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Scribe > Course 3 > Flashcards

Course 3 Flashcards

1
Q

What are the 6 parts of an HPI?

A
  1. Identify pt
  2. Quality, Severity, location, and radiation
  3. Assoc sx and pertinent neg
  4. Modifying factors
  5. Context
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2
Q

What are the 5 types of way to describe the CC?

A
  1. Quality
  2. Severity
  3. Onset
  4. Timing
  5. Location
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3
Q

In HPI what is everything related to?

A

CC

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4
Q

What are the 4 most important symptoms to document for any trauma pt?

A

They are LOC, head injury, neck pain, and back pain

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5
Q

ROS; checklist

HPI; ________

A

Story

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6
Q

What are the 4 most important sx to document in a trauma?

A

LOC, head injury, neck pain, and back pain

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7
Q

How many body systems are in a ROS? How many systems with all marked negative need to be recorded? W/o all marked negative?

A

14
2
10

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8
Q

If you have a limited ROS for some reason you need to include a ______ statement

A

Caveat

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9
Q

What are the two subjective parts of a pt chart?

A

ROS and HPI because it is based on the pt interpretation

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10
Q

In a trauma pt, LOC is a red flag for what?

A

Hemorrhagic CVA or subdural hematoma

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11
Q

In a trauma pt, unilateral numbness is a red flag for what?

A

hemorrhagic CVA or subdural hematoma

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12
Q

In a trauma pt, bilateral numbness or weakness is a red flag for what?

A

Spinal cord injury

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13
Q

Back and back pain in a trauma pt is a red flag for what DDx?\

A

Spinal cord injury

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14
Q

SOB or CP in a trauma pt is a red flag for what DDx?

A

PTX or cardiac contusion

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15
Q

Abdominal pain in a trauma pt is a red flag for what DDx?

A

Splenic or liver laceration

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16
Q

CHI

A

Closed head injury

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17
Q

What are the main trauma risk factors (2)

A

Blood thinners and severe MOI

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18
Q

Fever in a AMS pt is a red flag for what DDx?

A

Sepsis

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19
Q

Numbness/weakness/tingling in a AMS pt is a red flag for what DDx?

A

CVA

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20
Q

Changes in speech or vision in a AMS pt is a red flag for what DDx?

A

CVA

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21
Q

HA in a AMS pt is a red flag for what DDx?

A

Hemorrhagic CVA

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22
Q

Hx of depression of drug abuse in AMS?

A

Drug overdose

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23
Q

Hx of diabetes in a AMS pt?

A

Hypoglycemia

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24
Q

Tongue bite wounds are a red flag for syncope pt?

A

Seizure

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25
Q

Numbness/weakness/tingling are a red flag for syncope pt?

A

CVA

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26
Q

Changes in speech or vision are a red flag for syncope pt?

A

CVA

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27
Q

CP are a red flag for syncope pt?

A

MI

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28
Q

SOB are a red flag for syncope pt?

A

PE

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29
Q

Palpitations are a red flag for syncope pt?

A

Arrhythmia

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30
Q

Near-syncope, sweating, dizziness, and lightheadedness are a red flag for syncope pt?

A

Vasovagal syncope and dehydration

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31
Q

Weakness/numbness/ tingling are a red flag for syncope pt?

A

CVA and SAH

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32
Q

Changes in speech or vision are a red flag for syncope pt?

A

CVA, SAH

33
Q

SAH

A

Subarachnoid Hemorrhage

34
Q

Difficulty with balance are a red flag for syncope pt?

A

CVA, SAH

35
Q

Fever are a red flag for syncope pt?

A

Meningitis

36
Q

Neck pain are a red flag for syncope pt?

A

Meningitis

37
Q

AMS are a red flag for syncope pt?

A

Meningitis, CVA, and SAH

38
Q

Worst HA of life/thunderclap onset are a red flag for syncope pt?

A

Hemorrhagic CVA, SAH

39
Q

Syncope and seizure are a red flag for syncope pt?

A

CVA, SAH

40
Q

Nasal congestion, runny nose, N/V are a red flag for syncope pt? (5)

A 
Dehydration
Benign positional vertigo (BPV) 
Migraine HA
Tension HA 
Sinusitis
41
Q

Weakness/numbness in LE are a red flag for low back pain pt?

A

Spinal cord injury

42
Q

Numbness of the groin are a red flag for low back pain pt?

A

Spinal cord injury or Cauda Equina

43
Q

Cauda Equina

A

Low back pain

44
Q

Loss of bowel or bladder control are a red flag for low back pain pt?

A

Cauda Equina

45
Q

History of IVDA are a red flag for low back pain pt?

A

Spinal abscess

46
Q

Suprapubic pain are a red flag for female lower abdominal pain pt?

A

Ovarian torsion

47
Q

Pregnancy are a red flag for low back pain pt?

A

Ectopic pregnancy

48
Q

Fever, RLQ pain are a red flag for low back pain pt?

A

Appendicitis

49
Q

N/V, vaginal spotting, vaginal discharge, dysuria, and flank pain are a red flag for female lower abdominal pain? (3)

A

Ovarian cyst
UTI
STD

50
Q

RLQ pain are a red flag for abdominal pain pt?

A

Appendicitis

51
Q

RUQ Pain are a red flag for abdominal pain pt?

A

Cholecystitis

52
Q

LLQ Pain are a red flag for abdominal pain pt?

A

Diverticulitis

53
Q

LUQ Pain are a red flag for abdominal pain pt?

A

Pancreatitis

54
Q

Fever are a red flag for abdominal pain pt?

A

Appendicitis, pancreatitis, and diverticulitis

55
Q

Blood in vomit or stool are a red flag for abdominal pain pt?

A

GI bleed

56
Q

Melena are a red flag for abdominal pain pt?

A

GI bleed

57
Q

Dizziness are a red flag for abdominal pain pt?

A

GI bleed, abdominal aortic aneurysm (AAA)

58
Q

Dysuria, N/V/D, and constipation are a red flag for abdominal pain pt?

A

UTI, Gastroenteritis, Gastritis, and Constipation

59
Q

Productive cough are a red flag for SOB pt?

A

PNA

60
Q

Orthopnea/Dyspnea on exertion are a red flag for abdominal pain pt?

A

CHF

61
Q

Bilateral leg swelling are a red flag for SOB pt?

A

CHF

62
Q

Bilateral leg swelling are a red flag for SOB pt?

A

CHF

63
Q

Hemoptysis are a red flag for SOB pt?

A

PE

64
Q

Unilateral leg swelling are a red flag for SOB pt?

A

DVT causing a PE

65
Q

Wheezing are a red flag for SOB pt?

A

Asthma

66
Q

Hx of tabacco abuse are a red flag for SOB pt?

A

COPD

67
Q

CP are a red flag for SOB pt?

A

MI, PE, and PNA

68
Q

Cough, sputum, nasal congestion, and sore throat are a red flag for SOB pt?

A

Bronchitis or UTI

69
Q

Worse with physical exertion are a red flag for CP pt?

A

MI

70
Q

Worse with deep breaths are a red flag for CP pt?

A

PE

71
Q

Radiation to the back are a red flag for CP pt?

A

Aortic dissection

72
Q

Recent trauma are a red flag for CP pt?

A

PTX

73
Q

SOB are a red flag for CP pt?

A

MI, PE, PTX

74
Q

Diaphoresis, N/V are a red flag for CP pt?

A

MI

75
Q

Pleuritic pain are a red flag for CP pt?

A

PE, PTX

76
Q

Calf pain are a red flag for CP pt?

A

DVT causing PE

77
Q

Pain with torso movement or palpations are a red flag for CP pt?

A

chest wall pain and Costochondritis

78
Q

Burning pain are a red flag for CP pt?

A

GERD

Scribe (7 decks)

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