Pathophysiology Flashcards
1
Q
CAD Etiology
A
Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina (CP specifically due to heart muscle ischemia)
2
Q
CAD Catch Prase
A
CP WITH PHYSICAL EXERTION
3
Q
CAD Chief Complaint
A
CP or Chest pressure
- Worse with exertion
- Improved by rest or NTG
4
Q
CAD Assoc. Med
A
ASA 324 mg PO, NTG 0.4 mg SL
5
Q
CAD Dx by
A
Cardiac Catheterization (not diagnosed in ED)
6
Q
CAD Scribe Alert
A
1) CAD greatest risk factor for MI
2) Stress test/Cardiac Catheterization to see severity
3) CAD if PMHx of Angina, MI, CABG, cardiac stents, or angioplasty
4) ASA 324mg PO ASAP unless given PTA or contraindicated due to bleeding or allergy
7
Q
MI Etiology
A
Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle
8
Q
MI Catch Phrase
A
Chest pressure WITH DIAPHORESIS, N/V, SOB
9
Q
MI Risk Factor
A
CAD, HTN, HLD, DM, Smoker, FHx of CAD
10
Q
MI Chief Complaint
A
CP or Chest Pressure
11
Q
MI Dx By
A
EKG (STEMI) or elevated Troponin (non-STEMI) reg =.05
12
Q
MI Assoc. Med
A
ASA, NTG, B-Blocker, Thrombolytic (heparin)
13
Q
CHF Etiology
A
The heart becomes enlarged, inefficient, and congested with excess fluid.
14
Q
CHF Catch Phrase
A
SOB with PEDAL EDEMA and ORTHOPNEA
15
Q
CHF Chief Complaint
A
SOB - ORTHOPNEA (worse lying flat)
- PND (paroxysmal nocturnal dyspnea)
- DOE (dyspnea on exertion)
16
Q
CHF PE
A
Rales in lungs
JUV in neck
Pitting pedal edema
17
Q
CHF Assoc. Med
A
Diuretics (Lasix, Furosemide) to inc. urination
18
Q
CHF Dx By
A
CXR or ELEVATED BNP (B-type Natriuretic peptite)
19
Q
CHF Scribe Alert
A
Fluid traffic jam in the heart
20
Q
AFIB Etiology
A
Electrical abnormalities in the ‘wiring’ of the heart causes the top of the atria to quiver abnormally
21
Q
AFIB Chief Complaint
A
Palpitations (fast, pounding, irregular)
22
Q
AFIB Risk Factors
A
Paroxysmal A fib (ocassionally)
Chronic A fib (more frequently)
23
Q
AFIB PE
A
IRREGULARLY IRREGULAR RHYTHM, Tachycardia
24
Q
AFIB Dx By
A
EKG (ECG)
25
AFIB Assoc. Med
Coumadin (Warfarin): Blood thinner
| Digoxin: slow HR
26
AFIB Scribe Alert
ED concern of RVR (rapid ventricular response)
| Pt 'cardioverted' (put back into NSR)
27
Pericarditis
Inflammation of the sac surrounding the heart causing CP
28
Pleurisy
Inflammation of the sac surriounding the lungs is causing pleuritic CP
29
Costochondritis
Irritations of the ribs causing CP worsened by pressing on the sternum
30
Chest Wall Pain
Irritation of the chest wall causing pain with palpation of the chest
31
Pleural Effusion
Fluid collecting around the lungs causing SOB or CP
32
PE Etiology
A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs
33
PE Catch Phrase
PLEURITIC CHEST PAIN with tachycardia and hypoxia
34
PE Risk Factor
Known DVT or PE, FHx, Recent surgery, Cancer, AFIB, Immobility, Pregnancy, BCP, Smoking
35
PE Chief Complaint
SOB or Pleuritic chest pain (CP worse w/ deep breath)
36
PE Dx By
CTA (CT chest w/ IV contrast) or VQ scan (preg or kidney issues)
D-dimer: (-) No PE for sure (+) might have clot
37
PNA Etiology
Infiltrate (bacterial infection) and inflammation inside the lung
38
PNA Catch Phrase
Productive cough w/ fever
39
PNA Chief Complaint
SOB or PRODUCTIVE COUGH
40
PNA Assoc. Sx
Cough w/ sputum, fever, chest pain
41
PNA PE
Rhonchi
42
PNA Dx By
CXR
43
PNA Scribe Alert
CAP: Community aquired PNA
| Req documenting Abx, Vital signs, Sa02, Mental status, and blood cultures.
44
PTX Etiology
Collapsed lung due to trauma or a spontaneous small rupture of the lung
45
PTX Chief Complaint
SOB and ONE-SIDED chest pain
| -sudden onset, often trauma pt (gradual)
46
PTX PE
Absent breath sounds unilaterally
47
PTX Dx By
CXR
48
PTX Scribe Alert
Document % of lung collapsed. Pt will have a chest tube to reinflate the lungs
49
COPD Etiology
Long-term damage to the lung's alveoli (emphysema) along with inflammation and mucous production (chronic bronchitis)
50
COPD Risk Factors
Smoking
51
COPD Chief Complaint
SOB
52
COPD PE
Decreased breath sounds, wheezes, rales
53
COPD Assoc. Meds
Home 02 (how much and type for baseline)
54
COPD Dx By
CXR and Hx of smoking
55
RAD Etiology
COnstricting of the airway due to inflammation and muscular contraction of the bronchioles, know as a 'bronchospasm'
56
RAD Chief Complaint
SOB/Wheezing
| -Improved by nebulizer 'breathing treatments' (bronchodilators)
57
RAD PE
Wheezes (inspiratory/expiratory, L or R)
58
RAD Assoc. Meds
Inhalers, Nebulizers, Corticosteroids
59
RAD Dx By
Clinically
60
RAD Scribe Alert
1) Home nebulizer? 2) Recent steroids? 3) Hx of hospitalization for asthma 4) Hx of intubation 5) Asthma triggers
61
CVA Etiology
Blockage of the arteries supplying blood to the brain resulting in permanent brain damage
62
CVA Chief Complaint
UNILATERAL focal neurological deficits: numbness/weakness or changes in speech/vision
63
CVA Risk Factors
HTN, HLD, DM, Hx TIA/CVA, Smoking, FHx, CVA, AFIB
64
CVA PE
Nerological deficits: hemiparesis, unilateral parethesias, aphasia, visual field deficits
65
CVA Dx By
Clinically, Potentially normal CT Head
66
CVA Scribe Alert
Date and time they were "last known well" (at baseline) and source of info (assesses eligibility for tPA)
- not used if >3 hrs or unknown onset or Sx rapidly improving
67
Hemorrhagic CVA Etiology
Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain
68
Hemorrhagic CVA Chief Complaint
HA, sudden onset?
69
Hemorrhagic CVA Assoc. Sx
Changes in speech, vision, numbness, weakness, AMS, seizure, HA
70
Hemorrhagic CVA PE
Unilateral neurological deficits
71
Hemorrhagic Dx By
CT Head or LP
72
Hemmorhagic Scribe Alert
Document "tPA not indicated due to hemorrhage"
73
TIA Etiology
Vascular changes temporarily deprive a part of the brain of oxygen (Sx usually last lest than 1 hr)
74
TIA Chief Complaint
Transient focal neurological deficit
| -Changes in speech,vision,strength, or sensation
75
TIA Dx By
Clinically
76
TIA Scribe Alert
Document tPA considered and not indicated due to the fact that symptoms are resolved.
77
Meningitis Etiology
Inflammation and infection of the meninges; the sac surrounding the brain and spinal chord
78
Meningitis Chief Complaint
HA and neck pain
79
Meningitis Assoc. Sx
Fever, NECK PAIN, NECK STIFFNESS, and AMS
80
Meningitis PE
Meningismus (neck stiffness), nuchal rigidity
81
Meningitis Dx By
LP
82
Spinal Cord Injury Etiology
Injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury.
83
Spinal Cord Injury Chief Complaint
Neck pain or back pain, bilateral extremity weakness
84
Spinal Cord Injury PE
MIDLINE BONY TENDERNESS, deformities, step-offs, bilateral extremity weakness, numbness, decreased rectal tone
85
Spinal Cord Injury Dx By
CT Cervical/thoracic/lumbar
86
Spinal Cord Injury Scribe Alert
Pt often immobilized in C-collar
87
SZ Etiology
Abnormal electrical activity in the brain leading to abnormal physical manifestations. Often caused by epilepsy, EtOH withdrawls, or febrile seizure in pediatric pts
88
SZ Chief Complaint
Seizure activity, Syncope
89
SZ Assoc. Sx
Injuries (tongue bite), Confusion, Headache, Incontinence
90
SZ PE
Somnolent, Confused (Post-Ictal)
91
SZ Medications
Dilantin, Tegretol, Keppra, Depakote, Neurontin
92
SZ Scribe Alert
1) Similar SZ before? 2) Hx of SZ? 3) Date of last SZ 4) What SZ med? 5) Missed med dose?
93
Bells Palsy Etiology
Inflammation or viral infection of the facial nerve causes one-sided weakness of the entire face
94
Bells Palsy Chief Complaint
Facial Droop; sudden onset
95
Bells Palsy Assoc. Sx
Jaw or ear pain, increased tear flow of one eye
96
Bells Palsy Pert. Neg
NO EXTREMITY WEAKNESS, NO CHANGES IN SPEECH/VISION
97
Bells Palsy PE
Unilateral weakness of the upper and lower face
98
Bells Palsy Dx By
Clinially
99
Bells Palsy Scribe Alert
Most common cause of facial droop in young pt who do not have CVA risk factors. Document absence of other FND
100
HA Etiology
Various causes including hypertensive headaches (from high blood presure), recurrent diagnosed migranes, sinusitits, etc.
101
HA Chief Complaint
HA gradual onset - pressure, throbbing
102
HA Pertinent Neg.
NO FEVER, NO NECK STIFFNESS, NO NUMBNESS/WEAKNESS, NO CHANGES IN SPEECH/VISION
103
HA Scribe Alert
Not if similar/dissimilar to prior HA
| NEVER DOCUMENT 'WORST OF MY LIFE' UNLESS SPECIFICALLY INSTRUCTED
104
AMS Etiology
Multiple causes: most common are hypoglycemia, infection, intoxication, and neurological
105
AMS Risk Factors
Diabetic, elderly, demented, EtOH use, Drug use
106
AMS Chief Complaint
Confusion, decreased responsiveness, unresponsive
107
AMS Dx By
Case dependent
108
AMS Scribe Alert
Generalized, caused by things that affect the whole brain (drugs, low blood sugar). For pt w/o a Hx of dementia is from infection (freq. UTI)
109
Syncope Etiology
Temporary loss of blood supply to the brain resulting in LOC. Common causes of vasovagal and low blood volume (dehydration/hypovolemia), occasionally due to cardiac/neurologic causes.
110
Syncope Chief Complaint
Passing out vs about to pass out
111
Syncope Scribe Alert
What happened PRIOR, DURING, AFTER, AND HOW PT CURRENTLY FEELS.
112
Vertigo Etiology
Caused by inner ear problems (benign positional vertigo) or damage in specific center of the brain (possible CVA)
113
Vertigo Chief Complaint
Room spinning, disequilibrium, WORSENED WITH HEAD MOVEMENT
114
Vertigo Assoc Sx
N/V, TINNITUS
115
Vertigo PE
Horizontal Nystagmus (eye exam) + Romberg (stand and close eyes) + Dix-Hallpike Test (Sit up in bed and slam down)
116
Vertigo Assoc. Med
Meclizine (Antivert)
117
Vertigo Dx By
Clinically
118
APPY Etiology
Infection of the appendix causes inflammation and blockage, possibly leading to rupture.
119
APPY Chief Complaint
RLQ pain
| -Gradual onset, constant, worsened with mvmt
120
APPY Assoc. Sx
Decreased appetite (anorexia), fever, N/V
121
APPY PE
McBurney's point tenderness, RLQ tenderness
| Peritoneal signs: guarding, rebound, rigidity
122
APPY Dx By
CT A/P with PO contrast, ultrasounds
123
SBO Etiology
Physical blockage of the small intesine
124
SBO Risk Factor
Elderly, infants, abd surgery, narcotic pain meds
125
SBO Chief Complaint
Abd pain, VOMITING, Constipation
126
SBO Assoc. Sx
Abd distension, bloating , no BMs
127
SBO PE
Abd tenderness, buarding, rebound, abnormal bowel sounds, ABD DISTENSION, tympany
128
SBO Dx By
CT A/P with PO Contrast
| AAS (acute abdominal series)
129
Cholecystitis Etiology
Minerals from the liver's bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder
130
Cholecystitis Catch Phrase
RUQ abd pain after eating fatty foods
131
Cholecystitis Chief Complaint
RUQ pain: sharp, worsened with eating/deep breaths/palpation
132
Cholecystitis PE
RUQ tenderness, Murphy's sign
133
Cholecystitis Dx By
Abd US, RUQ
134
GI Bleed Etiology
Hemmorhage in upper or lower GI tract can lead to anemia
135
GI Bleed Chief Complaint
Hematemesis (upper), coffee ground emesis (lower), hematochezia (lower), melena (upper)
136
GI Bleed Assoc. Sx
Generalized weakness, lightheadedness, SOB, abd pain, rectal pain
137
GI Bleed PE
Pale conjunctiva, pallor, tachycardia, rectal exam: melena, grossly bloody stool
138
GI Bleed Dx by
Guaiac positive stool
139
GI Bleed Scribe Alert
ED concern is need for a possible blood transfusion due to significant blood loss
140
Diverticulitis Etiology
Acute inflammation and infection of abnormal pockets of the large intestine, known as diverticuli
141
Diverticulitis Risk Factor
Diverticulosis, advanced age
142
Diverticulitis Chief Complaint
LLQ pain
143
Diverticulitis Assoc. Sx
Nausea, Fever, Diarrhea
144
Diverticulitis Dx By
CT A/P with PO Contrast
145
Pancreatitis Etiology
Inflammation of the pancreas
146
Pancreatitis Risk Factors
ETOH ABUSE, cholecystitis, specific meds
147
Pancreatitis Chief Complaint
LUQ epigastric pain
148
Pancreatitis Assoc. Sx
N/V
149
Pancreatitis PE
Epigastric tenderness
150
Pancreatitis Dx By
Elevated Lipase lab test
151
GERD Etiology
Stomach acid regurgitation into the esophagus
152
GERD Chief Complaint
Epigastric pain - burning, improved w/ antacids
153
GERD PE
Epigastric tenderness
154
GERD Assoc. Med
GI Cocktail
155
GERD Scribe Alert
PT WITH CARDIAC RISK FACTORS AND EPIGASTIC PAIN WILL ALWAYS GET A CARDIAC WORKUP
156
C. Diff Colitis
Opportunistic bacteria that causes persistent diarrhea
157
Gastroenteritis
V/D, GI bug often viral or bacterial
158
Crohn's Disease
Immune disorder causing D and abd pain
159
IBS
Chronically sensitive bowels prone to diarrhea
160
Gastritis
Irritated stomach with vomiting, stomach ache
161
UTI Etiology
Infection in the urinary tract (bladder or urethra)
162
UTI Risk Factors
Female
163
UTI Chief Complaint
Dysuria, hematuria
164
UTI Assoc. Sx
Frequency, Urgency, malodorous urine, AMS (elderly)
165
UTI PE
Suprapubic tenderness
166
UTI Dx By
Urine dip (done in ED) or Urinalysis (lab test for Nitrite, WBC, and bacteria in urine)
167
Pyelonephritis Etiology
Infection of the tissue in the kidneys, usually spread from a UTI
168
Pyelonephritis RIsk Factors
Female, frequent UTI
169
Pyelonephritis Chief Complaint
Flank pain with dysuria
170
Pyelonephritis Assoc. Sx
Fever, N/V
171
Pyelonephritis PE
Costo-vertebral angle (CVA) tenderness
172
Pyelonephitis Dx
CT Abd/Pel w/o contrast or confirmed UTI w/ CVA tenderness on exam
173
Renal Calculi Etiology
Kidney stone dislodges from the kidney and travels down the ureter. Scraping causes sever flank pain and bloody urine
174
Renal Calculi Chief Complaint
Flank pain: SUDDEN ONSET, radiating to groin
175
Renal Calculi Assoc. Sx
Hematuria, N/V, UNABLE TO VOID
176
Renal Calculi Exam
CVA tenderness
177
Renal Calculi Dx By
CT Abd/Pelvis, RBC in US may be a clue
178
Ectopic Pregnancy Etiology
Fertilized egg develops outside the uterus, usually in the fallopian tube. High risk for rupture and death
179
Ectopic Pregnancy Risk Factors
Pregnant female, STD
180
Ectopic Pregancny Chief Complaint
Lower abdominal pain or Vaginal bleeding while pregnant
181
Ectopic Pregnancy Dx By
US Pelvis
182
Ectopic Pregnancy Scribe Alert
Any pregnant female complaining of lower abdominal pain or vaginal bleeding considered
183
Ovarian Torsion Etiology
Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in infarct of the ovary
184
Ovarian Torsion Chief Complaint
RLQ or LLQ pain
185
Ovarian Torsion PE
Adenexal tenderness, tenderness in the RLQ or LLQ
186
Ovarian Torsion Dx By
US Pelvis
187
Ovarian Torsion Scribe Alert
TIme sensitive, document accurate times for pt arrival, US resluts, and any physician consultations
188
URI Etiology
Most often viral infection causes congestion, cough, and inflammation of the upper airway
189
URI Assoc. Sx
Fever, sore throat, headache, myalgias
190
URI PE
Rhinorrhea, boggy turbinates, pharyngeal erythema
191
URI Dx By
Clinically
192
URI Scribe Alert
Document complaints of CP or SOB accurately so as not to create impression of Sx of MI or PE
193
Otitis Media Etiology
Viral or bacterial infection of the tympanic membrane (TM) causing ear pain and pressure
194
Otitis Media Chief Complaint
Ear pain, ear pulling
195
Otitis Media Assox. Sx
Fever, sore throat, dry cough, congestion
196
Otitis Media PE
Erythema, effusion, dullness, bulging of TM
197
Otitis Media Dx By
Clinically
198
Steptococcal Pharyngitis Etiology
Bacterial infection of the tonsils and pharynx causing a sore throat and frequently swollen lymph nodes
199
Streptococcal Pharyngitis Chief Complaint
Sore Throat
200
Streptococcal Pharyngitis PE
Pharyngeal Erythma, Tonsilar hypertrophy, tonsilar exudate
201
Streptococcal Pharyngitis Dx By
Rapid Strep
202
Strptococcal Pharyngitis Scribe Alert
Abx help, main concern is possible Peri-Tonsilar Abscess (PTA): uvular shift or tonsillar asymmetry
203
Conjunctivitis Etiology
Infection of the outer lining of the eye, known as the conjunctiva
204
Conjunctivitis Chief Complaint
Eye redness, irritation, or pain
205
Conjunctivitis Assoc. Sx
Eylid malting, eye discharge, fever
206
Conjunctivitis PE
Conjunctival injection (redness), edema, and exudates
207
Conjunctivits Dx By
Clinically
208
Epistaxis Etiology
Rupture of blood vessel inside the nose causes blood to flow out the nose and into the throat
209
Epistaxis Chief Compaint
Nose bleed
210
Epistaxis Risk Factors
BLOOD THINNERS, HTN
211
Epistaxis PE
Anterior, posterior, septal source
212
Epistaxis Dx By
Clinically
213
Epistaxis Scribe Alert
Cauterization may be needed or stopped with Nasal Tamponade "Rhino-rocket". May have coagulation labs (PT/INR) drawn to make sure blood isn't too thin
214
Musculoskeletal Back Pain Etiology
Deterioration or strain of the back creates pain that is worse with movement
215
Musculoskeletal Back Pain Chief Complaint
Back pain: most commonly lumbar pain
216
Musculoskeletal Back Pain Assoc. Sx
Shooting posterior lower extremity pain
217
Musculoskeletal Back Pain Pert. Negs.
No LE WEAKNESS, NO INCONTINENCE
218
Musculoskeletal Back Pain PE
PARASPINAL TENDERNESS, +SLR diagnoses sciatica
219
Musculoskeletal Back Pain Scribe Alert
Document any recent trauma related to the back pain
220
Extremity Injury Etiology
Trauma crates pain/swelling in an extremity
221
Extremity Injury Chief Complaint
Extremity pain
222
Extremity Injury Assoc. Sx
Swelling, bruising, deformity, use limitation
223
Extremity Injury Pert. Neg
NO MOTOR WEAKNESS, NO NUMBNESS/TINGLING
224
Extremity PE
DISTAL CSMT (circulation, sensory, motor, tendon) INTACT, no tendon laxity, ROM LIMITED SECONDARY TO PAIN
225
Extremity Scribe Alert
Make sure to document splint application procedure in notes if applicable.
226
AAA Etiology
Widened and weakened arterial wall at risk of rupture
227
AAA Chief Complaint
Midline abdominal pain
228
AAA PE
Midline pulsatile abd mass, abd bruit, unequal femoral pulses, hypotention
229
AAA Dx By
CT A/P with IV contrast dye
230
Aortic Dissection Etiology
Separation fo the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death
231
Aortic Dissection Chief Complaint
CP radiating to the back, RIPPING OR TEARING
232
Aortic Dissection PE
Unequal brachial or radial pulses, HTN
233
Aortic Dissection Dx By
CT Chest with IV contrast dye
234
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 block the vein.
235
DVT Risk Factors
PMHx of DVT, PE, FHx, Recent surgery, CA, immobility, pregnancy, BCP, smoking, LE Trauma, LE Casts
236
DVT Chief Complaint
Extremity pain and swelling, usually lower extremity
237
DVT PE
Calf tenderness, cords, Homan's sign
238
DVT Dx By
US/Doppler of the extremity
239
Cellulitis Etiology
Infection of the skin cells
240
Cellulitis Chief Complaint
Red, swollen, painful, and sometimes warm
241
Cellulitis PE
Erythema, edema, increased calor, induration
242
Cellulitis Assoc. Meds
Abx
243
Cellulitis Dx By
Clinically
244
Abscess Etiology
Skin infection with an underlying collection of pus
245
Abscess Chief Complaint
Red, swollen, and painful lump
246
Abscess PE
Fluctuance (pus-pocket), induration, purulent drainage
247
Abscess Dx By
Clinically
248
Abscess Scribe Alert
Document I&D
249
Rash Etiology
Changes in the skin's appearance due to systemic or localized reaction. May be caused from medication, virus, bacteria, fungus, insect.
250
Rash Chief Comlaint
Rash: red, itchy, painful
251
Rash PE
Urticaria (hives or wheals), macules (flat), papules (raised bumps), vesicles (small blisters), blanching (not dangerous), petechale (dangerous rash), pupura (dangerous rash)
252
Rash Dx By
Clinically
253
Allergic Reaction Etiology
Immune response causing an inflammatory reaction consisting of swelling, itching, and rash.
254
Allergic Reaction Risk Factor
Known drug or food allergy
255
Allergic Reaction Chief Complaint
Rash, swelling, itching, SOB
256
Allergic Reaction PE
Edema, facial angiodema, urticara
257
Allergic Reaction Dx By
Clinically
258
Allergic Reaction Scribe Alert
ED concern is Anaphylaxis or respiratory failure
259
DKA Etiology
Shortage of insulin resulting in hyperglycemia and production of ketones
260
DKA Risk Factors
DM
261
DKA Chief Complaint
Persistent vomiting with a Hx of DM, hyperglycemia, AMS
262
DKA Assoc. Sx
SOB, polydipsia, polyuria
263
DKA PE
Ketoic odor "fruity", dry mucous membranes, tachypnea, cousmal breathing
264
DKA Dx By
Arterial blood gas (ABG or VBG) showing low pH or Positive Serum ketones
265
Psychological Disorder Etiology
Various types of psychological disease produce abnormal thoughts, behaviors, or actions
266
Psychological Disorder PMHx
Bipolar disorder, schizophrenia, PTSD, depression, anxiety, alcoholism, drug abuse, suicide attempt
267
Psychological Disorder Chief Complaints
SI, HI, Hallucinations, substance abuse, self injury, overdose
268
Psychological Disorder PE
Flat affect, SI, HI, Tangential or pressured speech
269
Psychological Disorder Scribe Alert
Differentiate between medical (physical) and psychiatric complaints
270
Trauma Etiology
Depending on the Mechanism of Injury (MOI) physical trauma may break bones, sever nerves, rupture blood vessels, or damage internal organs
271
Trauma Chief Complaint
MVA, fall, GSW
272
Trauma PE
Glasgow Coma Scale (GCS)
273
Trauma Assoc. Med
Blood thinners?
274
Trauma Dx By
Trauma protocol depending on MOI: Ct or XR
275
Trauma Scribe Alert
Neurological injury: LOC, confusion, numbness, weakness, HA, neck/back pain
Internal organ injury: SOB, CP, Abd pain
