Day 2: Pathophysiology Flashcards
Doc thought process
- subjective complaints and risk factors
- differential diagnoses
- objective evaluation
- final diagnosis
Pertinent positive
specific symptoms that raise the physician’s suspicions for that disease
Pertinent negative
symptoms NOT present that cause doc to doubt certain diagnoses
CAD
MAJOR DDX FOR CP
Etiology: narrowing of coronary arteries, causing angina (CP due to heart ischemia)
1. catch phrase: “chest pain with physical exertion”
2. CC: CP or chest pressure (worse with exertion, improved with rest)
3. Associated Meds: ASA 324 mg PO, NTG .4 mg SL
4. Dx by: cardiac catheterization, not Dx in ED
5. a) CAD greatest risk factor for MI
b) stress test or cardiac cath assess severity of CAD
c) pt has CAD if they have PMHx Angina, MI, CABG, cardiac stents, or angioplasty
d) EVERY patient complaining of CP should receive ASA, unless given PTA or contraindicated due to bleeding or allergy
MI (STEMI, non-STEMI)
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR CP
Etiology: acute blockage of coronary arteries results in ischemia and infarct of the heart muscle
1. Catch phrase: CP with diaphoresis, N/V, and SOB
2. Risk factors: CAD, HTN, HLD, DM, Smoker, FHx of CAD < 55 y.o.
3. CC: CP or chest pressure
4. Dx by: EKG (STEMI) or elevated Troponin (non-STEMI)
5. Assoc. Med: ASA, NTG, B-blocker, Thrombolytic (Heparin)
6. Note: Acute MI pt must receive ASA 324 mg ASAP. STEMI pt must get to Cath-lab w/in 90 min of arrival. Document ED arrival and depart times
CHF
CRITICAL CARE DDX
MAJOR DDX FOR SOB
Etiology: heart enlarged, inefficient, and congested with excess fluid
1. catch phrase: SOB w/pedal edema and orthopnea
2. CC: SOB: worse lying flat (orthopnea), Paroxysmal Nocturnal Dyspnea (PND), DOE
3. PE: rales, JVD
4. Assoc med: Diuretics (lasix, furosemide) -> urinate extra fluid
5. Dx by: CXR or elevated BNP (B-type natriuretic peptid)
6. note: think of CHF as fluid traffic jam in the heart; fluid backs up in neck (JVD) and down the legs (pedal edema)
A-Fib
Etiology: electrical abnormalities in the “wiring” of the heart causes top of heart (atria) to quiver abnormally
- CC: palpitations
- risk factors: Paroxysmal A-Fib, chronic A-Fib
- PE: irregularly irregular rhythm, tachycardia
- Dx by: EKG(ECG)
- Assoc meds: coumadin (warfarin), blood thinner
- Note: ED concern is Rapid Ventricular Response (RVR). These pts will often be “cardioverted”, put back into NSR
Non-cardiac causes of CP
- Pericarditis: inflammation of the sac surrounding the heart
- Pleurisy: inflammation of the sac surrounding the lungs
- Costochondritis: irritation of the ribs causing CP, worsened by pressing on the sternum
- Chest Wall Pain: irritation of the chest wall causing pain with palpation of the chest
- Pleural Effusion: fluid collecting around the lungs causing SOB or CP
PE
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR CP OR SOB
Etiology: blood clot becomes lodged in pulmonary artery, blocks blood flow to lungs
1. Catch phrase: pleuritic CP w/Tachycardia and hypoxia
2. risk factors: known DVT, PMHx of DVT or PE, FHx, recent surgery, cancer, A-fib, Immobility, Pregnancy, BCP, smoking
3. CC: SOB or pleuritic CP (worse w/deep breaths)
4. Dx by: CTA chest (CT chest w/IV contrast) or VQ scan. D-dimer aids in detecting clots, but cannot diagnose a PE
PNA (pneumonia)
CORE MEASURE
MAJOR DDX FOR FEVER/SOB/CP
Etiology: infiltrate (bacterial infection) and inflammation inside the lung
1. catch phrase: productive cough with fever
2. risk factors: elderly, bedridden, recent chest injury, recent surgery
3. CC: SOB or productive cough
4. Assoc. Sx: cough with sputum, fever, chest pain
5. Assoc. Meds: Rocephin and Zithromax (Abx)
6. Dx by: CXR
7. Note: Community Acquired Pneumonia (CAP) protocol applies to pt’s with PNA. Document Abx, vital signs, SaO2, mental status, and blood cultures
PTX (Pneumothorax)
CRITICAL CARE DX
Etiology: collapsed lung due to trauma or spontaneous small rupture of the lung
1. CC: SOB and one-sided CP (sudden onset, often trauma pt’s)
2. PE: absent breath sounds unilaterally
3. Dx by: CXR
4. Note: document % lung collapsed (e.g. 20% PTX)
COPD
Etiology: long-term damage to lung alveoli (emphysema) along with inflammation and mucous production (chronic bronchitis)
- risk factors: smoking
- CC: SOB
- PE: decreased breath sounds, wheezing, rales
- Assoc Meds: Home O2 (document how much they use @ baseline)
- Dx by: CXR and hx of smoking
Asthma
Etiology: constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a “bronchospasm”
- CC: SOB/wheezing (improved with nebulizer “breathing treatments” (bronchodilators)
- PE: wheezes (inspiratory or expiratory)
- Dx by: clinical
- Note: Doc will ask: 1. Do you have a home nebulizer (machine)? 2. Have you been on steroids recently? 3. Hx of hospitalization for asthma 4. Hx of intubation?
Pulmonary Summary
PE : Pleuritic CP w/tachycardia and hypoxia : Dx by CTA Chest w/contrast
PTX: Unilateral CP and SOB : Dx by CXR
PNA: SOB w/productive cough : Dx by CXR
COPD: SOB with Hx smoking: CXR w/hx smoking
Asthma : wheezing with Hx of Asthma : Dx clinically
Ischemic CVA
CRITICAL CARE DDX
CORE MEASURE
MAJOR DDX FOR WEAKNESS/NUMBNESS
Etiology: blockage of the arteries supplying blood to brain resulting in permanent brain damage
1. C: unilateral focal neurological deficits: 1-sided weakness/numbness or changes in speech/vision
2. risk factors: HTN, HLD, DM, HxTIA/CVA, smoking, FHx CVA, Afib
3. PE: neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits
4. Dx by: clinically, potentially normal CT head
5. Note: always document date and time they were “last known well” as well as source of this information. used to assess eligibility for tPA, a blood thinner that can reverse CVA
Document tPA considered and not indicated due to: onset greater than 3 hours or unknown, unreliable time of onset; symptoms are rapidly improving
Hemorrhagic CVA
CRITICAL CARE DDX
MAJOR DDX FOR HA
Etiology: traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in brain
1. CC: HA (sudden onset, “worst of life”)
2. assoc. Sx: changes in speech, vision, sensation, or motor strength, AMS, Sz
3. PE unilateral neurological deficits
4. Dx by CT head or LP
5. Note: document tPA not indicate due to hemorrhage
TIA
Etiology: vascular changes temporarily deprive a part of the brain of O2, Sx usually last less than 1 hr
- CC transient focal neurological deficit (change in speech, vision, strength, or sensation)
- Dx clinically
- note: Document tPA considered and not indicated due to resolved symptoms
Meningitis (bacterial vs. viral)
CRITICAL CARE DX
MAJOR DDX FOR HA
Etiology: inflammation and infection of the meninges; the sac surrounding the brain and spinal cord
1. CC HA
2. Assoc Sx: fever, neck pain, neck stiffness, AMS
3. PE: meningismus, Nuchl rigidity
4. Dx by LP
Spinal Cord Injury
CRITICAL CARE DX
MAJOR DDX FOR TRAUMA, WEAKNESS, OR NUMBNESS
Etiology: injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury
1. CC nck pain or back pain, bilat. extremity weakness
2. PE: midline bony tenderness, deformities, or step-offs, Bilat. extremity weakness, numbness, decreased rectal tone
3. Dx by CT: C-spine, T-spine, L-spine
4. Note: document if spine is often immobilized w/C-collar
Sz
MAJOR DIAGNOSIS FOR SYNCOPE Etiology: abnormal electrical activity in brain leading to abnormal physical manifestations. Often caused by epilepsy, EtOH withdrawals, or febrile sz in pediatric pts 1. CC: Sz activity, syncope 2. Assoc Sx: injuries(bite tongue) confusion, headache, incontinence 3. PE: somnolent, confused (post-ictal) 4. Note: Doc will ask: a. has pt had similar sz in past? b. does pt have hx of sz 3. what was the date of their last sz d. what sz med do they take
Bell’s Palsy
Etiology: inflammation or viral infection of the facial nerve causes one-sided weakness of face
- CC: facial droop, sudden onset
- Assoc. Sx: jaw or ear pain, increased tear flow of one eye
- Pert. Neg: no extremity weakness, no changes in speech or vision
- PE: unilateral weakness of the upper and lower face
- Dx clinically
- remember to document the absence of other FND
HA
etiology: various causes including hypertensive HA, recurrent dx migraines, sinusitis, etc
1. CC: HA (gradual onset), pressure, throbbing
2. Pert. Neg: no fever, no neck stiffness, no numbness/weakness, no change in speech or vision
3. Note: always remember to doc if HA is similar or dissimilar to any prior HA.
AMS
etiology: multiple causes: most common are hypoglycemia, infection, intoxication, and neurological
1. risk factors: diabetic, elderly, demented, EtOH use, drug use
2. CC: confusion, decreased responsiveness, unresponsive
3. Dx by: case dependent
4. Note: AMS is generalized and usualy caused by things that affect the whole brain (drugs, low blood sugar)
Syncope
CORE MEASURE
Etiology: temporary loss of blood supply to the brain resulting in LOC. Many causes: common are vasovagal and low blood volume (dehydration/hypovolemia), occasionally due to cardiac/neurologic causes
1. CC: passing-out vs/ about to pass out
2. Note: document what happened prior, during, and after the syncopal episode, and how the pt feels now
Vertigo
Etiology: caused by two: vertigo may be from harmless problem of inner ear (benign positional vertio) or may be damage to the brain CVA
- CC room spinning, off balance , worsened w/head movt
- Assoc Sx: N/V, tinnitus
- PE: Horizontal Nystagmus, + Romberg, + Dix-Hallpike Test
- Assoc Me: Meclizine (antivert)
- Dx clinically
Abdominal Quadrants Summary
Epigastric: GERD, MI RUQ: Chlecystitis LUQ: Pancreatitis Periumbilical: SBO RLQ: Appendicitis LLQ: Diverticulitis Suprapubic: Ovarian Torsion, Ovarian Cyst, UTI Flanks: Pyelonephritis, Renal Calculi
Appy
CRITICAL CARE DX
MAJOR DDX FOR ABD PAIN
Etiology: infection of the appendix causes inflammation and blockage, possibly leading to rupture
1. CC: RLQ pain; gradual onset, constant worsened w/movement
2. Assoc Sx: decreased appetite (anorexia), fever, N/V
3. PE: McBurney’s point tenderness, RLQ tenderness, peritoneal signs: guarding, rebound, rigidity
4. Dx by CT A/P w/PO contrast
SBO (Small Bowel Obstruction)
CRITICAL CARE DX
MAJOR DDX FOR ABD PAIN
Etiology: physical blockage of the small intestine
1. risk factor: elderly, infants, abdominal surgery
2. CC: abdominal pain, vomiting
3. Assoc Sx: distension, bloating, no BMs
4. PE: abd tenderness, guarding, rebound, abnormal bowel sounds, abdominal distension, tympany
5. Dx by CT A/P w/ PO contrast; Acute Abdominal Series (AAS) (an xray)
Gallstones
MAJOR DDX FOR ABD PAIN
Etiology: minerals from the liver’s bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder
1. Catch phrase: RUQ abd pain after eating fatty foods
2. CC: RUQ pain, sharp, worse w/eating, deep breaths, and palpation
3. PE: RUQ tenderness, murphy’s sign
4. Dx by Abd US, RUQ
GI Bleed
OFTEN CRITICAL CARE DX
Etiology: hemorrhage in the upper or lower gastrointestinal tract can lead to anemia
1. CC hematemesis, coffee ground emesis, hematochezia, melena
2. Assoc Sx: generalized weakness, lightheadedness, SOB, abd pain
3. PE pale conjunctiva, pallor, tachycardia
4. Dx by heme positive stool (Guaiac positive)
Diverticulitis
Etiology: acute inflammation and infection of abnormal pockets of the large intestine
- risk factor: diverticulosis, advanced age
- CC LLQ pain
- Assoc Sx: nausea, fever, diarrhea
- Dx by CT A/P w/ PO contrast
Pancreatitis
Etiology: inflammation of pancreas
- risk factors: EtOH abuse, cholecystitis, specific medications
- CC: LUQ, epigastric pain
- Assoc Sx: N/V
- PE epigastric tenderness
- Dx by Elevated Lipase lab test (sometimes elevated Amylase)
Gastro-esophageal Reflux Disease (GERD)
Etiology: stomach acid regurgitating into the esophagous
- CC: epigastric pain, burning, improved w/antacids
- PE: epigastric tenderness
- Assoc Med: GI cocktail
- Note: pts w/ cardiac risk factors and epigastric pain will alwasy get a cardiac workup
Other causes of abd pain
Gastroenteritis: vomiting and diarrhea, GI bug, often viral or bacterial
Crohn’s Disease: immune disorder causing diarrhea/abd pain
IBS: chronically sensitive bowels prone to diarrhea
Gastritis: irritated stomach w/vomiting “stomach ache”
UTI
Etiology: infection inf the urinary tract
- Risk factors: female
- CC dysuria
- Assoc Sx: frequency, urgency, malodorous urine, AMS (elderly)
- PE suprapubic tenderness
- Dx by urine dip or UA (nitrite, WBC, and bacteria in urine
Pyelonephritis (Pyelo)
Etiology: infection of the tissue in the kidnesy, usually spread from a UTI
- risk factors: female, frequent UTIs
- CC: flank pain w/dysuria
- Assoc Sx: fever, N/V
- PE: CVA tenderness (costo-vertebral angle)
- Dx by CT abd/pel w/o contrast or confirmed UTI w/ CVA tenderness on exam
Kidney Stone (Urolithiasis, Nephrolithiasis, Renal Calculi, Renal Colic)
Etiology: stone dislodges from kidney, travels down ureter. stone scrapes and irritates the ureter, causing severe flank pain and bloody urin
- CC flank pain, sudden onset, radiating to groin
- Assoc sx: hematuria, N/V, unable to void
- PE CVA tenderness
- Dx CT ABD/pelvis RBC in UA may be clue
Ectopic Pregnancy
CRITICAL CARE DX
MAJOR DDX FOR VAGINAL BLEEDING WHILE PREGO
1. risk factors: pregnant female, (HCG pos) STD, PID
2. CC: lower abd pain or vaginal bleeding while pregnant
3. Dx by US pelvis -> determine location of fetus
4. Note: any female w/ abd pain and preg will get US pelvis to rule out ectopic pregnancy
Ovarian Torsion
CRITICAL CARE DX
MAJOR DDX FOR PELVIC PAIN
1. etiology: twisting of an ovarian artery reducing blood flow to an ovary, possilby resulting in an infarct of the ovary
2. CC lower abd pain (RLQ or LLQ)
3. PE: Adnexal tenderness (R or L), tenderness in the RLQ or LLQ
4. Dx by US pelvis -> assesses blood flow to ovaries
5. Note: time sensitive, document all times
Testicular torsion
CRITICAL CARE DX
MAJOR DDX FOR PELVIC PAIN
1. etiology: twisiting of the spermatic cord resulting in loss of blood flow and nerve function to the testical
2. CC testicular pain
3. PE: testicular tenderness and swelling R or L
4. Dx by US scrotum
URI
etiology: most often viral infection causes congestion, cough, and inflammation of the upper airway
1. CC cough/congestion
2. Assoc sx: fever, sore throat, HA myalgias
3. PE rhinorrhea, boggy turbinates, pharyngeal erythema
4. Dx clinically
5. note: pay special attn to c/o CP or SOB for URI pts; always be careful to describe the CP or SOB accurately so as to not accidentally create the impression of symptoms consisten w/MI or PE
Otitis Media (middle ear infection)
etiology: viral or bacterial infection of the TM causing ear pain and pressure
1. CC ear pain, ear pulling
2. Assoc Sx fever, sore throat, dry cough, congestion
3. PE erythema, effusion, dullness, or bulging of the TM
4. dx clinically
Streptococcal Pharyngitis
etiology: bacterial infection of the tonsils and pharyn causing a sore throat and frequently swollen lymph nodes
1. CC sore throat
2. PE pharyngeal erythema, Tonsillar hypertrophy, Tonsillar exudates (pus)
3. Dx by rapid strep
4. Note: most sore throats are viral, however, strep is bacterial so Abx will help; concern of Peri-Tonsillar Abscess (PTA). signs include uvular shift or tonsillar asymmetry
Conjunctivitis (Pink Eye)
Etiology: infection of the outer lining of the eye
- CC eye redness, irritation, or pain
- Assoc Sx eyelid matting
- PE conjunctival injection, edema, and exudates
- Dx clinically
Epistaxis (nose bleed)
Etiology: rupture of a blood vessel inside the nose causes blood to flow out of the nose and into the throat
- CC nose bleed
- risk factors: blood thinners (coumadin/warfarin, ASA, Plavix) or HTN
- PE anterior, posterior, or septal source of the bleeding
- Dx clinically
- Note: nose bleeds can be cauterized or stopped w/pressure from a nasal tamponade called a “rhino-rocket”
Musculoskeletal Back Pain
etiology : deterioration or strain of the back creates pain that is worse with movement
- CC back pain, lower usually
- Assoc sx: shooting posterior lower extremity pain
- Pert. Neg: no LE weakness, no incontinence
- PE: paraspinal tenderness, positive straight leg raise (+ SLR diagnoses Sciatica, back pain that radiates down the legs)
- Note: document any recent trauma related to back pain as it increases concern of spinal injury
Extremity Injury
etiology: trauma creates pain/swelling in an extremity
1. CC extremity pain
2. Assoc Sx. swelling, bruising, deformity, use limitation
3. Pert. Neg: no motor weakness, no numbness tingling
4. PE Distal CSMT intact (circulation, sensory, motor, tendon), no tendon or ligament laxity, ROM limited seconary to pain
5. note: document any splint with Splint Application Procedure Note
AAA
CRITICAL CARE DX
MAJOR DDX FOR ABD PAIN
etiology: widened and weakened arterial wall at risk of rupture
1. CC midline abd pain
2. PE midline pulsatile abdominal mass, abdominal bruit, unequal femoral pulses, hypotension
3. Dx by CT A/P w/ IV contrast
Aortic Dissection
CRITICAL CARE DX
MAJOR DDX FOR CP OR BACK PAIN
etiology: separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and deaht
1. CC CP radiating to back (ripping/tearing)
2. PE unequal brachial or radial pulses, hypotension
3. Dx by CT chest w/IV contrast
DVT
MAJOR DDX FOR LEG PAIN/SWELLING
etiology: blood slows down while flowing through long straight veins in extremities, slow-flowing blood is more likley to clot. once formed the clot can continue to grow and eventually occlude block the vein
1. risk factors: PMHx of DVt or PE, FHx, recent surgery, cancer, immobility, pregnancy, BCP, smoking LE traua, LE casts
2. CC extremity pain and swelling (atraumatic), usually a LE
3. PE calf tenderness, cords, Homan’s sign
4. Dx by US/Doppler of the extremity
Cellulitis
etiology: infection of the skin cells
1. CC red swollen painful and sometimes warm area of the skin
2. PE erythema, edema, increased warmth (calor), induration
3. Assoc meds, Abx
4. Dx clinically
Abscess
etiology: skin infection w/an underlying collection of pus
1. CC red swollen, and painful lump
2. PE fluctuance (pus pocket) induration, purulent discharge
3. Dx clinically
4. Note: must drain, document I&D procedure notes for abscesses
Rash
etiology: changes in the skin’s appearance due to systemic or localize reaction. may be caused from medication, virus, bacteria, fungus, insect, etc
1. CC rash, red, pruritic, painful
2. PE: Urticaria (hives or wheals), Macules (flat) Pauples (raised bumps) Vesicles (small blisters), Blanching (not dangerous) Petechaie (dangerous rash) Purpura (dangerous rash)
3. Dx clinically
Allergic reaction
etiology : immune response causing an inflammatory reaction consisting of swelling, itching, and rash
- risk factors: known drug or food allergy
- CC: rash, swelling, itchy, or SOB
- PE edema, facial angioedema, Urticaria (hives, wheals)
- Dx clinically
- Noe: ED concern is Anaphylaxis or Respiratory failure
Allergy vs. Adverse Reactions
Allergic: Rash, Itching, Swelling, SOB due to airway swelling
Adverse Reaction: N/V, Abd Pain, Diarrhea, Dizziness
DKA
CRITICAL CARE DX
etiology: shortage of insulin resulting in hyperglycemia and production of ketones
1. risk factors DM
2. CC persistent vomiting with a hx of DM
3. Assoc Sx: SOB, polydipsia, polyuria
4. PE ketotic odor, dry mucous membranes, dehydration, Tachypnea
5. Dx by: Arterial Blood Gas (ABG or VBG) showing low pH (acidosis) or Positive Serum ketones
Psychological Disorder
etiology: various types of psych disease produce abnormal thoughts, behaviours or actions
1. PMHx: Bipolar Disorder, Schizophrenia, PTSD, Depression, Anxiety, Alcoholism, Drug Abuse, Suicide Attempt
2. Possible CC: Suicidal Ideation(SI), Homicidal Ideation (HI), Hallucinations, (Auditory or Visual), Substance Abuse, Self injury, Overdoes
3. PE flat affect, SI, HI, Tangential or pressured speech
4. Notes: careful to document MEDICAL (PHYSICAL) COMPLAINts
Trauma
etiology: depending on the mechanism of injury (MOI) physical trauma may break bones, sever nerves, rupture blood vessles or damage internal organs
1. CC MVA, fall, GSW
2. PE Glasgow Coma Scale (GCS)
3. Assoc Med: blood thinners?
4. Dx by: trauma protocol depending on MOI, CT or XR
5. Note: Neuro Injury (brain, spine): LOC, confusion, numbness, weakness, HA, neck/back pain
Internal Organ Injury (Lungs, Spleen, Liver): SOB, CP, Abd pain
