Osce Study Chart

Symptom & Background

Earache

Key Questions Is this an acute infection? How old are you? Have you had a fever?

Generally an inflammatory Have you had an URTI? process: in children its in the middle ear. In adults it Have you had ear infections before? is referred from other Is there a family history of ear infections? head and neck structures What environmental conditions might suggest increased risk? Does anyone around you smoke? Do you?

What these questions will tell you

Physical Exam

Need to view TM and Acute otitis media (AOM) declines after 6 external ear canal. Fever present in 60% of children with AOM Lavage indicated if (infants <2mo uncommon, high fever is blockage. CI if history systemic illness) suggests perforation. Organisms travel up eustatian tube --> Note behaviours in obstruction --> mucus and bact growth children: irritability, poor feeding, congestion, fever. High risk of recurrens of AOM Having a sibling or parent with chronic OM Older infants may pull on makes you 2x as likely. May be environ'tal painful ear, bang head on affected side.

2-3x inc risk. Leads to functional eustachian tube obstruction, decreases protective ciliary action in the tube

Child: does the child attend day care? Child: does the infant take a bottle lying down?

Inc exposure to organisms Swallowing lying down may allow nasopharyngeal fluid to enter middle ear Have you been swimming recently? Swimming causes loss of protective cerumen and excessive moisture and irritation to the canal Have you recently been in an airplane or been scuba Barotrauma --> acute serous otitis. Failure diving? of eustachian tube to open and equilibrate --> fluid collection in middle ear.

Inspect External Ears

Palpate External Ears. Also pre and postaruicular Do you have diabetes? Predisposition to malignant otitis externa (a lymph notes. Pre may be enlarged in AOM and otitis cellulitis), OM, and mastoiditis externa. Post in Have you ever had dermatitis, eczema, or psoriasis? Overproduction of sebum can cause otitis mastoiditis. externa Child: does the child have a nonrepaired cleft palate? Can cause functional obstruction of the Inspect Ear Canals with eustachian tubes Otoscope What does the presence of pain tell me? Visualize any discharge, Where specifically is the pain felt? Is it in one ear or Otitis externa - pinna. Mastoiditis - mastoid. noting color, consistency, both? Bilateral - otitis externa. Referred pain or and odor. Disharge usually AOM is unilateral. Children may tug at ears means infection, however, CSF must be kept in mind with trauma. How severe is the pain? Does it interfere with AOM - deep pain or blockage of ear. Inspect Tympanic

How long have you had this pain? Is the pain constant or intermittent? If intermittent, how long does it last? Does the pain travel (radiate) to other areas? What does the presence of discharge or itching tell me? Do you have any discharge from the ear? Do you have any itching in the ear?

Serous otitis - bubbling, popping, or stuffy. Membrane noting light Otitis externa - tender and may have reflex. Normal: transluscent itching. Cerumen impaction - vague and pearly grey. Normally discomfort concave. TMJ - lasts a few minutes and occurs 3Bulging: increased 4x/day, sometimes with headache, worse hydrostatic pressure in the morning (grinding). Chronic pain may be dental malocclusion or RA. Perform Pneumatic Otoscopy (Insufflation) Discharge seen after TM ruptures, can be secondary to mastoiditis. Itching indicates infection of the external canal. Can also be precursor to herpes zoster of CN V.

Tests mobility of the TM by creating a seal - normal if there is slight motion when air is insufflated

What does a history of trauma or injury tell me?

Test hearing acuity: Weber and Rinne Have you had any recent trauma to the ear? Trauma can perforate the eardrum.Fractur Examine Related Body of the petrous temporal bone can destroy Systems: head and neck. Have you had any head trauma? the inner ear. Cotton-tipped swabs can Conjunctiva, mucosa and How do you clean your ears? Do you use cottonscratch the canal. patency of nose, sinuses, tipped swabs? larynx/tonsils, teeth and Do you have a history of excessive earwax? Accumulation can cause hearing loss, gums tinnitus, pressure sensation, vertigo, infection. Self-cleaning can cause harm. Child: does the child have a history of putting objects can cause ear pain and inflammation Perform an Intraotic into ears? Manipulation. Face the Have you had any recent insect bites around the Can lead to acute pain and tenderness of patient, insert a single fingertip in each ear and ear? the external canal and may develop pull the patient toward you secondary infection. Have you been exposed to any loud noise? Loud prolonged noise can destroy cochlear as they are instructed to open and close their hair cells. mouth. Pain is elicited in 90% of patients with a TMJ disorder. Is hearing loss a clue? Do you have any difficulty hearing?

Blockage, inflammation, neoplasm. Most common cause of CHL is cerumen. Chronic OM can cause hearing loss.

Do you have any dizziness? Do you have any ringing in the ear? Child: do you think the child can hear normally? Does he or she turn their head to listen?

May indicate serious inner ear condition.

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Audiometry. Tests frequency and intensity of sound that can be perceived.

Hemorrhage over matoid - Mastoid Process battle's sign - basal skull Radiography fracture radiographs of mastoid. Pain in opening of ear or inflamed skin suggests bacteria Fungal and yeast infections CT of temporal bone for are white or dark patches cholesteatoma and congenital syndromes

Could this be related to a systemic disease?

sleeping, eating, or other activities?

Lab Tests Tympanometry. Insert a probe into the external ear while pressure in the eardrum is continually changed. Provides indirect measure of pressure in the middle ear.

Evaluate CN V, VII, and IX. CN V: feel masseter as patient clenches teeth. Sharp/dull over CV V - 3 branches. Taste is CN VII and IX and both apply sensation to external ear.

DDX Physical Findings Diagnostic Studies Discharge; inflamed, swollen external canal; pain None with movement of pinna; TM normal or not visible

Condition Earache DDX External otitis

History More common in adults, especially those with diabetes, ear pickers, or swimmers. Bilaral itching; pain.

Acute otitis media

More comon in children <6 years; those with smoke exposure, recent URTI; severe or deep pain; unilateral; sensation of fullness More common in children but occurs in adults with URTI; unilateral pain; senation of crackling or decreased hearing

Red, bulging TM; fever; decreased light reflex; opque TM; decreased TM mobility

Cholesteatoma

Hearing loss; recent perforated TM

Pearly white leasion on or behind TM

Immediate referral

Mastoiditis

History of recent otitis media; chronic otitis pain behind ear

Swelling over mastoid process; fever, palpable tenderness, and erythema over mastoid

Radiograph of mastoid sinuses reveals cloudiness, referral

Foreign body or cerumen impaction

Both children and adults have pain or vague sensation of discomfort; decreased hearing

Visualize foreign body or cerumen; may detect foul odor; conductive hearing loss

None

Barotrauma

History of flying, diving; severe pain; hearing loss; sensation of fullness; history of recent nasal congestion

Retraction of bulging of TM; perforation of TM; fluid in canal

Tympanogram

Trauma

History of blunt trauma, penetrating trauma

Perforation of TM

Serous otitis

None initially

Fluid line or air observed behind TM; conductive Tympanogram hearing loss; decreased TM mobility

Radiographs/CT scan as directed by injury Cervical lymphadenitis History of cervical node swelling; pain in ear common Enlarged, tender, cervical lymph nodes; may see Throat culture if indicated. Monospot in children early onset of AOM in children if indicated in adolescent Cervical nerves 2, 3 (referred Pain in skin and muscles of neck and in ear canal Dermatome evaluation for cervical nerve None pain) Cranial nerves (referred pain) History, depending on CN involved Test function of CNs V, VII, IX, X; ear Radiograph/CT scan directed by CN examination normal involvement TMJ disorder None More common in adults, 50% related to dental Malocclusion; bruxism; normal external and problems; discomfort to severe pain; unilateral; pain middle ear structures and function; jaw click; worse in morning abnormal CN function; ear examination normal

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Is this an emergency?

All these symptoms signal acute Assess degree of illness Generally limited to epiglottitis. Rare but can cause airway (emergency questions) identification of GABHS obstruction. Syptoms: sore throat, difficulty swallowing, respiratory distress (drooling, dyspnea, inspiratory stridor). MC due to H. Have you been unable to lie down? Most common Inspect the mouth look for Rapid screening tests: influenzae type b, age 2-5. inflammation of the ulcers. throat swap for strep mucosa of the antigens. If positive: tx, if oropharynx. Less negative: throat culture. Have you been restless, unable to stay still? Peritonsillar abcess also needs immediate Inspect the posterior commonly a symptom of a Monospot is a rapit slide referral (sx of this and cellulitis are severe pharynx and observe systemic illness (i.e. swallowing: grade tonsils test that detects Have you been unable to carry on a conversation? sore throat, odynophagia, trimsus (diff mono). Classified as heterophil Ab opening mouth), medial deviation of the (1: behind pillars, 2: those with ulcers and soft palate, and peritonsillar fold.) between pillars and uvula, agglutination, not specific those without. Make sure for EBV 3: touching uvula, 4: you idetify group A Bbeyond midline). hemolytic strep (GABHS) Is the sore throat related to an infectious cause? Do not examine the due to sequelae parynx if you suspect epiglottitis (may Is anyone else at home sick? Increases likelihood of bact/viral infxn Culture - "gold standard" precipitate obstruction). for GABHS. Can confirm Beyond midline: gonorrhea Are any of your friends or co-workers sick? peritonsillar abscess. Grey When did the pain start? Sudden onset of sore throat is caused by exudate: diptheria. Yellow GABHS. Gradual onset is mono. In viral exudate: GABHS. pharyngitis sore throat is a day after other sx. Noninfectious - insidious onset. How severe is the pain? Strep infxn pain is intense. Influenza/ "Doughnut lesions": red, ASO titer - for enzyme adenovirus throat is severe with edema. raised hemorrhagic lesions streptolysin. Detects Noninfectious "scratchy or annoying" with yellow center are previous strep infection. diagnostic for GABHS Does not aid in diagnosis What does the presence of fever tell me? but in associated Have you had a fever? Present with GABHS (38.5C, malais, HA Palpate the cervicofacial infections (e.g. rheumatic and painful swallowing) and epiglottitis. lymph nodes: anterior fever) Adenovirus has high fever (more than 40C) enlarged in strep, posterior if viral . Cardinal sign of mono. When did it start? Fever that recurrs may indicate peritonsillar CBC with diff - 50% abcess. lymphocytes and 10% atypical lymphocytes How high has it been? Inspect the nasal confirms mono mucosa: red, swollen What does the presence of upper respiratory indicates infection. Pale, symptoms tell me? Do you have a cough? Presense of these 2 are rare with strep and boggy indicate allergy. CT scan - obstruction or suggest viral infection. Influenza is assoc Purulent discharge: swelling Have you had a runny nose? What color is the sinusitis with several days of fever, cough and drainage? Do you have mucus dripping from the back of your rhinorrhea. Clear nasal discharge common Inspect the conjunctiva: Nasal smear - presence to allergic pharyngitis. nose and down your throat? red may indicate of eosinophils on a nasal pharyngoconjunctival fever smear stained with Do you have any eye redness or discomfort? Rare with strep, common to viral or caused by adenovirus. Non Wright's stain suggest allergies purulent discharge. Watery allergic, inflammatory Have your eyes been itchy or watery? discharge: allergic process Have you had any hoarseness? Viral or allergen exposure. Have you been sneezing? Viral or allergen exposure, can be seasonal. What do associated symptoms tell me? Inspect the tympanic membrane - can have Do you have muscle aches? Myalgia common in GABHS, influenza. nontypical H. influenza Have you had any nausea, vomiting, or diarrhea? AOM Does the presence of risk factors help me to Palpate the thyroid narrow the cause? acute thyroiditis How old are you? GABHS is usually 5-15 years. Rare under Inspect the skin - scarlet 3. Influenza is all ages. Parainfluenza, fever has maculopapular adenovirus and RSV is in children. Mono in erythema that spares teenagers. palms and soles What is your smoking history? Musocal irritations What kind of work do you do? Irritants: working outdoors, housekeepers Auscultate the lungs (chemicals) could be mycoplasma pneumoniae in Do you engage in oral sex? Pharyngitis from chlamydia trachomatis adolescents (adventitious) and neisseria gonorrhea

Sore Throat

Have you been drooling? Have you been unable to swallow?

Are you taking any medications?

Immunosuppression seen with meds

Do you have any chronic health problems? Are your immunizations up to date?

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Palpate the abdomen splenomegaly in mono

Sore Throat DDX: Sore throat, difficulty with secretions, odynophagia Pharyngitis without ulcers: (seen in pediatric patients >2), unable to lie flat, Epiglottitis cannot talk

Respiratory distress, drooling, toxic appearance; Refer immediately DO NOT EXAMINE PHARYNX

Peritonsillar/ retropharyngeal History of recurrent tonsilitis; sore throat, difficulty abscess swallowing, respiratory symptoms, fever, malaise

Orthopnea, dyspnea, asymmetrical swelling, abscess, trismus

Rever immediately; CT scan; head and neck radiographs; laryngoscopy

Viral pharyngitis

Scratchy, sore throat, malaise, myalgias, headache, chills, cough, rhinitis

Erythema, edema of throat, tender posterior cervical nodes

None

Group A B-hemolytic streptococcal pharyngitis

Most common in persons 5-15 years; known exposure; fall/winter season; sudden onset of fever, severe sore throat, and malaise; absence of cough and upper respiratory symptoms

Temp >38.5C (101.5 F); exudate; anterior cervical lymphadenopathy

Positive rapid strep antibody screen, strep culture

Mononucleosis (EBV)

Young adults; slow onset of malaise, low-grade +/- pharyngeal exudate, palatine petechiae, temperature, mild sore throat posterior cerv LN, splenomegaly History of orogenital sexual activity; may be Pharyngeal exudate; bilateral cervical asymptomatic lymphadenopathy Exposure to irritants; postnasal drip; allergic symptoms Sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy

Gonococcal pharyngitis Inflammation

Positive monospot; CBC with differential >50% leukocytes Gram stain; gonorrhea culture Eosinophils in nasal secretions with allergies

Pharyngitis with ulcers: More common in children; immunosupressed; painful Lymphadenopathy; small greyisk papulovesicular Serology Herpangina (coxsackie virus) throat; fever, malaise lesions of the soft palate and pharynx, progressing to shallow ulcres, <5mm Fusospirochetal infection (Vincent's angina)

Poor oral hygiene; painful ulcers, foul breath, bleeding Gray necrotic ulcers without vesicles on the gums ginigcal margins and interdental papillae

Gram stain reveals spirochetes

Apthout stomatitis

Oral trauma, ill-fitting dentures; painful ulcers vary in size; absence of other symptoms

None

Herpes simplex infection

History of trauma to the mucosa; pain, fever, headache Immunosuppressed; persons on antibiotics or with diabetes; sore mouth/throat

Candidiasis

Shallow ulcers, no vesicles; indurated papules that procress to 1cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes Perioral lesions; lymphadenitis; vesicles on palate, pharynx, gingiva Curdlike white plaques that bleed when scraped off

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Viral culture KOH smear shows hyphae; culture

Nasal Symptoms and Sinus Congestion

What are the primary symptoms that will help me narrow the possibilities? How long have these symptoms been present? Acute symptoms with fever/chills: acute infectious rhinitis Do you have a history of nasal or sinus problems? Chronic: rarely infectious, associated with anatomical abnormalities that impair the sinus drainage system Do the symptoms occur at any particular time of the Allergic rhinitis if with sneezing, wheezing, year or season? itchy/burning eyes that are seasonal. IgE response. Early spring (tree pollens), early Is there a family history of allergies or asthma? summer (grass), early fall (weed pollens) Do you have other symptoms? If I suspect sinus problems, what do I need to Maxillary: toothache. Frontal: frontal know? headache worse on wakening. Ethmoid can refer to the vertex, forehead, occipital Do you have a history of sinus problems? or temporal regon. Sphenoid: top of head. Do you have pain? Please point to the areas.

Perform a general inspection Take vital signs: acute viral rhinitis or acute sinusitis may be afebrile.

Nasal smear eosinophils confirms allergic rhinitis

Inspect the face: children with chronic allergic condition have an allergic "salute" (crease on nose from wiping), allergic "shiners" are dark circles under eyes from venous congestion/stasis.

CT Scan

Do your symptoms change with position changes?

Sinus radiographs for severe/chronic sx

MRI Sinus aspiration - the only way to confirm diagnosis of bacterial sinusitis

Maxillary sinusitis: worse with bending or Periorbital cellulitis is the Allergy skin testing leaning forward. Postnasal discharge most common serious worse with lying down with sinusitis complication of severe bacterial sinusitis. How long have you had these symptoms? Children: chronic sinusitis is >30 days Do associated symptoms provide any clues? Acute bacterial infection: purulent nasal Perform a regional discharge. Acute rhinitis: bacterial or viral examination of the head and has fever, myalgia, chills. Sinus and neck: eyes (visual complaints: pressure/pain of the cheeks, acuity), ears, LN. forehead, behind eyes. Do you have other acute symptoms such as cough, Acute sinusitis: <30 days, persistent cough, Examine the mouth and fever, or muscle aches? fever >39C for 3 days, malodorous breath. teeth: look for abscesses, MC maxillary and ethmoid sinuses, dental root infection. occasionaly frontal and rarely sphenoid Erythema of tonsils in acute viral rhinitis. Do you have other chronic symptoms, such as eye Seen with chronic sinusitis, not bettwe with pain, bad breath, or fatigue? meds. Is it viral or bacterial? Test for smell severe nasal congestion or What color is your nasal discharge? Yellow or green purulent is viral or ethmoid sinusitis causes bacterial. Watery/clear is allergic. anosmia How long have you had these symptoms? URTI is 5-10 days then subsides Are the symptoms unilateral or bilateral? Is it on Infectious/allergic: bilatral. Unilateral are Inspect condition of one side or both? MC anatomical cause: polyps, septal dev, nasal mucosa and foreign body. turbinates Are there risk factors that will narrow the Smoking has inc risk of sinusitis: more Inspect for masses: nasal diagnosis? mucus and paralysis of the nasal cilia. Risk polyps look like skinned for upper and lower resp tract infections grapes. Septal deviation Do you smoke? predisposes to infection. Are you exposed to others who smoke? Do you have any other health problems? Have you had a recent history of head or facial Rare but serious post-trauma CSF trauma? rhinorrhea may be present. Have you been diving or swimming? Secondary to barotrauma, infection from Note the presence and contaminated water, or allergic response to color of any discharge chlorine pus in middle turbinate suggests bacterial sinusitis. Have you been exposed to infections in day care, CSF drainage will increase school, or work settings? in forward position Are you pregnant? Hormonal changes may lead to nasal congestion Is the patient using any drugs that would cause nasal congestion? Are you using nasal sprays or drops?

Transilluminate the sinuses - complete opacity suggests infection

Do you use cocaine or other drugs? What medications are you taking?

Palpate and percuss fornal and maxiallry sinuses for tenderness

Use for more than 1 week can lead to rebound nasal congestion. Also rebound nasal congestion BCPs, ACE inhibitors, B-blockers may cause nasal congestion Is there a systemic disease present? Cystic fibrosis can cause dec mucociliary Have you noticed any other general body symptoms? clearance. Also: diabetes, leukemia, AIDS, hypothyroidism, acromegaly, horner's syndrom, neoplasm can cause nasal sx. Do you have any chronic health problems?

Test for facial fullness and pressure - bending forward from the waist or valsalva will worsen sumptoms of a partial or complete sonus obstruction Examine the lungs Perform neurological testing if indicated severe complications from sinusitis - brain anbscesses

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Nasal symptoms DDX: Infectious rhinitis Allergic rhinitis Nonallergic rhinitis Rhinitis medicamentosus

Perennial but more common in winter months; recent Red, swollen mucosa; purulent discharge URI Family history of allergies; sneezing; recurrent pattern; Pale, boggy mucosa; rhinorrhea with clear, more common in children and young adults watery mucus No allergenic cause identified Similar to allergic rhinitis

Nasal smear for neutrophils, intracellular bacteria Nasal smear for eosinophils; allergy testing Absence of eosinophilia on nasal cytology

History of medication use: oral contraceptives, nasal sprays, antihypertensives; nasal congestion Smoker; recent URI; winter months; frontal headaches made worse with forward bending; sensation of fullness or pressure

Sollen mucosa; clear mucus or dry mucosa

None

Purulent discharge; maxillary toothache on percussion; postnasal drainage; decreased transillumination

None

Chronic sinusitis

History of previous sinus infections; dull ache or no pain; persistent symptoms

Same as above; decreased or no transillumination; obstruction such as deviated septum, polyps

Sinus radiographs; CT scan; sinus aspiration and culture

Obstruction

History of asthma, aspirin intolerance; foreign body in Increased pain with forward motion or valsalva; children; tumor in adults' infeants with choanal atresia: pain with percussion and palpation of the difficulty feeding; cyanosis if bilateral sinuses; no transillumination; septal deviation

Sinus radiographs; CT scan

Nasal polyposis

History of asthma. Aspirin intolerance.

Presence of polyps

May require biopsy

Osteomyelitis of the frontal bone

History of head trauma, diving

Appear severely ill; periorbital and fronal edema

Sinus and skull radiograph; blood culture

Acute sinusitis

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Non Emergent Chest Pain If acute ischemic heart disease is unlikely, other causes could be from pulmonary, GI, psychological, musculoskeletal, or pericarditis Many causes of noncardiac chest pain relate to anatomy. In children, costochondritis is most common and respiratory conditions associated with cough

First, is this a life threatening condition? Can you describe the pain? What does it feel like? E.g. dull, sore stabbing, burning, squeezing?

When did it start? What were you doing when it started? How long have you had the pain? What other symptoms have you noticed?

Does the patient have risk factors for CAD? How old are you? Do you smoke? Do you have high BP, diabetes, or heart dz? Do you have a history of MI? Has anyone in your family had a heart attack or stroke before age 60? If this is not a life-threatening condition, what does a description of pain tell me? Is the pain acute or chronic?

Substernal heaviness, pressure or squeezing provoked by exertion is anginal. Tearing pain is aortic dissection. PE: gripping, stabbing over lung. Sudden onset and dyspnea is with PE. Pneumonia is more gradual. Determine if it is exercise related Chronic pain is less likely to have a cause MI: n/d/v SOB, syncope. PE: SOB, apprehension, hemoptysis. Fever, cough, think sputum in pneumonia. Major risk factors for CAD: smoking, HT, low HDL, family history, age (men >45, women >55)

Observe general appearance. MI: diaphoretic, pale, anxious. PE: anxious, cyanotic. Rib fx: shallow breaths.

ECG - good to compare previous ECG's. ST elevation means injured myocardium. T wave inversion: ischemia.

Measure vital signs and respiratory patterns Aortic dissection: hypotension and unequal pulses.

Treatmill exercise testing - tests risk of severe CAD

Inspect the skin. Cool, pale, moist skin in MI, PE, or aortic dissection. Look for herpes zoster. Bruises. Look for central cyanosis.

Palpate trachea and chest - pneumothorax. Palpate for tenderness, depressions, buldges. Costochondritis is pain What were you doing when the pain first occurred? where bone meets Emergent chest pain: Point to where the pain is located. Does it spread to Localized pain is more likely non-emergent. cartilage. constricting, squeezing, any other part of your body? burning, heavy. It What seems to trigger the pain? Percuss the chest radiates. Does the pain awaken you from sleep? Awakening because of pain signals more Auscultate breath serious problems such as cardiac sounds ischemia. Non emergent chest pain: What do associated symptoms tell me? Auscultate for dull or sharp. adventitious sounds Usually infection. Do you have a cough or a change in your usual Submammary and cough? hemothorax areas. Pain Do you bring up sputum? If so, how much and what Pneumonia sputum: green, rust color, or Auscultate heart sounds provoked by body colour? red. - MI cannot be ID'd movements or breaths Do you have a fever? May indicate pneumonia, myocarditis,PE Observe spine for evidence of scoliosis Are you lightheaded or dizzy? MC caused by structural heart disease, arrhythmias, and cornary insufficiency. MC benign in children - breathing difficulties. Do you feel like your heart is racing? Is the pattern of pain related to activity and position change? Describe your recent physical activities.

Have you had any injury to your chest? Does chest movement or position make the pain better or worse?

Chronic pain is rarely emergent. May be related to URTI or GERD.

Caffeine, stress, hormonal changes, mitral Examine abdomen valve prolapse, and drugs can cause auscultate, palpate for palpitations tenderness/masses.

Do you have blood in your stools? Have you vomited any blood? Could this pain be from a systemic cause? Do you have any skin problems? Do you have any chronic health problems?

Cardiac Engymes: CKMD rise within 4 hours of MI, peak at 24 hrs. Troponins T and I are predictive for future events. Remain elevated 7-10 days. Echocardiography Ventilation/ Perfusion Lung Scan - for PE Pulmonary angiography

Arterial Blood gases detect resp alkalosis from hyperventilation

Radiography pneumothorax and pneumonia

CT Scan MRI

Physical activities can cause muscle strains, rib fracturs, contusions. Decreased exercise tolerance: shunts, CAD, or arrhythmias. Investigate any episode during exercise.

Examine extremities: aPTT and PT for clubbing, cyanosis, pulses anticoagulant therapy (atherosclerosis, aneurysm)

Recent muscle strain, hemo/pneumothorax, rib fracture. Pain of cardiac origin, except pericarditis, is not affected by respiration. Sharp, pleuritis pain relieved by sitting up is pericarditis. Pain worse with movement over sternum: costochondritis.

Serum amylase and lipase - pancreas.

Is there a GI origin for the patient's chest pain? Does the pain get better or worse from eating?

Exercise myocardial perfusion imaging

Bronchoscopy Pain of esophagitis and cardiac origin are hard to ddx, both better with nitro. Esophagitis is associated with meals. Peptic ulceration. Pancreatitis has hypotension. consider herpes zoster: persistent unilateral pain thet is pruritis, burning, or stabbing. Local inflammation of muscles in polymyositis, fibromyalgia, or SLE. Sickle cell disease can cause chest pain. Marfan syndrom: inc risk for aortic dissection

What does family history tell me? Has anyone in your family had heart disease, chest Hypertension, hypertrophic pain, or sudden death from cardiac arrest? cardiomyopathy, CAD have strong family history. Has anyone in your family been born with heart problems? What is the emotional state of the patient? In the past 6 months, have you had a spell or an Panic disorder, anxiety, depression. May attack in which you felt frightened, anxious, or very have difficulty taking a deep breath. uneasy? Or has your heart begun to race, felt faint, or you could not catch your breath?

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CBC - elevated WBC's with infection Esophageal pH - for GERD Endoscopy

Nonemergent Chest Pain DDX: Stable angina

Substernal chest pressure following exercise or stress Normal examination; possible transient S4 and relieved by rest or nitroglycerin; nausea, SOB, diaphoresis, sternal chest pressure

ECG during episode of chest pain

Myocarditis

Chest pain; history of fever, dyspnea

Heart murmur, friction rub, fever

ECG, chest radiograph

Pericarditis

Sharp, stabbing pain referred to left shoulder or trapezius ridge, usually worse during coughing or deep breathing; may be relieved by sitting forward; history of viral or bacterial infection, autoimmune disease

Fever before onset of pain, tachycardia, pericardial friction rub

WBC, ESR, ECG, chest radiograph

Aortic stenosis

Chest pain on exertion, subsernal and anginal in Radial pulse diminished; narrow pulse pressure; Echocardiogram, ECG, chest quality; fatigue, palpitations, DOE, dizziness, syncope loud, hars, crescendo-decresc murmur heard at radiograph 2nd R ICS leaning forward; thrill

Mitral regurgitation

Exertional chest pain, fatigue, palpitations, dizziness, Holosystolic, blowing, often loud murmur heard at Chest radiograph, ECG, DOE, syncope apex in L lateral position, which dec on echocardiogram inspiration; murmur may radiate to the axilla and possibly the back

Pnemonia

Productive cough of yellow or green or rust sputum; dyspnea; pleuritic pain

Fever; tachycardia, tachypnea; inspiratory crackles; vocal fremitus; percussion dull or flat over consolidation; bronchophony. Egophony

Chest radiograph; sputum cultures; ABGs

Mitral valve prolapse

Chest pain, varies in location and intensity; palpitations; anxiety; non-exertional pain of short duration, history of Marfan's syndrome Mild, localized chest pain, worse with deep breathing; recent URI

Dysrhythmias, possible midsystolic click over apex, hear best sitting or squatting; thoracoskeletal deformity common in children Shallow respirations, local tenderness, pleural friction rub

ECG, echocardiogram

Esophagitis

Substernal pain worse after eating and lying down; sour taste in mouth

Epigastric pain with palpation

Esophageal pH

Chest trauma (rib fracture)

History of injury or trauma; pain with deep breaths; splinting of chest wall Pain along sternal border, increases with deep breaths, distory of exercise, URI or physical activity

Shallow respirations; chest wall pain on palpation Chest radiograph

Pleuritis

Costochondritis

Herpes zoster Peptic ulcer disease Cholecystitis

Acute pancreatitis Lung tumors

Cocaine use

Pain with palpation over costochondral joints; normal breath sounds

Unilateral chest pain; painful rash

None initially

None

Normal breath sounds; vesicular rash along dermatome Epigastric pain 1-2hrs after eating, > antacits; Tenderness to palpation in the epigastric area; hematemesis and melena. Risks: smoking, alcohol signs of hypovolemia Right upper quadrant abdominal pain radiating to the Positive Murphy's sign; palpable gallbladder right chest, often following high-fat meal; nausea and vomiting

None

Severe left upper quadrant abdominal pain radiating into the left chest; pain worse supine; n/v, fever Chest pain, SOB, cough, hemoptysis, history of cigarette smoking; history of pneumonia

Serum amylase. Pancreas ultrasound or CT scan. Chest radiograph, CT scan of the chest, bronchoscopy

Left upper abdominal pain with palpation; hypotension Normal exam or diminished breath sounds over tumor and dull percussion over tumor

Upper GI radiograph, upper endoscopy, CBC Gallbladder ultrasound

Chest pain, SOB, diaphoresis, nausea; may relate to Tachycardia, hypertension substance use Precordial chest pain, history of stressful situations Normal exam

ECG, serial cardiac enzymes, drug screen ECG, chest radiograph

Pleurodynia

Severe, acute onset, stabbing, paroxysmal, pleuritis pain over lower ribcage and substernal edge; headache, malaise, nonproductive cough

None

Precordial catch syndrome

Sudden sharp not distressing pain near apex of heart; Normal examination seen in adolescence

Psychogenic origin

Pleural friction rub 25% of time; chest examination normal; fever usually present

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None

Is this a medical emergency?

Dyspnea

assess adequacy of the airway

Did this come on suddenly, or has it been New-onset acute may be an emergency developing gradually? Over what period of time did it such as: foreign body, anaphylaxis, PE, develop? pneumoT What were you doing before having difficulty breathing? Do you have other symptoms, such as itching or swelling?

Rule out epiglotitis in children: drooping, dysphonia, looks toxic. Anaphylaxis from insect bites or ingestion of potential allergins (meds, food)

Is the dyspnea caused by secondary obstruction Obstruction may be intraluminal (foreign in the lower respiratory tract? body, asthma), intramural (edema, Have you had a cough or cold symptoms recently? bronchiolitis), extramural (compression from tumor, lymph nodes) Do you have a history of asthma? Is there a family history of asthma? Is the dyspnea caused by trauma to the chest? Have you experienced trauma to the chest? limitation of movement of thoracic cage Is the dyspnea caused by a pulmonary embolus? Risk for PE: >60, pulmonary HT, CHF, chronic lung disease, ischemic heart Have you been confined to bed recently? Had recent disease, stroke, cancer. Also: 1) venous stasis, 2) hypercoagulability, 3) endothelial surgery? Had a recent fracture? injury. MC after prolonged immobility, Are you taking BCPs? Do you smoke? trauma to leg. Do you take any other medications? Are you feeling anxious or scared? People with PE feel a sense of impending doom. May be caused by O2 depletion Is the dyspnea related to a preexisting disease? CAD, valvular disease, CopD, or asthma can cause dyspnea. Also MI. Also things that dec oxygen capacity of blood (e.g. Do you have a history of heart problems? Lung anemia) problems (asthma)? Anemia?

Note general appearance Transcutanous pulse and observe posture: oximetry respiratory distress? Chest radiography

Electrocardiography Assess level of consciousness

Echocardiography

Observe chest movement: PE and pneumothorax have unequal expansion

Hemoglobin and Hematocrit anemia Spirometry: in COPD, FEV1 and the ratio are dec. In restrictive lung disease (pneumonia, pnumothorax, pleural effusion) FVC is reduced and ratio is normal or elevated

Inspect shape and symmetry of chest: kyphosis & scoliosis can cause dyspnea. Inc AP diameter in COPD (air trapping)

Look for retractions CT Scan contractions of intercostals Pulmonary angiography Observe rate, rhythm and for PE depth of respiration for 1 full minute - expiration longer in COPD. Tachypnea: resp distress.

CBC with diff for bacterial infection BUN and creatinine for renal function ABGs

Listen for stridor inspiratory airway obstruction Do you have any numbness or tingling in your body? Hyperventilation syndrome: nonemergent. Listen for audible wheeze Sputum culture Where? Paresthesias around mouth and distal and voice changes extremities. Have you noticed any other symptoms? > rest if lung/cardia orgin. < rest if from Take pulse, temperature, anxiety and blood pressure. What factors precipitate or aggravate dyspnea? Smoking most frequently causes chronic Palpate pulses. dyspnea. COPD > rest. What activities are associated with SOB? Inspect oral cavity foreign body. Do you take any prescription medication? Do you have any known allergies? Trees? Dust? Associated with asthma. Inspect the nose Pollen? Animals? Have you been exposed recently? patency and flaring Is there anything that makes your SOB better? Sit up? Stay indoors? Lie down? Use meds? Is the dyspnea caused by a neuromuscular problem? Are the patient's immunizations up to date? Child: has the infant had honey? Do you live on a farm? Child: are they at risk for lead poisoning? Do you have a headache, muscle weakness, or visual changes? Does the patient have any pertinent risk factors that will point me in the right direction? Do you or have you smoked? Are you exposed to cigarette smoke frequently? What type of work do you do? Have you had recent weight gain? Have you ever had eczema?

May result in paresis/paralysis of resp muscles. Can be caused by infections: poliomyelitis, tetanus. Botulism --> respiratory distress. Organophosphate chemicals can cause a myasthenia-like syndrome Could also be: meningitis, seizures, CNS lesion

Exposure to: asbestos, silicon, paint and chemical fumes, coal dust. Obese patients report SOB more frequently than their counterparts. Assoc with asthma

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Palpate the neck masses and trachea Examine skin and extremities: cyanosis, pallor (anemia), clubbing, peripheral edema, angioedema (allergy), cap refill, diaphoresis Palpate the chest Asses for vocal fremitus diminished in pneumothorax, asthma, emphysema. Inc in pneumonia, heart failure, tumor Percuss the chest Auscultate breath sounds Auscultate heart sounds

Dyspnea DDX: Emergent Conditions Pulmonary Embolus

Acute-onset dyspnea, cough, mild to severe chest Restlessness, fever, tachycardia, tachypnea, pain, sense if impending doom; hemoptysis; history of diminshed breath sounds, crackles, wheezing, DVT, recent surgery, oral contraceptive, smoker, pleural friction rub hyperco-aguability states

ABGs, chest radiograph, ECG, ventilation/ perfusion scan

Foreign body aspiration

Acute-onset dyspnea; history of eating or drinking Apnea or tachypnea, restlessness, suprasternal large amounts of alcohol; in children, history of putting retractions, intoxication, inspiratory stridor, small objects in the mouth; possible cough localized wheeze

Lateral neck radiograph, chest radiograph, bronchoscopy

Anaphylaxis

Acute-onset dyspnea; history of insect sting, ingestion of drug, or allergen Acute-onset dyspnea; sharp, tearing chest pain; pain may radiate to ipsilateral shoulder

None; emergency measures necessary Chest radiograph, ABGs

Pneumothorax

Angioedema, tachypnea, clammy skin, hypotension, bilateral wheezes, tachycardia Tachycardia, diminished breath sounds, decreased tactile fremitus, hyper-resonance of lung area affected; possible hypertension and tracheal shift Hoarse, seal-bark cough, fever (variable)

Croup

History of upper respiratory infection

Acute epiglottitis

Positional sitting forward; sore throat, anxious, toxic child

High fever, drooling, stridor, muffled voice

Bacterial tracheitis

Recent viral infection

Fever, stridor, purulent sputum

Status asthmaticus

Recent URI, exposure to allergins, breathlessness

Wheezing, coughing, tachycardia, tachypnea

Botulism

Honey ingestion in infant, contaminated food ingestion Hypoventilation, drooling, weak cry, ptosis, ophthalmoplegia, loss of head control

Nonemergent conditions: Pneumonia

Dyspnea, cough, sputum production (green, rust, or Fever, tachycardia, tachypnea, inspiratory Chest radiograph, sputum cultures, red), pleuritis chest pain, chills; in infants and children: crackles, asynchronous breathing, vocal fremitus, ABGs, WBC irritability and feeding problems percussion dull or flat over area of consolidation, bronchophony, egophony

Hyperventilation syndrome

Dyspnea, lightheadedness, palpitations, paresthesias Restlessness, anxiety, normal CV examination (perioral and extremities)

Chest radiograph

Laryngomalacia

Neonate, infant: history of stridor, history of URI

Inspiratory stridor; normal cough, cry

Refer for visualization of larynx

Vascular ring

Infant: dyspnea, brassy cough, difficulty swallowing

Inspiratory stridor with expiratory wheeze

Barium swallow, echocardiography

Heart failure

Chronic progressive dyspnea, cough, frothy sputum, fatigue, lightheadedness, syncope, weight gain, ankle swelling, palpitations, PND, orthopnea, hidsory of heart disease; in children, chronic progressive dyspnea, sweating above lip and forehead, expecially while eating

Altered level of consviousness, restlessness, ECG, chest radiograph, ABGs, jugular venous distention, tachypnea, use of echocardiogram accessory muscles to breathe, rales, rhonchi, wheezes, tachycardia, decreased peripheral pulses, cool extremities, desplaced PMI, S3, S4, ascites, liver enlargement

Anemia

Dyspnea on exertion, fatigue, palpitations, lightheadedness, history of chronic disease Dyspnea on exertion, weight gain, palpitation on exertion, sedentary lifestyle, cigarette smoker Dyspnea, paroxysmal cough, audible wheeze, history of asthma or allergies

Pallor, tachypnea, cool dry skin on extremities, possible orthostatis hypotension Overweight, tachycardia

CBC, iron studies

Restlessness, tachypnea, use of accessory muscles to breathe, intercostal retractions, decreased vocal fremitus, decreased breath sounds, inspiratory and possible expiratory wheezes

Spirometry, chest radiograph, ABGs

Chronic progressive dyspnea, dyspnea on exertion, persistent cough, minimal sputum, easy fatigue, history of smoking

Rapid shallow respirations, reddish complexion, Chest radiograph, pulmonary function test, exercise tests, ABGs increased AP diameter of thorax, use of accessory muscles to breathe, pursed lip breathing, decreased tactile fremitus, decreased respiratory excursion bilaterally, lungs hyperresonant, distant breath sounds, prolonged expiration, occasional wheezes, possible tachycardia, muffled heart sounds

Poor physical conditioning Asthma

COPD

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None initially; if respiratory distress increases, pulse oximeter and referral Admit; life threatening

Radiography of airway, WBC increased, tracheal culture Peak flows, chest radiograph, ABGs Pulmonary function testing, chest radiograph, fluroscopy, stool culture

Cardiac stress test

Amenorrhea

Is there a pregnancy?

Important to rule out pregnancy!

Are you sexually active?

Ask questions about having nonconsensual sex. Contraceptive failures may account for unintended pregnancy. Amenorrhea may occur after discontinuation.

Lack of menstruation that Are you using any birth control methods? may be a result of 1o or 2o causes. Are you trying to become pregnant?

Unintended or intended. Also may refer amenorrheic patient to infertility clinic.

Is this primary or secondary? Have you ever had a menstrual cycle?

Age range for menarche is 9-17yrs. If established menses (no outlet flow problem and HPO axis & endometrium functioning) at intervals of every 21-38 days then classification of secondary.

Have you started pubertal development? Can you show me how your breast and pubic hair look compare with these pictures? (see pics in book pg.314 3rd ed.)

Begins w/ growth spurt 1 yr before breast buds at ~11yrs. Pubic hair at beginning of menarche. Avg age for menarche 12 years 4months. Can look at peds growth chart to see if normal dev. Primary - lack of menses & 2o sex char. by 14 or lack of menses by 16 w/ 2o sex char. Ask about mother/sister's menses onset if delayed. Secondary - Absence of menses for 6 months or cycle > 35days.

At what age did you start you periods? When was your last normal menstrual period? What is the nature of your periods (amount of flow, frequency, duration)?

Are there any constitutional delays causing the amenorrhea? Has there been a change in weight, % body fat, or athletic training intensity?

Inc thyroid fxn - restlessness, diarrhea Dec thyroid fxn - constipation, fatigue

Could this be caused by hyperprolactinemia? Are you able to express a discharge or liquid from your nipples?

Thyroid stimulating hormone: Identifies hypothyroidism. Menses resumes w/ Assess nutritional status supplementation. and plot measurements on growth chart in Prolactin levels: fasting adolescents: under/ levels. overnutrition. Height, If high or galactorrhea weight, arm span. RO adenoma or illicit drugs. Screen for eating disorders: Anorexia or bulimia. Refer to DSM for criteria. Calculate BMI: 17% (19kg/m2) body fat needed for menses and 22% body fat for ovulation. BMI > 27% obesity = imbalance in HPO axis

Severe stress of anorexia can produce prolonged amenorrhea. Low body fat causes menstrual irregularity. Examine skin and hair: Obesity - sign of PCOS or cause of thyroid dysfxn, Cushing's, amenorrhea. androgen excess.

Stress can disrupt normal cyclic menses. Are you under unusual stress at school, home or work? Do you or anyone in your family have any congenital Turner's syndrome- abnormality of disorders or chronic diseases? components necessary for menses. Structural anomalies - prevent outflow. Anorexia, DM, Crohn's, SLE, GN, CF, pituitary adenoma, adrenal diseases & thyroid dysfxn. Could this be a thyroid dysfunction? Have you noticed changes in the texture of your hair Hyperthyroidism - heat intolerant or skin? Hypothyroidism - cold intolerant Are you bothered by hot or cold temperatures? Have you had any changes in your energy level / bowel function?

Note general Pregnancy Test: rule out appearance: short stature, pregnancy. under/overweight.

Nipple d/c not associated with breastfeeding or medications (dopamine antagonists/ estrogens).

Serum Follicle Stimulating Hormone: Inc FSH = ovarian failure w/ low E2 FSH & LH > 50, primary ovarian failure. Low FSH = hypothalamicpit. Dysfxn & 2o ovarian failure.

Perform head & neck exam: visual changes, webbed neck, lowset ears. Serum LH: LH:FSH > 2:1 suggestive of PCOS, >3:1 diagnostic.

Palpate thyroid gland and CNS Imaging: If both lymph nodes: FSH, LH low indicative of enlargement, bruits, pituitary problem. Use lymphadenopathy. contrast CT or MRI to determine ABN. Perform breast exam: sexual maturation level, axillary hair, galactorrhea.

Perform pelvic exam: maturation of female genitalia, secondary sex characteristics. Is there increased stimulation to your nipples? Galactorrhea - from clothing irritation, Absence of vagina, cervix sexual activity, LN dissection, herpes Have you had any surgery or disease of the breasts or uterus. zoster or chest wall? Outlet problems, assess vaginal walls. Could the hyperprolactinemia be caused by Meds such as phenothiazines or Bimanual examination medications? contraceptives cause amenorrhea (inc prolactin, induce estrogenic effect, toxic to enlarged ovaries, position/size of cervix / ovaries) What prescription medicines are you taking? Heroin and methadone lead to menstrual uterus. Have you used any street drugs? What kind of drugs abnormalities. have you used? Is a pituitary tumor causing the amenorrhea? Have you experienced any visual changes? Hyperprolactin state - pituitary tumor --> may cause headache, visual defects (optic Are you having an increased number of headaches? chiasm & nerves compressed)

Pelvic U/S & Vaginal U/S: presence of uterus & size, endometrial thickness, fibroids, tumors, cysts.

Progesterone Challenge Test (Prog. Withdrawl Test): administer progesterone (oral/IV). If +ve patient will bleed, functioning outflow tract, intact HPO axis.

Is this a problem of the HPO Axis? Have you experienced any problems with infertility? Main cause = failure of ovulation. PCOS b/w ages 15-30. Do you have excess hair on your face or chest?

50% of women w/ PCOS are hirsute & obese, difficulty conceiving. LH elevated. Androgen excess - truncal obesity, acne, male pattern baldness Are you having menopausal symptoms (Hot flashes, Estrogen deficiency - menopausal sx. May vaginal dryness)? see dyspareunia, dysuria. Prolonged may lead to osteopenia. Did you hemorrhage during childbirth? May lead to amenorrhea - Sheehan's syndrome. Is this a problem of the uterus? Endometriosis, incomplete abortion, or aggressive curettage of uterus can lead to Have you had a miscarriage or abortion, uterine infection, or any surgery or procedure involving your denuding of endometrial layer, scarring & Asherman's syndrome. uterus? What symptoms support a structural outflow problem? Do you have a cyclic abdominal bloating or cramping? Have you been amenorrheic since you had a cervical procedure?

Incomplete outflow tract (imperforate hymen/ cervical os) - dysmenorrhea w/ absence of menses Stenosis of cervical os - can occur after surgeries (cervical biopsies)

Estrogen & Progesterone Challenge test: +ve if flow w/in 27days, indicates inadequate estrogen production.

Chromosome Analysis: abnormalities in development.

Endrometrial Biopsy Basal Body Temp. Charting Progesterone Levels Maturation Index

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DDX: AMENORRHEA Pregnancy

Breast tenderness, morning sickness, urinary frequency.

Constitutional Problems: Delayed puberty

No menstruation at age beyond 16 years; more than 5 Breast stage 1 persists beyond age 13.4; pubic years b/w initiation of breast growth and menarche. hair stage 1 persists beyond 14.1.

Prolactin normal; TSH, T4 normal; CBC, UA normal; chemistry profile normal; bone age normal; skull radiograph normal

Anorexia nervosa / bulimia

Mean age 13-14; fear of being fat; low self-esteem; depression; isolation; overachiever; food is a parental battleground; preoccupation; hair loss; abdominal bloating, pain, constipation.

Amenorrhea before or after weight loss; cachexia; low body fat; short stature; yellow, dry, cold skin; acrocyanosis; increased lanugo hair; hypotension, systolic murmurs, often mitral valve prolapse.

TSH normal; prolactin normal; FSH & LH usually low; glucose normal; ECG: bradycardia, low-voltage changes, T wave inversion and occasional ST depression.

Exercise Induced Amenorrhea Began athletic training at young age; more common w/ long distance runners, ballerinas, gymnasts.

BMI < 17% body fat

TSH normal; prolactin normal.

Congenital or Chronic Disorders: Turner's syndrome

Congenital; short stature; infantile sexual development.

Characteristics: webbed neck, low set ears, shieldlike chest, short fourth metacarpal

Karyotype (45,X)

Cushing's syndrome

Weight gain; weakness; back pain

Thyroid dysfunction

Hypothyroid: delayed growth, weight gain, fatigue, constipation, cold intolerance; hyperthyroid: wt loss, nervousness, heat intolerance

Moon face, acne, hirsutism, purple striae of abdomen Hypothyroid: dry skin, fine hair, galactorrhea; hyperthyroid: moist skin, hyperpigmentation over bones, thin hair, goiter

Cortisol increased; 17-ketosteroids increased; CT adenoma Hypothyroid: TSH high; Hyperthyroid: TSH low; T3 high; T4 high

Polycystic Ovary Syndrome

Infertility

Hirsutism; obese; enlarged ovaries

Uterine and Outflow Tract Problems: Imperforate hymen/ stenotic cervical OS

Monthly bloating, cramping and pelvic pressure; no menses; cryotherapy or other procedure to cervix

Fibrotic hymen without patent opening; stenotic cervical os

U/S: enlarged overies w/ multiple fluid filled cysts; Testosterone high. Clinical diagnosis by history and findings

Asherman's syndrome

History of uterine infection; tuberculosis, Pelvic exam normal schistosomiasis; uterine iatrogenic scarring; curettage, irradiation

PCT negative; E and PCT negative; hysteroscopy adhesions

Hypothalamic-pituitaryOvarian Axis Problem: Menopause

Hot flashes, night sweats, insomnia, mood changes

Pale, dry vaginal mucosa; few rugae

FSH and LH high; estradiol low

Sheehan's syndrome

Recent history of postpartum hemorrhage and shock during delivery Breast nipple d/c; history of dopamine antagonists, estrogens, or illicit drugs; stimulation to nipples; exercise or sexual history of chest wall surgery or herpes zoster

Hair loss; depigmentation of skin; mammary and genital atrophy Nipple discharge: bilateral; multiduct; milky, clear or yellowish discharge

Pituitary and end-organ hormones low; hemoglobin low Wet mount or hemoccult of nipple discharge: -ve for RBCs; prolactin high; cone-down view of sella turcica; MRI or CT with contrast

Medications/ chest wall or nipple stimulation

Pituitary adenoma

Globular, enlarged uterus; soft, bluish colour cervix

Delayed puberty; history of visual changes, increasing Visual defects; galactorrhea headaches

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B-hCG pregnancy test positive; U/S positive.

Prolactin high; cone-down view of sella turcica positive; MRI or CT with contrast positive

Breast Lumps & Nipple Discharge

Is this lump likely to be malignant? How long has the lump been present? Is the lump changing (eg. Getting bigger, worse, more painful?) Is the lump in 1 breast or lumps in both?

Malignant lesion = single, hard, painless lump, unchanged by hormonal cycle, progressive increase in size Benign lump = unchanged, sometimes resolves w/in 2-3 menstrual cycles Malignant = solitary unilateral Benign = bilateral, identical quadrants

Inspect breast & nipples: arms at side, on hips, elevated above head, bending forward. Look for dimpling, asymmetry, inversion.

Ultrasound: differentiates solid from cystic. Mammography: for nonpalpable lesions

When was your last menstrual period?

Cyclic cysts less common after menopause Observe skin of breasts MRI: evaluates abnormal therefore warrant investigation. and nipples: erythema, lesions on mammogram, Peri/post menopausal at greater risk for prominent vessels, good for dense breast CA. eczema, pigmented lesions tissue Is there any discharge from the nipple? Ductal CA - nipple d/c w/ a lump (eg (Paget's), crack, exudate, Paget's - mass w/ bloody d/c.) retraction. 80-90% of breast lump Have you recently been treated for a breast Masses after ABC's suspicious for Fine needle aspiration found before diagnosis infection? malignancy & require biopsy. & Cytological Exam: Palpate breasts & through clinical breast differentiates solid vs. nipples: feel for lumps, Does the person have additional risk factors for Inc risk of malignancy if: exam. Risk of breast CA breast cancer? cystic (in-office) nodules, feel tail of - Hx of epithelial hyperplasia, ductal acceralerates after age Spence. carcinoma in situ (DCIS) or lobular 50. Nipple d/c associated Have you ever had breast cancer? carcinoma in situ (LCIS) Do you have a family history of breast cancer (first - tumors in adolesents more likely to be Palpate lymph nodes: Stereotactic or needle w/ pregnancy, breast feeding or estrogenic degree relative)? supra/infraclavicular, localization biopsy: for metastasis than primary tumor axillary. Note size, poorly defined masses meds. - 75% of all cases occur >50 yrs old Have you ever had ovarian, endometrial, colon, or consistency and mobility. - previous hx of breast biopsy for benign thyroid cancer? Do you have a family history of ovarian, endometrial, breast disease (LCIS) Assess nipple well: - genetic mutation (BRCA1, BRCA2 genes) depress nipple ino areola colon or prostate cancer? Core needle biopsy: for - Hx of CA (Ovarian, endometrial, colon, should move easily. difficult to palpate Have you ever received radiation to the chest or had thyroid) masses malignancy in childhood? Examine Nipple for - Family Hx (First deg. relatives) discharge: uni/bilateral, Is this condition more likely to be benign? single/multiple ducts, take Excisional biopsy: gold standard for masses. sample of d/c . How old are you? Fibrocystic breast changes b/w 20-30 Fibroadenomas b/w 15-39 Intraductal papilloma & ductal ectasia b/w 35-50 Breast carcinoma b/w 40-70 Have you had lumps before? Do you have a history Fibrocystic breasts - Painful, mobile lumps Transluminate breast Microscopy: of nipple of cystic breast changes or lumpy breasts? that increase in size & tenderness, discrete masses: solid mass will d/c reveals "fat cells" of borders changes correspond with not transluminate galactorrhea, leukocytes, menstrual cycle (malignant) RBCs. Does this lump feel like other lumps youve had? Do the lumps come & go or change with your periods? Have you ever had a mammogram or u/s? Why was it done? What were the results? Have you ever had a lump drained or biopsied? What was the diagnosis? Have you had breast implants?

Cyclical changes correspond w/ benign disease along w/ clear fluid aspirate from cyst. No changes of tissue on mammogram or U/S.

Ruptured implant pushes augmented breast tissue away from chest wall. Could this lump be mastitis related to lactation? Breast masses in lactating women usually associated w/ mastitis & a blocked duct. Usually caused by Staph aureus. Have you recently had a baby? CA in lactating women rare. Are you currently breast feeding/ suckling? Are your nipples sore, cracked or pierced?? May be site for infection Is your breast painful or hot? Areas of redness? Mastitis - painful, hot, red breast Inflammatory BR CA - swollen heavy, edematous breast (m/c in non lactating women) Have you had a fever? sign of infectious mastitis - associated w/ lactation & breast feeding Is this normal lactation? When was your last menstrual period? How frequent Fibrocystic changes manifest as are your cycles? spontaneous multiple duct d/c. Is it possible you are pregnant? What are you using Pregnancy - m/c cause of galactorrhea; for birth control? bloody d/c due to vascular engorgement When was your last delivery or miscarriage? How Normal lactation - milky, non purulent d/c long were you pregnant? Mastitis/ sub aerolar abscess - purulent d/c (DDx w/ inflammatory CA by use of ABCs) BCP - clear, serous or milky d/c Did you breastfeed? For how long? When did you Duct ectasia/ Papillomatosis - green/brown stop? d/c Is the nipple discharge clear or milky? Bloody d/c - benign or cancerous How long have you had the nipple discharge? Is the discharge related to high prolactin? What medications are you taking? Do you jog or run? If yes: Do you wear a sports bra? Do your nipples rub on your clothing? Are your breasts fondled, squeezed, or suckled during sexual activity? Do you have a thyroid condition? What medical / health problems do you have? If a newborn: has d/c been present since birth? Can nipple d/c be a sign of malignancy? Is the nipple d/c spontaneous or must it be expressed? Does it come from one or both nipples? Does it come from one or multiple nipple ducts? Do you also have a breast lump? Are you post menopausal?

New onset d/c requires further investigation. Discontinuation should elimate d/c Stimulation inc. PRL levels along w/ marijuana.

responsible for galactorrhea (eg. hypoT, pit. Adenoma, Cushing's, cirrhosis) Witch's milk - effects of maternal estrogen Spontaneous - concerning, lactation, systemic Unilateral spontaneous d/c - intraductal papilloma or CA Unilateral - ass. w/ intraductal papilloma / CA Single duct w/ intraductal papilloma / CA May be benign or malignant. Futher investigate. Higher incidence of CA

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Characterize lump: depth of lesion, contour, shape, Cytological smear: may flutuation, firmness, expose cancerous cells mobility. Ductography: for the cause of nipple d/c Serum PRL levels: elevated can produce d/c Thyroid functioning test: TSH high in hypoT cause of hyperprolactinemia

DDX: BREAST LUMPS & NIPPLE DISCHARGE Usually older than 35; unilateral new lump Single Breast Mass: Cancer

Single, hard, nontender, fixed lump; borders irregular or not discrete; may be erythema, dimpling, increased vessel patterns; may have nipple discharge

Diagnostic mammogram; ultrasound; tissue biopsy

Cysts

Younger age, often younger than 35; often multiple

round or elliptical; soft or fluctuant; mobile

Clinical exam; FNA:Clear aspirate; mammogram; U/S: cysts

Fibroadenoma

Common in adolescence

Single, sharply circumscribed mobile lump

Diagnostic mammogram; ultrasound; biopsy

Abscess

History of mastitis

Biopsy

Fat necrosis Lipoma

May have history of injury at site May have others on arms, trunk, buttocks, or back; usually nontender

Single mass; irregular shape; chronic abscess may be nontender Single, fixed and often irregular tumour Single tumours; smooth, well-defined; fluctuant consistency

Tuberculosis

History of Tb, Positive PPD, or chest radiography; immunocompromised patient status

Single; irregular shape; nontender

Biopsy

Ruptured implant

History of augmentation; change in shape or size of breast

Nodule palpated best when patient is sitting

Diagnostic mammogram; U/S; MRI

Primigravidas more often than gravidas; >1wk after delivery; breast feeding; tender nipples

Red, warm, tender; usually unilateral, one fourth Culture positive for S. aureus, E. of breast, or one lobule; breast engorgement; Coli, Strep; Elevated WBCs fever; nipple discharge: pus

Biopsy Biopsy

Inflammatory Breast Mass: Mastitis and acute abscess

Inflammatory Breast cancer

History of mastitis or inflammory process of breast Entire breast swollen; fever rarely present; axillary lymphadenopathy Multiple or Bilateral Breast Lumps: Fibrocystic breast changes Multiple breast lumps of both breasts; cyclic changes Bilateral nodularity; dominant lumps; tender, that worsen at time of menses mobile Nipple Discharge: Intraductal Papilloma Fibrocystic breast changes

Bloody nipple d/c; usual age is 40-50yr

Unilateral; subareolar

Biopsy

FNA; Ultrasound; Mammogram

Diagnostic mammogram; ductogram

Milky nipple d/c; cyclic changes that worsen at time of Spontaneous, clear or milky, bilateral, multiduct menses nipple d/c; multiple breast lumps Green nipple d/c Greenish or brownish nipple d/c

Diagnostic mammogram; ductogram

Neonatal Discharge (Witch's milk) Hyperprolactinemia

Milky d/c 1-2 wk after birth

None

Male Breast Disease: Acute Mastitis

Hx of clothing rubbing nipple (eg. Jogging); swelling or Red, warm, tender; usually unilateral, one fourth Culture positive for S. aureus, E. lump of chest wall; tenderness of site of breast, or one lobule; breast engorgement; Coli, Strep; Elevated WBCs fever; nipple discharge: pus

Cancer

Family Hx of male breast cancer; painless lump of chest wall

Duct ectasia

Milky or clear nipple d/c; amenorrhea; Hx of meds: estrogenic, dopamin depleters;hypoT; pregnancy; postabortion; nipple stimulators; visual changes

Enlarged breast tissue, milky d/c lasting 1-2 wk after birth Spontaneous, unilateral or bilateral, multiduct; clear or milky nipple d/c

Induration, retraction of nipple or mass in nipple well; fixed, nontender; lymphadenopathy

Page 14 of 52

Diagnostic mammogram; ductogram

Serum Prolactin levels; MRI if indicated

Mammogram; FNA; tissue biopsy

Diarrhea

What does this px mean by "diarrhea"? How frequent is the stool? What is the volume of stools?

Most cases are of viral origin and are self-limiting. Osmotic/ malabsorptive: nonabsorbable water Are the stools formed or liquid? soluble solutes. Secretory: At what intervals does the diarrhea occur? imbalance b/w fluid secretion & absorption. Exudative: mucosal Is this an infant, is there risk of dehydration? inflammation or How many wet diapers has the child produced in the ulceration. past 24 hours? Does the infant seem thirsty? Does the child have tears when crying? If this is an adult, is there risk of dehydration? How many times have you urinated in the past 24 hours? Are you thirsty? Do you have a dry mouth or dry eyes? Is this an acute or chronic problem? How long have you had diarrhea? Have you had this problem before?

Typical 1-3x/day to 2-3x/week. SI - large volume watery, infrequent, no urgency, intolerance LI - usu bacteria induced inflammation, less watery, mucous, colon CA, IBS Malabsorption - continous / intermittent loose IBS - alternating constipation / diarrhea Dehydration = < 6 wet diapers/24hrs or >4hr without urination Increase thirst, irritability, crying = DeH2O Mild dehydration - tears present; modsevere - no tears present

Inspect General Appearance

Assess hydration status: increased thirst, rapid pulse, dry mouth, decreased urine output, Fecal occult blood turgor & mobility, fontanel, testing: RBCs indicate peripheral perfusion bacteria or protozoa Temperature: elevated increases water loss Fever > 37.8C Weight: note wt loss failure to thrive, malabsorption, etc.

Observe abdominal contour: distension Related to rate of fluid loss Auscultate Abdomen: Ss/Sx: thirst, dry mouth, dry eyes, detect presence of bowel frequency & volume of urination, weakness sounds

Acute adults: infectious cause(viral), self limited, <2wks Acute children: loose/liquid d/t infection or congenital anomaly Chronic Adult: >2wks, parasites, meds, Does the presence or absence of blood help me IBS, lactose, IBD narrow the cause? Chronic children: >3wks, formula intolerance, infex, Giardia, malabs, IBD

Perform DRE: look for fissures/lacerations, feel for impacted stool

What colour are the stools?

Red: blood, food, drugs, food colouring Green-black: grape drinks, iron Dark gray: cocoa, chocolate Pale gray/white: cholestasis, jaundice, malabsorption Green: bile salts, chlorophyll veggies Malabsorptive - pain & flatulant stools Self limiting viral - pain, D/N/V, fever, tenesmus

Palpate lymph nodes: lymphadenopathy associated w/ lymphoma and AIDS

Serious organic disease (HIV, diabetes) persistent diarrhea that awakens patient

Cardinal manifestation of disease (GI tract, RTI) Viral gasteroenteritis, food poisoning, main cause of dehydration What occurred first: the diarrhea or vomiting? Diarrhea before vomiting = bacterial etiology Could this be caused by exposure to others or to Orofecal contamination & diaper; greater contaminated food? risk if attending daycare If a child: Does the child attend daycare? If a child: Are any of the other children in day care ill? Food bourne infxn: if acquired at social gathering Have you been around others who have similar symptoms? Could this be the result of exposure to animals? What pets do you have? Have you had contact with or have you handled dogs, cats, turtles? Could this be caused by exposure to contaminated water? Have you travelled recently? Where? Could sexual activities explain the diarrhea? Do your sexual practices include anal sex? Could this be a result of an immune problem? Have you been diagnosed with an immune system problem? Do you have frequent colds or other illnesses? Are you receiving chemotherapy? Could this be caused by medications? Have you taken any ABCs recently? Which ones? What prescription medicines are you taking? What over-the-counter meds/preparations are you currently using?

Campylobacter - infected dogs or cats Salmonella - infected turtles More susceptible to infxn if travel, camping (E.Coli, Giardia, Shigella, Salmonella, Campylo, Cryptosporidium) Shigella: in patients who engage in anal sex Proctitis: tenesmus and mucus IgA & IgGpain, deficiency - frequent cause of chronic diarrhea in children Enteropathy - AIDS, chemotherapy

Pseudomembranous colitis (C.Difficile): ABCs disturb normal flora of gut Antacids (Mg), ABCs, methyldopa, Antiinflams, laxatives, B-Blockers, Colchicine, salicylates

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Fecal fat: restrict fat & collect stools. D-Xylose Absorption test: malabsorption vs. maldigestion.

Wet mount: assess for bacteria, cysts, ova, larvae, trophozoites

Hemorrhoids - bright red blood upper GI bleed - black, tarry stools Infants - blood in stool = hemorrhagic disease

Generalized: diffuse inflammation UC: entire abdomen or lower abdomen IBS: over sigmoid colon Self limited diarrhea - mild cramping

Fecal Immunochemical Test (FIT): uses Anti-b's to detect human blood protein

Palpate abdomen for tenderness: peritonitis Stool pH: 5 indicates (rigid abdomen, rebound malabsoption tenderness, +ve iliopsoas, obturator.

Is there any noticeable blood in the stool or tissue? How much? What colour is the blood?

What does the presence or absence of pain tell me? Are you having any abdominal pain or gas with the diarrhea? Where is the pain? What does the pain feel like? Is the pain constant or does it come and go? Does the pain awaken you at night? Does the pain interfere with you activities (eg. Work, sleep, eating)? What do the associated symptoms tell me? Do you have any fever? Did you measure your temp? What was the highest temp? Do you have any vomiting?

Fecal leukocytes: found in inflammatory bowel disease, UC, Crohn's

C. difficile toxin assay: toxin causes necrosis of colonic epithelium

Stool culture: detects common bacteria

Stool for ova & parasites: requires fresh stool Giardia antigen test: tests for antigen 65 Indirect hemagluttinin assay: detects antibodies CBC w/ diff: may indicate presence of chronic disease, anemia, inflammatory dz.

Peripheral blood smear: examines cellular contents BUN & creatinine: indicates severe illness & dehydration Endoscopic studies: when cause cannot be determined

DDX: ACUTE Diarrhea Viral gastroenteritis (eg. Norwalk or rotavirus viral agents)

Abrupt onset 6-12 hr after exposure; nonbloody, watery diarrhea; lasts <1wk; nausea/vomiting, fever, abdominal pain, tenesmus

In children may see severe dehydration; hyperactive bowel sounds, diffuse pain on abdominal palpation

Shigella (gram negative rod; fecal-oral transmission; common in day care setting; common in gay bowel syndrome)

Acute onset 12-24 hr after exposure; lasts 2-3 days; large amounts of bloody diarrhea with abdominal cramping and vomiting

Lower abdominal tenderness, hyperactive bowel Fecal leukocytes, positive stool sounds, no peritoneal irritation culture

S.aereus food poisoning (gram-positive cocci; from improperly stored meats or custard filled pies)

Acute onset 2-6hr after ingestion; lasts 18-24hr; large Hyperactive bowel sounds amounts of watery, nonbloody diarrhea; cramping and vomiting

Clostridium perfrigens food Acute onset 8-20 hr after ingestion; lasts 12-24hr; poisoning (Gram-positive rod; large amounts of watery, nonbloody diarrhea; from contaminated food) abdominal pain and cramping Salmonella good poisoning (gram-negative bacilli; ingestion of contaminated food, poultry, eggs)

Hyperactive bowel sounds, diffuse pain on abdominal palpation

Acute onset 12-24 hr after exposure; lasts 2-5 days; Fever of 38.3-38.9C (101-102F) common; moderate to large amounts of nonbloody diarrhea with hyperactive bowel sounds, diffuse abdominal abdominal cramping and vomiting pain

None

Fecal leukocytes, negative anaerobic cultures of stool

Fecal leukocytes, positive stool culture, WBC count normal

Campylobacter jejeni (gram Acute onset 3-5 days after exposure; lasts 3-7 days; -ve rod; fecal-oral moderate amounts of bloody diarrhea transmission; household pet)

Fever, lower quadrant abdominal pain

Fecal leukocytes; positive stool culture

Vibrio cholera (gram -ve rod; fecal-oral transmission; ingestion of contaminated water, seafood or food)

Acute onset 8-24 hr after ingestion of contaminated food; lasts 3-5 days; large amounts of nonbloody, watery, painless diarrhea; can be mild or fulminate

Cyanotic, scaphoid abdomen, poor skin turgor, thready peripheral pulses, voice faint

Fecal leukocytes, negative stool culture

Enterotoxic E.Coli (gram -ve rod; fecal-oral transmission; ingestion of contaminated water or food)

Acute onset 8-18 hr after ingestion of contaminated No fever; dehydration is major complication food/water; lasts 24-48hr; moderate amounts of nonbloody diarrhea; pian, cramping, abdominal pain; adults in US generally do not develop this

Fecal leukocytes; positive stool culture

Entamoeba histolytica parasite (cysts in food & water, from feces)

Acute onset 12-24 hr after ingestion of contaminated Right lower quadrant abdominal pain; in small food or water; large amts of bloody diarrhea; number of cases hepatic abscess forms abdominal cramping & vomiting

IHA: Antibodies to E.Histolytica; positive titer is > 1:128

ABC-induced (begins after taking ABCs)

Mild, watery diarrhea: crampy abdominal pain

Pseudomembranous colitis (C.difficile ABC induced)

M/c ampicillin; Sx range from transient mild diarrhea- Lower quadrant tenderness, fever active colitis w/ bloody diarrhea, ab pain, fever

CBC: leukocytes; sigmoido/ colonoscopy, C.diff toxin assay or stool culture; C difficile toxin

Hemolytic uremic syndrome (HUS)

Children < 4yr w/ Hx of gasteroenteritis; Hx of bloody Fever, irritability; may have oliguria or anuria diarrhea, fever and irritability

CBC, platelet count, renal fxn test, periph. Blood smear; -ve stool culture

Diffuse abdominal pain on palpation; fever absent Usually not needed

Necrotizing enterocolitis

Premature or low birth we infant who presents w/ Vomiting, abdominal distension, lethargy, loose, Refer feeding intolerance bloody mucousy stools Bruising, ecchymoses, mild to moderate bleeding Lab studies typically show elevated Hemorrhagic disease of GI bleeding 2-3 days postnatal; Hx of lack on vit K newborn injection; Hx of mother on anti convulsants prenatally PT & PTT w/ dec. levels of vit K dependent factors DDX: CHRONIC DIARRHEA: Intermittent diarrhea alternating w/ constipation; Tender colon on palpation; may have abdominal Diagnosis of exclusion; mucus w/ stool; seldom occurs at night or awaken px; distension; no weight loss; afebrile sigmoidoscopy. Protoscopy IBS commonly present in morning; may have rectal urgency; episodes usually triggered by stress or ingestion on food; affects women 3 times more UC (distal colon most severely affected & rectum involved)

Hx of sever diarrhea w/ gross blood in stools, no growth retardation; few complaints of pain; age of onset 2nd & 3rd decades w/ peak I adolescence; postive family history

Crohn's (associated w/ uvetitis, erythema nodosum) CHO malabsorption

Overt rectal bleeding; initially no fever, weight CBC show leukocytosis or anemia, loss, or pain on palpation of abdomen; moderate ESR elevated; stool cultures to rule colitis: wt loss, fever, ab tenderness out other causes of diarrhea; colonoscopy

Hx of chronic bloody diarrhea w/ ab cramping, tender & rectal bleeding; in children Hx of growth retardation, wt loss, mod. Diarrhea, pain, anorexia Bloating, flatus, diarrheaab exacerbated by ingestion of certain disaccharides (lactose, milk products); may follow viral gasteroenteritis Fat malabsorption Greasy, fatty, malodorous stools; associated w/ deficiencies of vit K, A & D; cystic fibrosis Toddler's diarrhea 3-4 stools/day; some contain mucus; rare >4-5 yrs Celiac sprue/ PRO Increased stool frequency, looseness, paleness & hypersensitivity (rxn to protein bulkiness of stool w/in 3-6 mo of dietary onset; in wheat, rye, barley & oats) children are lethargic, irritable and anorectic; peak frequency 9-18mo

Wt loss, rare gross rectal bleeding, fistulas common Diffuse abdominal pain

Colonoscopy w/ biopsies

Rectal prolapse, poor wt gain, abdominal distension Physical exam & growth normal Failure to thrive, abdominal distension, irritability, muscle wasting

73 hr fecal fats; sweat test

Giardia parasite (primary cause of chronic diarrhea in children)

Low-grade fever, wt loss; chronic form: fatigue, growth retardation, steatorrhea

Giardia antigen test

Watery, foul diarrhea; common in daycare; among travellers and in male homosexuals

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Trial elimination of offending foods

Clinical diagnosis Clinical findings, improvement on gluten-free diet, CBC, anemia, folate deficiency, radiograpy, biopsy

Could this be related to a surgical procedure? Have you had surgery recently? Is this diet related? How much apple juice or how many sodas do you drink in a day? Do you drink milk or eat milk products?

Surgery can result in dumping syndrome after eating: inadequate mixing and digestion - also stagnation & bacterial overgrowth High carb content drinks lead to malabsorptive diarrhea Malabsorptive osmotic diarrhea Protein hypersensitivity: 2-3 wks after starting cow's milk or soy formulas

Do you eat wheat products? Gluten enteropathy or hypersensitivity What have you had to eat in the past 3 days? Loose stools: low fiber diet Could this be caused by food preparation problems? Have you recently eaten raw or undercooked poultry, Salmonella/ C. jejuni: undercooked poultry shellfish or beef? E.Coli: undercooked beef/ unpasterized milk Have you recently ingested unpasterized milk? Norwalk virus: shellfish Do you prepare poultry and/or beef on the same Food poisoning if 2 or more persons ill surface as other foods? from same food; infected food or toxic substances (lead, mercury) Is anyone else you know ill with similar sxs? Is there any family predisposition that may point to a cause? Have you or anyone in your family been diagnosed CF leads to fat malabsorption & produces with cystic fibrosis? fatty, foul smelling diarrhea Does anyone in your family have a history of chronic IBD genetically linked diarrhea, UC, or IBD?

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Cryptosporidium sp. /Isospora Recurrent episodes; variable amounts watery, belli protozoan parasites nonbloody diarrhea; amounts can be massive (fecal-oral; ingestion of contaminated water or direct oral anal contact)

Postgastrectomy dumping syndrome

Wt loss, severe right upper quadrant abdominal pain with biliary tract involvement

Following GI surgery, diarrhea occurs after meals; Diaphoresis and tachycardia diarrhea occurs after meals b/c of increased transit of food through colon

Diabetic enteropathy

Stool for O &P

Upper GI series

Nocturnal diarrhea, postprandial vomiting, fatty stools Findings associated w/ diabetes from malabsorption HIV enteropathy (direct infxn Insidious onset, recurrent large amounts of nonbloody Findings associated w/ HIV infection of mucosa & neuronal cells in diarrhea, mild to moderate nausea / vomiting GI system)

Diagnosis of exclusion in diabetic persons Testing for HIV

Medication induced

Usually not needed

Mild to moderately severe nonwatery, nonbloody diarrhea

No specific findings related to diarrhea

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Is this really constipation? How many stools are there per day? Complete failure to What is the consistency of the stool? evacuate the lower colon Is the constipation acute or chronic? associated with difficulty When did the constipation start? defecating, infrequent How long have you been constipated? Is this an BMs, straining, ab pain, individual episode or is it chronic? pain on defecating. Can At what age did the constipation first begin? be acute or chronic.

Constipation

Normal = 3-12 Constipation <3 BM/wk Hard, dry stools charac of constipation Recent onset suggests lifestyle or phys health changes (Meds, diet, activity) Chronic ass w/ lack of dietary fiber and bulk or systemic disorders (DM, hypoT) Colon CA = new onset >40yrs Infants: inadequate fluid/fiber

If the constipation is acute, what conditions should I consider? Have you been ill recently? Have you have a fever? Dehydration & fever cause hardening of stools Reflex ileus sometimes seen w/ pneumonia. Do you have any chronic health problems? Renal acidosis / Diabetes insipidus Medical dz can cause constipation b/c of neurological gut dysfxn (myopathies, endocrine, electrolytes) If the constipation is chronic or recurrent, what should I consider? What do you usually eat in a day? How many glasses of liquid do you drink/day? What are your usual bowel habits? How active are you? What medications are you taking? Do you use laxatives? How often? How long have you used laxatives? How can I further narrow the causes? What does your stool look like? Is the stool size large or small? What is the general shape of the stool (eg. Small, round, ribbonlike)? Is the stool formed or liquid? Have you had any involuntary loss of stool? Does the constipation alternate with periods of diarrhea? What else do I need to consider? Do you have the urge to defecate? Do you have any urinary tract symptoms? Do you have any nausea or vomiting? Is there any pain with defecation?

Is there any bleeding with defecation? How much? What colour are your stools? Are the stools very dark coloured or black?

Anxiety

Dec. peristalsis: diets that lack bulk, roughage, inadequate fluids (<6 glasses/day), inc. calcium (formation of calcium caseinate in stools) High proteinBM diets movement. Postponing b/cstimulate of time constraints

Plot growth curve in Fecal occult blood children: slow growth may testing: ulcerative or indicate megacolon malignant lesions, screen for colon CA Perform abdominal exam: contour, distension, auscultate, masses, Fecal Immunochemical tenderness, hernias. Test (FIT): uses Anti-b's to detect human blood protein Perform DRE: look for fissures/lacerations, feel for impacted stool, rectal prolapse, sphincter tone

Perform focused neuro exam: Test relevant DTRs & superficial reflexes. Inturruption of T12-S3 nerves causes loss of voluntary control of defecation

Lack of PA reduces peristaltic reflex Narcotics, imipramine, diuretics, Ca channel blockers, anticholinergics Use of stimulants to empty colon removes peristalsis stimulus for 2-3 days.

Serum Thyroid Stimulating hormone: inc TSH = hypoT (cause of constipation)

Anoscopy: indicated if DRE detects hemi's, fissures, strictures, masses

Lack of fluids/fiber = dry hard stools Fecal incontinence in elderly characteristic of IBS (stools described as hard and pellet-like) Hirschsprungs dz: no urge to defecate b/c stool accumulates in lower rectum voiding problems may be abdominal mass Intestinal obstruction: bilous vomiting in newborn Obstruction adults: vomiting Intermittent, in recurrent pain ass.w/pain w/

Flexible sigmoidoscopy & colonoscopy

Barium enema: contrast technique to detect diverticula, polyps, masses Colon transit studies: severe chronic constipation

constipation IBS: crampy lower ab pain w/ distension Diverticulosis: noncrampy dull pain on left Hemorrhoids/fissures: pain w/ defecation Hemorrhoids /fissures - bright red blood upper GI bleed - black, tarry stools Red: laxatives or vegetables Black/ dark brown: iron & bismuth (from drugs) functional megacolon 2o to constipation: involuntary passage of feces Also fear of toilet/ coercive toilet training

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Serum electrolytes: hypokalemia, hypocalcemia (causes of constipation)

Urinalysis

Aganglionic megacolon: infreq. Small, hard stools Ribbonlike: IBS or narrowing of colon

If this is a child, is there anything else I need to consider? Is there fecal soiling of underpants? Is there crying with defecation? Crying w/ fissure or large hard stools If an infant: Is there a Hx of delayed passage of May indicate Hirschsprung's disease meconium stool? Has the child begun to drink milk? Cow's milk common cause of constipation Has the child recently started toilet training? Stool witholding develops sometimes Does the child have urinary frequency? May result in constipation Is there a family history or genetic predisposition? Is there a family Hx of constipation or IBS? Genetic predisposition seems to exist. Have you experienced any of the follwing symptoms DSM IV criteria for Generalized Anxiety WITH anxiety/worry more days than not for at least 6 Disorder months: -Patients will often report sense of doom 1) Restlessness, keyed up, on edge and fear of losing control 2) Being easily fatigued 3) Difficulty concentrating or mind going blank 4) Irritability 5) Muscle tension 6) Sleep disturbance

CBC: Hematocrit & Hb below normal

Ask: dyspnea, chest discomfort, fatigue, restlessess, sleep disturbance Physical findings: tachycardia, palpitations, and diaphoresis

None noted

Simple constipation

Low dietary fiber & bulk; inadequate fluid intake; physical inactivity; pain before and w/ bowel movements; anorexia

Functional constipation

Preschool and school-age children; Hx of abdominal Palpable stool in LLQ; large dilated rectum w/ pain and stool soiling. packed stool; external sphincter intact May have tender, palpable colon Onset in young adulthood; alternating diarrhea and constipation; mucus in stools Passage of hard stool 3-5 day interval; diarrhea, small Hard feces in rectal ampulla; may have palpable stools; common in those confined to bed feces filled bowel Common in older adults; physical inactivity; decreased Normal abdominal and rectal examination stool frequency; stool dry & hard Delayed passage of meconium at birth; no urge to Empty rectal ampulla on examination defecate

Abdominal radiography, unprepped barium radiography Sigmoidoscopy if indicated

Anorectal lesions

Rectal pain on defecation; Hx of hemorrhoids; blood on stool, on toilet tissue, or in toilet

On rectal exam: Hemorrhoids, fissures, tears, abrasions; increased sphincter tone

Anoscopy

Drug induced

Hx of chronic laxative use; Hx of taking med that produce constipation

Normal rectal and abdominal exams

Tumors

Diarrhea more common than constipation; recent onset: pain & abdominal distension, stool leakage, urgency; late onset: wt loss, anorexia; increased increased incidence over age 40; uncommon in children

May have palpable abdominal mass or organomegaly

None if resolved; consider sigmoidoscopy, barium enema if not resolved CBC, FOBT or FIT, sigmoidoscopy, colonoscopy, barium enema

IBS Obstipation/ impaction Slow transit Hirschsprung's disease

Normal abdominal and rectal examination; may feel fecal masses in colon and rectum

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None if resolved; consider sigmoidoscopy if not resolved

Sigmoidoscopy if indicated FOBT or FIT to rule out tumors Colonoscopy

Define the Nature of the Problem What kind of sleep problem are you having?

Insomnia Are you having difficulty falling asleep?

Inspect Ears and nose Inspect mouth, throat, neck (tonsils, adenoids) checking for obstruction for sleep apnea Auscultate LU: asthma CHF is risk factor for sleep Often related to poor sleep hygiene practices, use of stimulants or medications, apnea Palpate abdomen: GERD disruption of circadian rhythms, pain, upper abdominal pain anxiety Sleep disorders include: sleeplessness (insomnia), disturbance of behaviour associated with sleep (parasomniacs), excessive sleepiness (hypersomnia)

Are you having difficulty staying asleep?

Sleep disrupted d/t physiological factors, illness, depression, pain, meds or alcohol

How long has the problem been going on?

Acute/transient (few days) - d/t stress, illness, environmental disturbance, jet lag Short term (weeks) Chronic (months to years) - d/t sleep disorder, mood disorder, medications, sleep disturbance

Is this a specific Sleep Disorder? Do you have a creeping, crawling or uncomfortable feeling in your legs that is relieved by moving the legs? Does the bed partner report patients arms and or legs jerk during sleep?

Restless leg syndrome: sxs increase in evening, esp when person is lying down and still Common > 65yoa. Periodic Limb movement disorder: b/l repeated, rhythmic jerking or twitching

Do you snore loudly, gasp, choke, or stop breathing Obstructive sleep apnea: loud snoring and restless sleep patterns. May during sleep? report insomnia and excessive daytime sleepiness Passive parental smoking can be a risk factor for snoring in children (smoke provoke mucosa --> narrowed pharynx --> snoring) Do you have difficulty staying awake during the day Narcolepsy: excessive daytime sleepiness. or doze off during routine tasks (driving)? Adults: fall asleep during tasks like driving Child: difficulty getting up in am, when awakened appear confused, aggressive (phys or verbal), fall asleep at school, doing hmwk, watching TV Do you have episodes of muscle weakness? Could the Sleep Problem be Secondary to an Illness? Have you been ill recently? Do you have a chronic health condition? What medications do you take? Do you have depression or anxiety?

Cataplexy: episodes of sudden muscular weakness and atonia; emotional trigger

Ask: Do you lean against wall for support b/c legs feel rubbery?

Children: OM, chronic otitis, upper airway obstruction GERD, COPD, PUD, CHF - paroxysmal nocturnal dyspnea Anything causing nocturia anidepressants, decongestants, bronchodilators, b-blockers, thyroid meds, phenytoin, methyldopa, corticosteroids, antihistamines Depression: early morning waking Anxiety: trouble falling asleep

Could this be related to Sleep Hygiene? What is your bedtime routine? What else do you do in your bedroom?

Is it consistent? - can cause disruptive rhythms Work or watching TV can cause disruptive envt noice can affect sleep, decrease REM Do you consume alcohol, nicotine, caffeine, diet pills alcohol shortens total sleep time and exacerbate GERD and sleep (with ephedrine) before bed? apnea Alcohol withdrawal in heavy drinker can be assocaited with restlessness and sleep disturbance Do you exercise before bed? avoid for 1-2 hours before bedtime How do you put your child to sleep? Child who is put to bed when they are still awake will learn to use selfcomforting methods so even if they wake in the middle of night, they will fall back asleep Toddlers fearful of separation must establish routine Where does your child sleep? Sleeping with parents can be disruptive if parents move Should be quiet and dark room Could this be lifestyle related? Are you a shift worker? Interruption of circadian rhythm Do you sleep in the same bed each night? Affects quality of sleep, increase light sleep, shorter REM Do you travel frequently? Jet lag Could this be age related? How old is patient? Newborns: 20 min - 4 hrs What age was child when problem began? School age - 8 hrs/night Does your child wake up screaming at night? Night terrors - inconsolable for up to 30 min and then falls asleep Does your child have problems going to bed? again, happen within first few hours of sleep, not readily awakened, no Does your child refuse to go to sleep? recolleciton of event Nightmares - can be consoled, child is awake, and dream is remembered Could this be conditioned insomnia? Are you able to fall asleep easily in places other than Usually insomnia develops initially in response to psychosocial stressor the bedroom? Can fall asleep outside bedroom but awake in bed If a child: what do they do when they wake up at night? If a child: what do you have to do to get them back asleep?

Children need to develop self-comforting behaviours Conditioned to feeding after waking at night, can prevent development of more mature circadian rhythm usually once/night and 15 min. Takes great effort to wake person and they have little or no memory of episode

Sleep walking?

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Sleep diary: keep for 1-2 weeks. Record bedtime, total sleep time, time until sleep onset, times they wake, quality of sleep, etc

Sleep labs Polysomnography overnight sleep study for 1-2 nights

DDX Insomnia Restless leg syndrome

Irresistable urge to move legs in bed

Normal

None

Periodic limb mvmt

> 65yoa, rhythmic jerking of legs or arms while asleep Normal

None

Obsructive sleep apnea

Apneic episodes, loud snoring, restless sleep patterns decrease oxygen, enlarged adenoids, tonsils

sleep studies

Narcolepsy

Excessive sleepiness, cataplexy

refer to sleep specialist

Secondary to illness or medications

GERD, COPD, PND, CHF, prostatitis, nocturea, depression or anxiety

consistent with medical condition

consistent with medical condition

Poor sleep hygiene

routine, habits, env't not conductive to sleep use of alcohol, caffiene, diet pills, nicotine

normal

sleep diary

Lifestyle

shift work, travel, jet lag

normal

sleep diary

Night terrors

Inconsolable awakening occuring early in sleep, lasting 15 min, no memory of event

both normal

both none

Nightmares Night awakening

Occur later in sleep cycle, dream is remembered Single to repeated awakening at night

Sleep refusal

child refuses to sleep

normal

none

Conditioned insomnia

identify intial trigger with persistent problem

physical exam to r/o underlying condition

sleep diary

Somnanbulism

sleep walking in early sleep cycle

normal

None

Trained night crier

child unable to soothe self

normal

none

Trained night feeder

Hx of frequent feedings on awakening at night

normal

none

Use medical examination to eliminate associated depends on examination illness

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HTN Dx: depend on two or more blood pressure readings taken at each of two or more visits after initial screening Definition is 140/90 Stage 1 HTN is defined as a systolic blood pressure of 140-159mmHg and a diastolic blood pressure of 120-139/80-89 is preHTN, 90-99mmHg follow up annually Stage 2 HTN is defined as a systolic blood pressure greater or equal to 160mmHg, or a diastolic blood pressure greater or equal to 100mmHg

HTN

BP!!! CV exam Resp exam Vision changes Peripheral neuropathy/pulses

Presenting Condition What have previous blood pressure readings been? A gradual rise in blood pressure with age is normal, but a sudden increase could suggest a secondary cause or malignant hypertension Have there been any symptoms or signs of clinically Episodes of weakness or dizziness overt cardiovascular disease? (cerebrovascular disease), angina pectoris (coronary artery disease), or dyspnea caused by pulmonary edema (congestive heart failure). Such episodes could show that hypertension is already causing target organ damage and that it should be treated more aggressively Does the patient have diabetis mellitus?

Have you been experiencing headaches?

Diabetic patients with hypertension are particularly at risk of cardiovascular disease and should be treated more aggressively than nondiabetic patients Contrary to popular opinion, headache is not a characteristic symptom of hypertension, although it may be associated with severe hypertension

Have you been experiencing heat or cold intolerance, sweating, slow or fast heart rate, or palpations?

Such symptoms may point to underlying hyperthyroidism or hypothyroidism as a cause of hypertension, or pheochromocytoma

How much alcohol do you drink?

Excessive alcohol consumption can raise blood pressure

Excessive consumption of sodium chloride and caffeine can raise the blood pressure Is your diet high in salt? Do you cook with a lot of salt? How much salt do you add at the table? How much coffee and tea do you drink? Do you eat regular amounts of licorice? Is the patient obese?

Do you smoke? Do you have a history of anxiety? What medications do you take?

Is there a family history of hypertension?

Is there a family history of other cardiovascular disease?

Licorice has mineralocorticoid properties similar to aldosterone, and excessive intake can directly cause hypertension Obese patients are at an increased risk of hypertension and should be encouraged to lose weight Smoking increases cardiovascular risk, and a diagnosis of hypertension is a good opportunity for advice on giving up Anxiety disorders, especially panic disorder, can result in significant episodic elevation of blood pressure Specifically, estrogen therapy, such as oral contraceptives, can be associated with hypertension Essential hypertension has a strong genetic component, and the lack of a family history increases the likelihood of a secondary cause Patients with a family history of cardiovascular disease are at an increased risk of complications of hypertension

Hypertension should be treated urgently and aggressively in the following emergencies: Hypertensive encephalopathy Intracranial hemorrhage Unstable angina Acute myocardial infarction Acute left ventricular failure with pulmonary edema Dissecting aortic aneurysm Pregnancy-induced hypertension Malignant hypertension

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What Does the Patient Mean by Dizziness? Describe how you feel when you are dizzy

Dizziness

Do you feel as though you or the room is spinning? Do you feel your balance is off?

Includes vertigo, lightheadedness, loss of balance. Needs visual, vestibular, and sensory systems Central: neopastic or vascular, CNS Peripheral: inner ear or vestibular appraratus

Vertigo - patient or env't is spinning Neoplasms and progressive vetibule loss produces changes in vestibular fuction. Slow onset and manifest as imbalance Loss of balance, lack of coordination with absence of vertigo - result of degenerative, neoplastic, vascular, or metabolic disorder

Do you feel like you are about to faint?

In Children: parents may describe as trouble walking, irritable, or behaviour differences Do you feel lightheaded? Or about to faint?

Maybe peripheral neuropathy or dysfunciton of vestibular or cerebellar system Near syncope

In elderly: have you previously been diagnosed with orthostatic hypotension is most common blood pressure irregularities? cause of dizziness in the elderly - d/t abnormal BP regulation Does the Vertigo Result from a Systemic Cause? CV problems common cause of vertigo. May be vasomotor instability decreasing systemic vascular resistance, venous What other medical problems do you have? return - can lead to transient decline in cardiac output

Take VS and BP, orthostatic HoTN

MRI brain - acoutis neuroma or central cause of vertigo. Order if sudden onset or with severed headaches, General appearance: looks direction-changing nystagmus, or neurlogical ill (labyrinthitis) signs Acute nausea and vomit: vestibular neuronitis Vision exam: change in visual acuity/ new corrective lenses may cause transient imbalance Ear Exam: look for signs of CT - persistent vertigo infection (serous otitis, OM) and in all cases with Cholesteatoma: shiny additional sigsn of white irregular mass, foul- neurological disturbance smelling d/c With renal failure, HTN, Look at TM: trauma hematological malignancy Rinne and Weber tests: with sudden onset sensorineural loss lateralizes to unaffected ear; AC > BC (but both reduced) EEG - vertigo with alterations of consciousness

Would you describe yourself as anxious or nervous? Psychogenic dizziness. Sxs are vague and CN VIII - nystagmus include fatigue, fullness in head, lightheadedness, feeling apart from env't. Do the episodes occur with any specific activity or When turning, especially when rolling in Neurological exam: CN, movement? bed usually d/t vertigo. cerebellar function (gait, Disequilibrium - unsteady while walking balance), rapid-alternating mvmts, sensory and motor Is the vertigo central (brainstem or cerebellar) or function peripheral (vestibular) in origin? Do you have migraine headaches? Do you have other symptoms that bother you?

H/a - vascular related cause of central vertigo. Often with migraines Central vertigo nearly always have neurological sxs (double vision, facial numbness, hemiparesis) Cerebellar causes also will have loss of balance, motor dysfunction, coordination problems Peripheral origin - no additional neurological symptoms

CBC - anemia Glucose levels - DM BUN - renal failure Syphilis - 2nd or 3rd like Meniere's diseases

CV exam: HR and rhythm, auscultate carotid and temporal arterires for bruits for CVS cause of vertigo

Do you have nausea and vomitting?

Suspect peripheral vestibular apparatus problem Common with vestibular neuronitis and labyrinthitis

When do the episodes occur?

If first arising in morning, usually vestibular disorder If turning in bed - benign positional vertigo (BPV)

What Do the Characteristics of the Episodes Tell Few secs: BPV, d/t rapid head mvmt Me? Min - Hrs: Meniere's disease or recurrent vestibulopathy Days - Wks: vestibular neuronitis. >lying completely still. Stroke can produce long-lasting episodes. How long do the episodes of dizziness last?

Is the onset sudden or gradual?

Sudden >60min: central causes like infection, brainstem infarction, inflammation, hemorrhage, trauma Child <30min: seizure, migraine, BPV Chronic persistent: brainstem lesion, anemia, diabetes, thryotoxicosis, psychosomatic disorder Sudden: labyrinthitis, Meniere's, stroke, vestibular basilar Gradual: acoustic neuroma, BPV

Do you have any hearing loss?

Meniere's triad: vertigo, hearing loss, tinnitus (also fullness in ears) CN VII or lesions in inner ear: tinnitus, hearing loss, pain in ear Hearing loss, no tinnitus: labyrinthitis U/l hearing loss w/ tinnitus: acoustic neuroma

Do you have ringing in your ears? What Else Should I Consider?

What medications are you taking? Are you now or have you recently been ill?

Have you had any recent injury to your head? Did you have dizziness before the head injury? Have you had any previous ear surgery?

Salt retaining or oxotoxic: vertigo, lightheadedness, or unsteadiness Psychotropic drugs - vertigo AntiHTN drugs - HoTN Sedatives, alcohol, anticonvulsants - disequilibrium

Vestibular neuronitis - recent viral infxn Currently ill - labyrinthitis (ass w/ concomitant bac/viral infxn) Sinus/ear infxn, middle ear infections: dysfunction of vestibular apparatus Temporal bone fracture, whiplash can cause labyrinth damage Cholesteatoma: hx of chronic middle ear infections, otorrhea, conductive hearing loss. Prior procedures can produce peripheral vertigo b/c vestibular apparatus disrupted

Page 25 of 52

Central Causes Brainstem/cerebellar problems elderly, acute onset, recurrent vertigo, tinnitus, hearing OK

MS

30-40yog

Migraine

h/a hx, other migraine sxs

Peripheral Causes BPV

adults, with position changes, recurrent episodes, lasts sec-min, > no motion

MRI ataxia, double vision, coordination problems, sensory/motor deficits, nystagmus, impaired RAM and finger-finger testing HEARING OK maybe normal MRI maybe have sxws of vertebrobasilar vascular abnormalities nystagmus NO tinnitus HEARING OK

MRI

Benign paroxysmal vertigo of children, preschoolers, sudden onset with crying childhood

vomitting, pallor, sweating, nystagmus, no LOC, neurological, audiological can be normal

hypoactive or abset response to caloric testing

Meniere's Disease

nystagmus, fluctuating hearing loss, low tones, sensorineural nausea and vomitting, nystagmus NO HEARING LOSS

Vestibular neuronitis

sudden onset, lasts hours, recurrent, tinnitus and fullness in ears sudden onset, previous viral infection

Labryinthitis

sudden onset, lasts hours to days

provoke position changes

current illness, nystagmus, hearing loss maybe tinnitus, n/v adults, gradual onset, mild vertigo, persistent tinnitus, u/l hearing loss, poor speech discrimination facial numbness, weakness

audiometry

Perilymph fistulas

history of trauma, hearing loss

nystagmus and vertigo, sensorineural hearing loss

audiometry

Otitis/sinusitis

pain in ear or face, Hx of infecitons, gradual onset of vertigo

serious otitis, OM, tenderness on sinus, purulent nasal d/c, NO nystagmus

Systemic Causes Psychogenic

vague sxs, recurrent, anxious, other psychiatric diagnosis

normal neurological and auditory exams

CV

CV hx, antiHTN meds

Neurosyphylis

vertigo, tinnitus, fullness in ears

depends on px and conditions orthostatic BP, dysrhythmias, carotid/temporal bruits Various clinical sxs, papilledema, aphasia, monoplegia/hemiplegia, central nervous palsies, pupillary abN, Argyll-Robertson pupil, focal neurological deficits

Acoustic neuroma

Page 26 of 52

MRI

hyperventilation to reproduce the vertigo

Is This Really Syncope?

Syncope

Did you lose consiousness? Did you have any prodromal symptoms?

Syncope is the reversable What precipitated the event? Or What were you loss of consciousness and doing when the event occurred? postural tone that results from a sudden decrease in cerebral perfusion

If you lost consciousness, how long did it last?

Was there any limb jerking during the event? Did anyone see you faint? Does This Require Immediate Referral?

Do you have a history of heart disease?

Distinguish syncope from dizziness, vertigo and resyncope where loss of consciousness and postural tone does not occur Prodromal symptoms of sweating, vertigo, nausea and or yawning associated with syncope. Aura and tongue biting associated with seizures Loss of consciousnes precipitated by pain, Observe Hydration exercise, urination, defecation or stressful Status events is probably not a seizure. Breath- Dehydration leads to holding spells in children causes syncope syncope and are usually precipitated by pain, anger, a sudden startle or frustration. Syncope that occurs with rest or in supine suggests seizure or arrythmia. Syncope with no warning suggests cardiovascular origin. Disorientation after event, slowness in returning to consciousness and unconsciousness lasting longer than 5 minutes indicate seizure Rhythmic movements during event suggest seizure, although they can occur with syncope History from witness give you useful info. Presence of structural heart disease increases risk of sudden death. Hospitalization required if history of coronary artery disease, congestive heart failure or ventricular arrythmia. Aortic or mitral stenosis or prosthetic valves may cause syncope. Complete heart block is leading cause of syncope.

Do you have a congenital heart problem? Are you having chest pain and/or shortness of breath?

Obstructive mechanical blockage may be caused by pulmonary embolism, cardiac ischemia or myocardial infarction with pump failure Did this occur after exercise? Syncope after exercise is of cardiac origin until proven otherwise. Syncope after exertion ina well-trained athlete who has no heart disease is of vasovagal origin. What Do Associated Symptoms Tell Me? Supraventricuar and ventricular tachycardia are associated with syncope and sudden death.Ventricular fibrillation is What other Sx did you have or are you having? always fatal unless reversed with electrical Did you have/ have you been having palpitations? defibrillation. Have you had headaches? Pain of migraine headaches can affect brain stem and cause sycope. Headache continues after consciousness has been regained and is associated with other migraine symptoms Have you had vertigo, dizziness, diplopia or other May accompany migraine or transient vision changes? ischemic attack Is This Neurocardiogenic in Origin? vasovagal syncope is neurocardiogenic Did this occur in response to a specific situation (eg., and tends to occur in families. Often precipitated by emotional stress, fear, stressful event, urination, defecation?) extreme fatigue or injury and can occur without any antecedent cause. Warm temperature, anxiety, blood drawing and What position were you in when you fainted? Sitting, crowded rooms can cause peripheral standing or lying flat? vasodilation. Situational syncope can occur in response to urination, defecation, cough Are you an athlete? Do you have a history of any or emotional stress. Post-tussive heart problems? syncopefollows paroxysmal coughing Is This Orthostasis? caused by increased intrathoracic What medications are you taking? 10% of syncopal episodes are caused by prescription medication, over the counter medications, and recreational drugs that Have you recently started taking blood pressure produce orthostasis, bradycardia or medicine or increased its dose? prolonged QT interval. What other health problems/conditions do you have? Diabetes may induce hypoglycemia. Also anemias and chronic GI bleeding from an ulcer can cause syncope. Pregnancy, prolonged bed rest and dehydration can lead to orthostatic hypotension. Is This Explained by Other Factors? Psychogenic syncope often associated with repeated episodes in which Have you had this before? How often? unpredictable motor reflexes appear with a Did it occur with suddden head turning? lack of pathological reflexes. Carotid sinus If a child: Has the child had Kawasaki disease? hypersensitivity produces a cardioinhibitory response that results in a profound drop in heart rate or may induce an abrupt vasopressor response with a drop in blood pressure. Children who had Kawasaki disease are at risk for coronary heart disease which may present as chest pain associated with exercise. Do you have Lyme Disease? Lyme Disease can cause dysrhythmia in the form of heart block which can lead to syncope. What Other Things Do I Need to Consider? A family history of idiopathic hypertrophic subaortic stenosis is a risk factor for sudden death. Family member who had MI Do you have a family history of sudden death? before age 30 is also risk for sudden death. Do you have a family history of fainting?

Neurogenic syncope is common in families

If a child: Did the mother have SLE when pregnant?

Page 27 of 52

Perform Heart and Lung Exam Look for cardiac cause Perform a Neurological Exam Perform a Abdominal exam Examine extremities for signs of thromboembolism

ECG to rule out cardiac cause Event Monitoring or Continuous Loop Monitoring Used in patients with suspected cardiac arrythmia and syncope Doppler Studies Detect hemodynamics of intra and extracranial arteries. Treadmill testing Stress test for arrythmias Echocardiography For people with exercise induced syncope to rule out left ventricular outflow tract obstruction Electrophysiological studies Test for arrythmias Baseline Blood Testing Electroencephalograph y For seizure CT Scan for neurological cause Toxicology Screen for unexplained syncope Tilit-table testingSimulate syncope and if positive indicates neurogenic cause

Cardiac Causes Organic Shortness of breath, chest pain, palpitations, exercise May have bradycardia or tachycardia, cyanosis, heart Disease and Arrythmias associated Loud S2, S3; murmur, lift

Refer, electrocardiogram, Holter, echocardiogram, Doppler studies, treadmill

Neurocardiogenic Causes Vasovagal

Emotional event, standing for long periods, crowded room, warm environment

tilt table test

Situational

occurs with cough, micturition, defecation, swallowing none

None

Breath holding

infants 6 mo to 5 yrs, associated with anger, pain, brief cry. Breath is held, loss of consciousness, may have twitching

cyanosis or pallor

None

Hyperventilation

Anxiety or fear induced event, shortness of breath

none

None

Couch syncope

History of asthma, coughing paroxysm awakens child wheezes from sleep, becomes flaccid with clonic muscle spasm, loss of consciousness

Orthostasis Orthostatic hypotension

Position change from lying/sitting to standing. Pregnancy, prolonged bedrest

Medication Related Prescribed medications Drug induced

History of antidepressants, antiarrythmic agents, beta- Depends on underlying condition blockers, or diuretics History of use of illicit drugs Arrythmia may be present

Neurological Causes Migraine Seizure

Headache, vomiting, photophobia, positive family history convulsion, incontinence, postical phase

Psychiatric Causes Mental disroder

Symptoms consistent with depression, anxiety, panic none

Hysterical reaction

Adolescent, event occurs with audience present. Gentle fall, memory or incident exact

none

None

Unknown

no diagnostic characteristics

none

workup negative

none

None

Hypotension on testing orthostatic blood pressure 20 mm Hg drop in systolic pressure on standing

Usually none, nystagmus, photophobia usually none, nystagmus

None Toxicology screen None electroencephalogram

psychiatric evaluation

Page 28 of 52

ABDOMINAL PAIN subjective feeling of discomfort.

Is this an acute Condition?? 1.how long ago did the pain start? Was the onset sudden or gradual??

3 processes produce:

How severe is the pain (1-10)

acute and severe could mean emergency

1. tension in the GI from mm contraction or distension

Child? What is their level of activity?

avoidance of favourite activities indicates an organic problem

2. Ischemia

does the pain wake you from sleep?

serious! An organic dz wakes a child from rest

3. Inflammation of the perotineum

course of the pain? Getting worse/better?

pain that is severe and progressing = bad, Abdominal Musculature likely an emergency rigid - perotineal irritation may require surgery

Urine culture suspect UTI

pain can also occur from within or outside the abdominal wall

last BM?

obstipation occurs with complete obstruction but diarhea may present with partial obstruction.

Test for STI's all types

had this pain before?

chronic pain may be bc potential emerg event is brought into check but is not resolved. If >1yr consider IBS or colorectal, endometrial or inflam causes

where is the pain?

1.visceral pain - perceived midline - dull deep, diffuse. Orginates from epigastric, periumbilical and hypogastric causes from intraabdominal extraperotineal organs. 2. paritoneal pain - localized and sharp. Originates from the intraperitoneal organs.

does it travel anywhere? describe pain

acute onset of pain that is getting prgressively worse may signal surgical emergency (severe 6-12hr form the onset = emerg) ex. ectopic preg, perforation, obstruction, ruptured aortic anuerysm, intussiception

General Appearance CBC visceral pain = restless and inc WBC move about - obstr, stones, infection/inflam gastroenteritis inc neutrophils - bacterial parietal pain = lie still, don't infection want to move appendicitis, rupture, perforation children - do they look sick, Urine/serum HCG lethargic withdrawn to RO pregnancy ESR inflam, or tissue injury, pregnancy Vitals fever - acute inflam condition, mc renal or lung infection

Colour of skin Fecal Occult Blood Test Cullen's sign - ectopic preg RO GI bleeding or pancreatitis Grey-Turners sign pancreatitis Imaging Ultrasound

pain will radiate from distribution of nerves Abdominal Distention that supplies affected area "The F's": fluid, fat, feces, fetus, flatus, fibriod, full gives clues to the specific condition (ie. bladder, false pregnancy, colicky/cramping from a hollow viscus) fatal tumour.

related to activity?/ triggers?

relieved by defecation or diet changes --> intestines. Associated with meals --> GI tract. With sex -->pelvic origin. With position changes --> referred from a MSK origin. Exertional pain could mean cardiac origin

vomiting?

if vomit precedes pain unlikely a surgical problem. Vomiting may be from: irritation of the nerves of perotineum obstruction of involuntary mm tube absorbed toxins Pain with vomiting - acute obstr of urethra or bile duct. In intestinal obstruction timing indicates how high the obstruc is in the GIT appearance? clear=gastric fluid. bile coloured=upper GI. Feculent=distal intestinal obs.

Aucultate bowel sounds absent - peritonitis or ileus. Hyperactive gastroenteritis, intestinal obstr (tinkling), GI bleed

Stool characterisitics

blood = in the intestinal tract diarrhea may preceed perforation of appendix children - diarhhea may suggest acute gastroenteritis

Percuss unexpected dullness

Page 29 of 52

Urinalysis eval of KI infection, stone, failure or systemic process

CT Sigmoidoscopy, colonoscopy, proctoscopy

ACUTE 1. Ectopic preg

women childbearing age sudden spotting and cramping in lower quad after missed period

hemorrhage, shock and lower abd peritoneal irritation. Enlarged uterus and cervical motion tenderness

HCG + ultrasound ruptured ectopic preg = sugical emerg

2. peptic ulcer perforation

sudden severe, intense, steady epigastric pain that radiates to sides, back and shoulder. Hx pain < empty ST

Pt lying still. Epigastric tenderness, rebound tenderness, abd mm rigid, bowel sounds decr.

Radiograph - surgical emerg

3. dissection of aortoc aneurysm

sudden excruciating pain in chest or abd. May radiate pt looks shocked, vitals indicate impending to back. shock, decr femoral pulses.

CT or MRI and cardiac enzymes surgical emergency

4. peritonitis

sudden severe pain, diffuse and worsens with movement/cough

CBC with differential. Abd radiograph

5. acute pancreatitis

Hx of cholithiaisis or alcohol abuse. Pain LUQ steady, pt appears acutely ill. Abd distention, decr bowel CBC with differential. boring and unreleived by change position. N/V sounds, diffuse rebound tenderness, mm rigidity US sweating. in abd Abd radiograph

6. mesenteric adenitis

fever, pain in RLQ, other sx suggestive appendicitis

7. cholecystitis/lithiasis

colicky pain changing to chronic pain. RUQ pain may tender to palpation or percuss on RUQ. GB radiate to scapula. N/V and hx of daark urine or light palpable in some. Murphy's ss +ve stools

8. ureterolithiasis

colicky pain changing to chronic pain. Pain in low abd CVA tenderness, incr sensitivity and lumbar and Urinalysis and flack radiating to groin. N/V abd distention, chills, groin, hematuria CT fever, incr unrination

9. UTI/pyelonephritis

Urinary sx of UTI. Back pain with pyelonephritis.

10. PID

LQ pain that incr in severity. May have irreg bleeding, abd tenderness, adnexal tenderness, guarding, vaginal dc and vomiting - MC in sex active women rebound tenderness, feverm vaginal dc

11. Obstruction

abd radiograph sudden crampy pain in umbillical area of epigastrium, hyperactive, high-pitched bowel sounds, fecal vomiting mass may be palp, abd distention, empty rectum on DRE

12. Ileus

abd distention, vomiting, obstipation and cramps

minimal/absent peristalsis on auscultation

gaseous distention of isolated segments of small and large intestines shows on radiographs

13. Intussusception

sudden onset pain in infants

fever, vomit, jelly stools

abd films

gaurding. Rebound tenderness, bowel sounds decr.

pain in RLQ, may be pharyngitis and cervical adenopathy

altered voiding pattern, malodorous urine, fever

Page 30 of 52

CBC with differential. Adenovirus found in surgical specimen. CBC with differential. US Abd radiograph serum amylase and lipase

Urinalysis Culture WBC, ESR elevated cultures and gram staining.

Clues to implicate organ?? Do you have GI symptoms? changes in bowel habits/stools or eating habits?

gas, bloating, diarrhea, constipation, and rectal bleeding - usu pain intestinal origin heartburn and dysphagia - esophagitis

pain relieved by defecation/burping?

pain relieved by defecation/flatus - IBS

Pain or difficulty with movement, limited ROM, swellings

pain produced by MSK and refered to abd

Pain with exertion, palpitations, chest pain, fast HR? referred pain from chest not uncommon. RO MI as cause. On extertion - angina or CAD cough or difficulty breathing/SOB? Pneumonia - pain often perceived in abd pleurisy - in abd with deep insp Pain Psychogenic?

how do you feel? mood? Energy? Dx of mental health disorder? Other

Palpate start gentle and finish with area of pain. Rebound tenderness and gaurding peritoneal irritation. Palpate LV, GB (murphy's sign), SP, KI, aorta, BL

Palpate for masses neoplasm, obstruction, hernia, feces. Intussusception in infants.

not organic pain Palpate groin

Meds?

Palpate Hernias

recent surgeries?

sugery can produce adhesions thatmay cz Percuss for flank intest obtsr tenderness KI issue could be stone

weight loss?

colon cancer?

Test for peritoneal irritation 1. obtrurator mm test 2. iliopsoas mm test 3. Rovsings test

camping recently or chikd in day care?

untreated water ingestion - parasite parasites also transmitted in day cares

Perform pelvic Exam in women/Genital prostate exam on men

Check peripheral pulses

Page 31 of 52

14. malrotation/ vulvulous

infants

15. incarcerated hernia

MC elderly. Constant severe pain in RLQ or LLQ that hernia or mass that is non-reproducible worsens with strain

CHRONIC LOWER ABD PAIN 1. IBS

billous emesis

abd films upper gastro series

begins in adolescence. Hypogastric pain, crampy. Variable infrequent duration, assoc with bowel function. Gas bloating distention relief with passing flatus/feces.

Unremarkable

2. lactose intolerance

crampy pain after eating dairy

Unremarkable

Proctosigmoidoscopy barium enema stool positive for blood failure to improve after 6-8 wk therapy trial elim of dairy

3. diverticular dz

older pt. localized pain

abd tenderness, fever

Barium enema, elevated ESR,

4. constipation

colicky or dull and steady pain. Does not progress or worsen.

fecal mass palpable. Stool inrectum

none if habitual/lifelong constipation barium enema if metabolic or systemic cause suspected

5. dysmenorrhea

premenstrual pain. Decr with age.

normal pelvic exam

GYN consult

6. uterine fibroids

pain related to menses, intercourse

palpable myomas

7. hernia

localized pain incr with exertion

hernia noted

8. ovarian cysts

young

adnexal pain and palpable ovarian cysts

pelvic USG if neoplasm cannot be excluded proctoscopy, barium enema is strangulation suspected pelvic USG

9. abd wall disorder

trauma

bruising or swelling, no GI/GU sx

CT uf internal dz

UPPER ABD PAIN CHRONIC 10. esophagitis/GERD burning, gnawing pain in mid epigastrium. Pain after Unremarkable eating. May be relieved after antacids 11. Peptic Ulcer

12. Gastritis

13. Gastroenteritis 14. Functional Dyspepsia 15. recurrent abd pain

burning, gnawing pain. Soreness. Empty feeling or may have epigastric tenerness on papl hunger. MC with empty ST, stress and alcohol. Relieved with food. Pain steady, mild or severe in the epigastrium constant burning pain the in epigastric are. May N/V Unremarkable diarrhea or fever. Alcohol, NSAIDs and salicylates agg diffuse crampy pain with N/V diarrhea, fever hyperactive bowel sounds. Dehydration if very severe. vague complaints of indigestion, heartburn, gas, abd Unremarkable distention children 5-10 yo. Enviro pr psycholog stress. Unremarkable

Page 32 of 52

upper gastro series radiogrpahy or endoscopy if sx severe upper gastro series, endoscopy, gastric analysis

pt should respond to therapy

no dx test needed CBC, fecal occult blood test (FOBT) CBC, urinalysis, ESR, FOBT

Urinary Problems in Females and Children

Have you had a fever or chills?

systemic inflammatory response - acute Inspection: ill appearance condition such as pyelonephritis or lithiasis likely to have upper UTI of Urinary system such as pyelonephritis, urolithiasis. Lower problems are fever-free and appear well.

Have you had nausea or vomiting?

Accompany a UTI, pyelonephritis, or Also, neonates with UTI's Microscopic Urinalysis: lithiasis. Systemic inflammatory response may present with Jaundice. color, sediment, RBC's, indicating an acute presentation WBC's, Casts

Have you and acute pain in the abdomen or back?

Upper UTI and pyelonephritis. Urinary Vitals: Hypertension is tract stones can cause localized back pain seen in patients with that radiates to the thighs nephritis

KOH and Wet Mount: if you suspect vulvovaginitis

Are you positive for HIV? Or receiving chemo?

immunocompromised individuals are susceptible to infections

Palpate and Percuss: the flanks and costovertebral angle for pain, this may indicate renal capsule distention

Ultrasonography: renal US to assess size and contour of KI, bladder US to assess for tumors of the bladder or thickening of the bladder wall.

In an infant: has the infant been irritable with lethargy?

In babies, UTI may present as irritability, anorexia and weight loss.

Pain the lower quadrant lower ureter involvemnet

Radiography: urinary calculi

Have you had any recent injury?

Hematuria can be caused by injury to the flanks

Suprapubic tenderness lower UT

Have you been hit recently?

Domestic violence can cause blood in the urine d/t trauma

Deep palpation for any masses

Are you sexually active? And how frequently do you Acute bacterial cystitis d/t frequent sexual engage in this behavior? intercourse, use of diaphragm or spermicidal gel.

Page 33 of 52

distended bladder rises above the symphysis and is a sign that the bladder isn't emptying. Enlarged bladder may cause pain.

Urine Dipstick: Specific gravity, leukocyte esterase, nitrites, protein, glucose, ketones, blood

DDX Common causes of Urinary Problems in Females and Children Uncomplicated UTI Dysuria, frequency, mild Nausea, nocturia, urgency, voiding small amounts; neonates and young infants present with anorexia, irritability, fever

NO fever; appears well; no CVA tenderness; may have suprapubic tenderness; Note: neonates and young infants may present with failure to thrive, bacteremia

Urine dipstick: + blood, +leukocyte esterase, +nitrites, microscopic analysis: RBC's WBC's no casts; urine C&S; in children, voiding cystourethrogram and renal US are recommended

Urine dipstick: may have + blood, + leukocyte esterase, + nitrites, urine culture; molecular testing vaginal specimen

Urethritis

Dysuria; vaginal d/c, Hx of new sex partner, frequent sex, partner with urethritis, multiple sex partners

Appears welll has no CVA tenderness or fever

Vulvovaginitis

Hx of vaginal itching, dc, burning, dryness, postmenopausal

inflamed or atrophic labia, vaginal or cervical d/c Microscopic exam, vaginal cultures, molecular testing

Interstitial cystitis

Frequent painful urination, hematuria, most often appears well and has no physical findings; middle-age women, often frustrated b/c no cause has suprapubic tenderness, may be present been previously found for long standing and persistend symptoms

urinalysis usually negative, x-ray and cystometric studies to rule out other urological disease, cystoscopy

Pyelonephritis

fever, chills, back pain, n/v, toxic appearance, some patients also have frequency and dysuria

Microscopic examination, WBC's may have white cell casts or bacterial casts, urine C and S: E.coli, klebsiella, proteus mirabilis, enterobacter, blood cultures

Urolithiasis

Pain, hematuria, may have symptoms of secondary may have CVA tenderness, loosk ill during infection, renal colic, pain that radiates to inner thigh, periods of acute pain, may have abdominal nausea, vomiting distention

feels and looks ill, fever, CVA tenderness, abdomen may be tender

Poststreptococcalglomerul Hx of skin or thorat infection 1-3 weeks prior, lethargy, Hypertension, perioribital edema, CVA onephritis anorexia, vomiting, abdominal pain tenderness, may have dyspnea, cough, pallor Chemical Irritation

Hx of bubble baths, soaps, lotions, sprays, urgency, dysuria

No fever, erythematous labia, urethral opening

Page 34 of 52

urinalysis, gross or microscopic hematuria, WBC's with or without bacteria, crytstalline structures may be present, noncontrast helical CT

U/A: +proteinuria, +hematuria, +ASO titer, serum C3 low early in disease hematuria common, gross hematuria, unusual and casts never seen

Vaginal Discharge and Itching

What kind of vagnitis might this be? What is the amount, color, and consistency of your discharge? Do you have itching, swelling, or redness? Is there an odor? Is this likely a sexually transmitted infection?

Common vaginal infections pospubertal: Trichomonas, Candida and bacterial vaginosis

Most common cervical infections: Chlamydia, Neisseria gonnorrhea, and herpes simplex

Are you sexually active? Do you have multiple partners? Do you have a new partner? Have you had sex against your will? (Child: has anyone touched your private parts?) What form of protection do you use? How often? Have you or your partner(s) ever been tested or treated for a STI? Do you have any rashes, blisters, sores, lumps, or bumps in the genital area?

Green, offensive smelling: T. vagnitis. Purulent: gonorrhea and chlamydia. Moderate white, curd-like: candida. BV is thin and either white, green, gray or brownish. Vagnitis causes inflammation --> erythema and edema. Candida has itching.

Note vital signs Fever in serious infection such as PID (uncommon in vaginitis)

Fishy: BV (positive whiff). Foreign body. MC in women of childbearing age (12-50) with a new partner.

Perform an external genitalia examination check lymph nodes (inguinal), erythema, excoriations and induration. Discharge in labial folds.

Recent treatment may indicate tx failure Vesicles: herpes. Warts are common (M contagiosum may extend to thighs). Painless ulcer suggests syphilis (solitary)

Can this be vaginitis that is not related to an STD? Have you ever been told you have diabetes or Could be immunocompromised Cushing's syndrome or that you are positive for HIV? Have you been ill recently?

Are you taking antibiotics, hormones, or BCPs? Postmenopausal women Have you received chemotherapy? have discharge related to Does the itching seem to be worse at night? atrophic vaginitis (def of Describe some of your recent activities estrogen) Is the patient premenarche? Is the condition acute, recurring, or chronic? How long have you had this? Is it getting better or worse? Have you ever had these symptoms before? How many episodes have you had in the past year? Are the episodes related to any particular activity or time? If this is acute, could it be related to a previous infection? Have you been tested and treated for this condition recently? What medication was prescribed? How long ago? Did you take all of the medication? What other prescriptions were you taking at that time? If this is chronic, what should I suspect? Do any family members or sexual partners have vaginal or urinary infections? Any itching, rashes, sores, lumps or bumps? Do you have a new or untreated partner? What are your sexual practices? Vaginal, oral, and/ or anal sex? How many yeast infections have you had this year?

Chickenpox, scarlet fever, measles can cause vaginitis Associated with candida. (Alter pH and flora) Pinworms! Bike riding, pools/hot tubs, tight fitting pants --> moisture/heat and mechanical irritation or infection Predisposed due to nonestrogenized vagina and lack of hair and labial growth After new partner suggests acute STI. Assoc with condoms/jelly suggest sensitivity to the product. Related to bathing: chemical irritation

Watch for self-diagnosis of a "yeast infection" Can have tx failure if stop taking meds. May have drug interactions Transmission of candida, M. contagiosum, herpes, lice, pinworms. Also poor hygiene.

Consider diabetes or immunocompromised state (HIV) if more than 3x candida/yr.

What are other possible causes for this vagnitis? local irritation, altered flora. Perfumes, douches, sprays, lubricants, bubble baths all are offenders in allergic vaginitis. What are your personal hygiene practices? Do you douche? Changes flora and pH. Also scented/coloured toilet paper can irritate. Direction of wiping is also important (microbes from anus to vagina) May cause allergic inflammation Have you changed brands of contraceptive products? Could you have forgotten to remove your diaphragm Itching, burning, foul, purulent discharge. or tampon? Also assoc with vaginal bleeding. Are there any associated symptoms that point to a cause? Do you have burning or pain with urination? Atrophic vaginitis: dysuria, dyspareunia, Frequency, hesitation, nocturia? vaginal dryness. Do you have painful intercourse? Endometriosis or PID, or fibroids. STIs leading to PID. Do you have any abdominal or pelvic pain? Infant: is there an eye infection? Gonorrhea or chlamydia Infant: is there a cough? Pneumonia assoc with chlamydiosis

Page 35 of 52

Perform oral exam look for oral thrush

Potassium Hydroxide (KOH) and wet mount. Whiff test is + for BV. Look for hyphae: candida. Clue cells for BV Test for pH - normal is less than 4.5. Above this: BV, trich, or atrophic Funal culture or sabouraud agar culture

Herpes culture Perform an internal vaginal examination look Tzank smear - for herpes at the cervix and vaginal walls Modified diamond's culture - for trich (rarely used) Perform a bimanual Thayer-Martin culture examination - POSITIVE for gonorrhea CERVICAL MOTION is DNA probe for from PID and warents Chlamydia, Gonorrhea, immediate evaluation, and herpes treatment, or referral to prevent scarring, ectopic pregnancy, and infertility Serology for syph Urinalysis Microscophy and skin scraping for scabies and pubic lice Perform a vaginal-rectal exam

Scotch tape test - for pinworms (Enterobius) Acetic acid test for HPV FSH - to determine premenopause

Vag Discharge DDX Physiolocial discharge

Increase in discharge; no foul odour, itching, or edema Clear or mucoid, pH <4.5.

Up to 3-5 WBCs; epithelial cells, lactobacilii

Bacterial vaginosis

Foul-smelling discharge

Homogenous, thin, white or gray discharge, pH >4.5

Presence of KOH "whiff" test, presence of clue cells,
Candida vulvovaginitis

Priuritic discharge

Whie, curdy, pH 4-5.0

KOH prep: mycelia, budding, branching yeast, pseudohyphae

Trichomoniasis

Watery discharge; foul odour

Atrophic vaginitis

Dyspareunia; vaginal dryness

Profuse, frothy, greenish discharge; red friable cervix; pH 5.0-6.6 Pale, thin vaginal mucosa; pH >4.5

Round or pear-shaped protozoa; motile "gyrating" flagella Folded, clumped epithelial cells

Allergic vaginitis Foreign body

New bubble bath, soap, douche, etc. Foul smell, erythema, "lost tampon"; pH<4.5 Red and swollen vulva; vaginal discharge; past history Bloody, foul smelling discharge of use of tampon, condom, or diaphragm Partner with non-gonococcal urethritis; asymptomatic May or may not have purulent discharge

Chlamydia

Pelvic inflammatory disease (PID) Itching and lesions DDX Syphilis

Bleeding, abdominal pain, fever, and vaginal discharge; increasing amount of dicharge and bleeding after sex History of painless ulcerative lesion; rash on palms and soles; warty growth on vagina or anus

WBCs WBCs DNA probe; >10 WBC's/HPF

Cervical motion test and adnexal tenderness; WBC, culture, DNA probe, gram may also have guarding and rebound tenderness staining Chancre: usually 1, painless ulceration; condylomata lata: flat, whitish papule or plaque; maculopapular rash: palm, soles, body

VDRL, RPR, FTA-ABS

Genital warts

Mild-to-moderate itching, foul vaginal discharge; child: Moist, pale-pink, verucous projections at base; Acetic acid test: white history of sexual abuse; adult: new or multiple located on vulva, vagina, cervix, or perianal area partners; past history of warts

Herpes

History of prodromal syndrome, paresthesias, burning, itching, may have mucoid vaginal discharge

Molluscum contagiosum

History of contact with infected person; if inflamed: itching

Grouped vesicles on a red base, erode to ulcer; if Viral culture; Tzank smear on mucous memb, exudate forms, if on skin, crusts form; redness, edema, tender ing lymph nodes Flesh-coloured, dome-shaped papules, some None with umbilication; usually 2-5cm in diameter

Page 36 of 52

Was onset abrupt or gradual? Does it chenge in a 24 hr. period?

Abrupt & shortlived = transient ischemic attack. DEMENTIA = insidious onset Sudden over a few hours = delirium

Is pateint alert and aware?

Yes = dementia and depression No/decreased alertness = delirium

Confusion/ Forgetfulness

Has the aptient seen, heard, felt things that are not there? Hx of head trauma? Medications?

Serum folate and B12 deficiencies may cz Cranial nerves: i.e. sense reversible dementia Hallucinations common in delirium of smell often impired in Uncommmon in dementia and depression dementia; slurred speech S-syphilis r/o neurosyphilis (although can occur in late stage dementia) Rapid alternating Mvmt: Rhomberg's, DTR (hyperreflexia in dementia); Urinalysis - r/o infxn Numerous drugs, illicit and pharmaceutical Language (apahsia in can alter mental states. Lumbar puncture - r/o dementia) Meds interactions meningitis NEURO exam

Tremor and gait disturbances at rest?

Associated with Parkinsons, HIV encehalopathy, liver dz, medication rxns, head trauma

H/A, fever, n/v?

H/A, N/V assctd. With stroke and tumor nd trauma Abdomen: inspect, percuss Fever in infxn, OH withdrawl for CVA tenderness. May indicate systemic cz of confusion i.e.urinary retention- UTI CVA tender-pyelonephritis Delirium = global cognitive losses involving Large Liver= hepatic memory, thinking, perception and encephalopathy judgement. Also irritability, disoriented, fearful Early Dementia = seletive cognitive losses, poor hygiene, socially withdrawn, Depression= fewer cognitive losses

What specific problems with mental abilities or tinking have you noticed?

Fatigue

MENTAL STATUS EXAM CBC- infxn, or anemia - What is the date? may contirbute to - Repeat words after me: confusion house, car, lake. Fluctuating symptoms in delerium More stable symptoms in depression and - What is this? (pointing to pencil) dementia

Does patient have any chronic health concerns?

HIV, alcoholism, renal failure, liver disease, severe anemia, COPD, CVD, predispose elderly to the development of confusion

Is this really fatigue?

Discriminate b/w fatigue & weakness. Pxs Psych screening for describe muscle weakness instead. depression & anxiety

Tell me what you mean by fatigue?

The sensation of profound Is the fatigue physiological? tiredness that is not Tell me about you lifestyle habits (Exercise & diet)? relieved by rest or sleep Tell me about your sleep pattern. and is not associated with prolonged activity. Chronic fatigue lasts more Do you require naps? than 6 months and onset Do you feel rested when you wake up in the am? is slow & progressive. When was your last menstrual period?

CBC w/ diff: may indicate presence of anemia (Hb, hematocrit), chronic blood loss Erratic eating patterns, over/undernutrition, Note general appearance inflammation or infxn missed meals, caffeine, stress, -demeanor employment. Lack of adequate sleep. Need b/w 6-8 hrs Vitals - fever, inc. HR/BP, adults; adolescents 8-9hrs; kids 10 hrs. Early am waking/ Xs sleep = sx of depression

orthostatic hypoT, BMI

Inspect skin, hair & nails - for signs of hypo/hyperT, Fatigue = early sx of pregnancy, post child nail biting, skin lesions (mono, Lyme dz) birth, perimenopausal (night sweats/ hot flashes = disrupted sleep) Do I need to consider an organic cause? 1st sign of HIV, hep, AIDS - STI contracted Examine Nose, eyes, from semen or blood. & through sex mouth & throat Do you practice saf sex (if sexually active)? practices that damage mucous membranes inflammation, lymph Have you ever had hepatitis? nodes, mucous Do you take any medication? Fatigue = side effect membranes Do you drink alcohol or use street drugs? alcohol , marijuana use result in fatigue - CV exam - heaves, bruit, CAGE questionnaire heart sounds, PMI What other clues can help me rule out an organic increased app may indicate hypoglycemia Examine LU - RR, A/P, cause? dec. app. May indicate infectious process fremitis, rales, wheezes Wt loss - malignancy, infxn, poor nutrition Examine Abdomen Have you noticed a change in appetite? Do you have any joint tenderness or pain? seen in juvenile rheumatoid arthritis (JRA) bowel sounds, Palpate (light & deep); rigid Have you noticed increased urination? DM type 2 = fatigue, poly abdomen (peritoneal dypsia/phagia/uria What other symptoms have you experienced? Sx such as muscle aches, abdominal pain, irritation), LV, KI, SP for general lethargy, dry skin & nails, SOB w/ tenderness exertion Could this have an environmental cause? Heavy metals & pesticides may cause MSK exam- joints for fatigue & neurological sx inflammation & swelling, Where do you work? test stamina (fatigue level) Have you been exposed to any toxins? Lyme disease (malaise, chronic fatigue before skin manifestations) Have you been camping? Neuro exam - Cognitive & physical fxn (attn span, What else do I need to know about fatigue? Psychological - Often related to stressful judgement, memory), CN, event & may have sudden onset. Describe the onset & pattern of your fatigue. When relflexes, cerebellar, motor Matabolic - slow, progressive onset did you first notice this? How severe is the fatigue? What makes the fatigue better or worse?

May limit social fxning, rec. activities Psych - usually < am, > w/ phys. Activity Organic - not relieved w/ sleep or rest Have you had a fever? Seen w/ infectious dz Prolonged fever - chronic infxn, inflammatory dz, malignancy How you had any bleeding? Heavy menses may lead to anemia, also GI ulcers, polyps, bowel CA If I suspect a psychological cause, what else do I Stressful events inc risk of depression need to know? Muscle atrophy w/ inactivity can lead to fatigue Describe your stress level and how you cope with stress in your life. Have you recently had a stressful event in your life? Family Hx of depression increases risk of Do you or anyone in your family have a problem with depression m/c women b/w 20-30 anxiety or depression? How are you doing in school?

Dec academic performance & dec. productivity may be early sx of dpression Overachievers may be compensating & hiding depression

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Ferritin - stored iron (low in iron def. anemia) Total Iron Binding Capacity- indirect measure of transferretin UA- infxn or systemic dz, hematuria, pyuria, leukocytes, ESR - rate at which blood settlesin anticoagulated blood; inc in inflammation (infxn, RA) Fasting Blood glucose>126mg/dl suggests diabetes Hepatic fxn - AST/ALT for general inflammation of liver (hepatitis) TSH - level identifies hypoT HIV infxn - enzyme linked immunosorbet assay to R/O infxn TB skin test - mantoux for Tb antibodies Monospot- detects heterophil Ab not specific to EBV Chest Radiographpneumonia, heart size, fluid (CHF)

DELERIUM

CONFUSION

DEMENTIA

DEPRESSION

reduced attn span; disorganized thoughts; decreased level of consciousness; irritability; memory impairment; disoreintation; perceptual disturbances; hallucinations; sudden onset,short lived less abrupt and less severe than delerium; apatheic, drowsy; disoreintation especially TIME, less for place, never for Self; diurnal variation less than delirium;

depends on underlying cz tremors affected speech (slow, incoherent etc) tremor, difficult motor relaxation

Insidious onset; stable course through day and night ; poor hygeine; weight loss; language difficulty; patient is alert; orientation often impaired; incontinence; irritability hallucinations absent until late stages; fragmeted sleep; "near miss" answers on Mental status exam

DSM IV 1. Memory Impairment 2. One or more of the following: a) Aphasia b)Apraxia c) Agnosia d) Disturbance in planning, organizing, sequencing 3. These defects casue impairment in social or occupational functioning

abrupt onset confusion; some diurnal variation; more consistent over time than delirium; Hx of phsychiatric problems; fluctuating cognitive losses; no hallucinations; suicidl thoughts; anxious mood

DDX: FATIGUE Physiological causes

Adolescent and younger adult, history of overwork, psychological stress, disturbed sleep, poor diet

Normal examination

None

Psychological causes: Depression: Children

Feeling sad, angry, irritable; Decreased academic performance; Somatic complaints

None

DSM-PC, DSM-IV

Depression: Adults

Loss of interest in usual activities; Feelings of worthlessness; Sleep problems Numerous somatic complaints, breathlessness

Depressed affect; normal examination

Depression screening instrument

Tachycardia, palpitations, diaphoresis

None

Anxiety Organic causes: Infection Drugs and Alcohol

Sudden onset; history of exposure; recent viral illness Fever; lymphadenopathy, localized signs of CBC, ESR, monospot erythema, edema History of smoking, alcohol use; antihistamines, Bilaterally enhanced or depressed DTRs; pupilary CAGE alcohol screening analgesic, antihypertensive meds changes; reduced attn span, judgement Anemia Increased pulse; pale mucosa; smooth red tongue CBC w/ indices, serum iron, ferretin, Breathlessness w/ exertion; menstruating female; recent surgery, delivery transferretin Hypothyroidism (myxedema) Poor appetite, fatigue, weight gain, cold intolerance T4 low, T3 low, TSH elevated Decreased pulse; dry skin, coarse dry hair, thyroid possibly enlarged, hoarseness Hyperthyroidism (Graves) Hyperactivity, heat intolerance, sleep problems Lid lag, fine thinning hair, tachycardia T4 increased, T3 increased, TSH depressed Organic causes: Male, middle aged or older, partner reports periods of Hypertension, obesity, narrowed upper airway sleep studies Sleep apnea no breathing during sleep, fatigue

Medications Heart Failure Cancer Mononucleosis (EBV) Hepatitis Fibromyalgia Chronic Fatigue Syndrome

Hx of allergies treated with antihistamines; meds for hypertension, heart disease, chronic pain Dyspnea, wt gain, fatigue, cough Fatigue, unexplained wt loss

Nasal congestion, cough, injected conjunctiva

Anxiety, JVP, displaced PMI, rales Observe, palpate & percuss all systems for lumps, lesions or consolidation; PE may be Young adult; slow onset of malaise, low-grade fever, normal Palatine petechiae, posterior cervical mild sore throat lymphadenopathy, spleenomegaly Jaundice, anorexia, fatigue, faver may be reported Jaundice, wt loss, athralgia, akin rash Female 20-50 yr, Hx of depression, sleep disturbance, Palpation of trigger pts will produce pain; normal chronic fatigue, general muscle and joint aches physical exam Fatigue greater than 6 mo, sudden onset of flu-like Physical exam may be normal, cerival & axillary symptoms that persist or recur lymphadenopathy

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Evaluate medication choices ECG, chest radiograph, ABGs CBC to rule out anemia,; leukocyte count Positive monospot; CBC w/ diff; >50% leukocytes Bilirubin increased; hepatitis panel None CBC, ESR

Limb Pain

Is the pain related to an urgent problem that Muscguloskeletal injury can rainge from needs immediate treatment to avoid disability or simple muscular strain to a significant death? fracture associated with nerve or vascular Have you had a recent injury? Priority of recent trauma is to assess injury. vascular and neurological integrety of the limb Do you have any other symptoms, such as fatigue, Suggests systemic disorder such as fever or swollen joints? infection or rheumatic disease. What is the severity of the pain? Unrelenting diffuse pain, often occurring at night, is an indication of bone involvement Does the pain occur with exercise or rest? Claudication and neurogenic pain increase with activity and decrease with rest, more immediately for vascular causes and more slowly for neurogenic causes

Symptoms of coldness, severe pain or paresthesia warrant physical exam immediately to assess need for emergency treatment. Ask specifically about the mechanism of injury and also wether or not the patient heard any noise to assess if there is a broken bone

What does the location of the pain tell me? Where does it hurt?

Location of pain provides a clue for Always observe for identifying the site where the pain symmetry and then originates functionally assess limbs Local pain receptors signal the site of and joint bilaterally irritation and an increase in sensitivity beginning with unaffected (hyperesthesia) results. Referred pain side. Order the exam so Could this be caused by a sprain or strain? generally involves the muscle chains, painful tests are done last. nerve pathways, and vessels. Unilateral, circumscribed limb or quadrant pain involves autonomic nerve fibers. Bilaterla pain is more likely to originate from systemic involvement. Diffuse pain with inconsistent distribution may be the result of psychosomatic conditions such as depression and anxiety Describe how the injury occurred? Strain involves injury to muscles and Observe patient walking, tendons, whereas sprains involve injury to removing coat, getting into ligamentous structures. Both produce sitting position. Look for a ripping or tearing sounds. limp. Have the patient Did you hear a noise with the injury, such as a A fracture produces diffuse swelling around locate the pain. Note any deformities ripping or cracking sound? the injured vone soon after injury. Deformity will be present if the fracture is displaced. Were you able to use the limb after the injury? Barotrauma --> acute serous otitis. Failure Assess vital signs. of eustachian tube to open and equilibrate Elevated temperatures are --> fluid collection in middle ear. seen in neoplastic, systemic and infectious If there is no history or trauma or a precipitating processes such as event, what else is causing the pain? osteomyelitis, septic arthritis and septic hip in Describe your usual daily activities at home, work Overuse: repetitive microtrauma results children and rheumatic and with hobbies from cumulative injury or overuse. disease.

Complete Blood Cell Count Evaluates for anemia associated with chronic disease, infection or neoplasm. Altered WBC count may indicate infection or leukemia. Erythrocyte Sedimentation Rate Elevated when inflammation is present. Non-specific Joint Aspiration Assess synovial fluid for elevated WBC, gram stain, culture and sensitivity, crystal analysis, presence of glucose and consistency.

Is the pain localized or generalized?

How does the pain afect your activities?

Inspect skin and nails. Lyme disease has a target lesion and rash on the trunk. Look for puncture or abcess which may be Do you have other illnesses? Presence of coronary artery disease source of infection. Look increases the risk of arterial insufficiency for ecchymosis and and associated caludication pain. bruising indicating trauma. Peripheral neuropathy associated with Look for swelling and In joint pain with injury, what do I need to know diabetes can produce a burning pain or about the specific joints involved? redness of joints. 'pins and needles' sensation, esp. lower Upper extremities: Shoulder, wrist, elbow key Measure limb extremities. questions circumference and length. Is the pain in your dominant limb? Pain in the dominant hand may indicate Palpate extremties and repetitive microtrauma or overuse. joints Did you fall on an outstretched hand or arm? Breaking a fall with an outstretched arm is Perform passive and active a common mecahnism of injury for a ROM of all limbs. Test for Did you overuse a joint? fracture or dislocation of the hand or wrist muscle strength with RROM. Neurological exam of dermatomes and myotomes. Lower extremities: Knee, ankle

Radiography Obtain at least two radiographic views, anteroposterior and latera becausae injuries are not always apparent on a single view. MRI and CT usually ordered by specialists. MRI good for spone, joint and soft tissue imaging. CT good for bone visualization

Activities: a person may adapt to chronic musculoskeletal problems by using an assistive device such as a cane or by limiting activities.

Antinuclear Antibodies Postive with RA ans SLE Rheumatoid Factor Positive in 80% of RA patients C4 Complement Increased in active inflam. Disease and autoimmune disorders such as juvenile RA

C-Reactive Protein Elevated in RA and infection Lyme Titer Enzyme-Linked Immunosorbent Assay Serology (ELISA) May detect anti-bodies for B. burgdoferi.

How is the pain affected by weight bearing or activity?

Continuing with activity means the injury did not totally disrupt any ligamentous structures.

Did you feel a sense of 'giving way?'

An inability to straighten or ben the knee suggests a mechanical blockage

Did you hear a pop, tear, or other sound?

A loud pop is virtually diagnostic of an ACL tear. A ripping sound suggests a meniscus injury. A cracking sound may signify a bony injury or dislocation of the patella

What position was your leg in when you hurt your knee? Could this be musculoskeletal joint disease?

A sudden change in direction or sudden stop may put more force on the ligaments than they can dissipate, resulting in acute rupture

What does the pain feel like?

sharp, piercing, stabbing, cutting, pinching, gnawing pain --> nerves and skin. Dull, tearing, boring, burning, cramping are common terms to describe pain arising from deeper structures such as muscles, joints, and internal organs. Pulsating, pounding, throbbing, or hammering --> vascular pain. gradually increasing sensations of pressure, tension, heaviness and calf pain --> venous obstruction. Severe pain that develops over 1 to 4 days is typical of osteomyelitis or septic arthritis in children, which is an emergency

What does the history of swelling tell me?

is there any swelling?

Swelling is always abnormal.

When did the swelling begin?

Within 2 hours after injury is the result of a fracture or hemarthosis. Swelling 6 - 24 hours after injury is usually of synovial origin. >24 hours suggests an inflammatory response.

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Musculoskeletal Inflammation Tenosynovitis

Repetitive trauma activities; pain with movement History of overuse; aching pain over affected bursae that radiates along the limb Pain in trigger sites throughout body, joint stiffness, disturbed sleep

Swelling over tendon, crepitus Local tenderness, swelling, limited joint motion, muscle weakness Fatty, fibrous nodules in muscles, palpation of trigger points elicits pain

none

Osteomyelitis

Presentation depends on age, location of infection, trauma, penetration, invasive procedure; refusal to bear weight (hip); constant pain

Fever, chills, vomiting, pain localized over affected area but progressively worsens; soft tissue injury or abcess

Increased WBC, ESR, C-reactive protein, radiographs

Joint Inflammation Osteoarthritis

Older adults, asymettrical joint pain and stiffness that DIP, PIP joints enlarged, Heberden's nodes. improves throughout the day, history of repetitive joint Limited cervical spine ROM trauma, obesity

ESR; radiograph may reveal osteophytes, loss of joint space

Rheumatoid arthritis

Morning stiffness of small joints, symmetrical involvement, anorexia, weight loss

Fever, rehumatoid nodules, ulnar deviation of wrists

Increased ESR, positive rheumatoid factor, anemia on CBC, radiograph shows bony erosion

Juvenile rheumatoid arthritis

Fatigue, weight loss, failure to thrive, refusal to walk, joint pain and stiffness

Fever, rash, guarding of joints, limited ROM; joint Elevated WBC, ESR; positive swelling, nodules rheumatoid factor and antinuclear antibody

Septic arthritis

History of systemic infection, malaise, diaphoresis, refusal to bear weight (hip), acute joint pain

Fever, red, swollen joint, limited ROM

Gout

Acute pain of large joint, asymmetrical, males over 30 Inflamed swollen joint, tophi, sodium urate years, history of gout crystals

Increased serum uric acid level, ESR, WBC

Shoulder dislocation

History of trauma, pain History of trauma, pain

Limited rotation, arm abduction and hand supination Limited shoulder movemnt; obvious deformity

Radiograph of shoulder

Acromioclavicular joint injury Bicipital tendonitis

History of overuse of biceps; pain worse with movement Acute: younger persons, history of trauma, severe pain; chronic: older, pain worse with overhead movement, sleep disturbance

Positive Yergason's test; pain localized over the intertubercular groove Acute: inability to raise arm side-ways, shrug shoulders; chronic: tenderness over AC joint, crepitus, weakness in external shoulder rotation

radiograph (Fisk view)

repetitive motion of or pressure to the elbow, localized pain History fo repetitive contraction of extensor and supinator muscles, pain over lateral epicondyle that progresses Occurs in children, pain in the elbow or arm

warmth, redness and swelling over joint, full ROM radiograph to rule out fracture of the olecranon process Tenderness over later epicondyle; palaption none roduces pain, motion does not; supination against resistance worsens pain radiograph of elbow The afected arm is flexed and the hcild cries when attempts are made to move the joint

Wrist fracture

History of fall on an outstretched hand, pain and swelling of forearm and wrist

Palpation of snuffbox increases pain; observe for Three-view radiographs to determine joint deformity scaphoid or Colle's fracture

Finger fracture

History of trauma or fall, joint tenderness

Joint swelling, instability

Three-view radiographs (PA. lateral and oblique)

Ganglion

Noticeable lump on dorsal surface of wrist

Gelatinous filled, nodule, soft, transilluminates

none

Slipped capital femoral epiphysis Transient synovitis of the hip

Children during rapid growth spurts, knee pain worse with activity Children less than 10 yrs, history of upper respiratory infection, limp, pain in the anteromedial thigh and knee Boys 3-11 yrs, groin or medial thigh pain, limp

Limitation of medial hip rotation, limp

Radiograph of epiphyseal plate

Tenderness on palpation over anterior hip; hip movement increases pain and is limited; lowgrade fever. Decreased ROM of hip

Ultrasound, ESR

Iliopspas tendinitis

History of repetitive flexion of hip; pain worse with movement

With patient sitting, place the heel of affected leg none on the knee of the other; test is positive if pain is elicited

Chondromalacia patellae

Adolescent females; history of knee trauma or misalignment, knee pain worse with activity History fof overuse, especially running or jumping; dull, achy knee pain; click

Tenderness to palpation over knee

Bursitis Fibrositis

none none

WBC, culture of joint aspirate, ESR, C-reactive protein, ultrasound of joint

Musculoskeletal Pain Related to Trauma and Overuse

Rotator cuff tear

Olecrenon bursitis Lateral humeral epicondylitis Subluxation of radial head

Legg-Calve-Perthes disease

Patellar tendinitis

Q angle greater than 10 degress in males, 15 degrees in females, clicking or popping with knee movement

Page 40 of 52

Radiograph of shoulder

radiograph may reveal humeral displacement or spurs

AP and frog lateral radiograph of the hip; LCPD may show increased density of the femoral head

Four-view radiographs of knees to rule out arthritis none

Limb Pain Continued

Is this an acute or chronic problem?

Pain hours after injury is usually acute extensor injury or pveruse. Severe ligament sprain manifests immediately. Chronic problems compound each other whereas intermittent or episodic pain is characteristic of diseases of the musculoskeletal system

When did the pain first occur?

When did you first notice a problem?

Problems with activities of daily living are noticed

How is activity affected? What will this tell me?

What are your usual activities?

Repetitive microtrauma in lower extremities is due to inappropriate rate and intensity of training, shoe wear and playing surfaces

What activity makes the pain worse?

Intraarticular lesions usually worsen with joint motion and sports activities. Intraosseus tumors are less sensitive to joint motion.

What movements make the pain worse?

In children with septic hip pain increases with movement

What does joint stiffness or locking tell me?

Stiffness is felt after being in one position for too long. Locking of the knee is an abrupt occurrence where they somplain that something 'gets in the way' of fully extending the knee.

Have you had any joint stiffness?

Does activity make the stiffness worse or better?

common feature of inflammatory arthropathy eg RA or SLE

Do you have any locking of the knee?

Sign of chronic unstable meniscus tear

What does a history of a limp tell me?

limping is a pathological alteration of a smooth, regular gait pattern and is never normal

Is there pain with the limp? Did the limp come on suddenly?

Limp after strenuous running may indicate stress fracture

is the limp constant or intermittent?

neuromuscular diseases can result in progressive and painless muscle weakness or spasticity that affects ambulation in a variety of ways

what is the effect of running or climbing stairs?

quadraceps weakness causes difficulty climbing stairs

Could this be caused by systemic disease? Have you been treated with any antibiotics lately?

antibiotics can cause serum sickness in children. Fluoroquinoline antibiotics can produce tendinitis or tendon rupture in adults

have you had any recent immunizations?

transient arthralgia may occur 6-8 weeks after receiving MMR. Recurrent or permanent arthritis may follow rubella vaccination, esp. adult females

has the fever been constant or intermittent?

does the pain awaken you at night?

report by an adolescent of night pain is a red flag for intraosseous pain of a bone tumour. Growing pains may also awaken a child. Growing pains are bilateral

is the pain worse ar night? do you have a skin rash? Could the pain be caused by Lyme Disease? have you been camping or out in the woods? have you noticed any skin rash? What does past medical history tell me? Have you had anything like this before? Do you have a chronic disease? Could you have been exposed to any sexually transmitted disease? Have you been treated with cortisone? Have you had a recent cold or upper respiratory infection? Is this likely a mixed condition?

Lyme disease is an infection caused by tick-borne spirochete borrelia burgdorferi. Symptoms involve arthralgias, particularly knee joint target lesion Sickle cell anemia, IBD, Crohn's, hypo and hyperthyroidism, or collagen vascular diseases are frequently associated with skin rashes, psoriasis and limb or joint pain Gonorrhea may disseminate to the musculoskeletal system in 1-3% of ppl with disease. more than 80% develop arthritis cortisone-induced necrosis of the hip sickle cell anemia can cause hip pain . Viral infections may cause diffuse myalgia pre-existing systemic disorders can result in acute injury. A clue is that the extent of the injury seems out of proportion with the precipitating activity

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Limb pain DDX cont'd: Medial collateral ligament sprain

History of valgus stress to knee; limp; pain

Effusion and point tenderness over knee; valgus AP and lateral radiographs may and varus pressure to assess instability reveal a ligament avulsion of femoral origin

medial meniscus tear

History of twisting injury to the knee, pain, diffculty flexing; bearing weight, clicking or catching of knee with movement

Positive McMurray's test, clicking or locking during joint movement

Four-view radiographs to rule out bony deformity

Anterior cruciate ligament tear History of twisting or extension knee injury; audible Swelling; positive Lachman's test radiograph to rule out fracture 'pop' Osgood-Schlatter disease Adolescent males, knee pain and swelling aggravated Tenderness, warmth, swelling over anterior tibial Radiograph with knee rotated inward by activity, limp tubercle may show soft tissue swelling Baker's cyst

Ankle Sprain

Fullness or swelling of posterior knee, aggravated by Negative Foucher's sign; normal joint walking examination; positive Homan's sign in ruptured cyst History of inversion stress with audible pop, Swelling, soft tissue trauma, able to perform immediate swelling active ROM with ligament sprain

none

Pain is diffuse, varies in pattern of activity, setting; history of depressioin or anxiety

none

Radiograph needed only with tendernes over lateral malleolus to rule out fracture Shin splints Ache or pain over medial tibia that is worse with tenderness over medial tibia AP and lateral radiographs may exercise, history of running show a stress fracture; a bone scan will be positive with increased uptake along the medial tibia Achilles tendinitis Pain and tightness over Achilles tendon, especially Tenderness over Achilles tendon; pain worse with Lateral ankle radiograph reveals with walking or running dorsiflexion of ankle, calf weakness enlarged posterosuperior tuberosity of calcaneus Plantar faciitis History of chronic weight bearing, aching feet, muscle Misalignment of foot structures, sepecially talus, none spasms, obesity calcanues, and plantar ligaments Viral serum titer Muscle Pain (Myalgia) Viral Hisotry of upper respiratory infection, malaise, chills, Fever, I;;-appearing adult or child Infections cold symptoms, general muscle aches Psychogenic Fibromyalgia

Systemic Disorders Leukemia Sickel cell disease

Normal examination orpatient response to examination maneuvers disproportionate to physical findings or subjective complaints Female 20-50 yrs, history of depression, sleep Palpation of trigger points will produce pain; disturbance, chronic fatigue, general muscle and joint normal physical examination aches Fever, hepatosplenomegaly, bruising Acute Hip pain in children, refusal to walk

African-American, family history; appears after 6 mo of age; acute pain with swelling of hands and feet, abdominal pain, decreased appetite, malaise Systemic lupus erythematosus Female, transient arthritis of small joints, malar rash Lyme arthritis Neuroblastoma

Normal examination

Normal examination may habe joint tenderness on palpation History of exposure to endemic areas of deer tick, Asymmetrical swelling, warmth of joint, erythema chills, diffuse joint pain and swelling, often the knee is migrans, may have myocardial involvement affected Under 5 yrs, pain in bones Unexplained fever

Osteogenic sarcoma

Persons 10-25 yr, intermittent pain of lower femur, upper tibia, limp Nerve Entrapment History of sleeping with arm against head, morning Syndromes Thoracic shoulder pain, pain worse with lifting, paresthesia; outlet syndrome rounded shoulder posture Carpal tunnel syndrome History of repetitive upper extremity motion; paresthesia, weakness, or clumsiness of hand; symptoms worse at nights

Tenderness over affected area

none CBC Hemoglobin S genotype

Kidney function tests, antinuclear antibody, CBC Serum IgM and IgG antibodies, ESR

Urine for vannillylmandelic or homovanillic acid; CT scan Radiograph, serum alkaline phosphatase EMG

Bruit over supraclavicular fossa; pallor, decreased pulses of upper extremity, weakness, skin and nail atrophy Positive Phalen's and Tinel;s sign, weakness of none hand, dry skin over distribution of median nerve

Peroneal nerve compression History of pressure to the knee from a cast, sports Unilateral foot drop injury, or trauma; pain over head of fibula; clumsy gait

none

Tarsal tunnel syndrome

Tapping posterior tibial nerve elicits pain

none

Decreased sensory and pain sensation

Liver function tets, hemoglobin A1C to rule out diabetes

Neuritis

Pain in ankle and proximal foot, weakness of toe flexors, ill-fitting shoes Pain and sensory loss, usually of lower extremities; history of alcohol ingestion, diabetes

Page 42 of 52

Headache

A subjective feeling of pain caused by a variety of intracranial and extracranial factors

What Clues Indicate This Is a Potentially Serious, Need to know if patient is fully oriented Observe the Patient Life-Threatening Headache? before proceeding. Can screen with a Mini- Any patient who complains Mental Staus Exam. If patient shows a of headache and exhibits mental status deficit, immediate an ataxic gait, emergency treatment is indicated uncoordinated movements, or reduced mental How did the headache begin? Onset of sudden severe headache with alertness should be neurological signs is an emergency; the immediately transported to patient needs immediate emergency an emergency center for treatment neurological evaluation What is your age? Have you had this type of New onset headache in children or elderly headache before? or persons over 50 years of age is a warning sign of a serious cause On a scale from 0 (no pain) to 10 (worst pain ever) New, severe headache or headache Take Vital Signs and how severe is the pain? different than prior occurences and Obtain Growth headache that progressively worsens are Parameters Fever warning signs of serious causes may be the only sign of infection. Bradycardia and Is there a history of recent trauma to the head? Trauma may cause subdural or eppidural bleeding. Anyone who experienced head narrowing of pulse pressure are signs of trauma must be carefully observed for at increased intracranial least 24 hours for signs of neurological pressure. In children, damage plotted height and weight Was there a loss of consciousness? Higher chance of neurological signs significantly below average Do you notice any other symptoms associated with Headache associated with infection considers hypothalamic headache pain? presents with fever and possibly stiff neck. neoplasm. Macrocephaly Intracranial hemorrhage associatedw ith may indicate confusion, vomiting, lethargy and focal hydrocephalus or brain neurological signs. Brain tumours in tumour children associated with vomiting, recurrent morning headaches, reflex asymmetry and papiledema Do you have any chronic health problems?

Persons with AIDS have increased risk of cryptococcal meningitis, encephalitis or generalized sepsis. Persons treated with anticoagulants or elderly are at increased risk of headache from a serious cause. Headaches secondary to metabolic disorders can be result of hyponatremia, uremia, hypoglycemia or hypercapnia

After Determining the Headache Is Not Serious, How Can I narrow Down the Causes? What does it feel like? Where does it hurt?

A moderately intense, constant throbbing headache is associated with dilatation of cervical arteries. Severe pain indicates an expanding lesion. is steady Pain secondary to Migraine trauma orpain inflammation is felt at near the site of trauma. Tension headaches can feel like a 'hatband' distribution. Orbital pain is present with increased intraocular pressure. Periorbital pain may be present with sinusitis, migraine or trigeminal neuralgia. TMJ pain may be present. COntraction of muscles of head and neck cause nonpulsatile pain.

What makes it worse?

Triggers such as sound, odour and estrogen fluctuations are associated with migraine. Food triggers such as chocolate and cheese can trigger migraines. Migraines are worse with activity. Stress can trigger any type of headache.

How long have you had this headache?

Tension type headaches and migraines last less than 24 hours. Cluster headaches are less than 3 hours Auras can occur before, during or after headaches and last no more than 30 minutes. Other prodromal symptoms include fatigue, depressed or euphoric mood, increased or decreased appetite, constipation or diarrhea and yawning. Activities: a person may adapt to chronic musculoskeletal problems by using an assistive such asheadaches a cane or by A patient device with constant for more than 3 months may demonstrate papilledema, bilateral or unilateral cranial nerve VI palsies, gait or balance disturbances or spasticity of the lower extremities. Continuous headaches for four weeks or more without these symptoms is of psychogenic origin.

Can you tell when it is coming on?

How does the pain afect your activities? What Does the Chronicity of Pain Suggest? How frequently do you get a headache?

Can you describe any pattern to the headache?

headaches throughout the day indicate tension type.Sinus headache gets worse as the day goes on and when leaning forward then get better at night. Headaches associated with ypertension are occipital, worse on waking and lessen as the day goes on. Meningeal inflammation produces pain that fluctuates throughout the day with no clear pattern. Migraines are episodic. Cluster headache pain is short often less than one hour and intense.

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Palpate and Percuss the Skull Focal tenderness and induration seen on tension type headaches. Tenderness over nodular temporal arteries indicates temporal arteritis. Brain abcesses cause pain with localized traction and tenderness on percussion. Auscultate the Cranium Intracranial arteriovenous malformations mimic migraine. Evaluate for cranial bruits over orbit and skull

Inspect the Ears, Eyes, Nose, Mouth and TMJ Looking for signs of sinusitis, infection, eye changes, TMJ problems, facial paralysis/weakness

Perform Opthalmoscopy Look for papiledema and hemorrhage. Optic disc atrophy sugggests chronic intracranial pressure or lesion at optic chiasm.

Assess Cranial Nerve Function May provide evidence for more serious causes of headaches secondary to inflammation, traction or metabolic imbalance.

Complete Blood Cell Count Detects major blood dyscrasias. Hypoxia secondary to severe anemia can cause headache. Blood Cultures Do if patient has fever, headache, nuchal rigidity and altered mental status CT Scan Detects intracranial disease. DO for new-onset headache or if headache is associated with neurological signs. Lumbar Puncture Do if infection is suspected but contraindicated if increased intracranial pressure Erythrocyte Sedimentation Rate Non-specific for temporal arteritis inflammation Skull Radiograph Do for post-traumatic headache

Primary Headache Without Common in adults, bilateral pain, general or localized Normal physical examination; neck muscle Structural or Systemic in bandlike distribution; history of anxiety, stress or tightness or fasciculations may be palpated Pathology Tension depression (muscle) headache

None

Migrain without aura (common)

More common in children; unilateral, throbbing pain; nausea

photophobia and phonophobia

none

Migraine with aura (classic)

Pain precipitated by environmental stimuli; visual disturbances (scintillating scotoma) precede pain

nausea and vomiting, photophobia and phonophobia

None

Mixed headache

Throbbing, constant pain during waking hours; muscle Mix of findings related to tension and migraine tightness; family history of migraine headache pain

Cluster headache

Rare in children; abrupt, nighttime onset; unilateral periorbital pain that is severe

Benign exertional headache

Sudden onset related to physical exertion, Valsalva or normal ysical exam coitus

None

Ipsilateral rhinorrhea, nasal stiffness, conjunctival None injection, sweating, ptosis May need to distinguish from subarachnoid hemorrhage with CT scan

Secondary Headaches With Structural or Systemic Pathology

Radiographs (Waters view) Low or no fever, pain on palpation of frontal, maxillary sinuses; purulent nasal or postnasal discharge Malocclusion, caries, abcesses of teeth present, dental referral gum disease

Infectious Origin Sinusitis

Frontal, upper molar, or periorbital pain: cough, rhinorrhea

Dental Disorders

Localized pain in jaw and top of head

Pharyngitis Otitis media Meningitis

Sore throat ear pain, pain with swallowing Severe headache, chills, myalgias, stiff neck; toxic child or adult

Fever; infection of the posterior pharynx Fever, red, bulging tympanic membrane Positive Kernig's and Brudzinski's signs; fever, photophobia, petechial rash may be present; mental status changes

Throat culture None Lumbar puncture

Neurogenic Origin Trigeminal neuralgia

Persons over 55 yrs; bursts of sharp pain over the face innervated by the affected nerve; triggered by stimulus to the affected nerve

Normal physical examination; stimulation of triggers may provoke pain

None

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How long does the headache last?

Examine the Neck Do full ROM and assess stiffness which may Have you had this kind of headache before? Acute-onset headaches must be evaluated indicate muscle tension or for organic causes. Subacute and chronic meningitis ones are usually caused by vascular Do you use alcohol? Take any medications? Test for Meningitis eg inflammation or muscle tension. Migraines Kernig's sign. Assess usually begin between 10 and 30 yrs. New Deep Tendon Reflexes onset migraines in adults over 50 yrs is for cerebral lesions. unusual. Tension headaches usually begin What Associated Symptoms Does the Patient Associated with migraines. Vomiting can Assess Motor Strength Have? be a sign of increased intracranial and Coordination of pressure. Headaches from tumours Extremities produces early morning vomiting without Asymmetrical increase in Do you have any nausea or vomiting? nausea. muscle tone on affected side, contralateral to the DO you notice any vision changes? Auras procede migraines. Cluster hemisphere lesion headaches associated with ipsilateral suggests a cerebral lesion. conjunctival injection, lacrimation and If person exhibits forearm edema of eyelid. drift with arms extended Does light bother you? Often present with migraines but not and eyes closed may have tension headaches. Present in meningitis a motor neuron or cerebellar disturbance with Are you dizzy? 1/3 people with migraines have vertigo expanding intracranial What Do the Aggravating and Alleviating Factors Meningeal irritation headaches are better lesion. Suggest? with lying down. Tension headaches respond to analgesics. Rest relieves migraines but not tension headaches in children. Sleep, rest in dark quiet room Does anything make the headache better? Have Children Draw a relieves migraines in adults. Increased Picture of Their headache with sneezing or coughing may Headache Help indicate benign headache or lesion at level to diagnose type of Does anything make the headache worse? of foramen magnum that is not clinically headache eg. Children will present yet. Migraines are worse withe draw flashes of light for What Does Family History Indicate? xertion. Cluster headaches are worse lying migraine aura. down. Headaches wrose in morning and better on rising indicate tumour. Benign Does anyone else in the family have headaches? Tension type headaches have no family history. Migraine headaches have positive family history Is There Anything Else That Woud Help narrow Meningitis indicated. Lumbar punctures the Cause or Causes? can cause headache in 25% of people. Chronic infection predisposes to brain Have you been ill recently? abcess. Penetratin skull fractures allow Have you taken any medications or vitamins? bacteria to enter. Melanomas can Could you have been exposed to carbon monoxide? Exposure may cause severe, throbbing, generalized headache. Occupation exposure to toxins should be assessed. Winter headaches may be due to faulty kerosene or gas heater.

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Optic neuritis Cervical spine disorders Temporal arteritis Metabolic Origin Carbon monoxide poisoning Severe hypoglycemia Drug withdrawal Dietary ingestion

Cardiovascular Origin Intracranial tumour Hydrocephalus Subdural hematoma

Pseudotumour cerebri

Brain abcess Intracerebral hemorrhage

Acute onset of pain with extraocular movement, followed by blurred vision

Diminished visual acuity, decreased pupillary opthalmology, referral reflec, hyperemia of the optic disk; pain with extraocular movement May have a history of trauma; occipital pain, muscle Normal physical examination or pain associated Cervical spine radiograph stiffness with neck motion Age>50 yr; sharp localized temporal pain; malaise, fever, weight loss; tender over a nodular temporal Elevated ESR (>50); immediate anorexia, history of polymyalgia rheumatica artery referral for treatment History of exposure, throbbing headache, mild nausea, vomitting, change in mental status, Blood gases and dyspnea lethargy, loss of consciousness carboxyhemaglobin level History of diabetes or medication, alcohol and food Normal physical examination or pallor, sweating, Blood glucose level; may need selfingestion; generalized headache, dizziness, sense of and weakness monitoring of blood glucose to not feeling well establish pattern normal physical exam blood chemistry Pattern of headache associated with stopping medication or substance use blood chemistry Mild to moderately severe headache after ingestion of normal physical exam foods or medication

Sudden-onset headache that is progressive, exacerbated by coughing or exercise; worse in morning; history of trauma increases risk Progressive headache, vomiting, irritability History of head trauma, bleeding disorders, child abuse; adult over 35 yrs; sudden onset of 'worst ever' headache, often over the eye, transient loss of consciousness Teens, menopausal women, history of vitamin A or tetracycline ingestion; progressive headache

Papilledema, vomiting, asymmetrical reflexes, weakness, sensory deficit, or other neurological deficit Rapid enlargement of head, bulging fontanels unequal pupils, photophobia, neurological chnges, seizures

CT scan

Papilledema may be present

teens, menopausal women, history of vitamin A or tetracycline ingestion; progressive headache Risk factors; persons over 50 yrs, with AIDS, on anticoagulation therapy, or with hypertension

fever, seizures, focal neurological findings correlated with extent of the lesion If conscious, abnormal neurological findings correlated with extent of lesion

CT scan, neurology referral to assess risk related to lumbar puncture CT scan

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CT scan and referral CT scan and neurosurgical referral

Emergency transport for immediate evaluation (CT scan) and possible surgical treatment

Lower Back Pain

Do you have a fever?

The presence of a fever indicates an inflammation; spondyloarthropathy or systemic infection. Ask for chills, weight loss, fever. Also, may inquire about intravenous drug use or immunosuppressed conditions. Have you experienced any trauma? Acute trauma to the spinal cord can result in a fracture, dislocation or misalignment or the muscles, ligaments and IVD. Spinal cord injury should be suspected with anyone whose level of consciousness is impaired after an accident. Do you have any other health problems/been treated Assess for systemic diseases (metabolic, for cancer? inflammatory diseases and fibromyalgia). Patients with a history of cancer are more susceptible to spinal tumours.

What is your age?

Have you had a loss of your bowels or bladder control?

In the absence of trauma a sudden and severe onset of middle back pain can be a sign of an aortic aneurysm in a patient above the age of 30. Patients above 50 are at risk of compression fractures and cancer. Assess for cauda equina or S1-S2 nerve root compromise secondary to a herniated disk, nerve entrapment, spinal stenosis, infection or tumor. A Surgical emergency is indicated if there is saddle anesthesia, urinary retention and fecal incontinence.

Are you on any medications?

Long-term use of corticosteroids can lead to compression fractures of te vertebrae. Use of intravenous drugs may suggest infection as a cause

Where does it hurt?

Sciatica is usually sharp, burning pain that radiates down the posterior of the leg to ankle. Back pain with neck stiffness can indicate cervical osteomyelitis. Rheumatoid arthritis produces pain in the upper back and neck. Localized pain that is unremitting with rest can be a sign of a tumor. Flank pain can be a sign of kidney infection.

When did the pain start?/Duration of the pain?

Pain that is mild and or short duration (1-2 weeks) is rarely serious. Back pain lasting longer than 4 weeks needs to be reevaluated for further diagnostic studies. In children back pain that is present for more than 3 weeks is often due to organic and serious causes.

Does the pain interfere with your sleep?

Night pain is often a worrisome symptom that often signals a serious problem such as tumor, infection or inflammation. Genreally muscular issues are relieved at night. Nighttime back pain is unusual and indicates the need for a complete and thorough work-up. 2 types - (1) pain referred from the spine into areas lying within the lumbar and upper sacral dermatomes. (2) pain referred from the pelvic and abdominal viscera to the spine. Pain from the upper lumbar spine usually radiates to the anterior aspects of the thighs and legs, and that of the lower lumbar spine radiates to the gluteal regions, posterior thighs and calves. Visceral disease usually stays with in the abdomnial cavity (flanks). Gallbladder pain radiates around the trunk to the right scapula. Position does not affect the pain.

Does the pain travel?

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Assess the overall Plain radiographs appearance of the patient. Bone Scan Gait, symmetry, posture. CT scan

Perform range of motion of the spine. Straight Leg Raising, Deep tendon reflexes, muscle strength

MRI,

CBC - detect anemia as well as other conditions that might manifest as back pain, such as tumor or infection. Urinalysis - assess kidney and metabolic function, including infectious process, rule out pyelonephritis.

Spinal fracture

major trauma, impact or fall, strenous lifting, elderly minor fall, treated as a medical emergency

Tumor (osteoblastoma, spinal Pain unremitting with rest, general poor health such metastasis, osteoid osteoma) as weight loss, fatigue, weakness and anemia.

Infection (osteomyelitis, diskitis).

Cauda Equina Syndrome

palpable tenderness over site of fracture

considered an emergency; radiographs

weight loss, fever, tenderness near tumor

ESR; bone scan; plain film

The spine is the most common site for osteomyelitis in acute onset presents with fever, diaphoresis; adults. Staph aureus is the most common bacteria. tenderness over affected disk; positive SLR Stiffness and pain over the site of the infection. Tender spinous process, positive SLR test, paravertebral muscle spasm. Often secondary to pharyngitis or otitis media, intravenous drug use, diabetes mellitus, immunosuppression positive SLR, motor weakness Compression of the S1 nerve. saddle anesthesia, urinary retention and fecal incontinence. Unable to heel or toe walk, asymmetrical knee and ankle deep tendon reflexes.

Sciatica

acute back pain with radiculopathy; history of strain or paravertebral tenderness and spasm; positive trauma, relief with sitting SLR; sitting knee extension sensory findings

Aortic Aneurysm

severe acute-onset not related to activity or movement, increased risk in persons over age 30; anxiety, sweating confusion

Gallstones

Pyelonephritis

ESR; blood culture; bone biopsy; CT scan; MRI

surgical emergency

intact aneurysm will be a visible pulsatile midline emergency surgical referral upper quadrant abdominal mass; in a dissected aneurysm upper extremity pulse and pulse pressure are asymmetrical; posterior thoracic pain may be felt surgical referral Increased incidence with age; steady, intense pain in normal physical; positive Murphy's sign on RUQ with radiation to right scapula or shoulder; palpation of abdomen belching, bloating, fatty food intolerance

ill-appearing, sweating, nausea, back/flank pain. H/A

fever; cloudy malodorous urine, CVA tenderness Urinalysis, urine culture

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Is This Really A Fever?

Fever

How do you know you have a fever? Has the temperature been measured? How?

An elevation of Should Sepsis or Meningitis Be of Concern? temperature above normal daily variation and Has there been any recent head traumas? is a symptom of an underlying process Have you had recurrent ear infections? Have you had contact with anyone else who had meningococcal disease?

Fever in a Child Less Than 2 Months Old Fever in the first 2-3 months of life is relatively . uncommon but when it does occur it is usually Should be measured throughout day with a significant and often thermometer to monitor fever due to ominous diurnal variations in body temperature

Complete Blood Cell Count Leukocytosis with a left shift suggests bacterial infection. Atypical lymphocytes are characteristic if viral infection. Immature neutrophils suggest leukemia. Erythrocyte Observe the Patient Sedimentation Rate Do they appear ill, Elevation indicates Entrance for infection especially at base of dehydrated or lethargic? inflammatory condition, Look for toxic signs and skull non-specific responsiveness in children May have mastoiditis spreading to meninges Increased risk of contacting it

Have you had any headache, lethargy, confusion or Characteristic meningitis symptoms. Any stiff neck? patient with minimal neurological signs and symptoms should be evaluated for meningitis If an infant: How old is the baby? Fever in infants less than 2 months is uncommon but is serious. May be infection or indicator of underlying anatomical defect. UTI and bacteremia are indications of abnormal urinary tract structure. Infants with galactosemia may present in first weeks to 1 month of life with gramnegative sepsis. Infants can get sepsis from delivery instruments. All infants younger than 2 months with fever are considered to have sepsis or meningitis until proved otherwise What Does a Pattern of Fever Tell Me?

How long have you had the fever?

In adults, fevers in acute processes usually resolve in 1-2 weeks. Fevers that last 3 weeks or longer, that exceed temperatures of 38.4 degrees celsius and that remain undiagnosed after a week of intensive diagnostic study are classified as fevers of uknown origin. In children there are three types of fevers. Short-term fever is of short duration, readily diagnosed and resolves within 1 week. Fever without localizing signs is of brief duration and is not explained by history or physical exam findings. Fever of unknown origin is usually greater than 38.5 degrees celsius that lasts longer than 2 weeks o more than four occasions.

What has the highest temperature been? When did Dehydration and febrile seizures are this occur? related to height of fever. Temperatures greater than 41.1 degress celsius seen in heat illness, central nervous system disease or these in combo with infection. Higher the fever, greater likelihood of bacteremia. Is the Fever Caused by a Localized Infection?

Do you have frequency, burning or urgency with urination? Are you having any unusual vaginal/penile discharge? Do you have any face or sinus pain?

Do you have nasal discharge? What colour?

Take Vital Signs and Note Temperature Adults - oral temp. Children and infants - rectal temp. Temp > 40 degrees celsius is a marker for bacterial infection though people with these high temps do not necessarily have major diseases. Extreme fever of > 41.5 degrees celsius is rarely due to infection and is more likely seen in drug fevers, CNS injury, malignant hyperthermia, stroke and HIV

Observe Skin and Mucous Membranes Look for rashes. Presence of a petechial rash is a serious infection that requires immediate referral and hospitalization, may indicate meningococcemia or Rocky Mountain spoted fever.

Antistreptolysin Titer indicates streptococcal antigen HIV Testing Urinalysis Urine Culture and Sensitivity Stool for Leukocytes Stool Culture and Sensitivity Stool Sample for ova and Parasites Sputum for Acid-Fast bacilli Sputum for Gram Staining Sputum for Culture and Sensitivity Cultures of Discharge

Examine the Head and Neck Sinuses, ears, tympanic membrane, eyes and fontanels

Palpate Lymph Nodes Anterior cervical - suspect viral or bacterial pharyngitis. Preauricular or postauricular - suspect ear UTI commonly produces systemic infection. Posterior cervical symptoms including fever UTIs can produce discharge. So can pelvic - suspect mono. Supraclavicular - suspect inflammatory disease in women. These neoplasms. Axillary also produce fever suspect breast inflammation, local Acute sinusitis produces fever infection, neoplasm. Localized lymphadenopathy suspect local infectious process. Generalized lymphadenopathy suspect immunosuppression such Viral upper respiratory tract infections as HIV or neoplasm. produce fever

DNA Probe for Gonococcus and Chlamyia Blood Cultures for septicemia Lumbar Puncture for meningitis Radiographic Imaging May detect infiltrates, effusions, masses or nodes.

Do you have a cough? Is it productive? What colour is the sputum? Do you have ear pain? Fever can be present in otitis media Is your throat sore? Are you having any nausea/vomiting, diarrhea? Do you have any joint pain?

Examine the Lungs and Chest Check for respiratory Viral and bacterial pharyngitis produces infection. Sputum colour: fever. GI tract infection produces fever. yellow/green - bacterial. Connective tissue disorder, osteomyelitis Brown - check smoking and septic arthritis produce fever. Apthous history. Blood streaked ulcers with pharyngitis and cervical Uri or bronchitis. lymphadenopathy seen in children with Hemoptysis - tumour, periodic children. trauma, pulmonary emoblism.

Do you have any apthous ulcers? Can The Diagnostic Possibilities Be Narrowed or Prodromal Rash can occur with varicella, Palpate Breasts if a Cause Be Eliminated? rubella, erythema infectiosum (1 day), Indicated scarlet fever (2 days), rocky mountain Examine Have you noticed a rash? Perform Gitonitourinary spotted fever (3 days), measles (4 days), System if Indicated Neurological/Mental roseola infantum (5 days) Examine Musculoskeletal Status Exam system if indicated Do you ache all over? Fever localized to a site without general body manifestations are often bacterial in nature. Fever accompanied by muscle aches, malaise and respiratory symptoms are often viral in nature. Does the Patient Have a Increased Risk for Chronic conditions compromise immunity and increase susceptibility to infection. Recent surgical Complications? procedures can provide a locus for occult infection and also induce an inflammatory response which causes fever without infection Page 49 of 52

URI

Any age group; systemic symptoms; often known contact with ill others

fever < 38.7 degrees C; cough; nonpurulent sputum; erythema of pharynx, viral exanthem

None

Gastroenteritits

nausea, vomiting, diarrhea; abdominal cramping

Mild fever; abdomen may be diffusely tender

None

UTI

Female>male; burning urgency, frequencyin adults; systemic symptoms/bedwetting in children

CVA tenderness with upper UTI; fever with upper U/A; urine C and S; CBC if suspect UTI upper UTI

PID

May have pelvic or lower abdominal pain

May have suprapubic tenderness; cervical discharge; CMT, adnexal tenderness

CBC; culture, DNA probe

Prostatitis

Perineal discomfort, frequent urination, chills and malaise

Prostate tender to palpation; fever

Segmental urine specimens; C and S of urine; C and S of prostate discharge

Pharyngitis

Sore throat; may or may not have other upper respiratory symptoms

Erythematous pharynx; may have pharyngeal or CBC; culture; rapid strep test if tonsillar exudate or ulcers; may have palatine suspect strep; Monospot if suspect petechiae in mononucleosis; lymphadenopathy mono

Sinusitis

facial or sinus pressure or pain; headache

Purulent nasal discharge; sinuses tender to percussion; headache or pressure worsens on bending forward

Ear infections

Earache, pain; may have upper respiratory symptoms; High or low grade fever, TM red, may bulge, child tugs at ear landmarks absent; TM mobility impaired; child irritable, restless

Pneumatic otoscopy

meningitis

nonspecific symptoms; nausea, vomiting, irritability

Petechiae, nuchal rigidity, positive Kernig's and Brudzinski's signs, bulging fontanel in infant

Lumbar puncture

Osteomyelitis

Pain in affected bone or joint

Swelling or tenderness over affected joint

Kawasaki disease

Under 5 yrs; males>females; fall and spring

Factitious fever

Vague or no symptoms

Roseoloa infantum

Irritable child with fever for 4-5 days

Radiographs or CT scan of limited value

Culture; CBC; radionuclide scan, CT, MRI High fever, spikes; persists despite antibiotic WBC increased, shift to left, slight therapy; may have seizures; fever for 5 days with anemia, thrombocytosis, positive Cat least 4 of the following: bilateral conjunctival reactive protein, ESR increased, hyerpemia, mouth lesions, edema, erythema, serum IgM, IgE increased. Normal physical no weight loss; pulse rate Discrepancy betweel oral/rectal desquamation ofexam; skin, nonvesicular erythematous normal (not consistent with temperature temperature and urine temperature; rash, cervical lymphadenopathy elevation) repeated monitored temperaturetaking does not support previous findings

Enterovirus

Mild nonspecific febrile illness lasting 2-5 days; summer and early fall peaks

Normal physical examination; when fever breaks, None rash appears Physical exam usually normal initially, repeat Urinalysis, urine C/S, chets x-ray, exam in 24 hours as needed BC, rule out systemic disease, malignancy non-exudative pharyngitis with or without None lymphadenopathy frequently observed

Occult bacteremia

Fever in children older than 3 month

No localizing signs, child appears well

Blood culture, WBC

Periodic fever in children

Abrupt fever on periodic basis (about every 6 wks); last about 4 days; child aged 2-5 yrs, malaise

Cervical adenopathy, apthous stomatitis

WBC and ESR elevated

Fevers without localizing signs No other specific symptoms

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Chronic conditions compromise immunity and increase susceptibility to infection. Recent surgical procedures can provide a locus for occult infection and also induce an inflammatory response which causes fever without infection

Do you have any chronic health problems? Have you had any recent surgery? Have you been diagnosed with an infectious disease Prone to relapse or reoccurrence recently? Are you sexually active? How many partners?

High-risk sexual activity increases risk of HIV and pelvic inflammatory disease

Are immunizations up to date? Does anyone in the family have TB or hepatitis?

More likely to contract illness if not immunized Exposure increases risk of infection. Inquire about constitutional symptoms such as cough or night sweats (TB) or malaise and abdominal discomfort (hepatitis) In infants and children, behaviour changes may be the only indication the hcild is ill. Mildy ill infants are alert, active, smile and feed well. Moderately ill infants may be fussy or irritable but continue to feed, are consolable and may smile. Severely ill infants appear listless, cannot be consoled and feed poorly or not at all

Does the Parent Report a Behaviour Change in the Child? Is the child sleepier than normal? Is the child more irritable? How is the child acting? Could the Fever Be Caused by Something Acquired While Traveling? Have you been out of the country recently? Have you been in the woods or camping recently? Could the Fever Be Medication Related or Caused by Poisoning? What medications have taken recently?

Describe the foods you have eaten in the past 3 days. Could the child have eaten a poisonous plant?

Risk of amoebiasis, malaria, schistosomiasis, typhoid fever or hepatitis Risk of ticks, Q fever, tularemia, Rocky Mountain spotted fever, Giardia or Lyme disease

Medications may hide an occult infection or induce a fever. Immunosuppressent medications predispose to infection. Some medication interfere with thirst recognition and sweating. Aspirin overdose can cause a fever. Food poisoning fever may occur up to 72 hours after ingestion of contaminated food Plants containing alkaloid atropine (Nightshade, Jessamine and Thornapple) cause dilated pupils, flushed skin and fever

Could Exposure to Animals Explain the Fever? Has a cat scratched you recently?

Cat Scratch Disease is a bacterial infection of gram-negative bacillus transmitted by cats. Single node or regional adenopathy and low grade fever are present.

Have you been around any other animals?

Dogs - brucellosis and leptospirosis. Rabbits - tularemia. Birds - ornithosis, histoplasmosis, psittacosis. Hamsters and cats - lymphocytic choriomeningitis

Could This Be the Result of a Recent Immunization? What immunizations have you had recently?

History of immunization followed by 4 hours of high fever indicate adverse reaction. MMR may cause elevation of temperature 10-14 days after.

Could The Fever Be Caused by Heat Exposure? Were you overdressed? Is the infant overbundled?

Classic heatstroke occurs when the person is unable to dissipate the environmental heat burden

Do you have air conditioning or windows that open? During a heat wave a person may become overheated if they don't have air conditioning How warm is the room you live/sleep in?

Windows may not open due to safety reasons and cause overheating

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