose bleeds that do not stop spontaneously are often cauterized (burned) or stopped with pressure by Nasal Tamponade, on blood thinners will have coagulation labs (PT/INR) drawn to make sure their blood is not too thin.
Musculoskeletal back pain: etiology
Deterioration or strain of the back creates pain that is worse with movement.
Musculoskeletal back pain: CC
Back pain:
Most commonly low back (lumbar) pain
Musculoskeletal back pain: assoc. Sx
Shooting posterior lower extremity pain.
Musculoskeletal back pain: pert. negs.
No LE weakness, no incontinence
Musculoskeletal back pain: physical exam
Paraspinal tenderness, positive straight leg raise (+ SLR diagnoses Sciatica; back pain that radiates down the legs)
Musculoskeletal back pain: scribe alert
Remember to document if there is any recent trauma related to the back pain; trauma increases the physician’s concern about possible spinal injury
Extremity injury: etiology
trauma creates pain/swelling in an extremity
Extremity injury: CC
Extremity pain
Extremity injury: assoc. Sx
Swelling, bruising, deformity, use limitation.
Extremity injury: pert. negs.
No motor weakness, no numbness or tingling
Extremity injury: physical exam
Distal CSMT intact (Circulation, Sensory, Motor, Tendon) No tendon or ligament laxity ROM limited secondary to pain.
Extremity injury: scribe alert
Remember the majority of extremity injuries will receive some type of splint; always remember to document a Splint Application Procedure Note!
AAA: etiology
Widened and weakened arterial wall at risk of rupture
AAA: CC
Midline pulsatile abd mass, abd bruit, unequal femoral pulses, hypotension
AAA: diagnosed by
CT A/P with IV contrast dye
Aortic dissection: etiology
Separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death.
Aortic dissection: CC
Chest pain radiating to the back:
ripping or tearing
Aortic dissection: physical exam
Unequal brachial or radial pulses, hypotension
Aortic dissection: diagnosed by
CT Chest with IV contrast dye
DVT: etiology
Blood slows down while flowing through long straight veins in the extremities; slow-flowing blood is more likely to clot. Once formed the clot can continue to grow and eventually occlude (block) the vein.
DVT: risk factors
PMHx of DVT or PE, FHx, Recent Surgery, CA, Immobility, Pregnancy, BCP, smoking, LE Trauma, LE Casts
DVT: CC
Extremmmity pain and swelling (atraumatic):
Usually located in a lower extremity
DVT: physical exam
Calf tenderness, cords, Homan’s sign
DVT: diagnosed by
US/Doppler of the extremity
Cellulitis: etiology
Infection of the skin cells
Cellulitis: CC
Red, swollen, ppainful, and sometimes warn area of skin
Cellulitis: physical exam
erythema, edema, increased warmth (calor), induration
Cellulitis: assoc. meds
Abx
Cellulitis: diagnosed by
Clinically
Abscess
Cellulitis with fluctuance
Abscess: etiology
Skin infection with an underlying collection of pus
Abscess: CC
red, swollen, and painful lump
Abscess: physical exam
Fluctuance (pus-pocket), induration, purulent drainage
Abscess: diagnosed by
Clinically
Abscess: scribe alert
Abscesses must have the pus-pocket drained. Remember to always document Incision and Drainage (I&D) Procedure notes for abscesses.
Rash: etiology
Changes in the skin’s appearance due to systemic or localized reaction. May be caused from medication, virus, bacteria, fungus, insect, etc.
Rash: CC
Rash:
Red, pruritic or painful
Rash: physical exam
Urticaria Macules Papules Vesicles Blanching Petechaie Purpura
Urticaria
Hives or wheals (rash)
Macules
flat (rash)
Papules
raised bumps (rash)
Vescicles
small blisters (rash)
Blanching
not dangerous rash
Petechaie
dangerous rash
Purpura
dangerous rash
Rash: diagnosed by
Clinically
Allergic reaction: etiology
Immune response causing an inflammatory reaction consisting of swelling, pruritis, and rash.
Allergic reaction: risk factors
Known drug or food allergy
Allergic reaction: CC
Rash, swelling, itching, or SOB
Allergic reaction: physical exam
Edema, facial angiodema, urticaria
Allergic reaction: diagnosed by
Clinically
Allergic reaction: scribe alert
ED concern is Anaphylaxis or Respiratory failure
True allergic reactions
Rash
Itching
Swelling
SOB due to airway swelling
DKA: etiology
Shortage of insulin resulting in hyperglycemia and production of ketones
DKA: risk factors
DM
DKA: CC
Persistent vomiting with a Hx of DM
DKA: assoc. Sx
SOB, polydipsia (increased thirst), polyuria (increased urination
DKA: physical exam
Ketotic odor “fruity”, dry mucous membranes (dehydration), tachypnea
DKA: diagnosed by
Arterial blood gas (ABG or VBG) showing low pH (acidosis) or Positive Serum ketones
Psychological disorder:; etiology
Various types of psychological disease produce abnormal thoughts, bahaviors, or actions
Psychological disorder: PMHx
Bipolar Disorder, Schizophrenia, PTSD, Depression, Anxiety, Alcoholism, Drug Abuse, Suicide Attempt
Psychological disorder: CC
SI HI Hallucinations Substance abuse Self injury OD
SI
Suicidal Ideation
HI
Homicidal Ideation
Psychological disorder: physical exam
Flat affect, SI, HI, Tangential or Pressured speech
Psychological disorder: scribe alert
Pay very careful attention to differentiating between medical (physical) and psychiatric complaints. As an emergency physician the main concern is medical clearance; determining that the pt is not medically ill. After medical clearance; determining that the pt is not medically ill. After medical clearance, the pt is cleared to be evaluated from a psychiatric standpoint.
Trauma
Physical Injury
Trauma: etiology
Depending on the MOI physical trauma may break bones, sever nerves, rupture blood vessels, or damage internal organs.
MOI
Mechanism of Injury
Trauma: CC
MVA, fall, GSW
Trauma: physical exam
GCS
GCS
Glasgow Coma Scale
Trauma: assoc. med
blood thinners (Coumadin, ASA, or Plavix)
Trauma: diagnosed by
Trauma Protocol depending on MOI: CT or XR
Trauma: scribe alert
Neurological Injury (Brain, Spine): LOC confusion numbness weakness HA Neck/Back Pain Internal organ injury (lungs, Spleen, Liver): SOB CP Abd Pain
Trauma (MOI): etiology
Refers to the way damage to skin, muscles, organs, and bones happen.
Healthcare providers use MOI to determine how likely it is that serious injury has occurred.
Trauma (MOI): rapid forward deceleration (MVC)
- Head-On collision (windshield starring, airbag deployment
- T-Bone Collision
- Rear-Impact Collision
- Rollover Collision
- Victim Ejected From Vehicle (Spinal cord injury, head injury)
- MVA/ ATV Crash (helmets)
- Auto vs. Pedestriam
Trauma (MOI): rapid vertical deceleration “Falls”
Dependent upon distance body part impacted landing surface and type of landing surface
Severe: greater than 3x the height of pt or > 20 ft
Trauma (MOI): penetrating trauma
- Stab wounds: location, blade length, angle of penetration
2. Firearms: Type of weapon, caliber, distance, bullet deformity
DDx
A short list of diseases the doctor considers when diagnosing a pt.
Pertinent Positives
Specific Sx that raise the physician’s concern for that particular disease
Pertinent Negatives
Specific Sx that are not present which cause the physician to doubt certain diagnoses
Risk Factors
“red Flags: that would put a pt at risk for that particular Dz.
Etiology
The study of the causes of Dz.
Pleura
Membrane lining the thoracic cavity (parietal pleura) and covering the lungs (visceral pleura)
Artery
A blood vessel that carries oxygenated blood from the heart throughout the body
CTA
Computed Tomography Angiography