Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Scribe terms > course 3 > Flashcards

course 3 Flashcards

1
Q

Subjective

A

Based on the Patient’s feeling(HPI, ROS)

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

Objective

A

Factual information from provider (PE)

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

History of present illness

A

The story of the patient’s chief complaint.

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

Review of systems

A

head to toe list of patient’s symptoms .

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

intermittent

A

comes and goes

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

Waxing and waning

A

always present but changing with intensity

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

modifying factors

A

something that makes a symptom better or worse.

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

Exacerbate

A

to make worst .

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

Element

A

description

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

onset

A

when did the complaint begin

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

timing

A

has it been constant, intermittent, waxing or waning.

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

location

A

where is the discomfort

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

quality

A

Does it feel sharp, dull, aching, cramping….?

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

severity

A

How bad is it? Mild, mod, severe or 0-10

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

modifying factors

A

What makes it better? What makes it worse?

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

Associated Sx

A

Do any other symptoms accompany the complaint?

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

context

A

Is there anything else that’s important?

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

A complete HPI requires atleast..

A

4 complete elements

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

Outline for HPI

A
  1. complaint + onset
  2. Timing, quality, severity
  3. What makes it better or worse
  4. Associated symptoms
  5. Pertinent negatives
  6. Context
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

I took tums and it didn’t help

A

the symptoms were unchanged by tums

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

I have low back pain, but always have that

A

He notes chronic back pain, unchanged from baseline

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

It hurts when I touch it

A

The symptoms worsen with palpations in the area

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

Nothing makes it better or worse

A

the symptoms are unchanged by any position or activity

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

My sister has the same cold

A

positive sick contact with sister who has similar symptoms.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

If I try to eat or drink anything, I throw it back up

A

The vomiting exacerbated by PO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

it feels like a fizzing soda in the middle of my chest

A

He describes the Sx as a “fizzing soda” in his central chest.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

don’t s of HPI

A

Use days of week, use got, start sentences the same, write self diagnoses, include Hx that is no relevant.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Key to writing a trauma HPI

A

focusing on the MOI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Four most important Sx to document for any trauma pt.

A

LOC, Head injury, Neck pain, back pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

A complete ROS requires..

A

At least ten elements. If cannot make a complete ROS, state and explain why. When all other systems are negative only require 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Constitutional .

A

Fever, weight loss, swets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Eyes

A

change in vision, eye pain, double vision.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Ear/nose/throat

A

Ear ache, Nose bleed, Congestion, Sore throat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

cardiovascular

A

Chest pain, Palpitations, Leg swelling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

respiratory

A

SOB, Cough, Sputum, Wheezing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

gastrointestinal

A

Abdominal pain, N/V/D, Black or bloody stools

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Genitourinary

A

Dysuria, Frequency, Urgency, Hematuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Musculoskeletal

A

Joint pain, Muscle pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

integumentary/skin

A

Rash, Itching, Abrasion, Laceration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

neurological

A

Headache, Syncope, Seizure, Numbness, Focal weakness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

psychiatric

A

Depression, Anxiety

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

endocrine

A

Polyuria, polydipsia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

hematologic/lymph

A

Bleeding gums, easy bruising, swollen lymph nodes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

immunologic

A

HIV/AIDS, Splenectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

worse with physical exertion-cp

A

MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

worse with deep breaths -cp

A

PE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

radiation to the back -cp

A

aortic dissection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

recent trauma- cp

A

PTX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

SOB -cp

A

MI, PE, PTX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Diaphoresis, Nausea, vomiting -cp

A

MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Pleuritic pain -cp

A

PE, PTX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Calf pain -cp

A

DVT` causing PE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Minor DDx of Cp

A

chest wall pain, costochondritis, Pleural effusion, GERD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Associated Sx - Cp with minor DDX

A

pain with torso movement or palpation(chest wall, costo-), burning (GERD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

MI risk factors

A

CAD, HTN, HLD, dM, Smoking, FHx CAD <55 y/o

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

PE risk factors

A

Hx DVT/PE, known DVT, recent surgery, mobilization, A-fib, cancer, pregnancy/BCP

57
Q

Hx of tobacco abuse -SOB

A

COPD

58
Q

Chest ain-SOB

A

MI, PE, PNA

59
Q

minor DDx of SOB

A

Bronchitis, URI

60
Q

Associated Sx of Bronchitis, URI

A

cough, sputum, Nasal congestion, Sore throat.

61
Q

Mi risk factors

A

CAD, HTN, HLD, DM, Smoking, FHx CAD < 55 y/o

62
Q

PE Risk factors

A

Hx DVT/PE, Known DVT, Recent surgery, Immobilization, A-Fib, Cancer, Pregnancy/Birth Control

63
Q

Abd pain -RLQ

A

appendicitis

64
Q

RUQ pain

A

cholecystitis

65
Q

LLQ pain

A

diverticulitis

66
Q

LUQ pain

A

Pancreatitis

67
Q

Fever - Abd pain

A

appendicitis, cholecystitis, diverticulitis

68
Q

Blood in vomit or stool

A

GI bleed

69
Q

Melena

A

GI bleed

70
Q

Dizziness - Abd pain

A

GI bleed, AAA - (anemia, low blood volume)

71
Q

Minor DDx of Abd pain

A

gastroenteritis, gastritis, constipation

72
Q

Associated Sx with Gastroenteritis, gastritis, constipation

A

Dysuria, Nausea/Vomiting, Diarrhea, Constipation

73
Q

Diarrhea risk factors

A

Recent foreign travel, recent camping, bad food exposure, sick contacts, recent antibiotics, recent hospitalization

74
Q

Suprapubic pain

A

ovarian torsion

75
Q

pregnancy - with lower abd pain

A

ectopic pregnancy

76
Q

Fever, RLQ pain for femail

A

appendicitis

77
Q

minor DDx for female Lower abd pain

A

Ovarian Cyst, UTI, STD

78
Q

Associated Sx with female lower abd pain

A

Nausea/Vomiting, Vaginal Spotting, Vaginal Discharge, Dysuria, Flank pain

79
Q

Female Abd pain risk factors

A

Possibility of Pregnancy, Unprotected Sex, History of STD

80
Q

Weakness/numbness in lower extremities

A

spinal cord injury

81
Q

numbness of the groin

A

spinal cord injury or cauda equina

82
Q

loss of bowel or bladder control

A

spinal cord injury or cauda equina

83
Q

History of IVDA - w/ lower back pain.

A

Spinal abscess

84
Q

Fever - with lower back pain

A

spinal abscess

85
Q

Abdominal Pain- with lower back pain

A

Abdominal Aortic Aneurysm (AAA)

86
Q

Minor DDx of Low back pain

A

Musculoskeletal back pain, Back Strain, Sciatica

87
Q

Associated Sx of Low back pain

A

Radiating pain down the backs of the legs (sciatica)

88
Q

Back pain risk factors

A

Recent trauma, hx of IVDA, spinal hardware

89
Q

Weakness/numbness/tingling W/ Dizziness HA

A

CVA

90
Q

Changes in speech or vision

w/ Diz/HA

A

CVA, SAH

91
Q

difficulty with balance w/ Diz HA

A

CVA, SAH

92
Q

fever W/ Diz/HA

A

Meningitis

93
Q

neck pain w/ Diz/HA

A

Meningitis

94
Q

AMS w/ Diz/HA

A

meningitis, CVA, SAH

95
Q

Worst headache of life/ thunderclap onset

A

Hemorrhagic CVA, SAH

96
Q

syncope or seizure w/ Diz/HA

A

CVA, SAH

97
Q

Minor DDx of Dizziness and HA

A

Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis,

98
Q

Associated Sx Minor DDx for Dizziness/HA

A

Nasal congestion, runny nose, nausea, vomiting

99
Q

CVA risk factors

A

HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, AFib

100
Q

tongue bit wound

A

Sz

101
Q

SAH

A

Subarachnoid Hemorrhage

102
Q

Numbness/weakness/Tingling with syncope

A

CVA

103
Q

Changes in speech or vision w/ syncope

A

CVA

104
Q

chest pain w/ syncope

A

MI

105
Q

SOB w/ syncope

A

PE

106
Q

Palpitations w/ syncope

A

Arrhythmia

107
Q

Minor DDx of Syncope

A

Vasovagal syncope, dehydration

108
Q

Associated Sx with with vasovagal syncope, dehydration

A

Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness

109
Q

Associated Sx with with vasovagal syncope, dehydration

A

Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness

110
Q

Fever with AMS

A

Sepsis

111
Q

Numbness/Weakness/Tingling w/ AMS

A

CVA

112
Q

HA w/ AMS

A

Hemorrhagic CVA

113
Q

Hx of depression or drug abuse w/ AMS

A

Drug overdose

114
Q

Hx of DM w/ AMS

A

hypoglycmia

115
Q

Minor DDx of AMS

A

UTI (Elderly), ETOH abuse, Narcotic abuse, drug abuse

116
Q

AMS risk factors

A

Dementia/Alzheimers, DM, Psychiatric history, Substance abuse

117
Q

LOC w/ Trauma

A

Hemorrhagic CVA, Subdural Hematoma

118
Q

Unilateral numbness/weakness/tingling w/ trauma

A

Hemorrhagic CVA, Subdural Hematoma

119
Q

Bilateral Numbness/weakness/tingling w/ trauma

A

spinal cord injury

120
Q

Neck pain or back pain w/ trauma

A

spinal cord injury

121
Q

SOB or CP w/ Trauma

A

PTX, cardiac contusion

122
Q

Abd Pain w/ trauma

A

Splenic or Liver Laceration

123
Q

Minor DDx W/ trauma

A

Closed Head Injury, simple fracture, dislocation, strain/sprain, laceration

124
Q

Trauma risk factors

A

Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe Mechanism of Injury

125
Q

General PMHx

A

• HTN, HLD, CA, DM (IDDM/NIDDM)

126
Q

Cardiovascular PMHx

A

• MI, CAD, Angina, CHF, AFIB

127
Q

Pulmonary PMHx

A

• PE, PNA, COPD, Asthma

128
Q

GI PMHx

A

• GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis

129
Q

Genitourinary PMHx

A

• Kidney stones, UTI, Renal insufficiency/failure

130
Q

Neurological PMHx

A

• CVA, TIA, Epilepsy/Seizure, Migraines, Dementia, Alzheimer’s

131
Q

Psychological PMHx

A

• Depression, Anxiety, Bipolar, Schizophrenia

132
Q

Other PMHx

A

• DVT, MRSA, RA (Rheumatoid Arthritis), CBP (Chronic Back Pain)

133
Q

ENT PSHx

A

• Tonsillectomy, Adenoidectomy, PE tubes

134
Q

Cardiac PSHx

A

• CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement

135
Q

Abd PSHx

A

• Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy, Nephrectomy

136
Q

GU PSHx

A

• Hysterectomy, C-section, Oophorectomy, Salpingo- oophorectomy, Tubal ligation, TURP

137
Q

Ortho PSHx

A

• AKA/BKA, Hip Arthroplasty, Spinal fusion

138
Q

Neuro PSHx

A

Carotid endarterectomy, craniotomy, VP shunt

139
Q

Other PSHx

A

• Mastectomy, PICC line

Scribe terms (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions