Scribeamerica Course 3 & 4

Front 1

What are the HPI elements? (8)

Back 1

Onset, Timing, Location, Quality, Severity, Modifying factors, Associated Sx, Context

Front 2

What is important to document for a prior evaluation? (5)

Back 2

1. What Sx prompted prior evaluation?

2. How long ago did prior evaluation occur?

3. Who did they see?

4. What Tx did they received? Did it help?

5. What Dx was given?

Front 3

If pt has had any prior testing/study relating to their complaint, document...

Back 3

Specific name of test, date, and specific results

Front 4

What are the 4 most important Sx to document for any trauma pt?

Back 4

LOC, Head injury, Neck pain, Back pain

Front 5

What are the 14 Body Systems?

Back 5

Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Endocrine, Lymph, Immunologic

Front 6

What are female abdominal pain risk factors?

Back 6

Possibility of pregnancy, unprotected sex, history of STD

Front 7

What are back pain risk factors?

Back 7

Recent trauma, hx of IVDA, spinal hardware

Front 8

Red flag: Tongue bite wound

Back 8

Seizure

Front 9

AMS Risk Factors?

Back 9

Dementia/Alzheimers, DM, Psychiatric history, substance abuse

Front 10

Trauma Risk Factors?

Back 10

Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe MOI

Front 11

What happens in a basic PE?

Back 11

1. Looking at the patient (general appearance)

2. Auscultate heart

3. Auscultate lungs

4. Palpate abd

5. Examine legs

Front 12

What happens in a detailed PE?

Back 12

1. Detailed eye exam

2. Hearing/vision assessment

3. GYN exam

4. Neurological exam

5. Gait assessment

Front 13

If the physician auscultates the abdomen...

Back 13

They are looking for hyperactive/hypoactive bowel sounds

Front 14

If the physician "pounds" on the back...

Back 14

They are looking for CVA tenderness

Front 15

If the physician examines the throat...

Back 15

They are looking for pharyngeal erythema or exudates

Front 16

If they physician examines the inner ear...

Back 16

They are looking for TM erythema or bulging

Front 17

If the physician touches the wrists...

Back 17

They are looking for radial pulses

Front 18

If the physician squeezes the calf muscles

Back 18

They are looking for calf tenderness

Front 19

Normal: NAD

Back 19

Abnormal: Mild/Moderate/Severe Distress

Front 20

Normal: Well developed, well nourished

Back 20

Abnormal: Cachetic/Emaciated/Malnourished

Front 21

Normal: Alert

Back 21

Abnormal: Somnolent (sleepy, drowsy), Obtunded (out of it), Unresponsive

Front 22

Normal: Atrumatic/Normocephalic (AT/NC)

Back 22

Abnormal: any signs of trauma

Front 23

Angiodema

Back 23

An allergic reaction on the face (swelling)

Front 24

EOMI

Back 24

Extra Ocular Movements Intact - checking visual tracking

Front 25

Normal: EOMI

Back 25

Abnormal: EOM entrapment

Front 26

Normal: Sclera are anicteric (white part of eye is white)

Back 26

Abnormal: Scleral icterus (yellowing of sclera indicative of liver failure)

Front 27

Normal: Normal conjunctiva (pale part of lower eyelid)

Back 27

Abnormal: Pale conjunctiva/conjunctival injection (indicative of anemia)

Front 28

Fundoscopic Exam of Internal Eye (w/ophthalmoscope) looks for...

Back 28

Clear anterior chamber and sharp disc margins

Front 29

Papilledema

Back 29

Swelling of the eye

Front 30

Hyphema

Back 30

Trauma/blood in the eye

Front 31

Wood's lamp or Fluorescien

Back 31

Check external eye for corneal abrasion or ulcerations

Front 32

Visual Acuity Test

Back 32

20/20 - Normal

20/10 - Excellent

20/ >30 - Poor

Front 33

Cerumen

Back 33

Earwax

Front 34

Nares/naris

Back 34

Nostrils

Front 35

Septal hematoma

Back 35

Septal tissue swelling/bulging

Front 36

Boggy turbinates

Back 36

Swollen inner nose due to inflammation

Front 37

DMM

Back 37

Dry Mucous Membranes - indicates dehydration

Front 38

Edentulous

Back 38

Missing teeth

Front 39

Tonsillar Exudate

Back 39

White plaque --> strep throat

Front 40

PTA

Back 40

Peritonsillar Abscess - collection of pus in tonsil that may block airway

Front 41

Tonsillar Hypertrophy

Back 41

Swollen enlarged tonsils

Front 42

Carotid bruit

Back 42

Will have whoosing sound, plaque build up

Front 43

Cervical Lymphadenopathy

Back 43

Swollen lymph nodes

Front 44

Vertebral Point (Midline) vs. Paraspinal Tenderness

Back 44

Concern for spinal cord issues vs soft tissue tenderness

Front 45

Thyromegaly

Back 45

Enlarged thyroids (feel neck and tell pt to swallow)

Front 46

Most common murmur

Back 46

2/6 Systolic Ejection Murmur

Front 47

Extrasystoles

Back 47

Extra heart beats

Front 48

Pleural Rub

Back 48

Swelling of lungs rubbing against ribs

Front 49

Name the five pulse points.

Back 49

Radial, carotid, femoral, dorsalis pedis (DP), posterior tibialis (PT)

Front 50

Normal pulse refills how long?

Back 50

Capillary refill less than 2 seconds

Front 51

How to write pulses?

Back 51

0 = Absent

1+ = Barely palpable

2+ = Easily palpable (Normal)

3+ = Full

4+ = Bounding/Aneurysmal (at risk of rupture)

Front 52

CTA

Back 52

Clear to auscultation

Front 53

Abnormal pulmonary findings?

Back 53

Diminished breath sounds, wheezing, rales, rhonchi, tachypnea, respiratory distress, accessory muscle use

Front 54

TTP

Back 54

Tender to Palpation

Front 55

Peritoneal Signs

Back 55

Signs of a surgical abdomen (Voluntary Guarding, Rebound Tenderness, Rigidity (Involuntary Guarding))

Front 56

Rebound Tenderness

Back 56

When you let go and the pt feels the pain

Front 57

Distended abdomen

Back 57

A protruding abdomen (like w/SBO)

Front 58

Rectal Prolapse

Back 58

Rectal protrudes outside of the body, may go back in on its own

Front 59

Bony tenderness

Back 59

Fracture

Front 60

Soft tissue tenderness

Back 60

Contusion (like a hematoma/swelling)

Front 61

Calf tenderness

Back 61

DVT

Front 62

Homan's sign

Back 62

Checks for DVT (checking for firmness)

Front 63

Midline Deformities/Step-Offs

Back 63

A series of spinal cord injuries, like a staircase

Front 64

Jaundice

Back 64

Yellow

Front 65

Cyanotic

Back 65

Blue (indicative of hypoxia)

Front 66

Urticaria

Back 66

Hives

Front 67

Petechiae

Back 67

Small red/purple spots

Front 68

Purpura

Back 68

Hyper-pigmentation (purply)

Front 69

Induration

Back 69

Cellulitis

Front 70

Lymphangitis

Back 70

Spreading infection

Front 71

Contusion

Back 71

Like a firm raised area

Front 72

Avulsion

Back 72

Flap of the skin as if you got bitten by a dog

Front 73

Somnolent

Back 73

Drowsy, sleepy

Front 74

Aphasia

Back 74

Difficulty getting words out

Front 75

Dysarthria

Back 75

Slurred speech, difficulty speaking

Front 76

Hypoesthesia

Back 76

Decreased sensation

Front 77

Numbness

Back 77

Absent sensation

Front 78

Deep Tendon Reflexes (DTRs)

Back 78

0 = Absent

1+ = Hypoactive

2+ = Normal

3+ = Increased

4+ = Unsustained clonus

Front 79

Anisocoria

Back 79

Unequal pupils

Front 80

How to check for coordination?

Back 80

Normal finger-to-nose, Normal heel-to-shin

Front 81

Ataxia

Back 81

Walking all over the place/off-balance

Front 82

Antalgic

Back 82

Painful walking

Front 83

Nystagmus

Back 83

Walking w/vertigo, off-balance

Front 84

Positive Romberg

Back 84

Standing upright

Front 85

Normal RAM

Back 85

Normal Rapid Alternating Movements

Front 86

Dysdiadochokinesia

Back 86

Inability to perform normal RAM

Front 87

Flat affect

Back 87

No emotion

Front 88

Hypomanic

Back 88

Inappropriately happy/energetic

Front 89

Pressured speech

Back 89

Hesitant to reply to you

Front 90

GCS

Back 90

Glasgow Coma Scale = 3-15 scale checking for major neuro deficits

Front 91

Racoon eyes

Back 91

Blood draining from brain collecting at eye orbits

Front 92

Battle's sign

Back 92

Blood draining from brain collecting behind ears (extremely rare and severe)

Front 93

Hemotympanum

Back 93

Bleeding from brain coming out of the ear

Front 94

What does a GCS of 3 mean?

Back 94

Clinically dead on arrival

Front 95

Rectal laxity

Back 95

Decreased rectal tone

Front 96

Normal motor strength

Back 96

5/5 and Symmetric, Sensation intact