Exam (elaborations) ScribeAmerica Final Exam 2023/2024

What are the 5 vital signs? correct answerHeart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information? correct answersubjective The Physical Exam is what type of information? correct answerobjective What is the difference between the HPI and ROS? correct answerHPI focuses on details related to the pt's chief complaint. ROS is a head-to-toe checklist of symptoms, including the chief complaint, associated sx, and all other complaints from the pt What does disposition (dispo) mean? correct answerThe patient's destination after they leave the ED What is the abbreviation for a heart attack? correct answerMI - myocardial infarction What is the abbreviation for high blood pressure? correct answerHTN - hypertension What is the medical term for acid reflux? correct answerGERD - gastroesophageal reflux disease What is the medical term for stroke? correct answerCVA - cerebrovascular accident What is the term for gallbladder removal? correct answercholecystectomy What does NKDA stand for? correct answerno known drug allergies What is the medical term for redness? correct answererythema/injection What is the medical term for bruising? correct answerecchymosis What is CAD? correct answerCoronary Artery Disease Explain the difference between CAD and an MI correct answerCAD is a broad term for heart disease MI is an ongoing, active heart attack, included in CAD What are "cardiac risk factors"? correct answerHTN, HLD, DM, CAD, smoking, FHx CAD 55 y/o Name two ways than an MI can be diagnosed? correct answerSTEMI = EKG non-STEMI = elevated troponin What are some associated sx of MI other than chest pain? correct answerdiaphoresis, N/V, SOB What are some associated sx for CHF? correct answerSOB, orthopnea, PND (paroxysmal nocturnal dyspnea), DOE, bilateral pitting pedal edema What 2 studies would diagnose CHF? correct answerCXR and elevated BNP How is AFib diagnosed? correct answerEKG What are risk factors for a PE? correct answerKnown DVT, PMHx of DVT/PE, FHx of DVT/PE, smoking, pregnancy, BCP, immobility, recent surgery, CA, AFib What study would diagnose a PE? correct answerCT chest with IV contrast (CTA scan) or VQ scan *D-dimer can only rule it out* How is a PTX diagnosed? correct answerCXR What social history will most COPD patients also have? correct answersmoking What PE finding closely associates with asthma? correct answerwheezing What is PNA? correct answerPneumonia - bacterial infection (infiltrates) and inflammation inside the lung What might a person with PNA complain of? correct answerProductive cough and fever What might be the chief complaint of a person with gall stones? correct answerRUQ abdominal pain What PE finding is closely associated with cholecystitis? correct answerMurphy's sign How are gall stones diagnosed? correct answerAbdominal ultrasound of the RUQ How is appendicitis diagnosed? correct answerCT A/P with PO contrast How is pancreatitis diagnosed? correct answerElevated lipase, sometimes elevated amylase (less specific) What studies would diagnose diverticulitis? correct answerCT A/P with PO contrast What is pyelo? correct answerPyelonephritis, kidney infection (different and worse than a UTI), usually spread from a UTI Name the 2 types of CVAs correct answerischemic CVA and hemorrhagic CVA *TIA is not a stroke* What study would diagnose a brain bleed? correct answerabnormal head CT, LP What sx might a person with an ischemic CVA c/o? correct answerfocal neurological deficits (FNDs): hemiparesis, unilateral paresthesias (numbness/weakness/tingling), visual field deficits, aphasia How is an ischemic CVA diagnosed? correct answernormal head CT How does a TIA differ from a CVA? correct answerTIA is a mini-stroke, symptoms resolve in less than an hour CVA is a stroke, symptoms last longer and potentially do not resolve What is a common cause of seizures in children? correct answerFever What study would diagnose meningitis? correct answerLP What are 4 important things to document for syncopal episodes? correct answerHow the patient was feeling before, during, and after the episode, as well as how they currently feel What is a DVT? correct answerDeep vein thrombosis What are risk factors for a DVT? correct answerKnown DVT, PMHx of DVT/PE, FHx of DVT/PE, smoking, CA, recent surgery, pregnancy, BCP, AFib, immobility What are common signs of a DVT? correct answerextremity pain, swelling (atraumatic) What is an AAA? correct answerabdominal aortic aneurysm What procedure will be performed for every abscess? correct answerI&D What are the ONLY three sx of a true allergic reaction? correct answerrash, itching, swelling Name 3 important things to document for any trauma patient correct answerLOC, head injury, neck/back pain Describe the significance of an HPI correct answerThe HPI is the story of the symptoms and events that led to the patient's ED visit. It includes the chief complaint and the associated sx. Name 5 "elements" of the HPI correct answeronset, timing, location, severity, quality, associated sx, modifying factors, contesxt What should you focus on when writing an HPI? correct answerdocumenting the answers to every question the doctor asks