Class 2 - Diseases

Question 1

What is the physicain work up (asking the patient questions) designed to do?

Answer 1

It will point towards OR away from a particular differential diagnosis.

Question 2

What are associated symptoms?

What are pertinent negatives?

Answer 2

Specific symptoms that RAISE the physicians suspicion for a particular Differential Diagnosis (DDx)

Specific symptoms that are not present which LOWER physicians suspicion for a particular (DDx)

Question 3

What is the foundation of Pathology? (4)

Answer 3

Etiology (The physiological process causing the symptoms)

Risk Factors (What puts the patient at risk?)

Chief Complaint (The typical major symptom)

Associated Symptoms or Sx (Other symptoms that raise the physician’s suspicion for the disease)

Question 4

What is the TRIIIIIIIPLE THREAT?!

Answer 4

Hyperglycaemia

Hypertension

Hyperlipidemia

Question 5

Describe some of the effects of chronically high blood glucose?

Answer 5

• Diabetic retinopathy - Damage small vessels of the eyes, causing hemorrhage, leading to blurred, nearsightness, or loss of vision.
• CVA due to damage blood vessels
• Increasing risk factor for CAD, CHF, and diabetic cardiomyopathy
• Renal Failure by damaging the glomeruli (strainer of the blood) of the kidneys
• Peripheral Vascular Disease - damage to blood vessels decreases blood flow to extremities and results in infections, ulcers, and potential amputations
• Neuropathy - damage to peripheral nervous system causing distal parethesias and extremity pain

Question 6

Describe some of the effects of chronically high blood pressure?

Answer 6

• Retinopathy
• CVA
• Cardiac disease
• Renal failure

Question 7

Describe some of the effects of chronically high cholesterol?

Answer 7

• CVA
• Cardiac Disease
• Pancreaitis due to free fatty acids in the blood can damage pancreatic cells, leading to inflammation.

Question 8

Cardiovascular Diseases

Coronary Artery Disease (CAD)

Etiology:
Risk Factors:
Chief Complaint/MF:
Associated Sx:
Medications:
Dx By:

Answer 8

Etiology: Narrowing of the coronary arteries causing reduced blood flow to the heart muscle.

Risk Factors: HTN, HLD, DM, Smoking, Family history of CAD/MI < 55 y/o

Chief Complaint: Angina (exterional chest pain or chest pressure)
MF: Worse with exertion, improves with rest and/or NG

Associted Sx: Shortness of breath

Medications: Vasodilators such as NTG/ASA

Dx by: Cardiac catheterization (CAD cannot be dx in the ED)

Question 9

What type of PMHx determines that a patient has CAD?

Answer 9

Angina, MI, CABG, Cardiac Stents, or angioplasty.

Question 10

Cardiovascular Diseases

Myocardial Infarction (MI)

Etiology:
Risk Factors:
Chief Complaint/MF:
Associated Sx:
Medications:
Dx By:

Answer 10

Etiology: Acute blockage of the coronary arteries causing ischemia or infarct to the heart muscle

Risk Factors: HTN, HLD, DM, Smoking, CAD, FHx of CAD <55 y/o

Chief Complaint/MF: Angina
MF: Worse w/ exertion, improved with rest and/or NG

Associated Sx: Diaphoresis, nausea/emesis, shortness of breath

Medication: Vasodilators (ASA or NTG), Thrombolytics (Heparin)

Dx by: STEMI (ST-Segment Elevation Myocardial Infarction) by an ECG/EKG

Non-STEMI: dx by elevated troponin

Question 11

What is important to document when dealing with MI or suspected MI cases?

Answer 11

Many timestamps!

ED arrival time, EKG time, ASA time, cath lab departure time.

STEMI patients must get to Cath-lab within 90 minutes of arrival.

Question 12

Cardiovascular Diseases

Congestive Heart Failure (CHF)

Etiology:
Risk Factors:
Associated Sx:
Medications:
Physical Exam:
Dx By:

Answer 12

Etiology: The heart becomes enlarged, inefficient, and congested with excess fluid. (thickening of ventricular walls resulting in smaller filling capacity of chambers and ejection of blood.

Risk factors: HTN, HLD, DM, Smoking, Kidney Disease, History of CHF

Chief Complaint: Shortness of Breath
MF: Worse with lying flat (Orthopnea), Worse with exertion (Dyspnea on Exertion), and episodically worse at night - Paroxysmal Nocturnal Dyspnea (PND)

Associated Sx: Bilateral lower extremity swelling, fatigue, cough

Medications: Diuretics (Lasix/Furosemide)

Physical Exam: Rales (Crackles) in lungs, Jugular Vein Distention (JVD), Pedal edema

Dx by: CXR and elevated BNP (B-type Natriuretic Peptide) This peptide can act on the kidneys to excrete more salt and water.

Question 13

What should you do if a patient has CHF history?

Answer 13

Document current dosage of Lasix.

Search echocardiograms and document the cardiac output (EF or ejection fraction) and cardiac valve function)

Question 14

Cardiovascular Diseases

Atrial Fibrillation (A Fib)

Etiology:
Risk Factors:
Chief Complaint:
Associated Sx
Medications
Physical Exam
Dx By

Answer 14

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

Risk Factors: Paroxysmal A Fib, Chronic A Fib, Alcoholism

Chief Complaint: Palpitations (fast, pounding, irregular)

Associated Sx: Global Weakness, Fatgue, Lightheadedness

Medications: Anticoagulants (warfarin/coumadin) and Digoxin (slows heart down to allow ventricles to fill more with blood)

Physical Exam: Irregularly irregular rhythm

Dx By: ECG/EKG

Question 15

What is emergency department concern with Afib?

Answer 15

Rapid Ventricular Response (RVR) which is Afib with a rate greater than 100 bpm.

Patients who has Afib are at increased risk for developing blood clots and often take a anticoagulent aka blood thinner.

Question 16

Respiratory Diseases

Pulmonary Embolism (PE)

Etiology
Risk Factors
Chief Complaint
Associated Sx
Dx By (screening tool as well)

Answer 16

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

Risk Factors: Known DVT (and/or PMHx/FHx of one or PE), Afib, Recent Surgery, Cancer, Immobility, Pregnancy, BCPs (Birth Control Pills), Smoking

Chief Complaint: Chest Pain
MF: Worst with deep breaths (pleuritic)

Associated Sx: Shortness of Breath. Patients often are hypoxic (low oxygen sat <92%), tachycardic (elevated heart ate)

Dx By: Screening tool D-Dimer (blood test that assesses for fibrin degradation fragments aka protein fragments from a blood clot) Can produce false positives when pt has other issues

Dx tool: CTA Chest (CT Chest w/ IV Contrast)

Question 17

What does a PE share with a DVT?

Answer 17

Risk factors

DVTs or Deep Vein Thrombosis is a blood clot in the legs (not the lungs) and can result in a PE. Symptoms of a DVT is extremity pain and swelling. A DVT is dx by an ultrasound of that extremity.

Question 18

Respiratory Diseases

Pneumonia (PNA)

Etiology
Cheif Complaint
Associated Sx
Medications
Physical Exam
Dx By

Answer 18

Etiology: Infiltrate (bacterial infection) and inflammation inside the lungs around alveoli that help with gas exchange

Risk Factors: Elderly, Bedridden, Immunocompromised, Recent chest injury, recent surgery

Chief Complaint: Productive Cough

Associated Sx: Shortness of breath, fever, chest pain

Medications: Antibiotics - Rocephin and Zithromax

Physical Exam: Rhonchi (continous gurgling or bubbling sounds typically heard during both inhalationa and exhalation

Dx By: Chest X-Ray (CXR)

Question 19

What does it mean when community acquired pnemonia is suspected?

Answer 19

When multiple patients come from the same place with the same disease or malady. A hospital will generate best practice/methods to streamline treatment.

Question 20

Respiratory Diseases

Chronic Obstructive Pulmonary Disease (COPD)

Etiology
Risk Factors
Chief Complaint
Associated Sx
Treatment/Meds
Physical Exam
Dx By

Answer 20

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

Risk Factors - Single greatest risk factor is smoking (80-90% of all cases)

Chief Complaint - Shortness of breath

Associated Sx - Wheezing, Cough, Chest Tightness

Treatment - Bronchodilators, Supplemental oxygen, corticosteroids, ventilatory support

Physical Exam - Decreased breath sounds, wheezes

Dx By - Acute infections are a very common cause for a COPD Exacerbation. For this reason, a CXR may be ordered to rule out PNA. Otherwise, COPD is not dx in ED.

Question 21

What must a scribe document in the case of dealing with a COPD pt?

Answer 21

Pt’s baseline O2 requirement

Question 22

Respiratory Diseases

Asthma

Etiology
Risk Factors
Chief Complaint
Associated Sx
Treatment
Physical Exam

Answer 22

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

Risk Factors - PMHs, FMHs, smoking, occupational exposure, obesity, allergies

Chief Complaint - Shortness of breath
MF: Improved w/ “breathing treatments”, exacerbated by certain triggers

Associated Sx: Wheezing

Treatment: Bronchidilators, Corticosteroids, Inhalers (Inhaled corticosteroids) or nebulizers

Physical Exam: Wheezes (Inspiratory or Expiratory)

Question 23

What should be documented in an asthma case in which the patient becomes hypoxic and requires supplmented oxygen or additional interventions?

Answer 23

The pt’s oxygen saturation

Question 24

What are the two types of strokes that cause permanent brain damage and what is it known as?

Answer 24

Cerebrovascular Accident (CVA)

The two CVAs that cause irreversible damage:
- Ischemic CVA
- Hemorrhagic CVA

Question 25

What is a "mini-stroke" that DOES NOT cause permanent brain damage referred as?

Answer 25

Transient Ischemic Attack (TIA)

Question 26

What happens when the brain suffers an injury and what term is used to describe the effects?

Answer 26

Damage typically affects a focal region of the brain. Focal Neurological Deficit (FNDs) are specfic deficits and dysfunction dependent on the area of the brain that was injured and the function that area of the brain performs.

Question 27

Neurological Diseases Ischemic Cerebrovascular Accident (CVA) Etiology Risk Factors Chief Complaint Medications Physical Exam Dx By

Answer 27

Etiology: Blockage of the arteries supplying blood to the brain resulting in permanent brain damage Risk Factors: HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, AFIB Chief Complaint: Unilateral FNDs: one-sided weakness/numbness or changes in speech/vision Medications: tPA (thrombolytics) will be administered if pt meets criteria Physical Exam: Unilaterial Focal Neurological deficits Dx By: Clinically, following a CT head in order to rule out Hemorrhagic CVA.

Question 28

What is important to do as a scribe when encountering a possible CVA?

Answer 28

Document date/time they were "last known well" for a baseline as well as source of info (was it the pt? familial historian?) This information is used to assess eligibility for tPA (tissue plasminogen activator) Also, document tPA considered and if it was not indicated due to: - Onset greater than 3 hours or Unk/Unrealiable time of onset - Symptoms are rapidly improving

Question 29

Neurological Diseases Hemorrhagic CVA Etiology Risk Factors Chief Complaint Associated Sx Physical Exam Dx By

Answer 29

Etiology - Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain Risk Factors - HTN, anticoagulant use, recent head trauma Chief Complaint - Severe, sudden onset ("thunder clap") Headache Associated Sx - Nausea, AMS, FNDs (unilateral weakness, numbness, tingling, changes in speech/vision) Physical Exam - Unilateral FNDs Dx By - CT Head is preferred method of dx. However, imaging is not completely reliable at detecting brain bleeds. Pt's clinical presentation will play role in diagnostic process. Rare cases, lumbar puncture (LP) may be performed for further diagnostic purposes.

Question 30

Why would tPA not be indicated in the case of a Hemorrhagic CVA?

Answer 30

tPA is a thrombolytic meaning it is an anticoagulant which could worsen a brain bleed and instigate death.

Question 31

Neurological Diseases Transient Ischemic Attack (TIA) Etiology Risk Factors Chief Complaint Dx By

Answer 31

Etiology - Vascular changes temporarily deprive a part of the brain oxygen (symptoms usually last less than 1 hour) Risk Factors - HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, AFIB Chief Complaint - Transient FND (changes in speech, vision, strength, or sensation) Dx By - Clincally

Question 32

Why would a scribe document that tPA was considered and then not indicated for a TIA?

Answer 32

SInce TIA symptoms typically last less than 1 hour, the symptoms typically resolve on their own therefore it is no longer indicated (there is no actively clotting mass in the brain)

Question 33

Neurological Diseases Meningitis Etiology Risk Factors Chief Complaint Physical Exam Dx By

Answer 33

Etiology: Inflammation and infection of the meninges which is the sac surrounding the brain and spinal cord. Risk Factors: Recent International Travel, recent exposure to a sick contact Chief Complaint: Headache, neck pain or stiffness, fever, AMS Physical Exam: Meningismus (means 3-symptom syndrome of nuchal ridigity, photophobia, and headache), Nuchal Rigidity (stiff neck) Dx By: Lumbar Puncture (LP)

Question 34

Scribes document the symptoms patients have and dont have; why is this especially important with meningitis?

Answer 34

Meningitis is notorously hard to diagnose. It is imperative to document EVERYTHING. Any person with a headache or fever will be asked if they have headache, neck pain, or fever.

Question 35

Neurological Diseases Altered Mental Status (AMS) Etiology Risk Factors Chief Complaint Dx By

Answer 35

Etiology - Globalized confusion, caused by things that affect the entire brain. Most common are hypoglycemia, infection, intoxication, and neurological Risk Factors - known infections (commonly UTIs in elderly patients), DM, elderly, Dementia, EtOH (ethyl alcohol) use, Drug use. Chief Complaint - Confusion, Decreased responsiveness, Unresponsive Dx By - Case Dependent

Question 36

Why is AMS very different compared to a FND?

Answer 36

AMS is generalized and typically by things that affect the whole brain. Remember, FND is very specfic deficits caused by damage in specfic parts of the brain that functions to control such actions.

Question 37

Neurological Diseases Syncope (Passing out) Etiology Chief Complaint

Answer 37

Etiology - Temp loss of blood supply to the brain resulting in loss of conciousness. There are a variety of causes; most common are vasovagal and low blood volume (dehydration/hypovolemia). Occasionally syncope occurs due to cardiac/neurlogic causes. Chief Complaint - LoC (Loss of conciousness), Fainting or Passing out

Question 38

What must a scribe document when dealing with a syncope case?

Answer 38

Document what happened: Before the episode During the episode After the episode (how were there upon waking?) How the pt is currently feeling Were they near-syncopal? Did they almost pass out or have lightheadedness?

Question 39

Gastrointestinal Diseases Appendicitis Etiology Chief Complaint Associated Sx Physical Exam Dx By

Answer 39

Etiology - Infection of the appendix causes inflammation and blockage, possibly leading to rupture Chief Complaint - Abdominal Pain (Location: RLQ) MF: Worst w/ movement Associated Sx - Nausea, emesis, fever, decreased appetite Physical Exam - RLQ tenderness, McBurney's point tenderness Dx By - CT abdomen/Pelvis w/ PO contrast

Question 40

Gastrointestinal Diseases Cholelithiasis Etiology Risk Factors Chief Complaint Physical Exam Dx by

Answer 40

Etiology - Minterals from the liver's bile condense to form gallstones which can irritate, inflame, or obstruct the gallbladder RF - Females, age 40 or older. Being Native American/Hispanic/Mexican origin. Overweight/Obese. Sedentary. Pregnant. Eating a high-fat diet. Chief Complaint - Abd pain RUQ, Quality Sharp Pain MF: Worse with eating fatty foods, deep breaths and palpation Physical Exam - RUQ tenderness, Murphy's Sign (sign of acute cholecystitis) Dx by - Abdominal Ultrasound (RUQ)

Question 41

Where are the three abdominal quadrants located? Epigastric, Suprapubic, Perumbilicial.

Answer 41

Epigastric is north and under the pectorals, Periumbilical is center mass of the belly button. Suprapubic is at the groin region.

Question 42

Genitourinary Diseases Urinary Tract Infection (UTI) Etiology Chief Complaint Associated Sx Physical Exam Dx By

Answer 42

Etiology - Infection of the urinary tract (bladder or uretha) Risk Factors - Female Chief Complaint - Painful urination (dysuria) Associated Sx - Urinary frequency, urgency, malodorous urine, AMS (elderly) Physical Exam - Suprapubic tenderness Dx By - Urine drip or Urinalysis

Question 43

What can happen if a UTI is left untreated?

Answer 43

It can migrate to the kidneys via the ureters causing Pyelonephritis. In these patients, their urinary symptoms may be similiar but also include flank pain, with fever, malaise and N/V. A PE finding of costovertebral angle (CVA) tenderness and a positive urine can dx this condition but may be further evaluated with a CT A/P.

Question 44

Genitourinary Diseases Kidney Stones Etiology Chief Complaint Associated Sx PE Dx By

Answer 44

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. Chief Complaint - Flank Pain Associated Sx - Blood in the urine (hematuria), N/V, unable to void PE - CVA tenderness Dx by - CT A/P; Red blood cells in the UA may be a clue

Question 45

Explain what the Costovertebral angle (CVA) is? What are other names for Kidney Stones?

Answer 45

It is the angle created by the 12th rib (last rib) and the spine. Within this gap, is where the kidneys sit. Nephrolithiasis, Renal Calculi, Urolithiasis

Question 46

Genitourinary Diseases Ectopic Pregnancy Etiology Risk Factors Cheif Complaint Dx By

Answer 46

Etiology - Fertilized egg develops outside the uterus, usually in the fallopian tube. High risk for rupture and death. Risk Factors - Pregnant Female (HCG positiive), STD (PID) Chief Complaint - Lower abdominal pain or vaginal bleeding while pregnant Dx - Ultrasound Pelvis (Determine location of fetus. Intrauterine

Question 47

What will any female with a positive pregnancy test recieve IF they complain of lower abdominal pain or vaginal bleeding?

Answer 47

They will recieve a pelvis ultrasound to rule out a possible extopic pregnancy.

Question 48

Acute Trauma Dx Describe the following disease along with their chief complaint and how they are dx'd. Hemorrhagic CVA

Answer 48

Rupture of the blood vessels in the head leading to bleeding in the brain Sever headache, change in menta status CT Head

Question 49

Acute Trauma Dx Describe the following disease along with their chief complaint and how they are dx'd. Spinal Cord Injury

Answer 49

Bruise, partial tear, or complete tear of the spinal cord Neck or back pain, bilateral extremity weakness CT C-spine, t-spine, and/or l-spine

Question 50

Acute Trauma Dx Describe the following disease along with their chief complaint and how they are dx'd. Pneumothorax

Answer 50

Collasped lung Shortness of breath, one-sided chest pain CXR

Question 51

Acute Trauma Dx Describe the following disease along with their chief complaint and how they are dx'd. Internal Organ Injury (Spleen, Liver)

Answer 51

Rupture leading to hemorrhage/bleeding Abdominal pain, abdominal distention CT Abdomen

Question 52

Acute Trauma Dx Describe the following disease along with their chief complaint and how they are dx'd. Fracture

Answer 52

Trauma creates pain/swelling Pain, swelling, bruising, use limitation X-ray

Question 53

What should you document for a trauma case? Three things that are pertinent _ _ _ _ _ _ of injury Something that increases risk of internal bleeding following a trauma. What is the objective measure of responsiveness in the PE, ranging from 3-15. Normal GCS is 15. Hint GCS

Answer 53

The mechanism of injury describes the trauma so healthcare providers can determine how likely it is that a serious injury has occured. Annotating that a patient takes blood thinners could increase the risk of internal bleeding following a trauma. The Glasgow Coma Scale

Question 54

Miscellaneous Diseases Back Pain Etiology RF CC PE

Answer 54

Etiology - deterioration or strain of the back creates pain that is worse with movement RF - Chronic back pain, age, physically demanding job CC - Back pain (mostly lumbar) PE - paraspinal tenderness, positive straight leg raise (+ SLR diagnoses sciatica; back pain radiates down the legs)

Question 55

Miscellaneous Diseases What is the difference between abdominal aortic aneurysm (AAA) and aortic dissection?

Answer 55

An AAA is the widened/weakened arterial wall at risk of rupture while the dissection indicates separation of the muscular wall from the membrane of the artery, putting the pt at risk of aoritc rupture and death.