Day 2: Pathophysiology

Question 1

The diseases being considered are known as the _____.

Answer 1

Differential Diagnoses

Question 2

Physician’s thought process

Answer 2

1. Subjective complaints and risk factors
2. Differential diagnoses
3. Objective evaluation
4. Final diagnosis

Question 3

All the questions asked by the physician during the HPI are designed to ______.

Answer 3

Investigate specific subjective complaints that may help point towards or away from a particular differential diagnosis.

Question 4

Pertinent positives

Answer 4

Specific symptoms that raise the physician’s suspicions for that disease

Question 5

Pertinent negatives

Answer 5

Symptoms NOT present that cause the physician to doubt certain diagnoses

Question 6

CAD (Coronary Artery Disease)

Answer 6

Etiology: Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina (CP specifically due to heart-muscle ischemia).

1. Catchphrase:“chest pain with physical exertion”
2. CC: CP or chest pressure (worse with exertion, improved with rest or NTG)
3. Associated Meds: ASA 324 mg PO (Per Os = by mouth), NTG 0.4 mg SL (Sublingual = under the tongue).
4. Dx by: Cardiac catheterization (Not Dx in the ED).

NOTES:

• CAD greatest risk factor for an MI.
• Stress test or cardiac cath assesses the severity of CAD.
• A pt has CAD if they have PMHx of Angina, MI, CABG, Cardiac stents, or Angioplasty
• EVERY patient complaining of CP should receive ASA 324 mg PO, unless given PTA (prior to arrival) or contraindicated (should not be used) due to bleeding or allergy.

Question 7

Myocardial Infarction (MI) STEMI, NON-STEMI

Answer 7

Etiology: Acute blockage of coronary arteries results in ischemia and infarct (area of dead tissue following prolonged ischemia) of the heart muscle.

1. Catchphrase: Chest pressure with diaphoresis (sweating), N/V, and SOB
2. Risk factors: CAD, HTN, HLD, DM, Smoker, FHx of CAD < 55 y.o.
3. CC: CP or chest pressure
4. Dx by: EKG (STEMI) or elevated Troponin (non-STEMI).
5. Assoc. Meds: ASA, NTG, B-blocker, Thrombolytic (Heparin). Thrombo = Clot, Lysis = Destroy

NOTE:

• Acute MI pts must receive ASA 325 mg ASAP.
• STEMI pts must get to Cath-lab w/in 90 mins of arrival.
• Document ED arrival and depart times!

Question 8

Congestive Heart Failure (CHF)

Answer 8

Etiology: The heart becomes enlarged, inefficient, and congested with excess fluid.

1. Catchphrase: SOB w/pedal edema and orthopnea.
2. CC: SOB: Worse with lying flat (Orthopnea), Paroxysmal Nocturnal Dyspnea (PND), Dyspnea on Exertion (DOE).
3. PE: rales (Crackles) in lungs, Jugular Vein Distention (JVD) in the neck, Pitting pedal edema.
4. Assoc Meds: Diuretics (Lasix, Furosemide) –> Urinate extra fluid
5. Dx by: CXR or elevated BNP (B-type Natriuretic Peptide).

NOTES:

• Think of CHF as a fluid traffic jam in the heart; fluid gets backed up in the neck (JVD) and down the legs (pedal edema).
• Paroxysmal nocturnal dyspnea (PND) — is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.

Question 9

Atrial Fibrillation (A-Fib)

Answer 9

Etiology: Electrical abnormalities in the “wiring” of the heart causes the top of the heart (atria) to quiver abnormally.

1. CC: Palpitations (Fast, Pounding, Irregular).
2. Risk Factors: Paroxysmal A-Fib, Chronic A-Fib
3. PE: Irregularly irregular rhythm, Tachycardia
4. Dx by: EKG (ECG)
5. Assoc Meds: Coumadin (Warfarin), Blood thinner –> prevents blood clots in atria. Digoxin: Slows down the heart rate.

NOTES:

• ED concern is Rapid Ventricular Response (RVR). These pts will often be “cardioverted”, put back into NSR.

Question 10

Non-cardiac causes of CP

Answer 10

1. Pericarditis: Inflammation of the sac surrounding the heart.
2. Pleurisy: Inflammation of the sac surrounding the lungs.
3. Costochondritis: Irritation of the ribs causing CP, worsened by pressing on the sternum.
4. Chest Wall Pain: Irritation of the chest wall causing pain with palpation of the chest.
5. Pleural Effusion: Fluid collecting around the lungs causing SOB or CP.

Question 11

Pulmonary Embolism (PE)

Answer 11

Etiology: Blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs.

1. Catchphrase: Pleuritic (sudden and intensely sharp, stabbing, or burning pain) CP w/Tachycardia and hypoxia
2. Risk Factors: Known DVT, PMHx of DVT or PE, FHx, Recent surgery, Cancer, A-fib, Immobility, Pregnancy, BCP (birth control pills), Smoking.
3. CC: SOB or Pleuritic CP (CP worse w/ deep breaths).
4. Dx by: CTA chest (CT chest w/ IV contrast) or VQ scan. D-dimer aids in detecting clots, but cannot diagnose a PE.

Normal D-Dimer –– No possible abnormal clotting.

Elevated D-Dimer –– Possible abnormal clotting.

Question 12

Pneumonia (PNA)

Answer 12

Etiology: Infiltrate (bacterial infection) and inflammation inside the lung.

1. Catchphrase: Productive cough with fever.
2. Risk Factors: Elderly, Bedridden, Recent chest injury, Recent surgery
3. CC: SOB or Productive cough
4. Assoc. Sx: Cough with sputum, Fever, Chest pain
5. Assoc. Meds: Rocephin and Zithromax (Abx)
6. PE: Rhonchi
7. Dx by: CXR

NOTES:

• Community-Acquired Pneumonia (CAP) protocol applies to pts with PNA. CAP protocol requires documenting Antibiotics (Abx), Vital Signs, SaO₂ (oxygen saturation as measured by blood analysis), Mental Status, and Blood cultures.

Question 13

Pneumothorax (PTX)

Answer 13

Etiology: Collapsed lung due to trauma or spontaneous small rupture of the lung.

1. CC: SOB and one-sided CP (sudden onset, often trauma pts).
2. PE: Absent breath sounds unilaterally
3. Dx by: CXR

NOTES:

Document % lung collapsed (e.g. 20% PTX)

Question 14

Chronic Obstructive Pulmonary Disease (COPD)

Answer 14

Etiology: Long-term damage to the lung’s alveoli (emphysema) along with inflammation and mucus production (chronic bronchitis).

1. Risk factors: Smoking
2. CC: SOB
3. PE: Decreased breath sounds, Wheezes, Rales
4. Assoc Meds: Home O₂ (Document how much O₂ they use @ baseline) –– Usually, 2 liters of home O₂ via nasal cannula.
5. Dx by: CXR and Hx of smoking.

Question 15

Asthma (Reactive Airway Disease)

Answer 15

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

1. CC: SOB/Wheezing –– Improved with nebulizer “breathing treatments” (bronchodilators)
2. PE: Wheezes (Inspiratory or Expiratory)
3. Assoc. Meds: Inhalers, Nebulizers, Corticosteroids.
4. Dx by: Clinically

NOTES:

The physician will ask asthma pt:

1. Do you have a home nebulizer (machine)?
2. Have you been on steroids recently?
3. Hx of hospitalization for asthma?
4. Hx of intubation (breathing tube)?
5. Asthma triggers?

Question 16

Pulmonary Summary

Answer 16

• *PE** –– Pleuritic CP w/ tachycardia and hypoxia –– Dx by CTA (CT Chest w/ IV Contrast)
• *PTX, Hemothorax** –– Unilateral CP and SOB –– Dx by CXR
• *PNA** –– SOB w/ productive cough –– Dx by CXR
• *COPD** –– SOB with Hx smoking –– Dx by CXR w/ Hx of Smoking
• *Asthma** –– Wheezing with Hx of Asthma –– Dx clinically

Question 17

Ischemic Cerebrovascular Accident (CVA)

Answer 17

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

1. CC: Unilateral focal neurological deficits: 1-sided weakness/numbness or changes in speech/vision
2. Risk Factors: HTN, HLD, DM, Hx TIA/CVA, Smoking, FHx CVA, Afib.
3. PE: Neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits
4. Dx by: Clinically, CT Head is often done to rule out any other acute abnormality.

• Hemiparesis – weakness or the inability to move on one side of the body.
• Paresthesias – Tingling or prickling, “pins-and-needles” sensation; usually temporary, often occurs in the arms, hands, legs, or feet.
• Aphasia – Loss of ability to understand or express speech, caused by brain damage.

NOTES:

Always document pt’s “last time known well,” as well as the source of this information –– Used to assess eligibility for tPA – a blood thinner that can reverse CVA.

Document tPA considered and not indicated due to: onset greater than 3 hours or unknown, unreliable time of onset; symptoms are rapidly improving.

Question 18

Hemorrhagic Stroke (CVA)

Answer 18

Etiology:“Brain bleed” –– Often a traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain.

1. CC: Severe HA (sudden onset, “worst of life”)
2. Risk Factors: Recent head trauma, HTN, anticoagulant therapy.
3. Assoc. Sx: Changes in speech, Vision, Sensation, or Motor Strength, AMS, Sz
4. PE: Unilateral Neurological Deficits
5. Dx by: CT Head or LP

NOTES:

• Document –– tPA is not indicated due to hemorrhage.
• tPA Contraindicated

Question 19

Transient Ischemic Attack (TIA)

Answer 19

Etiology: Vascular changes temporarily deprive a part of the brain of O₂, Sxs usually last less than <1 hour (mini-stroke) and there is no permanent brain damage.

1. CC: transient focal neurological deficit (change in speech, vision, strength, or sensation)
2. Dx: clinically

NOTES:

• Document tPA considered but not indicated due to resolved symptoms.

Question 20

Only ________ patients can qualify for tPA.

Answer 20

Ischemic CVA

Question 21

Meningitis: (Bacterial vs. Viral)

Answer 21

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

1. CC: HA and neck pain.
2. Assoc Sx: Fever, Neck pain, Neck stiffness, AMS, Photophobia.
3. PE: Meningismus, Nuchal rigidity
4. Dx by: Lumbar Puncture (LP)

AMS –– Altered Mental Status

Photophobia –– Sensitivity to light

Question 22

Spinal Cord Injury

Answer 22

Etiology: Injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury.

1. CC: Neck pain or Back pain, Bilateral extremity weakness.
2. PE: Midline bony tenderness, Deformities, or step-offs, Bilateral extremity weakness, Numbness, Decreased rectal tone
3. Dx by:

• CT Cervical Spine (C-spine) –– Neck
• CT Thoracic Spine (T-spine) –– Upper back
• CT Lumbar Spine (L-spine) –– Lower back

NOTES:

• Remember that during the initial physical exam, the spine is often immobilized with a C-collar and
  backboard; document accordingly.

Question 23

Seizure (Sz)

Answer 23

Etiology: Abnormal electrical activity in the brain leading to abnormal physical manifestations. Often caused by epilepsy, EtOH withdrawals, or febrile Sz in pediatric pts.

• *CC:** Sz activity, syncope (passing out)
• *Assoc Sx:** Injuries (tongue bite), Confusion, Headache, Incontinence – the inability of the body to control the evacuative functions of urinary or defecation.
• *PE:** Somnolent (drowsy, sleepy), Confused (postictal – the period of time immediately following a seizure).

Assoc. Meds: Dilantin, Tegretol, Keppra, Depakote, Neurontin.

NOTES:

The physician will ask:

• Has the patient had a similar Sz in the past?
• Does the patient have a Hx of seizures?
• What was the date of their last seizure?
• What seizure medication do they take?
• Have they missed any medication doses?
• How did you feel before, during, after, now?

Question 24

A fever is the number one cause of seizure in _____.

Answer 24

Pediatrics

Question 25

Bell's Palsy

Answer 25

**Etiology:** Inflammation or viral infection of the facial nerve causes one-sided weakness of the face. 1. **CC:** Facial droop, Sudden onset 2. **Assoc. Sx:** Jaw or ear pain, increased tear flow of one eye. 3. **Pert. Neg:** No extremity weakness, no changes in speech or vision 4. **PE:** Unilateral weakness of the upper and lower face. 5. **Dx:** Clinically **NOTES:** * Remember to document the absence of other FND (Focal Neurological Deficit).

Question 26

Headache (HA), Cephalalgia

Answer 26

**Etiology:** Various causes including hypertensive HA, recurrent dx migraines, sinusitis, etc 1. **CC:** HA (gradual onset), pressure, throbbing (strong regular rhythm, pulsating). 2. **Pert. Neg:** No fever, No neck stiffness, No numbness/weakness, No change in speech or vision. **NOTES:** * Always remember to document if the HA is similar or dissimilar to any prior HA. * Never document "Worst Headache of Life" or "Thunderclap onset" unless specifically instructed by a physician.

Question 27

Altered Mental Status ( AMS)

Answer 27

**Etiology:** Multiple causes: most common are hypoglycemia, infection, intoxication, and neurological. 1. **Risk Factors:** Diabetic, Elderly, Demented, EtOH use, Drug use. 2. **CC:** Confusion, Decreased responsiveness, Unresponsive. 3. **Dx by:** Case dependent **NOTES:** * AMS is generalized and usually caused by things that affect the whole brain (drugs, low blood sugar), very different than a focal neurological deficit. * **Focal neuro deficits** are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain. * The most common cause of AMS for patients with a Hx of dementia is an infection, most often caused by a UTI.

Question 28

Syncope

Answer 28

**Etiology:** Temporary loss of blood supply to the brain resulting in LOC (loss of consciousness). Many causes: most common are vasovagal and low blood volume (dehydration/hypovolemia). Occasionally syncope occurs due to cardiac/neurologic causes. 1. **CC:** Passing-out vs. About to pass-out (near-syncope). **NOTES:** * Document what happened prior, during, and after the syncopal episode, and how the pt currently feels.

Question 29

Vertigo

Answer 29

**Etiology:** Caused by two etiologies: vertigo may be from a harmless problem of the inner ear (benign positional vertigo) or it may be caused due to damage in a specific center of the brain (possible CVA). 1. **CC:** Room-spinning, Feeling off-balance (disequilibrium), worsened w/ head movement. 2. **Assoc Sx:** N/V, Tinnitus (ringing in ears). 3. **PE:** Horizontal Nystagmus, + Romberg, + Dix-Hallpike Test 4. **Assoc Meds:** Meclizine (Antivert) 5. **Dx:** Clinically **Nystagmus** –– involuntary rhythmic side-to-side, up and down, or circular motion of the eyes. **Romberg Test** –– a test that measures your sense of balance. **Hallpike Test** –– a test that doctors use to diagnose a particular kind of vertigo called benign paroxysmal positional vertigo (BPPV).

Question 30

Neurological Summary

Answer 30

**Diagnosis** –––––––– **Important things to document** * *Hemorrhagic CVA** –– tPA Ineligibility * *Ischemic CVA** –– tPA Eligibility, Last known normal * *Meningitis** –– HA, Fever, Neck pain * *Spinal Cord Injury** –– Bilateral extremity weakness * *TIA** –– When did Sx resolve? * *Seizure** –– Post-Ictal state, Missed Sz meds? * *Bell's Palsy** –– Absence of other FND * *HA/Migraine** –– Similar Sx in past? Gradual onset * *AMS** –– Infection? DM? Drugs? Baseline? * *Syncope** –– Before, during, after, current status * *Vertigo** –– N/V, Nystagmus

Question 31

Abdominal Quadrants Summary * Epigastric * RUQ * LUQ * Periumbilical * LLQ * RLQ * Suprapubic * Flanks

Answer 31

* *Epigastric:** GERD, MI * *RUQ:** Cholecystitis, Cholelithiasis * *LUQ:** Pancreatitis * *Periumbilical:** SBO – Small Bowel Obstruction * *RLQ:** Appendicitis * *LLQ:** Diverticulitis * *Suprapubic:** Ovarian Torsion, Ovarian Cyst, UTI * *Flanks:** Pyelonephritis, Renal Calculi

Question 32

Appendicitis (Appy)

Answer 32

**Etiology:** Infection of the appendix causes inflammation and blockage, possibly leading to rupture. 1. **CC:** RLQ pain –– Gradual Onset, Constant, Worsened w/ Movement. 2. **Assoc Sx:** Decreased appetite (anorexia), Fever, N/V 3. **PE:** McBurney's point tenderness, RLQ tenderness, Peritoneal signs: guarding, rebound, rigidity. 4. **Dx by:** CT A/P w/ PO Contrast (CT Abdomen/Pelvis with PO Contrast)

Question 33

Small Bowel Obstruction (SBO)

Answer 33

**Etiology:** Physical blockage of the small intestine. 1. **Risk Factors:** Elderly, Infants, Abdominal surgery, Narcotic pain medication 2. **CC:** Abdominal pain, Vomiting, Constipation 3. **Assoc Sx:** Abd Distension, Bloating, No BMs 4. **PE:** Abd tenderness, Guarding, Rebound, Abnormal bowel sounds, Abdominal distension, Tympany. 5. **Dx by:** CT A/P w/ PO contrast, Acute Abdominal Series (AAS) (an Xray)

Question 34

Gallstones (Cholelithiasis, Cholecystitis)

Answer 34

**Etiology:** Minerals from the liver's bile condense to form gallstones that can irritate, inflame, or obstruct the gallbladder. 1. **Catchphrase:** RUQ Abd pain after eating fatty foods. 2. **CC:** RUQ pain –– Sharp, Worse w/ eating, Deep breaths, and Palpation 3. **PE:** RUQ tenderness, Murphy's sign 4. **Dx by:** Abd US (Ultrasound), RUQ

Question 35

Gastrointestinal Bleed (GI Bleed)

Answer 35

**Etiology:** Hemorrhage in the upper or lower gastrointestinal tract can lead to anemia. 1. **CC:** Hematemesis (bright) (upper), Coffee-ground emesis (dark) (lower), Hematochezia (bright) (lower), Melena (dark) (upper). 2. **Assoc Sx:** Generalized weakness, lightheadedness, SOB, Abd pain, Rectal pain. 3. **PE:** Pale conjunctiva, Pallor, Tachycardia * **Rectal Exam:** Melena, Grossly (obvious) bloody stool. 4. **Dx by:** Heme positive stool (Guaiac positive) during a rectal exam. * **Hematemesis** –– The vomiting of blood. * **Coffee-ground emesis** –– The presence of coagulated blood in the vomit (looks like coffee-ground). * **Hematochezia** –– the passage of fresh blood per anus, usually in or with stools. * **Melena** –– dark sticky feces containing partly digested blood. * **NOTES:** * ED concern is the need for a possible blood transfusion due to significant blood loss.

Question 36

Diverticulitis

Answer 36

**Etiology:** Acute inflammation and infection of abnormal pockets of the large intestine known as diverticula. 1. **Risk Factors:** diverticulosis, Advanced age 2. **CC:** LLQ pain 3. **Assoc. Sx:** Nausea, Fever, Diarrhea 4. **Dx by:** CT A/P w/ PO Contrast **Diverticulosis** –– small pouches or pockets in the wall or lining of any portion of the digestive tract.

Question 37

Pancreatitis

Answer 37

**Etiology:** Inflammation of the pancreas. 1. **Risk Factors:** EtOH abuse, Cholecystitis, Specific medications 2. **CC:** LUQ, epigastric pain 3. **Assoc Sx:** N/V 4. **PE:** LUQ tenderness, Epigastric tenderness 5. **Dx by:** Elevated Lipase lab test (sometimes elevated Amylase) **Elevated lipase** usually indicates a problem in the pancreas, same for an elevated amylase.

Question 38

Gastroesophageal Reflux Disease (GERD)

Answer 38

**Etiology:** Stomach acid regurgitating into the esophagus. 1. **CC:** Epigastric pain – Burning, Improved w/ Antacids 2. **PE:** Epigastric tenderness 3. **Assoc Med:** GI cocktail (numbs and soothes the esophagus and stomach). **NOTES:** * Due to the proximity of the stomach to the heart, pts w/ cardiac risk factors and epigastric pain will always get a cardiac workup

Question 39

Other causes of Abd pain

Answer 39

* *Gastroenteritis** –– Vomiting and diarrhea, GI bug, often viral or bacterial. * *Crohn's Disease:** –– Immune disorder causing diarrhea/Abd pain. * *IBS:** –– Chronically sensitive bowels prone to diarrhea * *Gastritis:** –– Irritated stomach w/ vomiting "stomach ache."

Question 40

Gastrointestinal Summary

Answer 40

**_Diagnosis**_ ––––– _**Abdominal Region**_ ––––– _**Diagnosed by:_** * *Appendicitis** –– RLQ –– CT A/P with PO * *SBO** –– Periumbilical –– CT A/P with PO, AAS * *Cholecystitis** –– RUQ –– US RUQ * *GI Bleed** –– Any –– Guaiac (Heme) Positive * *Diverticulitis** –– LLQ –– CT A/P with PO * *Pancreatitis** –– Epigastric, LUQ –– Elevated Lipase * *GERD** –– Epigastric –– Endoscopy (not in ED)

Question 41

Urinary Tract Infection (UTI)

Answer 41

**Etiology:** Infection in the urinary tract. 1. **Risk Factors:** Female 2. **CC:** Dysuria 3. **Assoc Sx:** Frequency, Urgency, Malodorous urine, AMS (Elderly) 4. **PE:** Suprapubic tenderness 5. **Dx by:** Urine dip or UA (Urinalysis) Nitrite, WBC, and Bacteria in urine. **Dysuria** –– painful urination. **Urinalysis** –– can detect the presence of nitrites in the urine. Normal urine contains chemicals called nitrates. If bacteria enter the urinary tract, nitrates can turn into different, similarly named chemicals called "nitrites." Nitrites in urine may be a sign of a urinary tract infection (UTI).

Question 42

Pyelonephritis (Pyelo)

Answer 42

**Etiology:** Infection of the tissue in the kidneys, usually spread from a UTI. 1. **Risk Factors:** Female, Frequent UTIs. 2. **CC:** Flank pain w/ dysuria 3. **Assoc Sx:** Fever, N/V 4. **PE:** CVA tenderness (costovertebral angle) 5. **Dx by:** CT Abd/Pel w/o Contrast or confirmed UTI w/ CVA tenderness on exam. **Flank pain** –– Flank pain affects the area on either side of the lower back, between the pelvis and the ribs.

Question 43

Kidney Stone (Urolithiasis, Nephrolithiasis, Renal Calculi, Renal Colic)

Answer 43

**Etiology:** Stone dislodges from kidney, travels down the ureter. stone scrapes and irritates the ureter, causing severe flank pain and bloody urine. 1. **CC:** Flank pain, sudden onset, radiating to the groin. 2. **Assoc Sx:** Hematuria, N/V, Unable to void (Urinary retention is the inability to voluntarily urinate.) 3. **PE:** CVA (Costovertebral angle) tenderness 4. **Dx:** CT Abd/Pelvis, RBC in UA may be a clue.

Question 44

Ectopic Pregnancy

Answer 44

**Etiology:** Tubal pregnancy, when a fertilized egg develops outside the uterus (usually in the fallopian tube). High risk for rupture and death. 1. **Risk Factors:** Pregnant female, (HCG +) STD, PID. 2. **CC:** lower Abd pain or vaginal bleeding while pregnant. 3. **Dx by:** US pelvis –– to determine the location of the fetus. **HCG +** –– A pregnancy test measures a hormone in the body called human chorionic gonadotropin. **PID** –– Pelvic inflammatory disease, an infection of one or more of the upper reproductive organs, including the uterus, fallopian tubes, and ovaries. **NOTES:** * Any female w/ Abd pain and pregnant will get US pelvis to rule out ectopic pregnancy.

Question 45

Ovarian Torsion

Answer 45

**Etiology:** Twisting of an ovarian artery reducing blood flow to an ovary, possibly resulting in an infarct of the ovary. 2. **CC:** Lower Abd pain (RLQ or LLQ) 3. **PE:** Adnexal tenderness (R or L), Tenderness in the RLQ or LLQ 4. **Dx by** US pelvis –– assesses blood flow to ovaries. **Adnexal tenderness** –– A technical term for pain in the area of a woman's uterus. **NOTES:** * Time-sensitive, document all times.

Question 46

Testicular torsion

Answer 46

**Etiology:** Twisting of the spermatic cord resulting in loss of blood flow and nerve function to the testicle. 2. **CC:** Testicular pain. 3. **PE:** Testicular tenderness and swelling R or L. 4. **Dx by** US scrotum.

Question 47

Upper Respiratory Infection (URI)

Answer 47

**Etiology:** Most often viral infection causes congestion, cough, and inflammation of the upper airway. 1. **CC:** Cough/congestion 2. **Assoc Sx:** Fever, Sore throat, HA, Myalgias 3. **PE:** Rhinorrhea, Boggy turbinates, Pharyngeal erythema 4. **Dx:** Clinically **Rhinorrhea** –– a thin, mostly clear nasal discharge. **Myalgias** –– describe muscle aches and pain, which can involve ligaments, tendons, and fascia, the soft tissues that connect muscles, bones, and organs. **NOTES:** * Pay special attn to c/o CP or SOB for URI pts; always be careful to describe the CP or SOB accurately so as to not accidentally create the impression of symptoms consistent w/ MI or PE.

Question 48

Otitis Media (middle ear infection)

Answer 48

**Etiology:** Viral or bacterial infection of the TM causing ear pain and pressure. 1. **CC:** Ear pain, ear pulling. 2. **Assoc Sx:** Fever, sore throat, dry cough, congestion. 3. **PE:** Erythema, effusion, dullness, or bulging of the TM (Tympanic Membrane). 4. **Dx:** Clinically.

Question 49

Streptococcal Pharyngitis

Answer 49

**Etiology:** Bacterial infection of the tonsils and pharynx causing a sore throat and frequently swollen lymph nodes. 1. **CC:** Sore throat 2. **PE:** Pharyngeal erythema, Tonsillar hypertrophy, Tonsillar exudates (pus) 3. **Dx by** Rapid strep – a quick throat swab, **NOTES:** * Most sore throats are viral, however, strep is bacterial so Abx will help; concern of Peri-Tonsillar Abscess (PTA). Signs include uvular shift or tonsillar asymmetry.

Question 50

Conjunctivitis (Pink Eye)

Answer 50

**Etiology:** Infection of the outer lining of the eye. 1. **CC:** Eye redness, irritation, or pain 2. **Assoc Sx:** Eyelid matting 3. **PE:** conjunctival injection, edema, and exudates 4. **Dx:** Clinically

Question 51

Epistaxis (nose bleed)

Answer 51

**Etiology:** Rupture of a blood vessel inside the nose causes blood to flow out of the nose and into the throat. 1. **CC: N**ose bleed 2. **Risk Factors:** blood thinners (coumadin/warfarin, ASA, Plavix) or HTN 3. **PE:** Anterior, posterior, or septal source of the bleeding 4. **Dx:** Clinically **NOTES:** * Nose bleeds can be cauterized or stopped w/ pressure from a nasal tamponade called a "rhino-rocket"

Question 52

Musculoskeletal Back Pain

Answer 52

**Etiology:** Deterioration or strain of the back creates pain that is worse with movement. 1. **CC:** Back pain, lower usually 2. **Assoc Sx:** Shooting posterior lower extremity pain 3. **Pert. Neg:** No LE weakness, no incontinence 4. **PE:** Paraspinal tenderness, positive straight leg raise (+ SLR diagnoses Sciatica, back pain that radiates down the legs). **NOTES:** * Document any recent trauma-related to back pain as it increases concerns of spinal injury

Question 53

Extremity Injury

Answer 53

Etiology: Trauma creates pain/swelling in an extremity 1. **CC:** Extremity pain 2. **Assoc Sx:** Swelling, Bruising, Deformity, Use limitation. 3. **Pert. Neg:** No motor weakness, No numbness tingling. 4. **PE:** Distal CSMT intact (circulation, sensory, motor, tendon), no tendon or ligament laxity, ROM (range of motion) limited secondary to pain. **NOTES:** * Document any splint with Splint Application Procedure Note

Question 54

Abdominal Aortic Aneurysm (AAA)

Answer 54

**Etiology:** Widened and weakened arterial wall at risk of rupture. 1. **CC:** Midline Abd pain. 2. **PE:** Midline pulsatile abdominal mass, abdominal bruit, unequal femoral pulses, hypotension. 3. **Dx by** CT A/P w/ IV contrast.

Question 55

Aortic Dissection

Answer 55

**Etiology:** Separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death. 1. **CC:** CP radiating to back (ripping/tearing). 2. **PE:** Unequal brachial or radial pulses, hypotension. 3. **Dx by** CT Chest w/ IV Contrast.

Question 56

Deep Vein Thrombosis (DVT)

Answer 56

**Etiology:** Blood slows down while flowing through long straight veins in extremities, slow-flowing blood is more likely to clot. Once formed, the clot can continue to grow and eventually occlude/block the vein. 1. **Risk Factors:** PMHx of DVT or PE, FHx, Recent surgery, Cancer, Immobility, Pregnancy, BCP (Birth Control Pill), smoking LE trauma, LE casts. 2. **CC:** Extremity pain and swelling (atraumatic), usually a LE. 3. **PE:** Calf tenderness, cords, Homan's sign 4. **Dx by** US/Doppler of the extremity

Question 57

Cellulitis

Answer 57

**Etiology:** Infection of the skin cells. 1. **CC:** Red swollen painful and sometimes warm area of the skin 2. **PE:** Erythema, edema, Increased warmth (calor – heat), Induration 3. **Assoc Meds:** Abx 4. **Dx:** Clinically **Erythema** –– superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilation of the blood capillaries. **Edema** –– swelling caused by excess fluid trapped in your body's tissues. **Induration** –– An area of hardness in the skin.

Question 58

Abscess

Answer 58

**Etiology:** Skin infection w/ an underlying collection of pus. 1. **CC:** Red swollen, and painful lump 2. **PE:** Fluctuance (pus pocket) induration, purulent discharge 3. **Dx:** Clinically **NOTES:** * Must drain, document I&D (Incision and drainage) procedure notes for abscesses

Question 59

Rash

Answer 59

**Etiology:** Changes in the skin's appearance due to systemic or localized reactions. May be caused by medication, virus, bacteria, fungus, insect, etc... 1. **CC:** Rash, red, pruritic (the medical term for itchy skin), painful. 2. **PE:** Urticaria (hives or wheals –), Macules (flat) Papules (raised bumps) Vesicles (small blisters), Blanching (not dangerous) Petechiae (dangerous rash) Purpura (dangerous rash) 3. **Dx:** Clinically **Hives** –– a rash of round/irregular shape. **Wheals** –– an area of the skin that is temporarily raised, typically reddened and usually accompanied by itching.

Question 60

Allergic reaction

Answer 60

**Etiology:** Immune response causing an inflammatory reaction consisting of swelling, itching, and rash. 1. **Risk factors:** Known drug or food allergy 2. **CC:** Rash, swelling, itchy, or SOB 3. **PE:** Edema, facial angioedema, Urticaria (hives, wheals) 4. **Dx:** Clinically NOTES: * ED's concern is Anaphylaxis (a severe, potentially life-threatening allergic reaction) or Respiratory failure.

Question 61

Allergic vs. Adverse Reactions

Answer 61

**Allergic** –– Rash, Itching, Swelling, SOB due to airway swelling. **Adverse Reaction** –– N/V, Abd Pain, Diarrhea, Dizziness.

Question 62

Diabetic Ketoacidosis (DKA)

Answer 62

**Etiology:** A shortage of insulin resulting in hyperglycemia and production of ketones. 1. **Risk Factors:** Diabetes Mellitus (DM) type I and II (rare in type II). 2. **CC:** Persistent vomiting with a Hx of DM. 3. **Assoc Sx:** SOB, polydipsia (increased thirst), polyuria (increased urination). 4. **PE:** Ketotic odor "fruity", Dry Mucous Membranes, Dehydration, Tachypnea. 5. **Dx by:** Arterial Blood Gas (ABG or VBG) showing low pH (acidosis) or Positive Serum ketones. **ABG** –– measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery.

Question 63

Psychological Disorder

Answer 63

**Etiology:** Various types of psych diseases produce abnormal thoughts, behaviors, or actions. 1. **PMHx:** Bipolar Disorder, Schizophrenia, PTSD, Depression, Anxiety, Alcoholism, Drug Abuse, Suicide Attempt 2. **Possible CC:** Suicidal Ideation(SI), Homicidal Ideation (HI), Hallucinations, (Auditory or Visual), Substance Abuse, Self-injury, Overdose 3. **PE:** Flat affect, SI, HI, Tangential, or pressured speech. **Flat affect** –– A flat affect can be a negative symptom of schizophrenia, meaning that your emotional expressions don't show. **Tangential** –– A disturbance in the associative thought process in which one tends to digress readily from one topic under discussion to other topics that arise in the course of associations; observed in bipolar disorder, schizophrenia, and certain types of organic brain disorders. **NOTES:** * Be careful to document MEDICAL (PHYSICAL) COMPLAINTS.

Question 64

Trauma

Answer 64

**Etiology:** Depending on the mechanism of injury (MOI) physical trauma may break bones, sever nerves, rupture blood vessels or damage internal organs. 1. **CC:** MVA (motor vehicle accident), Fall, GSW (gunshot wound). 2. **PE:** Glasgow Coma Scale (GCS) 3-15 –– Assesses LOC following a trauma. 3. **Assoc Med:** Blood thinners? 4. **Dx by:** Trauma protocol depending on MOI, CT, or XR **NOTES:** Trauma DDx: * Neurological Injuries (Hemorrhagic stroke, spinal cord injury). * **Keywords:** LOC, Confusion, Numbness, Weakness HA, Neck/Back Pain. * Internal Organ Injury (Pneumothorax, Hemothorax, Abdominal Organ injury. * **Keywords:** SOB, Chest Pain, Abd Pain.