Scribe America Final Exam Study Guide: Medical Terminology and Documentation, Exams of Advanced Education

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Scribe America Final Exam Study Guide

What does ROS stand for? - Review of symptoms, head to toe checklist of symptoms The HPI and ROS are considered what type of information? - Subjective The physical exam is what type of information? - Objective If a physician told you a patients abdomen was nontender or the patients skin was plale, where would you document this information - Physical Exam (PE) What section focuses directly on the chief complaint? - HPI (History of present illness) What are the 5 vital signs? - 1. Heart rate (HR)

2. Respiratory rate (RR)
3. Blood pressure (BP)
4. Temperature (T)
5. Oxygen Saturation (SpO2) Surgical Hx example - CABG (Coronary artery bypass graft) Social Hx example - Smoker 1 ppd Family Hx example - Brother diagnosed with CAD < 55 y/o Removal of appendix - Appendectomy Removal of gallbladder - Cholecystectomy Removal of uterus - Hysterectomy Removal of tonsils - Tonsillectomy What are the 2 types of heart attacks and how are they diagnosed? - STEMI - EKG Non-STEMI - Troponin What are 3 cardiac risk factors? - HTN, HLD, Smoking, CAD, DM, FHx CAD < 55 y/o Chest pain, dyspnea, cough and fever correlated to which DDx? What study would be ordered? - PNA (Pneumonia) CXR

What are 3 symptoms a patient with an Ischemic CVA would present with? - Unilateral weakness/numbness, slurred speech, vision changes What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is the disease diagnosed? - Irregularly irregular rhythm (A-Fib) EKG Name 2 risk factors to hemorrhagic CVA - Head Trauma, anticoagulants (blood thinner medication), uncontrolled HTN How is AMS different from a focal neurological deficit? What is the major cause of AMS in the elderly? - AMS (confusion, lethargy, unresponsiveness) affects the whole brain (drugs, EtOH) and FND (one sided weakness/numbness, speech changes, vision changes) affects a small portion/localized of the brain AMS in elderly - UTI Layman's term for GERD - Heartburn, Indigestion, Acid Reflux Most common cause for seizures in children? - Fever Which drug causes smooth muscle relaxation, causing vasodilation and increase blood supply to heart muscle? - NTG (Nitroglycerin) Describe the significance of an HPI - Explains patients CC and answers "Why did the patient seek treatment?" CC of a headache, name 5 elements of the HPI and provide an applicable example of each element - Onset - 3 weeks ago Timing - intermittent Quality - pressure Severity - 9/ location - frontal/forehead Modifying factors - worse with light, better after Excedrin Context - does not take a blood thinner, no recent head injuries, Hx of similar HA

True or False: Patients entire ED visit is based on their answers to the questions asked during the interview? - True True or False: Accurate chronology is not important in an HPI - False What is the main different between HPI and ROS? - HPI - story of the CC ROS - head-to-toe checklist of subjective Sx True or False: Symptoms listed in ROS can contradict the Sx discussed in the HPI - False How would you document GPA for a patient who is currently pregnant, has been pregnant 4 time in the past, and has one child at home? - G - 5 P - 1 A - 3 List 5 body systems found in the ROS and provide 2 symptoms for each system. - Skin - Rashes, itching, redness General - fever, chills, weight loss Cardio - Chest pain,Palpitations Pulmonary - shortness of breath, dyspnea, cough, wheezing GI - abdominal pain, acid reflux Neuro - headache, seizures, unilateral weakness/numbness Psych - anxiety hallucinations, depression Read the paragraph below and determine the following for the detailed HPI: A 36 y/o female with a Hx of asthma presents to the ED with worsening wheezing that started 4 days. The patient says feels like she cannot take a full breath similar to her previous asthma exacerbations, but the albuterol inhalers prescribed by her pulmonologist (Dr. Aranibar) have not provided relief. She reports dyspnea and a mild dry cough since last night, but no fever, chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her bathroom this afternoon secondary to her dyspnea, prompting the 9 11 call. When paramedics arrived to the patient's home 30 minutes ago, tight expiratory

wheezes in all fields were appreciated and the patient's SpO2 was 90% on RA. The patient received a DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild symptom relief. - CC: wheezing Onset: 4 days ago Timing: worsening Location: Quality: "cannot take a full breath" Severity: not stated, but the spO2 reported by paramedics allows us to understand the objective severity Modifying factors: albuterol inhalers presrcibed by Dr. Aranibar has not provided relief. EMS provided DuoNeb breathing treatment and solumedrol 125 mg en route to ED with mild symptom relief Associated sx: dyspnea, mild dry cough Pertinent negatives: fever, chest pain, leg pain, leg swelling, recent travel Context: Hx of asthma, similar to asthma, EMS report (VS en route) What do you write on the chart if the doctor states, "The pulses are weak" after checking the patients pulse near the left groin - +1 left femoral pulse What organs are in the following quadrants: Epigastrium LUQ LLQ - Epigastrium - Stomach LUQ - Pancreas LLQ - Large intestine, Ovary What does EOMI stand for? What organ systems can this be found in? - Extra-ocular movements intact Eyes Where would you document stridor? - Stridor - high pitched sound heard on inspiration that is indicative of airway obstruction ENT (throat) or respiratory

Is it normal for toes to fan up or curl down when the adult Babinski reflex is assessed? - Curl down Can the scribe document "Regular heart rate", "Tachypnea", and "Lungs CTAB" in the same patients exam simultaneously? - Yes, nothing contradicts here the opposite of nuchal rigidity? - Supple Cyanotic skin correlates to? - Hypoxia - low oxygen in the bloodstream The patient reports dyspnea on exertion, leg swelling, and inability to lay flat at night due to increased SOB. The MD will likely examine for ____,______ and _____. - - Pedal edema

• Rales
• JVD Multi-part application question! Directions: Answer the following questions by

1. describing the PE finding in layman's terms.
2. list the DDx considered when the abnormality is present.
3. providing the appropriate body system you would chart the PE finding AND
4. studies you predict the MD to order Rovsing sign CVA tenderness Rhonchi Uvular shift (Google to find the test ordered, not technically in the workbook!). - Rosvings sign is characterized as RLQ pain with LLQ palpation, DDx is appendicitis, charted in abdomen/GI, and orders for CT A/P (abd/pelvis) CVA tenderness is characterized as tenderness in the flank (angle between the ribs/spine), DDx is pyelonephritis or pyelolithiasis (kidney stones), charted in the back region, orders for CT A/P and UA Rhonchi is characterized as rattling sounds in the lungs, DDx is PNA, charted in respiratory, orders for CXR Uvular shift is characterized as the uvula moved to one side, DDx is a peritonsillar abscess, charted in ENT section and orders for CT of the neck What organ do LFT's investigate? - Liver A high potassium is called ____ and this is commonly due to _____. - Hyperkalemia, renal failure

What does a chest tube treat? - PTX (pneumothorax) Name the procedure used to treat an abscess? - I&D (Incision and drainage) Name 2 procedures that follow sterile technique? - LP, Central line, chest tube What are the 3 reasons to consult another physician? - - admit patient

• contact specialist for advice
• contact PCP for more information What are 4 of the 12 EKG leads - I, II, III, V1, V2, V3, V4, V5, V6, aVL, aVR, AVF Hyponaturemia is _____ and indicates. - low sodium levels, dehydration The ____ shows the pH only, while the _______ shows the pH plus HCO3, CO2, and PaO2 - VBG ABG Can you share the patients chart with all nurses working in the hospital - No, but you may discuss the patient's case with the hospital staff (Tech, RN, MD, consulting team, case manager, etc.) directly treating the patient. Is it acceptable to use the physicians charting account to enter the EKG interpretation once the physician provided approval? - No, all chart done by a scribe must be completed in the scribe's charting account. Does the following past Hx meet level 5 billing requirements: HTN, Previous CVA in 2008 with residual LLE weakness, DM diagnosed at age 47, CABG x in 2011, and tonsillectomy. - No, this is only medical and surgical history which are considered 1 element Need 1 from FHx and SHx Give 5 examples of PHI - Name, Address, DOB, SSN, phone number, email, insurance information How many elements are required for a level 5 ROS with and without the "all systems negative" phrase - 10 systems 2 systems with "all system negative" phrase True or False: The "All systems negative" phrase is used for all chart - False, including the phrase is the physicians preference AND also never used on patients unable to complete the interview (advanced dementia, AMS, unresponsive)

Name 4 common events that are time stamped in the chart - - The moment the provider walks into the patients room for the intial evaluations

• medication orders
• consults
• procedure start/end times
• disposition times Describe a scenario where the R/B/A (risk benefit assessment) discussion would very commonly occur. - Before a high risk procedure such as the lumbar puncture, conscious sedation, cardioversion, receiving tPA, starting/stopping blood thinners, CTs for children List 2 examples of a "unique exam identifier" - Tattoos, scars, piercings amputations, G- tubes, trach scars, "zipper" sternotomy scar, birthmarks How many elements are included in this HPI: Ariana Venti is a 24 y/o female presenting to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over the central chest and worse when leaning forward. - 4 (level 5 billing) Quality - sharp Location - Central chest Onset - 4 hours ago Mod factor - worse when leaning forward Distress - Doctors judgment of discomfort secondary to pain Expand the following abbreviation into full medical term. NIDDM - Non-Insulin Dependent Diabetes Mellitus What is the following past surgical history term? Removal of the breast - Mastectomy What is the medical terms for the following past surgical history term? Removal of the uterus - Hysterectomy What is the medical term for the following past surgical history term? Stomach stapled - Bariatric surgery Which of the following are considered PHI? - Age, Name, floor admitted on, PHX, objective and subjective information provided

HITECH restricts you from - Texting you CS information about the patients that you saw during your shift Taking notes about a patient on a cloud-based systems like Good Docs or Evernote Arrange the following steps in order from first to last for a typical patients flow through the ED (Top to Bottom) - Triage Bed Placement History and Physical (H&P) Labs/Radiology/Medications Medical Decision Making (MDM) Disposition What FHx/SHx information is commonly asked for most pediatric patients? - Second hand smoke exposure, immunization status What is the medical term for the following past surgical history? Kidney removal - Nephrectomy According to your job description, if your doctor asks you to hold the patients neck while they are cleared from the blackboard you should: - Politely remind the doctor that is outside your job description, but offer to get a nurse or tech to help Auscultation - Listening with a stethoscope Scribes CANNOT - - Touch patients

• Write orders or prescriptions
• Give verbal orders
• Partake in any activity that may affect patient health or outcome
• Sign or authenticate any chart or record
• Handle bodily fluids or specimens Mid-Level Provider - NP, PA (works under supervision of physician to Dx and treat patients Charge Nurse - Manages ED pt flow Respiratory therapists (RT) - administers breathing treatments and assists with managing a pt's airway Level of Acuity - 5 (low) to 1 (high) High blood pressure - hypertension (HTN) high cholesterol - hyperlidemia (HLD)

Thyroid problem - Hyperthyroidism Hypothyroidism Diabetes - Diabetes Mellitus (DM) "I only take pills for my diabetes" - Non-Insulin Dependent Diabetes Mellitus (NIDDM) "I take shots (insulin) for my diabetes" - Insulin Dependent Diabetes Mellitus (IDDM) Heat Disease - Coronary Artery Disease (CAD) Heart attack - Myocardial Infarction (MI) Heart failure - Congestive Heart Failure (CHF) Irregular heartbeat - Arrhythmia, Atrial fibrillation (A-Fib) Murmur - Heart murmur Episodes of abnormally fast/racing heartbeat - Arrhythmia, Supraventricular Tachycardia (SVT) Emphysema/Chronic Bronchitis - Chronic Obstructive Pulmonary Disease (COPD) Blood clot in lung - Pulmonary Embolism (PE) Pneumonia - Pneumonia (PNA) Reflux - Gastroesophageal Reflux Disease (GERD) Ulcer - Gastric Ulcer or Peptic Ulcer Disease Crohn's/UC - Crohn's Disease or Ulcerative Colitis Irritable bowel - Irritable Bowel Syndrome (IBS) Bladder infection - Urinary Tract Infection (UTI) Kidney infection - Pyelonephritis (Pyelo) Kidney Stones - Renal Calculi "I'm on dialysis" - Chronic Renal Failure (CRF) End stage Renal Disease (ESRD) on dialysis

Enlarged Prostrate - Benign Prostatic Hypertrophy (BPH) Brain bleed - Hemorrhagic Cerebrovascular Accident (CVA) Stroke - Ischemic Cerebrovascular Accident (CVA) Mini-stroke - Transient Ischemic Attack (TIA) Bipolar - Bipolar Disorder "I drink a lot" - ETOH abuse or alcoholism "I do drugs" - Substance Abuse Blood clot in my leg - Lower extremity Deep Vein Thrombosis (DVT) Bulge in my aorta - Aortic Aneurysm Bad blood flow to my legs - Peripheral Vascular Disease (PVD) Numbness in my legs - Peripheral Neuropathy Low back pain - Chronic Low Back Pain Bulging/Herniated disc - Degenerative Disc Disease (DDD) Arthritis - Osteoarthritis (OA) Rheumatoid Arthritis (RA) Weak/Fragile bones - Osteroporosis Cancer - Cancer (CA) or Carcinoma Spread to my... - With metastases to the... They cut it out - Status-post (s/p) surgical resection It's gone - In remission Adenoids removed - Adenoidectomy Ear tubes - Myringotomy Pressure Equalizing Tubes (P.E.) Heart Cath - Cardiac Catheterization

Balloon - Angioplasty --> PMHx CAD Stents - Coronary Stents --> PMHx CAD Heart bypass - Coronary Artery Bypass Graft (CABG) --> PMHx CAD Valve surgery - Valve repair or replacement (Bovine vs. Mechanical) Pacer - Pacemaker Defibrillator - Automatic Implanted Cardiac Defibrillator (AICD) Surgery for AFib - Afib s/p cardiac ablation Hole in my neck - Tracheostomy (trach) Part of my lung removed - Partial Lobectomy Hernia repair - Herniorrhaphy Part of my colon removed - Partial colectomy Stomach stapled - Bariatric Surgery (gastric sleeve, gastric band/lap band, gastric bypass) Exploratory - Exploratory Laparoscopy (ExLap) Ovary removed - Oophorectomy Ovary and fallopian tubes removed - Salpingo-Oophorectomy Tubes tied - Tubal Ligation (female) Vasectomy (male) C-Section - Cesarean Section Prostate removed - Prostatectomy Prostate resection Transurethral Resection of the Prostate (TURP) Uterine product removed - Dilation and Curettage (D&C) Neck artery cleaned - Carotid Endarterectomy

Shunt - Cerebral Shunt Brain Surgery - Craniotomy (Brain bleed vs. Brain CVA) Dialysis fistula - AV Fistula (arteriovenous) Dialysis graft - AV graft (arteriovenous) PICC Line - Peripherally Inserted Central Catheter (PICC) Used for long term medication, antibiotics, nutrition Port - Port-a-cath Medi-Port Clot filter (lower abdomen) - IVC filter (Inferior vena cava) small device used to prevent clots from traveling in your blood to your lungs Leg amputated - AKA BKA Joint repair - Arthoplasty Metal plates/pins - Hardware Neck/back fused - Cervical/lumbar spinal fusion New hip - Total hip replacement Open reduction with internal fixation (ORIF) True allergy - Swelling Itching Rash Swelling of airways (SIRS) Coronary Artery Disease (CAD)

1. Catch Phrase
2. CC
3. Assoc. Meds
4. Dx tests

5. Scribe Alert - CAD is the narrowing of coronary arteries causing angina due to lack of blood flow to the heart muscle
6. CP with physical exertion
7. CP or chest pressure, worse with exertion, improved by rest or NTG

ASA (aspirin 324 mg PO) Acetylsalicylic acid NTG (Nitroglycerin 0.4 mg SL)

4. Cardiac Catheterization (not Dx in ED)
5. Single greatest risk for MI, stress tests/cardiac catheterization asses severity of CAD, Pt has CAD if they have a PMHx of Angina, MI, CABG, Cardiac stents, Angioplasty, every patient c/o CP receives ASA 324 mg PO, unless given PTA Myocardial Infarction (MI)
6. Catch phrase
7. Risk Factors
8. CC
9. Dx tests
10. Assoc. Meds
11. Scribe Alert - Acute blockage of coronary arteries resulting in ischemia and infarct of heart muscle
12. Chest pressure, diaphoresis, N/V, SOB
13. HTN, HLD, DM, Smoker, CAD + FHx of CAD < 55 y/o
14. CP or chest pressure
15. EKG - STEMI, Troponin - Non-STEMI
16. ASA, NTG, Thrombolytic (activase), Anti-coagulants (heparin)
17. Acute MI pts must receive 324 mg ASA PO ASAP, STEMI pts must get to cath-lab within 90 min. of arrival, Document arrival/depart times Congestive Heart Failure (CHF)
18. Catch phrase
19. CC
20. PE
21. Assoc. Med

5. Dx tests
6. Scribe alert - Heart becomes enlarged, inefficient, and congested with excess fluid
7. SOB with pedal edema and orthopnea
8. SOB, Orthopnea (worse with laying flat), Paroxysmal Nocturnal Dyspnea (PND), Dyspnea on Exertion (DOE)
9. Rales (crackles) in lungs, JVD in neck (jugular vein distention), pitting pedal edema
10. Diuretics (Lasix, Furosemide) - urinate extra fluid
11. CXR, BNP elevation
12. You can 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) Atrial Fibrillation (AFIB)
13. CC
14. Risk factors
15. PE
16. Dx
17. Assoc. Med
18. Scribe Alert - Electrical abnormalities in the "wiring" of the heart causes the top of the heart (atria) to quiver abnormally
19. Palpitations (fast, pounding, irregular)
20. Paroxysmal AFIB, Chronic AFIB
21. Irregularly irregular rhythm, Tachycardia
22. EKG
23. Coumadin (warfarin) - blood thinner, prevents blood clots in atria Digoxin - slows down heart rate
24. ED concern is RVR (rapid ventricular response), these pt's will often be cardioverted (put back into NSR) Non-Cardiac Chest Pain
25. Pericarditis
26. Pleurisy
27. Costochondritis

4. Chest Wall Pain
5. Pleural effusion - 1. Inflammation of the sac surrounding the heart causing CP
6. Inflammation of sac surrounding lungs causing Pleuritic CP
7. Irritation of the ribs causing CP worsened by pressing on the sternum
8. Irritation of the chest wall causing pain with palpation of the chest
9. Fluid collecting around lungs causing SOB or CP Pleuritic CP - CP with deep breaths Cardiovascular Summary Answer what it is (Laymen's terms) and how it is Dx
10. MI
11. AFIB
12. CHF
13. CAD
14. Angina - 1. Heart attack, EKG (STEMI) or Troponin (Non-STEMI)
15. Electrical problems, EKG
16. Fluid traffic jam, CXR or elevated BNP
17. major risk factor for MI, Cardiac catheterization
18. symptom of CAD, CP with exertion & Hx of CAD Pulmonary Embolism (PE)
19. Catch phrase
20. Risk factors
21. CC
22. Dx tests - Blood clot in the pulmonary artery which blocks blood flow to lungs
23. Pleuritic CP with tachycardia and hypoxia
24. Known DVT, PMHx of DVT, FHx of DVT, Recent surgeries, Cancer, AFIB, Pregnancy, BCP's, immobility, smoking
25. SOB or pleuritic CP
26. CTA Chest (IV contrast) or VQ Scan, D-Dimer test (detects blood clots - cannot Dx PE)

Pneumonia (PNA)

1. Catch Phrase
2. Risk Factors
3. CC
4. Assoc. Sx
5. Assoc. Meds
6. PE
7. Dx tests
8. Scribe Alert - Infiltrate (bacterial infection) and inflammation inside the lung
9. Productive cough with fever
10. Elderly, Bedridden, Recent chest injury, Recent surgery
11. SOB or Productive cough
12. Cough with sputum, Fever, Chest pain
13. Antibiotics (Rocephin and Zithromax)
14. Rhonchi
15. CXR
16. Community Acquired Pneumonia (CAP protocol applies to pt's with PNA. CAP protocol requires documenting Abx, vital signs, SaO2, Mental status and blood cultures Pneumothorax (PTX)
17. CC
18. PE
19. Dx tests
20. Scribe alert - Collapsed lung due to trauma or spontaneous small rupture of the lung
21. one sided chest pain, SOB, sudden onset, often trauma pt's
22. Absent breath sounds unilaterally
23. CXR
24. Document the percentage of lung collapsed (ex. 20% PTX). These patients will have a chest-tube placed to re-inflate the lung Chronic Obstructive Pulmonary Disease (COPD)

1. Risk factors
2. CC
3. PE
4. Assoc. meds
5. Dx tests - Long term damage to the lungs alveoli (emphysema) along with inflammation and mucous production (chronic bronchitis)
6. smoking
7. SOB
8. Decreased breath sounds, wheezes, rales
9. Home O2 (Document how much O2 they use at baseline)
10. CXR and Hx of smoking Asthma (reactive airway disease)
11. CC
12. PE
13. Assoc. meds
14. Dx tests
15. Scribe alert - constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a "bronchospasm"
16. SOB/Wheezing (improved by nebulizer "breathing treatments" bronchodilators)
17. Wheezes (inspiratory or expiratory)
18. Inhalers, nebulizers, corticosteroids
19. Clinically
20. The physician will as the asthma pt...

• do they have a home nebulizer machine?
• have they been on steroid recently?
• Hx of hospitalization for asthma?
• Hx of Intubation (breathing tube)?
• Asthma triggers? PE catch phrase - Pleuritic CP, tachycardia, hypoxia PTX catch phrase - Unilateral CP, SOB

PNA catch phrase - SOB and productive cough COPD catch phrase - SOB with Hx of smoking Asthma catch phrase - Wheezing with Hx of asthma Ischemic cerebrovascular accident (CVA)

1. CC
2. Risk factors
3. PE
4. Dx tests
5. Scribe alert - blockage of arteries supplying blood to the brain resulting in permanent brain damage
6. Unilateral focal neurological deficits, unilateral weakness/numbness, changes in speech/vision
7. HTN, HLD, DM, Hx TIA/CVA, smoking, FHx CVA, AFIB
8. Neurological deficits, hemiparesis, unilateral paresthesias (bowel/bladder incontinence), aphasia, visual field deficits
9. Clinically, potentially normal CT head
10. For any stroke pt, 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 thrombolytic that can reverse a CVA Document tPA considered and not indicated due to

• onset greater than 3 hours or unknown/unreliable time of onset
• symptoms are rapidly improving Transient Ischemic Attack (TIA) aka mini-stroke

1. CC
2. Dx tests
3. Scribe alerts - Vascular changes temporarily deprive a part of the brain of oxygen (symptoms usually last less than 1 hour)
4. Transient focal neurological deficits (SVSS = speech, vision, strength, sensation)
5. Clinically
6. TIA are also known as mini-strokes because Sx usually last < 1 hour and there is no permanent brain damage.

Document tPA considered and not indicated due to the fact that Sx are resolved. Hemorrhagic Cerebrovascular Accident (CVA), brain bleed

1. CC
2. Assoc. Sx
3. PE
4. Dx tests
5. Scribe alert - Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain
6. Headache (sudden onset, thunderclap, worst of life)
7. Changes in SVSS, AMS, Seizure, HA
8. Unilateral neurological deficits
9. CT head or LP (lumbar puncture)

• an LP would be used to attempt to identify a subdural hematoma that was clinically suspected but not visualized on the CT

5. Document tPA not indicated due to hemorrhage Meningitis (bacterial vs. viral)
6. CC
7. Assoc. Sx
8. PE
9. Dx tests - inflammation and infection of the meninges; the sac surrounding the brain and spinal cord
10. HA and neck pain
11. Fever, neck pain, neck stiffness, AMS, photophobia
12. Meningismus, Nuchal rigidity
13. Lumbar puncture (LP) Spinal cord injury
14. CC
15. PE
16. Dx tests
17. Scribe alert - Injury to the spinal cord may create weakness or numbness in the extremities past the site of the injury

1. Neck pain or back pain, bilateral extremity weakness
2. midline bony tenderness, deformities, step-offs, bilateral extremity weakness, numbness, decrease rectal tone
3. CT cervical spine (neck), CT thoracic spine (upper back), CT lumbar spine (lower back)
4. Remember that during the initial PE the spine is often immobilized with a C-collar and backboard; document accordingly. Seizure
5. CC
6. Assoc. Sx
7. PE
8. Meds
9. Scribe alert - abnormal electrical activity in the brain leading to abnormal physical manifestations. often caused by epilepsy, ETOH withdrawals, febrile seizure in peds
10. Seizure activity, Syncope
11. Injuries (tongue bite), confusion, HA, incontinence (urinary or fecal)
12. Somnolent (sleepy), confused, postictal state
13. Dilantin, tegretol, keppra, depakote, neurontin
14. Physician will ask

• has pt had similar sz in past?
• does pt have Hx of sz?
• when was date of last sz?
• what sz meds do they take?
• have they missed doses?
• how did you feel before, during, after, now? Bell's Palsy

1. CC
2. Assoc. Sx
3. Pert. Neg
4. PE
5. Dx tests
6. Scribe alert - inflammation or viral infection of the facial nerve (7) causing one sided weakness of entire face

1. facial droop, sudden onset
2. jaw or ear pain, increased tear flow of one eye
3. no extremity weakness, no vision changes or aphasia (r/o stroke)
4. unilateral weakness of the upper and lower face
5. clinically
6. 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 Headache (HA), Cephalgia
7. CC
8. Pert. neg
9. Scribe alert - various causes including hypertensive headaches (HTN) recurrent Dx migraines, sinusitis
10. HA, gradual onset, pressure, throbbing
11. No fever, neck stiffness, numbness/weakness, no changes in speech or vision
12. Always remember to document if the HA is similar or dissimilar to prior HA Never document worst headache of life or thunderclap onset unless specifically instructed by a physician (can be mistaken for hemorrhagic CVA) AMS (altered mental status)
13. Risk factors
14. CC
15. Dx tests
16. Scribe alert - common causes are hypoglycemia, infection, intoxication, neurological
17. Diabetic, elderly, demented, ETOH and drug use
18. Confusion, decreased responsiveness, unresponsive
19. Case dependent
20. most common cause of AMS for pt's w/o Hx of dementia is from UTI infection Syncope (fainting, passing out)

1. CC

2. Scribe alert - Temporary loss of blood supply to brain resulting in LOC

• vasovagal and low blood volume (dehydration/hypovolemia)
• cardiac/neurological causes

1. Passing out vs. about to pass our (near-syncope)
2. Document what happened prior, during, and after syncopal episode, how pt currently feels Vertigo (dizziness)
3. CC
4. Assoc. Sx
5. PE
6. Assoc. med
7. Dx tests - vertigo may be from inner ear (benign positional vertigo) caused by damage to specific center of brain (possible CVA)
8. Room spinning, feeling off balance (disequilibrium), worsened with head movement
9. N/V, Tinnitus (ringing in ears)
10. Horizontal nystagmus, positive Romberg test, positive Dix-Hallpike test
11. Meclizine (antivert)
12. Clinically Appendicitis (Appy)
13. CC
14. Assoc. Sx
15. PE
16. Dx tests - Infection of appendix causes inflammation and blockage, possible leading to rupture
17. RLQ pain
18. decreased appetite (anorexia), fever, N/V

• McBurney's point tenderness
• Psoas sign

• Obturator sign
• Rosvings sign

4. CT A/P with PO contrast Small bowel obstruction (SBO)
5. Risk factor
6. CC
7. Assoc. Sx
8. PE
9. Dx tests - physical blockage of small intestine
10. Elderly, infants, abdominal surgery, narcotic pain medication
11. abd pain, vomiting, constipation
12. abd distention, bloating, no BMs
13. abd tenderness, guarding, rebound, abnormal bowel sounds, abd distention, tympany
14. CT A/P with PO contrast, acute abdominal series (AAS) Cholecystitis, Cholelithiasis
15. Catch phrase
16. CC
17. PE
18. Dx tests - Minerals from liver's bile condense to for gallstones which can irritate, inflame or obstruct gallbladder
19. RUQ abd pain after eating fatty food
20. RUQ pain, sharp, worsened with eating, deep breaths and palpation
21. RUQ tenderness, Murphy's sign
22. RUQ abd US Hematemesis - vomiting bright blood Coffee ground emesis - vomiting dark blood Hematochezia - bright blood in stool Melena - dark blood in stool

Gastrointestinal bleed (GI bleed)

1. CC
2. Assoc. Sx
3. PE
4. Dx tests
5. Scribe alert - Hemorrhage in upper/lower GI tract can lead to anemia
6. blood in vomit/stool
7. general weakness, lightheadedness, SOB, abd pain, rectal pain
8. pale conjuctiva, pallor, tachycardia, Rectal exam (melena, grossly bloody stool)
9. Heme positive stool (Guaiac positive) during rectal exam
10. ED concern is need for possible blood transfusion Diverticulitis - Acute inflammation/infection of abnormal pockets of large intestine LLQ pain Nausea, fever, diarrhea Dx by CT A/P with PO contrast Pancreatitis - Inflammation of pancreas due to ETOH abuse, specific medications or having cholecystitis LUQ, epigastric pain with N/V LUQ tenderness as well as epigastric tenderness Dx by elevated lipase lab test (sometimes elevated amylase) Gastroesophageal reflux disease (GERD) - stomach acid regurgitating into the esophagus CC of epigastric pain, burning, improved with antacids Epigastric tenderness GI cocktail (numbs and soothes the esophagus and stomach) Due to the proximity of the stomach to the heart, patients with cardiac risk factors and epigastric pain will always get a cardiac workup

C. Diff colitis - opportunistic bacteria that causes persistent diarrhea (stool therapy) Gastroenteritis - Vomiting and diarrhea "GI bug" often viral or bacterial Crohn's Disease - Immune disorder causing diarrhea and abd pain IBS (irritable bowel syndrome) - chronically sensitive bowels prone to diarrhea Gastritis - Irritated stomach with vomiting "Stomach ache" Kidney stones - flank pain, sudden onset, radiating to groin Dx by CT A/P RBC in UA may be a clue Abdominal aortic aneursym (AAA) - widened and weakened arterial wall at risk of rupture CC - Midline abdominal pain PE - midline pulsatile abd mass, abd bruit, unequal femoral pulses, hypotension DX by CT A/P with IV contrast dye Aortic dissection - separation of muscular wall from membrane of artery, putting pt at risk of aortic rupture and death CC - chest/abd pain radiating to back (ripping or tearing) PE - unequal brachial or radial pulses, hypotension Dx by CT Chest or A/P with IV contrast dye DVT (deep vein thrombosis)

1. Risk factors
2. CC
3. PE
4. Dx tests - 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 the vein
5. PMHx of DVT or PE, FHx, Recent surgery, cancer, immobility, pregnancy, BCP, smoking, LE trauma, LE casts