1
Q
Course of diagnosis
A
- Subjective complaints and risk factors
- Differential diagnoses
- Objective evaluation
- Final diagnosis
2
Q
Associated symptoms
A
Specific symptoms that raise the physician’s suspicion for a particular differential diagnosis
3
Q
Pertinent negatives
A
Specific symptoms that are not present which lower the physician’s suspicion for a particular differential diagnosis
4
Q
The Triple Threat
A
Hypertension (HTN), Hyperlipidemia (HLD), Diabetes Mellitus (DM)
5
Q
Effects of chronically high blood glucose
A
Cerebrovascular accident, diabetic retinopathy, cardiac disease, renal failure, peripheral vascular disease, neuropathy
6
Q
Effects of chronically high blood pressure
A
Cerebrovascular accident, retinopathy, cardiac disease, congestive heart failure, renal failure
7
Q
Effects of chronically high cholesterol
A
Cerebrovascular accident, cardiac disease, pancreatitis
8
Q
Coronary Artery Disease (CAD) Etiology
A
Narrowing of the coronary arteries causing reduced blood flow to the heart muscle
9
Q
Coronary Artery Disease (CAD) Risk Factors
A
HTN, HLD, DM, Smoking, Family history of CAD/MI < 55 years old
10
Q
Coronary Artery Disease (CAD) Chief Complaint
A
Angina: Exertional chest pain or chest pressure
Modifying Factors: Worse with exertion, Improved with rest and/or nitroglycerin
11
Q
Coronary Artery Disease (CAD) Associated Symptoms
A
Shortness of breath
12
Q
Coronary Artery Disease (CAD) Medications
A
Nitroglycerin (NTG) to manage angina; Acetylsalicylic acid (ASA) to decrease the chance of a blockage
13
Q
Coronary Artery Disease (CAD) Method of Diagnosis
A
Cardiac catheterization (CAD cannot be diagnosed in the ED)
14
Q
Coronary Artery Disease (CAD) Pertinent Scribe Information
A
A patient has CAD if they have a past medical history of angina, MI, CABG, cardiac stents, or angioplasty
15
Q
Myocardial Infarction (MI) Etiology
A
Acute blockage of the coronary arteries causing ischemia or infarct to the heart muscle
16
Q
Myocardial Infarction (MI) Risk Factors
A
CAD, HTN, HLD, DM, Smoking, Family history of CAD < 55 years old
17
Q
Myocardial Infarction (MI) Chief Complaint
A
Chest pain or chest pressure
Modifying Factors: Worse with exertion, Improved with rest and/or nitroglycerin
18
Q
Myocardial Infarction (MI) Associated Symptoms
A
Diaphoresis, nausea/vomiting, shortness of breath
19
Q
Myocardial Infarction (MI) Medications
A
Acetylsalicylic acid (ASA), Nitroglycerin (NTG), Thrombolytic (Heparin)
20
Q
Myocardial Infarction (MI) Method of Diagnosis
A
STEMI: Diagnosed by EKG (may also have elevated troponin)
Non-STEMI: Diagnosed by elevated troponin
21
Q
Myocardial Infarction (MI) Pertinent Scribe Information
A
Document ED arrival time, EKG time, ASA time, cath lab departure time; STEMI patients must get to the cath lab within 90 minutes of arrival
22
Q
Congestive Heart Failure (CHF) Etiology
A
The heart becomes enlarged, inefficient, and congested with excess fluid
23
Q
Congestive Heart Failure (CHF) Risk Factors
A
History of CHF, HTN, HLD, DM, Kidney disease, Smoking
24
Q
Congestive Heart Failure (CHF) Chief Complaint
A
Shortness of breath
Modifying Factors: Worse with lying flat (orthopnea), Worse with exertion - Dyspnea on Exertion (DOE), Episodically worse at night - Paroxysmal Nocturnal Dyspnea (PND)
25
Congestive Heart Failure (CHF) Associated Symptoms
Bilateral lower extremity swelling, fatigue, cough
26
Congestive Heart Failure (CHF) Medications
Diuretics (Lasix, Furosemide) → Intended to cause urination of excess fluid
27
Congestive Heart Failure (CHF) Physical Exam Findings
Rales (crackles) in lungs, Jugular Vein Distention (JVD), Pedal edema
28
Congestive Heart Failure (CHF) Method of Diagnosis
CXR and elevated B-type Natriuretic Peptide (BNP)
29
Congestive Heart Failure (CHF) Pertinent Scribe Information
If patient has CHF history, document their current dosage of Lasix; search echocardiograms and document the cardiac output (EF or ejection fraction) and cardiac valve function
30
Atrial Fibrillation (A Fib) Etiology
Electrical abnormalities in the “wiring” of the heart causes the top of the heart (atria) to quiver abnormally
31
Atrial Fibrillation (A Fib) Risk Factors
Paroxysmal A Fib, Chronic A Fib, Alcoholism
32
Atrial Fibrillation (A Fib) Chief Complaint
Palpitations (fast, pounding, irregular)
33
Atrial Fibrillation (A Fib) Associated Symptoms
Global weakness, fatigue, lightheadedness
34
Atrial Fibrillation (A Fib) Medications
Coumadin/Warfarin (blood thinner), Digoxin (slows down heart rate)
35
Atrial Fibrillation (A Fib) Physical Exam Findings
Irregularly irregular rhythm
36
Atrial Fibrillation (A Fib) Method of Diagnosis
EKG
37
Atrial Fibrillation (A Fib) Pertinent Scribe Information
ED concern is Rapid Ventricular Response (RVR) which is A Fib with a rate greater than 100 bpm; patients who have A Fib are at increased risk for developing blood clots and often take a blood thinner
38
Pulmonary Embolism (PE) Etiology
A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs
39
Pulmonary Embolism (PE) Risk Factors
Known DVT, Past medical history of DVT/PE, Family history of DVT/PE, Recent surgery, Cancer, A Fib, Immobility, Pregnancy, Birth control pills (BCPs), Smoking
40
Pulmonary Embolism (PE) Chief Complaint
Chest pain
Modifying Factors: Worse with deep breaths (pleuritic)
41
Pulmonary Embolism (PE) Associated Symptoms
Shortness of breath, Hypoxia (low oxygen saturation), Tachycardia (elevated heart rate)
42
Pulmonary Embolism (PE) Method of Diagnosis
Screening tool: D-Dimer
Diagnostic tool: CTA chest (CT with IV contrast)
43
Pulmonary Embolism (PE) Pertinent Scribe Information
A deep vein thrombosis (DVT) is a blood clot in an extremity (not in the lungs); symptoms of a DVT include extremity pain and swelling and has the same risk factors as a PE; a DVT is diagnosed by an ultrasound of that extremity
44
Pneumonia (PNA) Etiology
Infiltrate (bacterial infection) and inflammation inside the lung
45
Pneumonia (PNA) Risk Factors
Elderly, Bedridden, Immunocompromised, Recent chest injury, Recent surgery
46
Pneumonia (PNA) Chief Complaint
Productive cough
47
Pneumonia (PNA) Associated Symptoms
Shortness of breath, fever, chest pain
48
Pneumonia (PNA) Medications
Rocephin and Zithromax (antibiotics)
49
Pneumonia (PNA) Physical Exam Findings
Rhonchi
50
Pneumonia (PNA) Method of Diagnosis
CXR
51
Pneumonia (PNA) Pertinent Scribe Information
Community Acquired Pneumonia (CAP) protocol requires documenting antibiotics (abx), vital signs, SaO2, mental status, and blood cultures
52
Chronic Obstructive Pulmonary Disease (COPD) Etiology
Long-term damage to the lungs' alveoli (emphysema) along with inflammation and mucus production (chronic bronchitis)
53
Chronic Obstructive Pulmonary Disease (COPD) Risk Factors
Smoking
54
Chronic Obstructive Pulmonary Disease (COPD) Chief Complaint
Shortness of breath
55
Chronic Obstructive Pulmonary Disease (COPD) Associated Symptoms
Wheezing, cough, chest tightness
56
Chronic Obstructive Pulmonary Disease (COPD) Treatment
Bronchodilators, supplemental oxygen, corticosteroids, ventilatory support
57
Chronic Obstructive Pulmonary Disease (COPD) Physical Exam Findings
Decreased breath sounds, wheezes
58
Chronic Obstructive Pulmonary Disease (COPD) Method of Diagnosis
COPD not diagnosed in ED; CXR ordered to check for pneumonia in ED due to acute exacerbation of COPD due to infection
59
Chronic Obstructive Pulmonary Disease (COPD) Pertinent Scribe Information
Document the patient's baseline O2 requirement
60
Asthma Etiology
Constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a "bronchospasm"
61
Asthma Risk Factors
Personal or family history of asthma, Smoking, Occupational exposures, Obesity, Allergies
62
Asthma Chief Complaint
Shortness of breath
Modifying Factors: Improved with “breathing treatments”, Exacerbated by certain triggers
63
Asthma Associated Symptoms
Wheezing
64
Asthma Treatment
Bronchodilators, corticosteroids, inhalers (inhaled corticosteroids) or nebulizers
65
Asthma Physical Exam Findings
Wheezes (inspiratory or expiratory)
66
Asthma Pertinent Scribe Information
Be sure to document the patient's oxygen saturation; if the patient becomes hypoxic, they may require supplemental oxygen or additional interventions
67
Cerebrovascular accident (CVA) vs Transient Ischemic Attack (TIA)
CVA and TIA both involve abnormal blood flow in the brain; CVA causes permanent brain damage, while TIA does not
68
Ischemic CVA Etiology
Blockage of the arteries supplying blood to the brain resulting in permanent brain damage
69
Ischemic CVA Risk Factors
HTN, HLD, DM, Smoking, History of TIA/CVA, Family history of TIA/CVA, A Fib
70
Ischemic CVA Chief Complaint
Unilateral focal neurological deficits: One-sided weakness/numbness or changes in speech/vision
71
Ischemic CVA Medications
tPA (thrombolytic) will be administered if the patient meets the criteria
72
Ischemic CVA Physical Exam Findings
Unilateral neurological deficits
73
Ischemic CVA Method of Diagnosis
Clinically, following a CT head in order to rule out hemorrhagic CVA
74
Ischemic CVA Pertinent Scribe Information
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; 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
75
Hemorrhagic CVA Etiology
Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain
76
Hemorrhagic CVA Risk Factors
HTN, Anticoagulant use, Recent head trauma
77
Hemorrhagic CVA Chief Complaint
Severe, sudden onset ("thunderclap") headache
78
Hemorrhagic CVA Associated Symptoms
Nausea, AMS, Focal neurological deficits (unilateral weakness, numbness, tingling, changes in speech/vision)
79
Hemorrhagic CVA Physical Exam Findings
Unilateral neurological deficits
80
Hemorrhagic CVA Method of Diagnosis
Combination of CT head, clinical presentation, and in rare cases lumbar puncture
81
Hemorrhagic CVA Pertinent Scribe Information
Document “tPA not administered due to hemorrhage”
82
Transient Ischemic Attack (TIA) Etiology
Vascular changes temporarily deprive a part of the brain of oxygen (symptoms usually last less than 1 hour)
83
Transient Ischemic Attack (TIA) Risk Factors
HTN, HLD, DM, Smoking, History of TIA/CVA, Family history of TIA/CVA, A Fib
84
Transient Ischemic Attack (TIA) Chief Complaint
Transient focal neurological deficits (changes in speech, vision, strength, or sensation)
85
Transient Ischemic Attack (TIA) Method of Diagnosis
Clinically
86
Transient Ischemic Attack (TIA) Pertinent Scribe Information
TIA's are also known as “mini strokes” because symptoms usually last \< 1 hour and there is no permanent brain damage; document TPA considered and not indicated due to the fact that symptoms are resolved
87
Meningitis Etiology
Inflammation and infection of the meninges (the sac surrounding the brain and spinal cord)
88
Meningitis Risk Factors
Recent international travel, Recent exposure to a sick contact
89
Meningitis Chief Complaint
Headache, neck pain or stiffness, fever, AMS
90
Meningitis Physical Exam Findings
Meningismus, Nuchal rigidity
91
Meningitis Method of Diagnosis
Lumbar puncture (LP)
92
Meningitis Pertinent Scribe Information
Meningitis is notoriously hard to diagnose; any person with a headache or fever will likely be asked if they have headache, neck pain, or fever; be sure to document all of the symptoms that the patient has and does not have
93
Altered Mental Status (AMS) Etiology
Globalized confusion, caused by things that affect the entire brain; most common are hypoglycemia, infection, intoxication, and neurological
94
Altered Mental Status (AMS) Risk Factors
Known infection (commonly UTI in elderly patients), Diabetic, Elderly, Dementia, Alcohol use, Drug use
95
Altered Mental Status (AMS) Chief Complaint
Confusion, Decreased responsiveness, Unresponsive
96
Altered Mental Status (AMS) Method of Diagnosis
Case-dependent
97
Altered Mental Status (AMS) Pertinent Scribe Information
AMS is very different compared to a focal neurological deficit (FND); AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar); focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain
98
Syncope (Passing Out) Etiology
Temporary loss of blood supply to the brain leading to loss of consciousness; there are a variety of causes, with the most common being vasovagal and low blood volume (dehydration/hypovolemia); occasionally syncope occurs due to cardiac/neurological issues
99
Syncope (Passing Out) Chief Complaint
Loss of consciousness (LOC), Fainting or passing out
100
Syncope (Passing Out) Pertinent Scribe Information
Document what happened:
1. Before the episode
2. During the episode
3. After the episode (were they sleepy, groggy, confused, or had slurred speech?; may be postictal)
4. How the patient is currently feeling
Were they near-syncopal? Did they almost pass out or have lightheadedness?
Patients who have had a syncopal episode may have also had a seizure so document any seizure-like activity
101
Appendicitis Etiology
Infection of the appendix causes inflammation and blockage, possibly leading to rupture
102
Appendicitis Chief Complaint
Abdominal pain
Location: RLQ
Modifying Factors: Worse with movement
103
Appendicitis Associated Symptoms
Nausea, vomiting, fever, decreased appetite
104
Appendicitis Physical Exam Findings
RLQ tenderness, McBurney's point tenderness
105
Appendicitis Method of Diagnosis
CT abdomen/pelvis with PO contrast
106
Cholelithiasis Etiology
Minerals from the liver's bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder
107
Cholelithiasis Risk Factors
Female 40 and older, Native American or Hispanic or Mexican origin, Being overweight or obese, Being sedentary, Being pregnant, Eating a high-fat diet
108
Cholelithiasis Chief Complaint
Abdominal pain
Location: RUQ
Quality: Typically sharp
Modifying Factors: Worse with eating fatty foods, deep breaths, and palpation
109
Cholelithiasis Physical Exam Findings
RUQ tenderness, Murphy's sign (sign of acute cholecystitis)
110
Cholelithiasis Method of Diagnosis
Abdominal ultrasound (RUQ)
111
Cholelithiasis Pertinent Scribe Information
As a complication, patients can develop acute cholecystitis; this can be indication for an emergent cholecystectomy
112
Urinary Tract Infection (UTI) Etiology
Infection of the urinary tract (bladder and/or urethra)
113
Urinary Tract Infection (UTI) Risk Factors
Female
114
Urinary Tract Infection (UTI) Chief Complaint
Painful urination (dysuria)
115
Urinary Tract Infection (UTI) Associated Symptoms
Urinary frequency, urgency, malodorous urine, AMS (elderly)
116
Urinary Tract Infection (UTI) Physical Exam Findings
Suprapubic tenderness
117
Urinary Tract Infection (UTI) Method of Diagnosis
Urine dip or urinalysis (UA)
118
Urinary Tract Infection (UTI) Pertinent Scribe Information
A UTI left untreated can migrate to the kidneys via the ureters causing pyelonephritis; in these patients, their urinary symptoms may be similar but also include flank pain, with fever, malaise, and nausea/vomiting; a PE finding of costovertebral angle (CVA) tenderness and a positive urine can diagnose this condition but may be further evaluated with a CT A/P; in most cases, these patients require admission and more aggressive treatment with IV antibiotics
119
Kidney Stones Etiology
A kidney stone dislodged from the kidney and begins traveling down the ureter; the stone scrapes and irritates the ureter, causing severe flank pain and bloody urine
120
Kidney Stones Chief Complaint
Flank pain
121
Kidney Stones Associated Symptoms
Blood in the urine (hematuria), Nausea/vomiting, Unable to void
122
Kidney Stones Physical Exam Findings
Costovertebral angle (CVA) tenderness
123
Kidney Stones Method of Diagnosis
CT abdomen/pelvis, Red blood cells in the UA may be a clue
124
Kidney Stones Pertinent Scribe Information
Common naming: Nephrolithiasis, Renal calculi, Urolithiasis
125
Ectopic Pregnancy Etiology
Fertilized egg develops outside the uterus, usually in the fallopian tube; high risk for rupture and death
126
Ectopic Pregnancy Risk Factors
Pregnant female (HCG positive), STD (PID)
127
Ectopic Pregnancy Chief Complaint
Lower abdominal pain, Vaginal bleeding while pregnant
128
Ectopic Pregnancy Method of Diagnosis
Ultrasound pelvis (determine location of fetus; intrauterine is a normal finding)
129
Ectopic Pregnancy Pertinent Scribe Information
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
130
Spinal Cord Injury Etiology
Bruise, partial tear, or complete tear of the spinal cord
131
Spinal Cord Injury Chief Complaint
Neck or back pain, Bilateral extremity weakness
132
Spinal Cord Injury Method of Diagnosis
CT C-spine, T-spine, and/or L-spine
133
Pneumothorax Etiology
Collapsed lung
134
Pneumothorax Chief Complaint
Shortness of breath, One-sided chest pain
135
Pneumothorax Method of Diagnosis
CXR
136
Internal Organ Injury Etiology
Rupture leading to hemorrhage/bleeding
137
Internal Organ Injury Chief Complaint
Abdominal pain, Abdominal distension
138
Internal Organ Injury Method of Diagnosis
CT abdomen
139
Fracture Etiology
Trauma creates pain/swelling
140
Fracture Chief Complaint
Pain, Swelling, Bruising, Use limitation
141
Fracture Method of Diagnosis
X-ray
142
Trauma Documentation Requirements
1. Mechanism of Injury → HPI
2. Patient on blood thinners? → HPI
3. Glasgow Coma Scale (GCS) → PE
143
Concerning symptoms s/p trauma
LOC, Confusion, Numbness, Weakness, Headache, Neck/back pain, Shortness of breath, Chest pain, Abdominal pain
Be sure to document positive and negative for each symptom
144
Back Pain Etiology
Deterioration or strain of the back creates pain that is worse with movement
145
Back Pain Risk Factors
Chronic back pain, Age, Physically demanding job
146
Back Pain Chief Complaint
Back pain (mostly lumbar)
147
Back Pain Physical Exam Findings
Paraspinal tenderness, Positive straight leg raise (+ SLR diagnoses Sciatica, which is back pain that radiates down the legs)
148
Back Pain Pertinent Scribe Information
Remember to document if there is any recent trauma related to the back pain; trauma increases the physician's concern about possible spinal injury; concerning symptoms include lower extremity weakness/numbness and bowel or bladder incontinence
149
Abdominal Aortic Aneurysm (AAA) Etiology
Widened and weakened arterial wall at risk of rupture
150
Abdominal Aortic Aneurysm (AAA) Risk Factors
Age, HTN, Smoking, CAD
151
Abdominal Aortic Aneurysm (AAA) Chief Complaint
Midline abdominal pain
152
Abdominal Aortic Aneurysm (AAA) Physical Exam Findings
Midline pulsatile abdominal mass, Abdominal bruit, Unequal femoral pulses, Hypotension
153
Abdominal Aortic Aneurysm (AAA) Method of Diagnosis
CT abdomen/pelvis with IV contrast
154
Aortic Dissection Etiology
Separation of the muscular wall from the membrane of the artery, putting the patient at risk of aortic rupture and death
155
Aortic Dissection Risk Factors
Age, HTN, Connective Tissue Disorder
156
Aortic Dissection Chief Complaint
Ripping or tearing chest pain radiating to the back
157
Aortic Dissection Physical Exam Findings
Unequal brachial or radial pulses, hypotension
158
Aortic Dissection Method of Diagnosis
CT chest with IV contrast
159
Sepsis Etiology
An infection that gets into the bloodstream; in response to a systemic infection, chemicals released from the immune system cause inflammation throughout the entire body, potentially leading to shock and death
160
Sepsis Risk Factors
Current infection: viral, bacterial, or fungal; Compromised immune system; Open wounds; Chronically ill; Young/old; Having an intense invasive device such as an IVC or breathing tube
161
Sepsis Chief Complaint
Fever, AMS
162
Sepsis Associated Symptoms
Symptoms vary, depending on the source of the infection
163
Sepsis Pertinent Scribe Information
Given that sepsis is a time-sensitive, life-threatening condition, healthcare providers must act quickly when trying to diagnose and treat this infection; think of the investigation and treatment as a series of four stages
164
Sepsis Protocol
1. Stage 1: Trending Vital Signs
2. Stage 2: Monitoring Labs
3. Stage 3: Preliminary Management
4. Stage 4: Finalized Management
165
Sepsis Protocol Stage 1: Trending Vital Signs
Looking for tachycardia (HR \> 100 bpm), fever (temp \> 100.4 °F), hypotension, and tachypnea
166
Sepsis Protocol Stage 2: Monitoring Labs
Physician will carefully monitor the patient's CBC to look for leukocytosis (elevated WBC) in addition to checking lactate, which indicates large amounts of dying cells
167
Sepsis Protocol Stage 3: Preliminary Management
Order a blood culture, start broad spectrum antibiotics (Zosyn, Vancomycin, Rocephin), and obtain broad infectious workup to look for source
168
Sepsis Protocol Stage 4: Finalized Management
Once the blood cultures return in a few days, there will likely be a shift in the antibiotic regimen based on the identity of the pathogen(s)
169
Cellulitis Etiology
Infection of the skin cells
170
Cellulitis Chief Complaint
Red, swollen, painful, and sometimes warm area of the skin
171
Cellulitis Medications
Antibiotics
172
Cellulitis Physical Exam Findings
Erythema, Edema, Increased warmth (calor), Induration
173
Cellulitis Method of Diagnosis
Clinically
174
Cellulitis Pertinent Scribe Information
If the patient has evidence of quickly spreading cellulitis, they may require a hospitalization for IV antibiotics
175
Abscess Etiology
Infection of skin with an underlying collection of pus
176
Abscess Chief Complaint
Red, swollen, painful lump
177
Abscess Medications
Antibiotics
178
Abscess Physical Exam Findings
Erythema, Edema, Increased warmth (calor), Induration, Fluctuance (pus-pocket)
179
Abscess Method of Diagnosis
Clinically
180
Abscess Pertinent Scribe Information
Abscesses must have the pus-pocket drained; remember to always document incision and drainage (I&D) procedure notes for abscesses
181
Headache Etiology
Pain in any region of the head
182
Headache Chief Complaint
Headache
183
Seizure Etiology
Abnormal electrical activity in the brain
184
Seizure Chief Complaint
Seizure activity or syncope
185
Bell's Palsy Etiology
Inflammation or viral infection of the facial nerve causes one-sided weakness of the entire face
186
Bell's Palsy Chief Complaint
Facial droop
187
Vertigo Etiology
The sensation that you, or the environment around you, is spinning
188
Vertigo Chief Complaint
Room spinning
189
Diabetic Ketoacidosis (DKA) Etiology
Shortage of insulin resulting in hyperglycemia and production of ketones
190
Diabetic Ketoacidosis (DKA) Chief Complaint
Vomiting
191
Suicidal Ideation Etiology
Thinking about suicide
192
Suicidal Ideation Chief Complaint
Suicidal thoughts
193
Ovarian Torsion Etiology
Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in infarct of the ovary
194
Ovarian Torsion Chief Complaint
Abdominal pain
195
Allergic Reaction Etiology
Immune response causing an inflammatory reaction consisting of swelling, itching (pruritus), and rash
196
Allergic Reaction Chief Complaint
Rash
197
Bronchitis Etiology
Inflammation of the lining of the bronchial tubes
198
Bronchitis Chief Complaint
Cough
199
Covid Etiology
Coronaviruses are a family of viruses that can cause illnesses such as the common cold and severe acute respiratory syndrome
200
Covid Chief Complaint
Fever, Cough, Tiredness
201
Otitis Media (OM) Etiology
Viral or bacterial infection of the tympanic membrane (TM) causing ear pain and pressure
202
Otitis Media (OM) Chief Complaint
Ear pain
203
Rash Etiology
Changes in the skin's appearance due to systemic or localized reaction; may be from medication, virus, bacteria, fungus, insect, etc.
204
Rash Chief Complaint
Rash
205
Upper Respiratory Infection (URI) Etiology
Most often viral infection causes congestion, cough, and inflammation of the upper airway
206
Upper Respiratory Infection (URI) Chief Complaint
Cough, Runny nose, Sore throat
207
C. Diff Colitis Etiology
Opportunistic bacteria that causes persistent diarrhea
208
C. Diff Colitis Chief Complaint
Diarrhea
209
Diverticulitis Etiology
Acute inflammation and infection of abnormal pockets of the large intestine, known as diverticula
210
Diverticulitis Chief Complaint
LLQ pain
211
Gastroesophageal Reflux Disease (GERD) Etiology
Stomach acid regurgitating into the esophagus
212
Gastroesophageal Reflux Disease (GERD) Chief Complaint
Epigastric pain
213
GI Bleed Etiology
Hemorrhage in the upper or lower GI tract that can lead to anemia
214
GI Bleed Chief Complaint
Hematemesis, Coffee ground emesis, Hematochezia, Melena
215
Gastritis Etiology
Irritated stomach with vomiting; “stomach ache”
216
Gastritis Chief Complaint
Abdominal pain
217
Gastroenteritis Etiology
Vomiting and diarrhea; “GI bug” often viral or bacterial
218
Gastroenteritis Chief Complaint
Vomiting and diarrhea
219
Pancreatitis Etiology
Inflammation of the pancreas
220
Pancreatitis Chief Complaint
LUQ and epigastric pain
221
Small Bowel Obstruction (SBO) Etiology
Physical blockage of the small intestine
222
Small Bowel Obstruction (SBO) Chief Complaint
Abdominal pain, Vomiting, Constipation
223
Diabetes Mellitus (DM) Etiology
The inadequacy of insulin in controlling the blood glucose level (insulin resistance)
224
Diabetes Mellitus (DM) Risk Factors
Family history of DM, Obesity, High carb diet, Lack of exercise
225
Diabetes Mellitus (DM) Chief Complaint
Unusual weight loss or gain, Polyuria, Polydipsia, Blurred vision, Nausea/vomiting
226
Diabetes Mellitus (DM) Medications
Insulin Dependent: Humalog, Lantus
Non-Insulin Dependent: Oral meds like metformin, glyburide
227
Diabetes Mellitus (DM) Method of Diagnosis
Fasting blood glucose, Hemoglobin A1C
228
Hypertension (HTN) Etiology
Higher than normal pressure of blood pushing against the walls of your arteries
229
Hypertension (HTN) Risk Factors
DM, Obesity, Age, Smoking, Alcohol use, Family history of HTN
230
Hypertension (HTN) Chief Complaint
Usually has no warning signs or symptoms
231
Hypertension (HTN) Medications
Different blood pressure medicines can work in different ways to keep blood pressure at a healthy level:
* Causing the body to get rid of water, which decreases the amount of water and salt in the body to a healthy level
* Relaxing the blood vessels
* Making the heart beat with less force
* Blocking nerve activity that can restrict the blood vessels
232
Hypertension (HTN) Method of Diagnosis
Having blood pressure measures consistently above normal may result in a diagnosis of high blood pressure (or hypertension)
233
Hypertension (HTN) Pertinent Scribe Information
Hypertension puts people at a higher risk for many diseases because of blood vessel damage throughout the body
234
Hyperlipidemia (HLD) Etiology
An elevated level of lipid in the blood causes plaque buildup along arterial walls
235
Hyperlipidemia (HLD) Risk Factors
Family history of HLD, Obesity, High lipid diet (high in saturated fats), Alcohol use, Physical inactivity
236
Hyperlipidemia (HLD) Chief Complaint
Usually has no warning signs or symptoms
237
Hyperlipidemia (HLD) Medications
Statins
238
Hyperlipidemia (HLD) Method of Diagnosis
Not often done in the ED, more relevant in the setting of being a risk factor for other emergent diseases
