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136 Cards in this Set
- Front
- Back
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Appendicitis (Appy) |
CC- RLQ pain- gradual, constant PE- Mcburney's point tenderness, RLQ tenderness Dx by - CT abdominal pelvis with PO contrast |
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Small bowel Obstruction (SBO) |
CC- abdominal pain, vomiting PE- Abdominal tenderness, guarding, rebound dx by - CT A/P w/ PO contrast, AAS |
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Gallstones |
Right Upper Quadrant pain after eating fatty foods, deep breaths + palpation PE- RUQ tenderness, Murphy's sign tenderness dx by - abdominal UltraSound, RUQ |
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Gastrointestinal Bleed (GI Bleed) |
CC- hematemesis, coffee ground emesis, hematochezia, melena PE- pallor, tachycardia DX by - heme positive stool, guaiac positive |
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Diverticulitis |
CC- LLQ pain Dx by - CT A/P w/ PO contrast |
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Pancreatitis |
CC- LUQ, epigastric pain PE- epigastric tenderness dx by - elevated lipase test |
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Gastroesophageal reflux disease (GERD) |
CC- Epigastric pain- burning improved with antacids PE- epigastric tenderness |
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Other Causes of Abdominal Pain |
Diff Colitis Gastroenteritis Crohn's disease IBS Gastritis |
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Gastrointestinal Summary |
Appendicitis - RLQ SBO- perimbilical cholecystitis- RUQ diverticulitis- LCQ GI bleed- any GERD- epigastric Pancreatitis- LUQ |
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Urinary Tract Infection |
CC- dysuria PE- suprapubic tenderness Dx by - urine dip or urinalysis |
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Pyelonephritis |
CC- Flank pain w/ dysuria PE- costovertebral angle tenderness dx by- CT abdomen/pel w/o contrast UTI w/ CVA tenderness on exam |
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Kidney Stone |
CC- flank pain, sudden onset, radiate to groin PE- CVA tenderness dx by CT abdomen/pelvis RBC in UA |
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Ectopic pregnancy |
CC- lower abdominal pain or vaginal bleeding while pregnant DX by Ultrasound pelvis- location of fetus |
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Ovarian torsion |
CC- lower abdominal pain -RLQ or LLQ PE - adnexal tenderness in RLQ or LLQ Dx by - Ultrasound pelvis, blood flow to ovaries |
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Testicular torsion |
CC- testicular pain PE- testicular tenderness and swelling dx by -ultrasound scrotum |
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Genitourinary summary |
UTI PYelo Kidney stone Ectopic pregnancy ovarian torsion testicular torsion |
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Upper respiratory infection |
CC- cough/congestion PE- rhinorrhea, boggy turbinates Dx by- clinically |
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Otitis media (ear infection) |
CC- Ear pain/ pulling Pe- erythema, effusion, dullness of the ear DX by -clinically |
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Streptococcal pharyngitis |
CC- sore throat PE- pharyngeal erythema tonsillar hypertrophy ( exudates) DX by rapid strep |
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Conjunctivitis |
CC- eye redness, irritation/pain PE- conjunctival infection, edema and exudates Dx by- clinically |
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Epistaxis |
CC- nose bleed PE- anterior, posterior bleeding dx by - clinically |
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Musculoskeletal back pain |
CC- back pain pertinent negatives- No LE weakness no incontinance PE paraspinal tenderness |
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Extremity injury |
CC- Extremity pain Pertinant negatives- no motor weakness, numbness/tingling PE- distal CSMT intact |
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Chronic obstructive pulmonary disease |
CC- SOB dx by CxR + history of smoking |
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Asthma |
CC- SOB/Wheezing Dx by -clinically |
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Pulmonary overview |
Respiratory systems PE PTX pNA COPD Asthma |
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Ischemic CVA |
major DDX for weakness/numbness CC- unilateral/neurodeficits Dx by -clinically, potentially normal head CT PE- visual field deficits, hemiparesis |
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Hemorrhagic CVA |
CC- headache - thunderclap PE unilateral neurodeficit Dx by- CT head or lumbar puncture |
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Transient Ischemic Attack |
CC- transient focal neurodeficit- changes in speech, vision dx by - clinically |
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Meningitis |
CC- headache PE meningismus, nuchal rigidity DX by - lumbar |
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Spinal Cord injury |
CC- neck pain or back pain bilateral + extremity weakness PE- midline bony tenderness, deformities or step offs dx by - CT cervical spine (neck) CT thoracic spine (upper back) CT lumbar spine (lower back) |
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Seizure (Sz) |
CC- seizure activity, syncope DDx for syncope PE- confused, post-ictal |
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Bell's Palsy |
CC- facial droop, sudden onset PE- unilateral weakness of the upper and lower face Dx by - clinically |
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Headache(cephalgia) |
CC- headache - gradual onset pressure, throbbing Pertinent negatives- no fever or neck stiffness, no changes in speech/vision |
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Altered Mental status (ams) |
CC- confusion, unresponsive Risk factors- diabetic, elderly, dementia Dx by - case dependent, clinically |
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Syncope |
CC- passing out vs about to pass out ddx for epilepsy |
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Vertigo |
CC- room spinning, feeling offbalance PE horizontal nystagmus, romberg DDx by- clinically |
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Neuro summary |
Hemorrhagic CVA Ischemic CVA meningitis Spinal cord injury TIA Seizure Bell's palsy HA/migraine AMS Syncope Vertigo |
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Abx |
Antibiotics |
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BID |
twice daily |
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CABG |
Coronary Artery Bypass Graft |
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CAD |
Coronary Artery Disease |
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CP |
Chest Pain |
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CVA |
CerebroVascular Accident Costovertebral Angle |
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CxR |
Chest x-ray |
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DM |
Diabetes Mellitus |
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DVT |
Deep Vein thrombosis |
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Dz |
Disease |
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FHx |
Family History |
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HA |
headache |
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HEENT |
Head, ears, eyes, nose, throat |
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HPI |
History of present illness |
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HTN |
Hypertension |
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LNMP |
Last normal menstrual period |
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LOC |
loss of consciousness |
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MI |
myocardial infarction |
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MVA/MVC |
Motor Vehicle Accident/collision |
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NKDA |
No Known Disease Allergies |
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NTG |
Nitroglycerin |
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N/V/D |
Nausea, Vomiting, Diahhrea |
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PE |
Pulmonary Embolism/physical exam |
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Pt |
Patient |
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ROM |
Range of motion |
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RUQ |
Right upper Quadrant |
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SOB |
Shortness of Breath |
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S/P |
status post (after) |
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Sx |
Symptoms |
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UTI |
Urinary Tract Infection |
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Pertinent positives |
Symptoms that help to confirm the suspicion for a disease |
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Pertinent negatives |
Lack of symptoms that rule out the suspicion for a disease |
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Coronary Artery disease |
Ddx for CP cc- CP- worse w/ exertion, better with nitroglycerin/rest Dx by - cardiac catheterization |
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Myocardial Infarction |
Ddx for CP CC- chest pain (pressure) dx by - ekg (stemi) or elevated troponin (non-stemi) |
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Congestive Heart Failure |
ddx for shortness of breath CC- SOB -worse when lying flat -PND -Dyspnea on exertion dx by CxR or elevated BNP |
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A fib |
CC- palpitations
dx by EKG |
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CV overview |
Cardiovascular (heart) MI A fib CHF CAD Angina |
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Pulmonary Embolism |
Ddx for CP + SOB CC- SOB, pleuritic CP( worse w/ deep breaths) dx by - CTA chest, d-dimer - detects clots |
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Pneumonia |
ddx for fever, SOB, CP CC- SOB or productive cough Dx by - CxR Associated symptoms - cough ,fever, CP |
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Pneumothorax (PTX) |
CC- SOB + one sided CP, sudden onset, trauma patients Dx by CxR |
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Abdominal Aortic Aneurysm (AAA) |
major DDX for abdominal pain CC- midline abdominal pain PE- midline pulsatile abdominal mass, abdominal bruit, unequal femoral pulses, hypotension dx by CT A/P with IV contrast dye |
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Aortic Dissection |
major ddx for CP or back pain CC- Chest pain radiating to back, ripping or tearing PE- unequal brachial or radial pulses, hypotension dx by - CT chest with IV contrast dye |
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Deep vein thrombosis |
Major DDX for leg swelling / pain CC- extremity pain and swelling (atraumatic) usually located in a lower extremity PE - Calf tenderness, Cords, Homan's sign dx by - US/Doppler of the extremity |
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Integumentary |
Skin |
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Cellulitis |
CC - red, swollen, painful and sometimes warm area of the skin PE- erythema, edema, increased warmth (calor), induration dx by - clinically |
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Abscess ( Cellulitis with fluctuance) |
CC- red, swollen, painful lump PE- fluctuance(pus-pocket), induration, purulent drainage dx by -clinically |
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Rash |
CC- red, itchy (pruritic), or painful rash dx by -clinically |
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Urticaria |
Hives or wheals |
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Mascules |
Flat |
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Papules |
Raised bumps |
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Vesicles |
Small blisters |
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Blanching |
not dangerous |
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Petechaie |
Dangerous Rash |
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Purpura |
Dangerous Rash |
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Allergic Reaction |
CC- rash, swelling, itching, or SOB PE- edema, facial angiodema, urticaria (hives) dx by - clinically |
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Adverse Reaction |
Nausea, vomiting, abdominal pain, diarrhea, dizziness- not an allergic reaction |
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Diabetic Ketoacidosis (DKA) |
CC- persistent vomiting with a history of Diabetes mellitus PE- ketotic odor, dry mucous membranes (dehydration), tachypnea dx by - arterial blood gas ( ABG or VBG ) showing low pH (acidosis) or positive serum ketones |
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Psychological disorder criteria |
PMHx- Bipolar Disorder, schizophrenia, PTSD, depression, anxiety, alcoholism, drug abuse, suicide attempt possible CC's- Suicidal ideations, homicidal ideation, hallucinations, substance abuse, self injury, overdose PE- flat affect, SI, HI, tangential or pressured speech |
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Trauma (physical injury) |
CC- motor vehicle accident, fall, gunshot wound PE- glasglow coma scale dx by - trauma protocol depending on method of injury (MOI)- CT or XR |
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Burns |
CC- burn wound, usually on the hand, wrist or forearm PE- first degree- affects only superficial skin 2nd degree- partial thickness, underlying layers of skin 3rd degree- full thickness burn, all layers of skin 4th degree- extends full skin into underlying muscle or bone dx by -clinically |
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HPI elements |
Onset- when did it begin? Timing- Is it constant, intermittent, or waxing + waning? Location- where is discomfort? Quality- sharp/dull Severity- how bad 1-10? Modifying factors- what makes it better/worse? Context- other important info |
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HPI do's and don'ts |
Don't use day of the week, write number of days ago symptoms started Don't use the word "got", use symptoms became worse/better Don't start every sentence the same way- pt states.. don't include pmhx pshx that is irrelevant to CC |
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Review of Symptoms |
List of all positives and negatives- head to toe review of patient's body systems- cannot contradict HPI |
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ROS body systems |
Constitutional- fever, weight loss ,sweats Eyes- vision Ears/nose/throat Cardiovascular- chest pain, leg swelling Respiratory- SOB, coughing, wheezing Gastrointestinal- Ab pain, N/V/D Genitourinary - dysuria etc. Musculoskeletal -joint pain muscle pain Integumentary/skin- rash/laceration neurological - headache sz etc. psychiatric- depression/anxiety endocrine - polyuria hematologic/lymph - bleeding gums immunologic- HIv/aids |
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GPA for childbirth |
G- total number of times pt has been pregnant P - total number of live births (viable children) pt has had A - total number of miscarriages/abortions |
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Constitutional normal/abnormal findings |
Normal- no acute distress (NAD), well developed/nourished, Alert Abnormal- Mild/severe/moderate distress, malnourished, unresponsive |
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Head normal/abnormal |
normal- Normocephalic abnormal- signs of trauma, sinus tenderness, angioedema |
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Eyes normal/abnormal |
normal- PERRL- pupils equal, round, reactive to light, extraocular movements intact EOMI abnormal- EOM entrapment, anisocoria |
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Tachypnea |
Increased breathing rate |
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Abdominal Quadrants |
RUQ, LUQ, RLQ, LLQ, R Flank, L flank, suprapubic, periumbilical, epigastrium |
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Peritoneal |
Abdominal |
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AMA |
against medical advice |
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ASA |
acetylsalicytic acid (asprin) |
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CSF |
cerebrospinal fluid |
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DKA |
Diabetic Ketoacidosis |
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DNR |
Do not resuscitate |
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DOE |
Dyspnea on exertion |
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EKG |
Electrocardiogram |
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Fx |
Fracture |
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G/P/Ab |
Gravida/Para/Abortion |
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GU |
Genitourinary |
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H&H |
Hemoglobin & hematocrit- RBC's |
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H&P |
History of present illness and physical exam |
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I&D |
Incision and drainage |
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IDDM |
Insulin Dependent Diabetes Mellitus |
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IUP |
Intrauterine Pregnancy |
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IVDA |
IV drug abuse |
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JVD |
Jugular Vein distension |
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MCA |
motorcycle accident |
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NAD |
No acute distress |
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NIDDM |
Non insulin dependent Diabetes mellitus |
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NSAID |
Non steroidal anti inflammatory drug |
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NSR |
normal sinus rhythm |
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PCP |
Primary Care physician |
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PO |
Per Os (by mouth) |
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prn |
As needed |
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PTA |
prior to arrival |
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Pediatric Abnormalities vs Adult |
Rashes, erythema and edema more common in pediatrics |
