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Scribe > Terminology > Flashcards

Terminology Flashcards

1
Q

Abrasion

A

Scrape of the skin due to something abrasive

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2
Q

Abscess

A

collection of pus underneath the skin

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3
Q

Antipyretic

A

Medication used to reduce a fever

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4
Q

Acute

A

New, usually rapid onset and of concern, opposite of chronic

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5
Q

Afebrile

A

Without a fever ( Temperature of less than 100.4)

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6
Q

Anterior

A

Located towards the front of the body

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7
Q

Appendicitis

A

Dangerous infection of the appendix

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8
Q

Auscultation

A

Listening to sounds arising within organs ( as the lungs or heart)

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9
Q

Benign

A

Normal, of no danger to health

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10
Q

Bradycardia

A

Slow heart-rate ( HR <60 bpm)

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11
Q

Bronchitis

A

infection of the bronchi (upper airway)

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12
Q

Bronchiolitis

A

infection of the bronchioles ( smaller air-tubes in the lungs)

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13
Q

Catheter

A

tube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage open

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14
Q

Chronic

A

long-standing, constant, opposite of acute

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15
Q

Cellulitis

A

Infection of skin cells

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16
Q

Conjunctivitis

A

infection of the outer layer of the eye

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17
Q

Dialysis

A

Process of removing waste from the blood for people with renal failure

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18
Q

Diaphoresis

A

sweating

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19
Q

Diffuse

A

spread out ( not localized)

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20
Q

Distal

A

Farther from the trunk of the body

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21
Q

Dyspnea

A

Difficulty breathing

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22
Q

Dysuria

A

painful urination

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23
Q

Ecchymosis

A

bruise

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24
Q

-ectomy ( suffix)

A

surgical removal ( e.g. tonsillectomy)

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25
Q

edema

A

swelling

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26
Q

emesis

A

vomiting

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27
Q

epilepsy

A

seizure disorder

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28
Q

epistaxis

A

nose bleed

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29
Q

erythema/erythematous

A

redness/red

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30
Q

exudates ( tonsillar)

A

pus-pockets on the tonsils

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31
Q

febrile

A

the state of having a fever ( Temperature of more than 100.4)

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32
Q

Grossly

A

obviously; a lot; wholly

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33
Q

hematemesis

A

gross amounts of blood in the vomit

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34
Q

hematuria

A

blood in the urine

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35
Q

hemoptysis

A

coughing up gross amounts of blood

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36
Q

Hemorrhage

A

excessive or profuse bleeding

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37
Q

Hepatomegaly

A

enlarged liver

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38
Q

hernia

A

protrusion of an organ through the wall of the cavity that normally contains it

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39
Q

hyperlipidemia

A

high cholesterol

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40
Q

hypertension

A

high blood pressure

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41
Q

hypotension

A

low blood pressure

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42
Q

hypoxia

A

low oxygen saturation of the body, not enough oxygen in the blood

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43
Q

ICD-10

A

a system to classify and code diagnoses, symptoms, and procedures

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44
Q

Infarct

A

area of dead tissue after a lack of blood supply

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45
Q

inferior

A

lower on the body, farther from the head

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46
Q

ischemia

A

lack of blood supply

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47
Q

-itis(suffix)

A

inflammation (e.g. appendicitis)

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48
Q

laceration

A

splitting of the skin due to trauma ( a cut due to something sharp)

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49
Q

lateral

A

farther from the midline ( a line that can be traced from nose to belly-button)

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50
Q

Lethargic

A

septic, very sick, about to die

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51
Q

Medial

A

nearer to the midline

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52
Q

Meningitis

A

dangerous infection of the outer lining of the brain

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53
Q

Otitis Externa

A

infection of the outer ear ( ear canal)

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54
Q

Otitis Media

A

infection of inner ear ( behind the eardrum)

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55
Q

Melena

A

black tarry school

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56
Q

myalgia

A

muscular pain, “muscle aches”

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57
Q

pallor

A

pale skin

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58
Q

palpation

A

examine by touch

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59
Q

palpitation

A

to beat rapidly, irregularly, or forcibly ( usually relating to the heart)

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60
Q

peritoneal signs

A

guarding/rebound/rigidity: PE findings indicating a rupture in the abdomen

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61
Q

pharyngitis

A

throat infection

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62
Q

pneumonia

A

bacterial infection of the lungs

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63
Q

posterior/dorsal

A

rear of the backside of the body

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64
Q

prone

A

body position lying flat, face down

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65
Q

proximal

A

nearer to the trunk of the body

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66
Q

pulmonary

A

relating to the lungs

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67
Q

purulence/purulent

A

pus/pus-like

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68
Q

rales

A

crackles; wet crackling noise in lungs

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69
Q

rhinorrhea

A

clear nasal discharge, “runny nose”

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70
Q

-scopy (suffix)

A

viewing with a scope (e.g. colonoscopy)

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71
Q

sepsis

A

dangerous infection of the blood

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72
Q

sinusitis

A

infection/inflammation of the nasal sinuses

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73
Q

small bowel obstruction

A

physical blockage of the small intestines

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74
Q

streptococcal pharyngitis

A

strep throat

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75
Q

superior

A

higher on the body, nearer to the head

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76
Q

supine

A

body position lying face up

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77
Q

syncope

A

“passing out”, loss of consciousness, or fainting

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78
Q

tachycardia

A

fast heart rate ( HR> 100bpm)

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79
Q

trismus

A

inability to open the jaw due to pain)

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80
Q

tachypnea

A

increased breathing rate

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81
Q

ulcerations

A

blisters or open-sores

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82
Q

vertigo

A

room-spinning dizziness ( not light-headed)

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83
Q

wheezing

A

high pitched sound heard in the lungs with asthmatics or lung disease

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84
Q

Abd

A

Abdomen, Abdominal

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85
Q

Abx

A

antibiotics

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86
Q

A fib

A

Atrial fibrillation

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87
Q

AOM

A

Acute Otitis Media ( new ear infection)

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88
Q

A/P

A

Assessment and Plan

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89
Q

ASA

A

Acetylsalicylic Acid (Aspirin)

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90
Q

BID

A

Twice daily

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91
Q

Bilat LE

A

Bilateral Lower Extremities

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92
Q

BM

A

Bowel Movement

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93
Q

BP

A

Blood Pressure

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94
Q

c

A

with

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95
Q

CA

A

Cancer, Carcinoma

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96
Q

CABG

A

Coronary Artery Bypass Graft

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97
Q

CAD

A

Coronary Artery Disease

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98
Q

CBC

A

Complete Blood Count ( bloodworm to look for infection or anemia)

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99
Q

CHF

A

congestive heart failure

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100
Q

CP

A

chest pain

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101
Q

c/o

A

complains of

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102
Q

COPD

A

chronic obstructive pulmonary disease

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103
Q

CRF

A

chronic renal failure

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104
Q

C-section

A

Caesarean Section

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105
Q

C-Spine

A

Cervical spine

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106
Q

CT or CAT

A

computerized assisted tomography

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107
Q

CTA

A

clear to auscultation

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108
Q

CV

A

cardiovascular

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109
Q

CVA

A

cerebrovascular accident

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110
Q

CXR

A

Chest X-ray

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111
Q

DM

A

Diabetes Mellitus

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112
Q

DOE

A

Dyspnea on Exertion

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113
Q

(pulse) DP/PT

A

Dorsalis Pedis/ Posterior Tibialis

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114
Q

DVT

A

Deep Vein Thrombosis

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115
Q

Dx

A

Diagnosis

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116
Q

EKG/ECG

A

Electrocardiogram

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117
Q

EOMI

A

Extraocular Movements Intact

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118
Q

EtOH

A

Alcohol

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119
Q

FHx

A

Family History

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120
Q

F/U

A

Follow-up

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121
Q

Fx

A

Fracture

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122
Q

GERD

A

Gastroesophageal Reflux Disease

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123
Q

GI

A

Gastrointestinal

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124
Q

G/ P/ Ab

A

Gravida/Para/Abortion

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125
Q

GU

A

Genitourinary

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126
Q

HA

A

Headache

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127
Q

HEENT

A

Head, Ears, Eyes, Nose, Throat

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128
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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129
Q

HLD

A

Hyperlipidemia

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130
Q

HPI

A

History of Present Illness

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131
Q

HTN

A

Hypertension ( high blood pressure)

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132
Q

Hx

A

History

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133
Q

H&H

A

Hemoglobin and Hematocrit

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134
Q

I&D

A

Incision and Drainage

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135
Q

IDDM

A

Insulin Dependent Diabetes Mellitus

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136
Q

IUP

A

Intrauterine Pregnancy

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137
Q

LLE

A

Left Lower Extremity

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138
Q

LLQ

A

Left Lower Quadrant

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139
Q

LNMP

A

Last Normal Menstrual Period

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140
Q

LOC

A

Loss of Consciousness

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141
Q

L-spine

A

Lumbar spine

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142
Q

LUE

A

Left Upper Extremity

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143
Q

LUQ

A

Left Upper Quadrant

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144
Q

MI

A

Myocardial Infarction

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145
Q

N/A

A

Not Applicable

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146
Q

NAD

A

No Acute Distress, No Acute Disease

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147
Q

NIDDM

A

Non-Insulin Dependent Diabetes Mellitus

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148
Q

NKDA

A

No Known Drug Allergies

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149
Q

nl/nml

A

Normal

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150
Q

NSAID

A

Non Steroidal Anti-Inflammatory Drug

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151
Q

NSR

A

Normal Sinus Rhythm

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152
Q

N/V/D

A

Nausea/Vomiting/Diarrhea

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153
Q

O2 Sat

A

Oxygen saturation (a.k.a SaO2 or SpO2 or Pulse Ox or Sat)

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154
Q

OB/GYN

A

Obstetrics and gynecology

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155
Q

OD

A

Overdose

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156
Q

OM

A

Otitis Media (inner ear infection)

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157
Q

OP

A

Oropharynx (mouth and throat)

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158
Q

ORIF

A

Open Reduction and Internal Fixation ( orthopedic surgery)

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159
Q

PCP/PMD

A

Primary Care Physician/ Primary Medical Doctor

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160
Q

PE

A

Physical exam/ Pulmonary Embolism

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161
Q

PERRL

A

Pupils are Equal, Round, and Reactive, to Light

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162
Q

PO

A

Per Os ( by mouth)

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163
Q

prn

A

As needed

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164
Q

Pt

A

Patient

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165
Q

PTA

A

Prior to Arrival/ Peritonsillar Abscess

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166
Q

PVD

A

Peripheral Vascular Disease

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167
Q

q

A

Every

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168
Q

QD

A

Every Day

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169
Q

QHS

A

At every bedtime

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170
Q

QID

A

four times a day

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171
Q

RLE

A

right lower extremity

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172
Q

RLQ

A

right lower quadrant

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173
Q

ROM

A

range of motion

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174
Q

ROS

A

Review of system

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175
Q

RRR

A

Regular rate and rhythm (normal heart sounds)

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176
Q

RUE

A

right upper extremity

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177
Q

RUQ

A

right upper quadrant

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178
Q

Rx

A

Prescription

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179
Q

r/o

A

Rule Out

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180
Q

SOB

A

shortness of breath

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181
Q

SOAP

A

Subjective, Objective, Assessment, and Plan

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182
Q

s/p

A

status post ( after)

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183
Q

Sx

A

Symptoms

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184
Q

T&A

A

Tonsillectomy & Adenoidectomy (tonsils and adenoids removal surgery)

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185
Q

TIA

A

Transient Ischemic Attack

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186
Q

TID

A

Three times a day

187
Q

TM

A

Tympanic membrane (Ear drum)

188
Q

Tx

A

Treatment

189
Q

T-spine

A

Thoracic spine

190
Q

UA

A

Urinalysis

191
Q

URI

A

Upper respiratory infection

192
Q

US

A

ultrasound

193
Q

UTD

A

up to date

194
Q

UTI

A

urinary tract infection

195
Q

WNL

A

Within Normal Limits ( normal, not of concern)

196
Q

y/o

A

Year(s) old

197
Q

Differential Diagnosis

A

a short list of diseases the doctor considers when diagnosing a patient

198
Q

Pertinent Positives

A

Specific symptoms that raise the physician’s concern for that particular disease

199
Q

Pertinent Negatives

A

specific symptoms not present which cause the physician to doubt certain diagnoses

200
Q

Risk Factors

A

“Red flags” that would put a patient at risk for that particular disease

201
Q

Scribe Alert

A

Important information you need to know as a scribe

202
Q

Etiology

A

The study of the causes of diseases

203
Q

Pleura

A

Membrane lining the thoracic cavity ( parietal pleura) and covering the lungs ( visceral pleura)

204
Q

Artery

A

A blood vessel that carries oxygenated blood from the heart throughout the body

205
Q

Risk Factors

A

What puts the patient at risk?

206
Q

Assoc. Sx

A

Pertinent positives; sx that raise the physician’s suspicion for the disease

207
Q

Pert. Neg

A

Pertinent negatives; important sx that are not present

208
Q

Assoc. Med

A

Medications related to the disease

209
Q

PE

A

common physical exam findings associated with the disease

210
Q

Diagnosed by

A

how the disease is ruled out or diagnosed

211
Q

Coronary Artery Disease (CAD) Risk Factors

A

Smoking, Hx of HTN, DM, high cholesterol, not physically active

212
Q

Coronary Artery Disease (CAD) Assoc. Symptoms

A

Chest pain or chest pressure, chest pain with physical exertion – worse with exertion ; improved by rest or NTG

213
Q

Coronary Artery Disease (CAD) Assoc. Med

A

Aspirin (ASA) 324 mg PO

Nitroglycerin (NTG) 0.4 mg SL

214
Q

Coronary Artery Disease (CAD)

Diagnosed by

A

Cardiac catheterization (Not diagnosed in the ED)

215
Q

Coronary Artery Disease (CAD) Scribe Alert

A

CAD is the single greatest risk factor for an MI
Stress test or the Cardiac Catheterization assess the severity of CAD
A patient has CAD if they have a PMHx of Angina, MI, CABG, Cardiac stents, or Angioplasty

216
Q 
Myocardial Infarction ( MI) stems, non-stemi 
Risk Factors
A

CAD, HTN, HLD, DM, Smoker, FHx of CAD <55 yo

217
Q

Myocardial Infarction (MI) Assoc. Symptoms

A

Chest pain or Chest pressure with diaphoresis, N/V and SOB

218
Q 
Myocardial Infarction (MI) 
PE
A

(+) diaphoresis

219
Q

Myocardial Infarction (MI) Assoc. Med

A

ASA, NTG, B-blocker, Thrombolytic (Heparin)

220
Q 
Myocardial Infarction (MI)
Diagnosed by
A

EKG (STEMI) or elevated Troponin (non-STEMI)

221
Q

Congestive Heart Failure (CHF)

Risk Factors

A

HTN, CAD, MI,DM, Sleep apnea, smoking, drinking

222
Q

Congestive Heart Failure (CHF)

Assoc. Symptoms

A

Shortness of Breath of pedal edema and orthopnea

  • worse with lying flat (orthopnea)
  • paroxysmal nocturnal dyspnea (PND)
  • dyspnea on exertion (DOE)
223
Q

Congestive Heart Failure (CHF)

Physical Exam

A

Rales (crackles) in lungs, jugular vein distension (JVD) in neck, pitting pedal edema

224
Q

Congestive Heart Failure (CHF) Assoc. Med

A

Diuretics (Lasix, Furosemide) –> Urinate extra fluid

225
Q

CHF diagnosed by

A

CXR or elevated BNP ( B-type Natriuretic Peptide)

226
Q

CHF Scribe Alert

A

think of CHF as a fluid traffic jam in the heart; fluid gets backed uptake neck (JVD) and down the legs (pedal edema)

227
Q

A Fib Assoc. Symptom

A

Palpitations ( Fast, Pounding, Irregular)

228
Q

A Fib Physical Exam

A

Irregularly irregular rhythm, Tachycardia

229
Q

A Fib Assoc. Med

A

Coumadin (Warfarin): Blood thinner, prevents blood clots in atria.
Digoxin: slows down heart rate

230
Q

A Fib Diagnosed by

A

EKG (ECG)

231
Q

A Fib Scribe Alert

A

ED concern is Rapid Ventricular Response (RVR). These patients will often be “cardioverted” which means they are put back into a regular rhythm, known as normal sinus rhythm (NSR)

232
Q

MI - What is it and diagnosed by?

A

Heart Attack (STEMI) or Elevated Troponin (Non-STEMI)

233
Q

AFib - W? D?

A

Electrical Problem

EKG

234
Q

CHF - W? D?

A

Fluid traffic jam

CXR or Elevated BNP

235
Q

CAD - W? D?

A

Major risk factor for MI

Positive cardiac catheterization (not in ED)

236
Q

Angina- W? D?

A

Symptom of CAD

Exertional CP with Hx of CAD

237
Q

Coronary Artery Disease (CAD) Etiology

A

narrowing of the coronary arteries limits blood supply to the heart muscle causing angina ( chest pain specifically due to heart muscle ischemia)

238
Q

Myocardial Infarction (MI) Etiology

A

Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle

239
Q

Congestive Heart Failure (CHF) Etiology

A

the heart becomes enlarged , inefficient, and congested with excess fluid

240
Q

Atrial Fibrillation (A Fib) Etiology

A

electrical abnormalities in the wiring of the heart causes the top of the heart ( atria) to quiver abnormally

241
Q

Pulmonary Embolism (PE) Etiology

A

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

242
Q

PE Risk Factors

A

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

243
Q

PE Assoc. Symptoms

A

SOB or Pleuritic chest pain (CP worse with deep breaths) with tachycardia and hypoxia

244
Q

PE Diagnosed by

A 
CTA chest ( CT chest w/ IV contrast) or VQ scan
[D-dimer aids in detecting clots, but cannot diagnose a PE]
245
Q

Pneumothorax (ptx) Etiology

A

collapsed lung dueto trauma or spontaneous small rupture of the lung

246
Q

ptx risk factor

A

being male, smoking age 20-40, COPD, previous hx of PTX

247
Q

ptx Assoc. Symptoms

A

SOB and one-sided chest pain
sudden onset
often trauma patients

248
Q

ptx physical exam

A

absent breath sounds unilaterally

249
Q

ptx diagnosed by

A

CXR

250
Q

Ischemic Cerebral Vascular Accident (CVA) Etiology

A

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

251
Q

CVA Risk Factor

A

HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, A Fib

252
Q

CVA Assoc. Symptoms

A

unilateral focal neurological deficits: one-sided weakness/numbness or changes in speech/vision

253
Q

CVA physical exam

A

neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits

254
Q

CVA Diagnosed by

A

clinically, potentially normal CT head

255
Q

CVA Scribe Alert

A

for any stroke patient ALWAYS document the date and time they were “last known well” ( at baseline) as well as the source of this information. this is used to assess eligibility for tPA, a powerful blood thinner that can reverse a CVA

256
Q

Hemmorrhagic CVA, brain bleed Etiology

A

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

257
Q

H CVA Risk Factor

A

HTN, High cholesterol, CAD, DM, Sicle Cell, elderly, family Hx

258
Q

H CVA Assoc. Sx

A

Headache ( sudden onset or worst of life), Changes in speech, vision, sensation ( numbness), or Motor strength ( weakness), AMS, Seizure

259
Q

H CVA Physical exam

A

unilateral neurological deficits

260
Q

H CVA Diagnosed by

A

CT Head or LP (Lumbar Puncture), done in the ED

261
Q

Transient Ischemic Attack (TIA) Etiology

A

vascular changes temporarily deprive a part of the brain of oxygen (symptoms usually last less than 1 hour)

262
Q

TIA Risk Factors

A

HTN, High Cholesterol, CAD, DM, Sickle cell, elderly, family Hx

263
Q

TIA Assoc. Symptoms

A

Transient focal neurological deficit

changes in speech, vision, strength, or sensation

264
Q

TIA diagnosed by

A

clinically

265
Q

TIA Scribe Alert

A

TIA’s are also known as “Mini Strokes” because symptoms usually last <1 hour and there is no permanent brain damage

266
Q

Meningitis Bacterial vs Viral

Etiology

A

inflammation and infection of the meninges, the sac surrounding the brain and spinal cord

267
Q

Meningitis Bacterial vs Viral Risk Factors

A

skipping vaccines, <5 years of age, pregnancy, compromised immune system

268
Q

Meningitis Assoc. Sx

A

meningismus, nuchal rigidity

269
Q

Meningitis Diagnosed By

A

Lumbar Puncture (LP), performed in the ED

270
Q

Spinal Cord Injury Etiology

A

injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury

271
Q

SC Assoc. Symptoms

A

Neck pain or Back pain, Bilateral extremity weakness

272
Q

SC Physical Exam

A

midline bony tenderness, deformities, or step-offs, bilateral extremity weakness, numbness, decreased rectal tone

273
Q

SC Diagnosed by

A

CT Cervical Spine (Neck)
CT Thoracic Spine (upper back)
CT Lumbar spine ( lower back)

274
Q

Seizures (Sz) Etiology

A

Abnormal electrical activity in the brain leading to abnormal physical manifestations. Often caused by epilepsy, ETOH withdrawals or febrile seizure in pediatric pts

275
Q

Seizures (Sz) Assoc. Sx

A

seizure activity, syncope, injuries ( tongue bite), confusion, headache, incontinence (urinary or fecal)

276
Q

Seizures (Sz) Physical Exam

A

Somnolent, confused (post-Ictal)

277
Q

Seizures (Sz) Medications

A

Dilantin, Tegretol, Keppra, Depakote, Neurontin

278
Q

Seizures (Sz) Scribe Alert

A 
the physician will ask...
1- has the pt had a similar sz in the past?
2- does the pt have a hx of seizures 
3- what was the date of their last sz?
4- what sz medication do they take?
5- have they missed in medication doses?
279
Q

Bells Palsy Etiology

A

inflammation or viral infection of the facial nerve causes one sided weakness of the entire face

280
Q

Bells Palsy Chief Complaint

A

Facial Droop; Sudden Onset

281
Q

Bells Palsy Assoc. Sx

A

Jaw or ear pain, increased tear flow of one eye

282
Q

Bells Palsy Pert. Neg

A

No extremity weakness, No changes in speech or vision

283
Q

Bells Palsy Physical Exam

A

Unilateral weakness of the upper and lower face

284
Q

Bells palsy diagnosed by

A

clinically

285
Q

Bells Palsy Scribe Alert

A

Bell’s Palsy is the most common cause of facial droop in young patients who do not have CVA risk factors. Remember to document the absence of other FND

286
Q

Altered Mental Status (AMS) Etiology

A

multiple causes most common are hypoglycemia, infection, intoxication, and neurological

287
Q

AMS Risk Factos

A

Diabetic, Elderly, Demente EtOH use, Drug Use

288
Q

AMS Assoc. Symptoms

A

confusion, decreased responsiveness, unresponsive

289
Q

AMS diagnosed by

A

case dependent

290
Q

AMS Scribe Alert

A

AMS is very different than a focal neurological deficits; they are generalized and typically caused by things that affect the whole brain (drugs, low blood sugar)
the most common cause of AMS for patients without a hx of dementia is from infection, most often caused by a UTI

291
Q

Hemorrhagic CVA document

A

tPA ineligibility

292
Q

Ischemic CVA document

A

tPA Eligibility, Last known normal

293
Q

Meningitis document

A

HA, Fever, Neck Pain

294
Q

SC injury document

A

bilateral extremity weakness

295
Q

TIA document

A

when did sx resolve?

296
Q

Seizure document

A

post-Ictal state, missed Sz meds?

297
Q

Bell’s Palsy document

A

absence of other FND

298
Q

AMS document

A

infection? DM? Drugs? Baseline?

299
Q

GERD quadrant

A

Epigastric

300
Q

MI quadrant

A

Epigastric

301
Q

Cholecystitis quadrant

A

RUQ

302
Q

Pancreatitis quadrant

A

LUQ

303
Q

SBO quadrant

A

periumbillical

304
Q

Appendicitis quadrant

A

RLQ

305
Q

Diverticulitis quadrant

A

LLQ

306
Q

Ovarian Torsion quadrant

A

Suprapubic

307
Q

Ovarian Cyst quadrant

A

Suprapubic

308
Q

UTI quadrant

A

Suprapubic

309
Q

Pyelonphritis

A

Flanks

310
Q

Renal Calculi

A

Flanks

311
Q

Appendicitis (Appy) Etiology

A

infection of the appendix causes inflammation and blockage, possibly leading to rupture

312
Q

Appy Assoc. Sx

A 
Decreased appetite ( anorexia), fever, N/V
RLQ pain
gradual onset
constant
worsened with movement
313
Q

Appy Physical Exam

A

McBurney’s point tenderness, RLQ tenderness

314
Q

Appy Diagnosed by

A

CT A/P with PO contrast

315
Q

Small Bowel Obstruction (SBO) Etiology

A

physical blockage of the small intestine

316
Q

SBO Risk Factor

A

Elderly, infants, abdominal surgery, narcotic pain medication

317
Q

SBO Assoc. Sx

A

Abdominal pain, vomiting, constipation, Abd Distension, bloating, no BMs

318
Q

SBO Physical Exam

A

abdominal tenderness, guarding, rebound, abnormal bowel sounds, abdominal dissension, tympany

319
Q

SBO Diagnosed by

A

CT A/P with PO contrast

Acute Abdominal Series (AAS)

320
Q

Kidney Stone (nephrolithiasis, renal calculi, urolithiasis) Etiology

A

A kidney stone dislodges from the kidney and begins traveling down the ureter, the stone scales and irritates the ureter, causing severe flank pain and bloody urine

321
Q

Kidney Stone Risk Factor

A

Family Hx, dehydration, obesity

322
Q

Kidney Stone Assoc. Sx

A

Flank pain sudden onset and radiating to groin, Hematuria, N/V, unable to void

323
Q

Kidney Stone Physical Exam

A

CVA tenderness

324
Q

Kidney Stone Diagnosed By

A

CT Abd/pelvis

RBC in UA may be a clue

325
Q

Ectopic Pregnancy (Tubal pregnancy) Etiology

A

fertilized eggs develop outside the uterus, usually in the fallopian tube, higher risk for rupture and death

326
Q

Ectopic Pregnancy Risk Factors

A

pregnant female (HCG positive), STD ( PID)

327
Q

Ectopic Pregnancy Assoc. Symptoms

A

lower abdominal pain or vaginal bleeding while pregnant

328
Q

Ectopic pregnancy Scribe Alert

A

Any female with a positive pregnancy test who is complaining of lower abdominal pain or vaginal bleeding will always receive an US pelvis to rule out a possible ectopic pregnancy

329
Q

Ovarian torsion Etiology

A

twisting of an ovarian artery reducing blood flow to an ovary possibly resulting in infarct of the ovary

330
Q

Ovarian torsion Assoc. symptoms

A

lower abdominal pain (RLQ or LLQ)

331
Q

Ovarian torsion physical exam

A

adnexal tenderness ( right or left). tenderness in the RLQ or LLQ

332
Q

Ovarian torsion diagnosed by

A

US pelvis –> Assesses blood flow to ovaries

333
Q

Ovarian torsion Scribe Alert

A

ovarian and testicular torsion are very time sensitive due to the risk of losing an ovary or testicle. Be sure to document accurate times for the pt arrival, US results, and any physician ( surgical) consultations

334
Q

Testicular torsion

Etiology

A

twisting of the spermatic cord resulting in loss of blood flow and nerve function to the testicle

335
Q

Testicular torsion Chief Complaint

A

testicular pain

336
Q

Testicular torsion Physical exam

A

testicular tenderness and swelling (right or left)

337
Q

Testicular torsion diagnosed by

A

US scrotum

338
Q

Abdominal Aortic Aneurysm (AAA) Etiology

A

widened and weaker arterial wall at risk of rupture

339
Q

AAA Assoc. Symptoms

A

Midline Abdominal pain

340
Q

AAA physical exam

A

midline pulsatile abdominal mass, abdominal bruit, unequal femoral pulses, hypotension

341
Q

AAA diagnosed by

A

CT A/P with IV contrast dye

342
Q

Aortic Dissection Etiology

A

separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death

343
Q

Aortic dissection Assoc. Symptoms

A

chest pain radiating to the back - ripping or tearing

344
Q

Aortic dissection PE

A

unequal brachial or radial pulses, hypotension

345
Q

Aortic dissection Diagnosed by

A

CT chest with IV contrast dye

346
Q

DVT Etiology

A

blood slows down while flowing through long straights veins in the extremities, slow flowing blood is more likely to clot; once formed, the clot can continue to grow and eventually occlude (block) the vein

347
Q

DVT Risk Factors

A

PMHx of DVT or PE, FHx, Recent surgery, cancer, immobility, pregnancy, BCP, smoking, LE trauma, LE casts

348
Q

DVT Assoc. Symptoms

A

Extremity Pain and swelling (Atraumatic) ;usually located in a lower extremity

349
Q

DVT diagnosed by

A

US/Doppler of the extremity

350
Q

Diabetic Ketoacidosis (DKA) Etiology

A

shortage of insulin resulting in hyperglycemia and production of ketones

351
Q

DKA Risk factors

A

Diabetes Mellitus (DM)

352
Q

DKA Assoc. Sx

A

Persistent vomiting with Hx of DM, SOB, polydipsia (increased thirst), polyuria (increased urination)

353
Q

DKA Physical Exam

A

ketotic odor “fruity”, Dry mucous membranes (dehydration), tachypnea

354
Q

DKA Diagnosed by

A

Arterial Blood Gas (ABG or VBG) showing low pH (acidosis) or positive serum ketones

355
Q

Peds-Dehydration Etiology

A

a shortage of fluids in the body most commonly caused by vomiting or diarrhea. May also be caused by long periods of poor PO intake

356
Q

Peds-Dehydration Chief Complaint

A

lethargic/listless; sunken eyes; poor urine output (UOP)

357
Q

Peds-Dehydration Physical exam

A

dry mucous membranes; cries without tears; sunken fontanel or eyes; Tachycardia ( 180-190 ppm); poor skin turgor

358
Q

Peds- Dehydration Diagnosed by

A

clinically, or by sodium (Na+) from basic metabolic panel

359
Q

Peds-Dehydration Scribe Alert

A

urine output (UOP) is one of the best indicators of hydration; if the physician asks always be sure to document how frequently the pt has been making wet diapers; whenever applicable, always remember to document “cries with tears on exam” to indicate the patient is well hydrated

360
Q

Peds- Viral Syndrome Etiology

A

infection by a virus causes a variety of symptoms that often develop simultaneously

361
Q

Peds- Viral Syndrome Assoc. Symptoms

A

runny nose; sore throat; dry cough; nasal congestion; headache; abdominal pain; N/V/D; muscle aches

362
Q

Peds- Viral Syndrome Physical exam

A

rhinorrhea; pharyngeal erythema; transmitted upper airway noises

363
Q

Peds- Viral Syndrome Diagnosed by

A

clinically

364
Q

Peds- Viral syndrome scribe alert

A

during the HPI, pay special attention to words like “lethargic”, “listless”, or “just not themselves”; mothers will often describe their child with these words when they have a viral syndrome, however these words NEVER BELONG IN YOUR WRITTEN HPI

365
Q

Peds-Allergic Reaction Etiology

A

immune response causing an inflammatory reaction consisting of swelling, itching (pruritus) , and rash

366
Q

Peds- Allergic Reaction Risk Factors

A

known drug or food allergy

367
Q

Peds-Allergic Reaction Assoc. Symptoms

A

Rash, swelling, itching, or SOB

368
Q

Peds-Allergic Reaction PE

A

edema, facial angioedema, urticaria (hives, wheals)

369
Q

Peds-Allergic Reaction Diagnosed by

A

clinically

370
Q

Peds-Allergic Reaction Scribe Alert

A

concern is anaphylaxis or respiratory failure

371
Q

Allergic Reaction

A

Rash, Itching, Sweating, SOB due to airway swelling

372
Q

Adverse Reaction

A

Nausea/Vomiting, Abdominal Pain, Diarrhea, Dizziness

373
Q

Rash Etiology

A

changes in the skin’s appearance due to systemic or focalized reaction ; may be caused from medication, virus, bacteria, fungus, insect etc.

374
Q

Rash Assoc. Symptoms

A

Rash; red, itchy (pruritic) or painful

375
Q

Rash Physical exam

A

urticaria (hives or wheals); macules( flat); papules (raised bumps); vesicles ( small blisters); blanching (not dangerous); Petechaie (dangerous rash); Purpura (dangerous rash)

376
Q

Rash Diagnosed by

A

clinically

377
Q

Sepsis (bacteremia) Etiology

A

organisms from an infection somewhere in the body (“the source”) across into the bloodstream causing a life-threatening blood infection

378
Q

Sepsis Risk Factors

A

known infection (UTI, PNA, etc.); immunecompromise; pyelonephritis; abdominal infections; meningitis

379
Q

Sepsis Chief complaint

A

fever, lethargic, listless

380
Q

Sepsis physical exam

A

febrile ( rectal temp greater than 38 C or 100.4 F); Tachycardia ( 180-190 bpm); hypotensive; toxic-appearing

381
Q

Sepsis diagnosed by

A

blood cultures

382
Q

Sepsis scribe alert

A

the majority of fever patients are NOT septic; to indicate this in the exam; remember to accurately document the pt’s constitutional: alert and vigorous; well hydrated, well perfused; mildly ill appearing but non-toxic

383
Q

Kawasaki Disease (KD) Etiology

A

unknown- suspected that some type of infection causes a body-wide immune response, leading to extensive damage of blood vessels

384
Q

Kawasaki Disease (KD) Assoc. Symptoms

A

CONSTANT fever ( for many days)

385
Q

Kawasaki Disease (KD) physical exam

A

febrile ( rectal temp greater than 38 C or 100.4 F); tachycardia ( 180-190 bpm); red rash on palms of hands and soles of feet; “strawberry tongue”

386
Q

Kawasaki Disease (KD) diagnosed by

A

clinically

387
Q

Kawasaki Disease ( KD) scribe alert

A

this dangerous disease is the reason it’s very important to always document fevers as INTERMITTENT
mothers will often carelessly say their child has had a fever “constantly for 4 days” however, pos further question they will often have actually improved after Motrin, thus intermittently resolved. YOU SHOULD NOT document a CONSTANT fever for more than 24 hours unless told to do so by your physician

388
Q

Streptococcal pharyngitis (strep throat) Etiology

A

bacterial infection of the tonsils and pharynx causing a sore throat and frequently stolen lymph nodes

389
Q

Strep Assoc. Symptoms

A

sore throat

390
Q

Strep PE

A 
pharyngeal erythema 
tonsillar hypertrophy (enlargement)
tonsillar exudates (pus)
391
Q

Strep diagnosed by

A

rapid strep

392
Q

Strep scribe alert

A

more sore throats are viral, however strep throat is bacterial so Abx will help
the biggest concern about a sore throat is the possibility of a Peri-Tonsillar Abscess (PTA)
Signs of PA include uvular shift of tonsillar asymmetry

393
Q

Foreign Body (FB) Etiology

A

foreign objects can become lodged in the body, most commonly the ear canal, nose, ear, eye, or throat

394
Q

FB Assoc. Symptoms

A

choking or “something stuck in nose/ear”

395
Q

FB physical exam

A

describe the foreign body; size; shape; location

396
Q

FB diagnosed by

A

direct visualization of the foreign body on exam, or by x-ray

397
Q

FB scribe alert

A

be sure to document respiratory status ( no SOB, airway patent, breathing easily, etc.) as well as a Foreign Body removal procedure- note for any FB that is removed by the physician

398
Q

Myocarditis Etiology

A

infection of the myocardium (heart-muscle) most often from a virus; will often cause chest pain in older children

399
Q

Myocarditis Assoc. Symptoms

A

chest pain, lethargic, irritable, low grade fever

400
Q

Myocarditis Physical exam

A

tachycardia, decreased capillary refill, gallop

401
Q

Myocarditis diagnosed by

A

clinically

402
Q

Myocarditis scribe alert

A

lethargic and irritable are used for serious illnesses only

403
Q

Tachycardia Etiology

A

fast heart-rate caused by a large variety of conditions, most commonly fever

404
Q

Tachycardia Assoc. Med

A

IV fluid; antipyretic (Tylenol or Motrin)

405
Q

Tachycardia Diagnosed by

A

bedside telemetry or physical exam

406
Q

Tachycardia Scribe Alert

A

definition of it varies between age groups ; remember to document re-evaluations for patients who are tachycardic
physician won’t discharge a tachycardic pt until heart rate is improved so remember to document their re-check of the pulse

407
Q

Tachycardia -Days old

A

> 160 bpm

408
Q

Tachycardia- Less than 6 months

A

> 180 bpm

409
Q

Tachycardia- 1-2 years

A

> 160 bpm

410
Q

Tachycardia- 3-10 years

A

> 140 bpm

411
Q

Tachycardia- 11-15 years

A

> 120 bpm

412
Q

Tachycardia- Adult

A

> 100 bpm

413
Q

Asthma (reactive airway disease) Etiology

A

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

414
Q

Asthma Assoc. Symptoms

A

SOB/Wheezing; improved by nebulizer “breathing treatments” (bronchodilators)

415
Q

Asthma PE

A

wheezes ( inspiratory or expiratory)

416
Q

Asthma Diagnosed by

A

clinically

417
Q

Asthma ScribeAlert

A 
the physician will ask the asthma pt...
1- do they have home nebulizers
2-have they been on steroids recently?
3- Hx of hospitalization for asthma?
4- Hx of intubation ( breathing tube)?
418
Q

Bronchiolitis Etiology

A

infection of the lower braces of the lungs leads to difficulty breathing

419
Q

Bronchiolitis Assoc. Sx

A

Fever, Cough, Wheezing, poor feeding, irritability, SOB, grunting

420
Q

Bronchiolitis PE

A

inspiratory rales or diffuse expiratory wheezing

421
Q

Bronchiolitis Diagnosed by

A

CXR or RSV

422
Q

Bronchiolitis ScribeAlert

A

oxygen saturations are very important to document for any pediatric respiratory pt, especially bronchiolitis patients

423
Q

Cellulitis Etiology

A

infection of the skin cells

424
Q

Cellulitis Assoc. Symptoms

A

Red, swollen, painful, and sometimes warm area of skin

425
Q

Cellulitis PE

A

Erythema, edema, increased warmth ( color), induration

426
Q

Cellulitis Assoc. Meds

A

Abx ( Antibiotics)

427
Q

Cellulitis Diagnosed by

A

clinically

428
Q

Abscess ( Cellulitis with fluctuance) Etiology

A

skin infection with an underlying collection of pus

429
Q

Abscess Assoc. Sx

A

Red, swollen, and painful lump

430
Q

Abscess PE

A

fluctuance (pus-pocket), induration, purulent drainage ( pus-like)

431
Q

Abscess Diagnosed by

A

clinically

432
Q

Abscess ScribeAlert

A

abscesses must have the pus-pocket drained. Remember to always document Incision and Drainage (I&D) procedure notes for abscesses

433
Q

Peds-Pertussis (whooping cough) Etiology

A

infection of the respiratory tract leads to constriction and a characteristic “barking-seal” sounding cough that is episodic

434
Q

Peds-Pertussis Assoc. Sx

A

barking cough, stridor, nasal congestion, post-tussive, emesis

435
Q

Peds-Pertussis Assoc. Med

A

Antibiotics

436
Q

Peds- Pertussis PE

A

often unremarkable

437
Q

Peds- Pertussis Diagnosed by

A

Clinically, or by Suptum culture

438
Q

Peds- Pertussis ScribeAlert

A

post-tussive emesis is a harmless type of vomiting that occurs after long coughing spells ; it’s not GI related, be sure to differentiate it from normal vomiting

439
Q

Peds-Pyloric Stenosis Etiology

A

enlargement of the tissue surrounding the pyloric valve causes obstruction of the stomach

440
Q

Peds-Pyloric stenosis Risk Factor

A

less than 3 months old

441
Q

Peds- Pyloric stenosis Assoc. Sx

A

vomiting ( project like); poor appetite; poor feeding; poor weight gain; poor satisfaction after meals

442
Q

Peds- Pyloric stenosis PE

A

firm, non-tender, mobile mass in RUQ, “olive-like”

443
Q

Peds-Pyloric stenosis diagnosed by

A

clinically or by US of RUQ

444
Q

Peds-Intussusception Etiology

A

a section of bowel telescopes into an adjacent section, putting the pt at risk for blockage and gut-ischemia

445
Q

Peds- Intussusception Risk factor

A

infants

446
Q

Peds- Intussusception Assoc. Sx

A

sudden onset, episodic abdominal pain, or vomiting without diarrhea, mucous or currant-jelly-like stools, pt appears completely well between episodes

447
Q

Peds- Intussusception PE

A

abdominal tenderness, abdominal distention, guaiac positive stools

448
Q

Peds- Intussusception diagnosed by

A

contrast enema ( not in ED) or AAS

449
Q

Peds- Gastro-enteritis Etiology

A

infection irritates the stomach and intestines causing vomiting and diarrhea

450
Q

Peds- Gastro-enteritis Risk factors

A

bad food exposure; day-care; sick contacts; recent Abx

451
Q

Peds- Gastro-enteritis Assoc. Sx

A

fever; decreased urination; irritability; vomiting and diarrhea

452
Q

Peds-Gastro-enteritis PE

A

dry mucous membranes; epigastric tenderness; mildly ill-appearing but non-toxic

453
Q

Peds- Gastro-enteritis Assoc. Med

A

Zofran 4mg ODT, IVF

454
Q

Peds-Gastro-enteritis diagnosed by

A

clinically

455
Q

Peds-Toddler’s Fracture Etiology

A

tripping/twisting of leg creates pain

456
Q

Peds-Toddler’s Fracture Assoc. Sx

A

non-weight bearing on affected extremity; will not put foot down; significant point TTP; may still crawl

457
Q

Peds- Toddler’s Fracture Pert. Negs.

A

no focal weakness, no sensory deficits, no other injuries

458
Q

Peds- Toddler’s Fracture PE

A

will not bear weight, NVI intact distally; point TTP over distal tibia

459
Q

Peds-Toddler’s Fracture ScribeAlert

A

remember the majority of extremity injuries will receive some type of splint; always remember to document a Splint Application Procedure Note!

460
Q

Peds-Nursemaid’s elbow Etiology

A

pulling motion on child’s wrist

461
Q

Peds- Nursemaid’s Assoc. Sx

A

child not using affected arm, child holding arm at side, crying

462
Q

Peds- Nursemaid’s Pert. Negs.

A

no motor weakness; no bruising/swelling

463
Q

Peds-Nursemaid’s PE

A

child holding arm at side; no focal point tenderness; NVI distally

464
Q

Peds- Nursemaid’s ScribeAlert

A

physicians will often reduce this joint during the exam. they typically use hyperpronation and/or supination w/ flexion; there is a procedure note for this, so don’t forget to enter the procedure into the chart

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