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Scribe Training > ED 2 > Flashcards

ED 2 Flashcards

1
Q

Pathophysiology

A

The study of abnormal changes in body functions that are the causes, consequences, or concomitants of disease processes

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2
Q

Associated Symptoms

A

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

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3
Q

Pertinent Negatives

A

Specific symptoms that are not present which lower physicians suspicion for a particular DDx

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4
Q

Diabetic Retinopathy

A

Damages small vessels of the eyes and can cause hemorrhaging leading to blurred vision, nearsightedness, or vision loss.

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5
Q

Renal Failure

A

Damage to glomeruli of the kidneys.

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6
Q

Neuropathy

A

Peripheral nervous system damage causes distal paresthesias and extremity pain.

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7
Q

Cerebrovascular Accident

A

Overtime high glucose levels can damage the body’s blood vessels, increasing chance of stroke.

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8
Q

Cardiac Disease

A

Damages blood vessels therefore increasing the risk factor for CAD, CHF, and diabetic cardiomyopathy.

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9
Q

Peripheral Vascular Disease

A

Damages blood vessels and decreases blood flow to extremities results in infections, ulcers, and potential amputations.

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10
Q

Effects of Chronically High Blood Pressure

A

CVA
Cardiac Disease
CHF
Retinopathy
Renal Failure

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11
Q

CVA

A

Damages and narrows arterial vessels and limits blood flow and increases risk of artery rupture.

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12
Q

Effects of Chronically High Blood Glucose

A

Diabetic Retinopathy
Cardiovascular Accident
Cardiac Disease
Peripheral Vascular Disease
Renal Failure
Neuropathy

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13
Q

Effects of Chronically High Cholesterol

A

CVA
Cardiac Disease
Pancreatitis

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14
Q

CHF

A
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15
Q

Pancreatitis

A
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16
Q

Coronary Artery Disease

A

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

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17
Q

CAD Risk Factors

A

HTN, HLD, DM, Smoking, Family history of CAD/MI <55y/o

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18
Q

CAD Chief Complaint

A

Angina
Modifying factors

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19
Q

CAD Associated Sx

A

Shortness of breath

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20
Q

CAD Medications

A

NItroglycerin to manage angina, Acetysalacylic Acid to decrease the chance of blockage

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21
Q

CAD Diagnosed by

A

Cardiac catheterization
*cannot be diagnosed in ED

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22
Q

CAD Scribe Alert

A

A patient has CAD if they have a PMHx of Angina, MI, CABG, Cardiac stents, or Angioplasty.

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23
Q

Myocardial Infraction

A

Acute blockage the coronary arteries causing ischemia or infaction to the heart muscle.

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24
Q

MI Risk Factors

A

CAD, Hypertension, Hyperlipidemia, Diabetes Melitus, Smoker, FHx of CAD < 55 yo

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25
Q

MI Assoc. Sx

A

Diaphoresis, Nausea/Vomiting, and Shortness of breath

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26
Q

MI Chief Complaints

A

Chest pain or chest pressure.
Modifying Factors: Worse with exertion, improved with rest and/or nitroglycerin

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27
Q

MI Medications

A

Acetylsalicylic Acid, Nitroglycerin, Thrombolytic

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28
Q

MI Diagnosed by

A
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29
Q

MI Scribe Alert

A

Document ED arrival time, EKG time, ASA time, cath lab departure time. STEMI patients must get to Cath-lab within 90 minutes of arrival

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30
Q

Congestive Heart Failure

A

The heart becomes enlarged, inefficient, anc congested with excess fluid.

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31
Q

CHF Risk Factors

A

History of CHF, Hypertension, Hyperlipidemia, Diabetes Mellitus, Kidney Disease, SMoking

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32
Q

CHF Chief Complaint

A

Shortness of Breath
MOdifying Factors: Orthopnea, Dyspnea on Exertion, and Paroxysmal Nocturnal Dyspnea

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33
Q

CHF Assoc Sx

A

Bilateral lower extremity swelling, fatigue, cough

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34
Q

CHF Medications

A

Diuretics -> urinate ectra fluid

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35
Q

CHF Physical Exam

A

Rales in lungs, Jugular Vein Distention, Pedal Edema

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36
Q

CHF Diagnosed by

A

CXR and elevated BNP

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37
Q

CHF Scribe Alert

A

If the patient has a CHF history, document their current dosage of Lasix. Search echocardiograms and document the cardiac output and cardiac valve function.

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38
Q

Atrial Fibrillation

A

Electrical abnormalities in the wiring of the heart causeing the atria to quiver abnormally

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39
Q

A Fib Risk Factors

A

Paroxysma A FIB, Chronic A Fib, Alcaholism

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40
Q

A Fib Cheif Complaint

A

Palpitations (Fast, Pounding, Irregular)

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41
Q

A Fib Assoc. Sx

A

Global Weakness, Fatigue, Lightheadedness

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42
Q

A Fib Medications

A

Coumadin/Warfarin and Digoxin

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43
Q

A Fib Physical Exam

A

Iregularly irregular rhythm

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44
Q

A Fib Diagnosed by

A

ECG/EKG

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45
Q

A Fib Scribe Alert

A

ED concern is Rapid Ventricular Response, which is Afib with a greater than 100 bpm. Patients who have AFib are at an increased risk for developing blood clots and often take a blood thinner.

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46
Q

Pulmonary Embolism

A

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

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47
Q

RE Risk Factors

A

Known DVT, PMHx of DVT or PE, FHx, Recent surgery, Cancer, A Fib, Immobility, Preganancy, BCP, Smoking

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48
Q

PE Cheif Complaint

A

Chest Pain
Modifying Factor: Worse with deep breaths

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49
Q

PE Assoc. Sx

A

Shortness of breath.
Patients often are hypoxic, techycardic

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50
Q

PE Diagnosed by

A

Screening tool: D-Dimer
Diagnostic tool: CTA Chest

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51
Q

PE Scribe Alert

A

A deep vein thrombosis is a blood clot in an extremity. Symptoms include extremity pain and swelling and have the same risk factors as a PE. A DVT is diagnosed by an ultrasound of that extremity.

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52
Q

Pneumonia

A

Infection and inflammation inside the lung

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53
Q

PNA Risk Factors

A

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

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54
Q

PNA Chief Complaint

A

Productive Cough

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55
Q

PNA Assoc. Sx

A

Shortness of breath, fever, chest pain

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56
Q

PNA Medications

A

Rocephin and Zithromax

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57
Q

PNA Physical Exam

A

Rhonchi

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58
Q

PNA Diagnosed by

A

Chest X-Ray

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59
Q

PNA Scribe Alert

A

Community-Acquired Pneumonia protocol requires documenting Abx, Vital Signs, SaO2, Mental Status, and Blood Cultures

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60
Q

Chronic Obstructive Pulmonary Disease

A

Long-term damage to the lungs alveoli along with inflammation and musuc production

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61
Q

COPD Risk Factors

A

Single greatest risk factor is Smoking (80-90% of all cases)

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62
Q

COPD Chief Complaint

A

Shortness of breath

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63
Q

COPD Assoc. Sx

A

Wheezing, cough, chest tightness

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64
Q

COPD Treatment

A

Bronchodilators, Supplemental oxygen, Corticosteroids, Ventilatory support

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65
Q

COPD Physical Exam

A

Decreased breath sounds, wheezes

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66
Q

COPD Diagnosed by

A

Acute infections are a very common cause for a COPD Exacerbation. For this reason, a CXR may be ordered to rule out PNA. Othersise COPD is not diagnosed in the ED.

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67
Q

COPD Scribe Alert

A

Document the paitents baseline O2 requierment

68
Q

Asthma

A

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

69
Q

Asthma Risk Factors

A

Personal or familial history of asthma, smoking, occupational exposures, obesity, allergies

70
Q

Asthma Chief Complaint

A

Shortness of Breath
Modifying Factors: Improved with “breathing treatments”, exacerbated by certian triggers

71
Q

Asthma Assoc Sx

A
72
Q

Asthma Treatment

A
73
Q

Asthma Physical Exam

A
74
Q

Asthma Scribe Alert

A
75
Q

Ischemic Cerebrovascular Accident

A

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

76
Q

CVA Risk Factors

A

HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, AFIB

77
Q

CVA CHief Complaint

A

Unilateral focal neurological deficits: one sided weakness/numbness or changes in speech/vison

78
Q

CVA Medications

A

tPA will be administered if the paitent meets the criteria

79
Q

CVA Physical Exam

A

Unilateral neurological deficits

80
Q

CVA Diagnosed by

A

Clinically following a CT Head in order to rule out Hemorragic CVA

81
Q

CVA Scribe Alert

A

Document the date and time they were “last known well” as well as the source of this information. This is used to assess eligability 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

82
Q

Hemorrhagic CVA

A

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

83
Q

Hemorrhagic CVA Risk Factors

A

HTN, anticoagulant use, recent head trauma

84
Q

Hemorrhagic CVA Chief Complaint

A

Severe, sudden onset Headache

85
Q

Hemorrhagic CVA Assoc. Sx

A

Nausea, AMS, Focal neurological deficits

86
Q

Hemorrhagic CVA Physical Exam

A

Unilateral neurological deficits

87
Q

Hemorrhagic CVA Diagnosed by

A

CT Head is the preferred method of speedy diagnosis. However, imaging is not 100% reliable in detecting a brain bleed. Therefore the paitents clinical presentation will also play a role in the diagnostic process. In rare cases, a LP may be performed for further diagnostic purposes

88
Q

Hemorrhagic CVA Scribe Alert

A

Document “tPA not indicated due to hemorrahge”

89
Q
A
90
Q

Transient Ischemic Attack

A
91
Q

TIA Risk Factors

A
92
Q

TIA Chief Complaint

A
93
Q

TIA Diagnosed by

A
94
Q

TIA Scribe Alert

A
95
Q

Meningitis

A

Inflammation and infection of the meninges; sac surrounding the brain and spinal cord

96
Q

Meningitis Risk Factors

A

Recent international travel, recent exposure to a sick contact

97
Q

Meningitis Chief Complaint

A

Headache, neck pain or stiffness, fever, altered mental status

98
Q

Meningitis Physica Exam

A
99
Q

Meningitis Diagnosed by

A
100
Q

Meningitis Scribe Alert

A
101
Q

Altered Mental Status

A
102
Q

Altered Mental Status Risk Factors

A
103
Q

Altered Mental Status Chief Complaint

A
104
Q

Altered Mental Status Diagnosed by

A
105
Q

Altered Mental Status Scribe Alert

A
106
Q

Syncope

A

Temporary loss of blood supply to the brain resulting in loss of consciousness. There are a variety of causes: volume. Occasionally, syncope occurs due to cardiac/neurologic causes.

107
Q

Syncope Chief Complaint

A

Loss of Consciousness, Fainting or Passing out

108
Q

Syncope Scribe Alert

A

Document what happened:
1. Before the episode
2. During the episode
3. After the episode
4. How the patient is currently feeling
Were they near-syncopal? Did they almost pass out or have lightheadedness?

109
Q

Appendicitis

A

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

110
Q

Appendicitis Chief Complaint

A

Abdominal Pain
Located RQL
Modifying Factor: Worse with mivement

111
Q

Appendicitis Assoc. Sx

A

Nausea, vomiting, feer, decreased appetite

112
Q

Appendicitis Physical Exam

A

RQL tenderness, McBurney’s point tenderness

113
Q

Appendicitis Diagnosed by

A

CT Abdomen/Pelvis with PO contrast

114
Q

Cholelithiasis

A

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

115
Q

Cholelithiasis Risk Factors

A

Females age 40 or older, Ppl of native american or Mexican decent, obesity, sedentary, pregnancy, high fat diet

116
Q

Cholelithiasis Chief Complaint

A

Abdominal pain
Located RQL
Quality Typically Sharp
Modifying Factors: Worse with eating fatty foods, deep breaths, and palpitations

117
Q

Cholelithiasis Physical Exam

A

RUQ tenderness, Murphy’s sign

118
Q

Cholelithiasis Diagnosed by

A

Abdominal Ultrasound

119
Q

Urinary Tract Infection

A

Infection of the urinary tract (bladder or urethra)

120
Q

Urinary Tract Infection Risk Factors

A

Female

121
Q

Urinary Tract Infection Chief Complaint

A

Painful urination (dysuria)

122
Q

Urinary Tract Infection Assoc. Sx

A

Urinary frequency, urgency, malodorous urine, AMS

123
Q

Urinary Tract Infection Physical Exam

A

Suprapubic tenderness

124
Q

Urinary Tract Infection Diagnosed by

A

Urine drip or urinalysis

125
Q

Urinary Tract Infection Scribe Alert

A
126
Q

Kidney Stones

A

A kidney stone disloged from the kidney and begins traveling down the ureter. The stone scrapes and irritates the ureter, causing severe flank pain and bloody urine.

127
Q

Kidney Stones Chief Complaint

A

Flank pain

128
Q

Kidney Stones Assoc. Sx

A

Blood in the urine, nausea/vomiting, unable to void

129
Q

Kidney Stones Physical Exam

A
130
Q

Kidney Stones Diagnosed by

A
131
Q

Ectopic Pregnancy

A

A fertilized egg develops outside the uterus, usually in the fallopian tube. High risk for rupture and death.

132
Q

Ectopic Pregnancy Risk Factors

A
133
Q

Ectopic Pregnancy Chief Complaint

A
134
Q

Ectopic Pregnancy Diagnosed by

A
135
Q

Ectopic Pregnancy Scribe Alert

A
136
Q

Acute Trauma Diagnoses

A
137
Q

Trauma Documentation Requierments

A

Mechanism of Injury ?*HPI
Blood Thinners? *HPI
Glasgow Goma Scale? *PE

138
Q

Back Pain

A

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

139
Q

Back Pain Risk Factors

A

Chronic back pain, age. physically demanding job

140
Q

Back Pain Chief Complaint

A

Back pain

141
Q

Back Pain Physical Exam

A

Paraspinal tenderness, positive straight leg raise

142
Q

Back Pain Scribe Alert

A

Remember to document

143
Q

Abdominal Aortic Aneurysm

A

Widened and weakened arterial wall at risk of rupture

144
Q

AAA Risk Factors

A

Age, HTN, smoking, CAD

145
Q

AAA Chief Complaint

A

Midline Abdominal Pain

146
Q

AAA Physical Exam

A

MIdline Pulsatile abdominal mass, Abdoninal bruit, Unequal femoral pulses, Hypotension

147
Q

AAA Diagnosed by

A

CT Abdomen/Pelvis with IV contrast dye

148
Q

Aortic Dissection

A

Se

149
Q

Aortic Dissection Risk Factors

A
150
Q

Aortic Dissection Chief Complaint

A
151
Q

Aortic Dissection Physical Exam

A
152
Q

Aortic Dissection Diagnosed by

A
153
Q

Sepsis

A

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

154
Q

Sepsis Risk Factors

A

Curret infection, Compromised immune system, Open WOunds, chronically ill. young/old, invasive device

155
Q

Sepsis Chief Complaint

A

Fever and AMS

156
Q

Sepsis Assoc. Sx

A

Symptoms vary, dependant on the source of infection.

157
Q

Sepsis Scribe Alert

A
158
Q

Sepsis Protocal

A
  1. Trending vital signs
  2. Monitoring labs
  3. Preliminary management
  4. Finalized management
159
Q

Cellulitis

A
160
Q

Cellulitis Chief Complaint

A
161
Q

Cellulitis Medications

A
162
Q

Cellulitis Physical Exam

A
163
Q

Cellulitis Diagnosed by

A
164
Q

Cellulitis Scribe Alert

A
165
Q

Abcess

A

Scribe Training (5 decks)

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