! ! ! ! !

Summary!of!Diagnosis!Reasoning!! And!! Clinical!Conditions! For! Objective!Structural!Clinical!Examination!

! ! ! ! ! ! ! ! ! ! ! Based!on:!Advanced!Health!Assessment!and!Clinical!Diagnosis!in!Primary!Care!4th!Edition,!Dains!JE,!Baumann!LC,!Scheibel!P.! Elsevier!Mosby,!St.!Louis!Missouri,!2012!

01#$#RASHES#AND#SKIN#LESIONS## ! Life!Threatening!Conditions!(RED!FLAGS)! 1. Fever! a. Common!in!viral!rashes!(exanthems,! measles)!usually!not!life!threatening.!! b. Meningococcemia!!Fever,!irritability,! hypotension,!macular!or!petechial!rash! 2. Allergic!Reactions! a. Urticaria!!Swelling!(angioedema)!of!the! extremities,!face,!lips,!tongue,!and/or! airway,!cough,!wheezing,!SOB,!heart! palpitations,!difficulty!swallowing! (dysphagia)! 3. Rash!with!mucosal!involvement! a. Toxic!Epidermal!necrolysis!!tender,! morbilliform,!erythematous!rash!with! fever,!conjunctivitis,!oral!ulcers,!and! diarrhea.!Usually!drug!induced! Location! 1. Children! a. Atopic!dermatitis!!Cheeks,!creases!of! elbow!&!knees! b. Seborrheic!Dermatitis!!scalp,!behind! ears,!thigh!creases,!eyebrows,!neck! c. Scabies!!axillae,!webs!of!fingers!&!toes,! intragluteal! 2. Other! a. Chemical!products!(lemon)!!Hands,! forearms! b. Eczema!!elbows!and!knees!flexor!side! c. Psoriasis!!elbows!and!knees!extensor! side! !

Onset!,!Acute!or!Chronic! ! Acute# Chronic# Allergic,!Contact!dermatitis! Acne!Vulgaris! Candida!dermatitis!(diaper!rash)! Bullous!pemphigus! Erythema!infectiosum! Erythema!Nodosum! Erythema!Multiforme! Kaposi!Sarcoma! Fixed!drug!eruptions! Mycosis!fungoides! Folliculitis! Polyarthritis!nodosa! HSV!(can!be!recurrent)! Psoriasis! HZV/Varicella! Rosacea! Impetigo! Seborrheic!Dermatitis! Infestations! ! (scabies/pediculosis)! Inset!Bites! ! Kawasaki!disease! ! Pityriasis!rosea! ! Septicemia!(meningococcal)! ! Scarlet!Fever! ! Tinea! ! Urticaria!(can!be!recurrent)! ! Viral!exanthem!(measles)! ! !! Evolution! 1. Initial!Presentation! 2. Change!in!lesions! 3. Spread!!See!table!of!conditions! a. Centripetal!,!Towards!the!center! b. Centrifugal!,!Away!from!the!center! c. Caudal!!Downwards! ! Rashes!&!Lesion!Lesions!,!1!

Pruritus! ! Always#Itch# May#Itch# Never#Itch# Atopic!dermatitis! Psoriasis! Warts! Urticaria! Impetigo! Neurofibromatosis! Insect!bites! Tinea! Vitiligo! Scabies! Pityriasis!rosea! Nevi! Pediculosis! ! ! Lichen!planus! ! ! Chickenpox! ! ! ! Associated!Pain! 1. Pain!!rare,!Herpes!Zoster,!postherpetic! neuralgia.!Severe!psoriasis!or!eczema!with! bleeding!fissures! 2. Soreness! 3. Tenderness!!Toxic!epidermal!necrolysis! 4. Burning! ! Associated!Symptoms! 1. Fever,!Sore!throat,!Headache!!infectious!disease,! HZ,!erythema!infectiosum,!scarlet!fever,! Kawasaki!disease! 2. Malaise,!sore!throat,!nausea,!vomiting!! Mononucleosis! ! ! ! ! ! ! !

Possible!sources!of!contagion! 1. Living!Situation!!Anyone!sick!at!daycare,!school,! at!home,!at!work?! 2. Travel!!Endemic!diseases! 3. Other!!Outdoor!occupations,!leisure!activities,! forest,!camping! 4. Pets!!Fleas,!Allergy! ! Aggravations! 1. Triggers!!Stress,!UV,!Heat,!Trauma,!!,!HSV,! 2. Menstruation!,!HSV! 3. Foods!!Rosacea,!HSV! ! Medication!! 1. New!drugs! 2. Medication!Allergies! 3. Recent!Vaccinations! ! Family!History! 1. Dermatological!problems! 2. Atopic!Diseases!!cluster!in!families! 3. Inheritance!!Psoriasis,!seborrheic!dermatitis,! rosacea! 4. Caf,au,lait!spots!!neurofibromatosis!in! children! ! Lifestyle! 1. Multiple!partners!!STDs,!HSV,!Syphilis! !

Rashes!&!Lesion!Lesions!,!2!

Condition!
Acne!Vulgaris!

Characteristics!
Comedones,!papules,! pustules!cysts! Flushing,!persistent! redness,!sebaceous! hyperplasia,!erythematous! papules,!telangiectasias,! ocular!involvement!40%!

Follicular#Eruptions# Distribution/Progression!
Face,!neck,!back,!chest,!upper! arms! Symmetrically,!usually!face! only,!may!involve!eyes!

Associations!
Onset!puberty,! topical/anabolic!steroids,! systemic!corticosteroids.! Lithium,!phenytoin! Topical!steroids,!systemic! corticosteroids!

Diagnostic!Labs!
Usually!None!

Rosacea!

Usually!None!

! Condition!
Impetigo! Folliculitis! Furuncle! Carbuncle!

Characteristics!
Vesicular!infection;!honey, colored!crusts!&!erosions! Superficial!perifollicular! papules!and!pustules! Very!tender,!deep,seated! inflammatory!nodule!that! develops!from!folliculitis! Multiple!coalescing! furuncles!

Infectious#Eruptions# Distribution/Progression!
Face;!any!area!of!body!with!a! minor!wound,!especially! excoriated!lesions! Any!hair,bearing!body! surface,!but!especially!scalp,! beard,!legs,!axillae! Same!as!folliculitis! Same!as!furuncle!

Associations!
Scratching!as!a!result!of! insect!bites,!atopic! dermatitis,!scabies! Shaving,!hot!tubs,!contact! with!mineral!oils,!occlusive! dressings! May!have!fever! Same!as!furuncle!

Diagnostic!Labs!
Bacterial!Culture! Bacterial!Culture! Incision!and!drainage!for! bacterial!culture! Same!as!furuncle!

! ! ! ! ! ! ! ! ! ! ! ! Rashes!&!Lesion!Lesions!,!3!

Condition!
Erythema!Infectiosum!

Characteristics!

Macular/Papular#Eruptions# Distribution/Progression!
Cheeks,!then!trunk!and! extremities!

Associations!

Diagnostic!Labs!
IgM,!IgG!

Measles!

Rubella!

Pityriasis!Rosea!

Scarlet!Fever!

Bright!red!rash!(slapped! cheeks)!follow!by!diffuse! MPR!on!trunk!and! extremities!leads!to!lacy! appearance!as!it!fades! Cough,!Coryza,! conjunctivitis,!Koplik!spots! on!buccal!mucosa,!rash! begins!with!spike!of! convalescent!fever;! centripetal;!sometimes! hemorrhagic! Tender!lymphadenopathy! of!post!auricular,!posterior! occipital!nodes;!MP!and! confluent!rash,!lacy,!not! pruritic,!last!3!days! Multiple!oval!erythematous! lesions,!inner!finer!circle;! ovals!line!up!along!skin! cleavage!lines!on!trunk,! Christmas!tree,like!pattern! Fine,!mildly!erythematous! papules!&!sandpaper!like! rash!on!trunk! High!fever!3,4!days!in! infants!&!young!child.!A! fever!returns!to!normal! diffuse!MPR!erupts!

1st!!day!,!neck!&!ears!faintly,! then!face,!arms,!and!chest;!2nd! ,!lower!torso!and!legs;!3rd!! feet!&!face;!4th!day!fades.!

Aplastic!anemia!in!children! with!underlying!hemolytic! anemia,!fetal!hydrops! reported!in!pregnant! woman.! Abd!pain,!OM,! bronchopneumonia,!severe! cases!encephalomyelitis!

IgM,!IgG!titers!

Begins!on!face!and!spreads! trunk!and!extremities!within! 1st!24hrs.! Trunk,!proximal!extremities,! rarely!on!face;!rash!is! preceded!by!a!heralded!patch! appearing!a!few!days!to!3! weeks!before!gen!eruption! Begins!axillae,!groin,!neck;! avoids!face,!circumoral!pallor! Begins!on!trunk!and!quickly! spreads!to!arms,!face,!neck! and!legs!

Infection!with!virus!while! pregnant!results!in! congenital!rubella! More!common!in!spring! and!fall!

IgG!titers,!Rubella!IgM!Ab!

If!present!on!the!palms!and! soles!and!hx!warrants! check!RPR!to!rule!out! secondary!syphilis! Culture!for!Strep!A!

Roseola!

Strawberry!tongue;!Pastia! lines;!areas!of!linear! hyperpigmentation!in!deep! creases! Posterior!cervical! lymphadenopathy!

None!

! ! ! ! !

Rashes!&!Lesion!Lesions!,!4!

Condition!
Hand,Foot,Mouth!Disease!

Characteristics!

Vesicular#and#Bullous#Eruptions# Distribution/Progression!
Painful!mouth!ulcers,!in! 24hrs.!painful!vesicles!on! fingers,!palms,!toes,!and!soles! Lower!Legs,!but!may!appear! anywhere!in!the!body!if!pets! on!furniture!or!bed.! Anywhere!in!the!body,!most! common!genitals!and!thighs,! mouth,!lips!and!chins;! disseminates!in! immunocompromised!

Associations!

Diagnostic!Labs!
Tzanck!smear!

Insect!Bites!

HSV!

Herpes!zoster!

Systemic!illness!!coxsackie! virus!A16,!painful!white! vesicles!surrounding!red! halo! Flea,!tick!most!common,! intensely!pruritic!eruption,! in!groups!of!three;!bulls! eye!rash!!Lyme! Primary,!grouped!vesicles! on!erythematous!base!at! site!of!inoculation;!regional! lymphadenopathy;! prodrome!itching,!tingling,! burning!or!tenderness! Unilateral!pain,!itching,! burning!precedes!3,5!days! of!eruption!vesicles,!crust!&! erosions!

Low!grade!fever,!sore! throat,!malaise;!cervical! and!submandibular! lymphadenopathy!possible! Exposure!to!dogs!or!cats!or! carpeted!areas!previously! in!contact!with!infected! animals;!outdoor!exposure! Other!STDs,!HIV;!Triggered! by!sun!stress,!fatigue,!fever,! trauma!

Confirmatory!biopsy! occasionally!needed! Tzanck!smear,!Viral! culture,!Screen!for!other! STDs,!HIV!is!history! warrants! Viral!culture,!Tzanck!smear!

Varicella!zoster!

Anywhere!on!body,!unilateral,! dermatomal,!Referral!to! ophthalmologist!if!eye! involved.!Lesion!in!tip!or!side! of!nose!! General!pruritic!vesicular! Usually!begin!on!trunk!and! lesions!in!different!stages!of! spread!to!face!and!proximal! healing;!erythematous,! extremities! ruptured,!crusted!with! scabs.!

Immunosuppression,!older! age,!local!trauma!in! children! Herpes!zoster!occurs!with! reactivation!of!the!virus!

ELISA!titers!to!confirm!

! ! ! ! ! ! ! ! ! !

Rashes!&!Lesion!Lesions!,!5!

Condition!
Candidiasis!

Characteristics!
Beefy,red,!well!demarcated! plaques,!scaling!edge,! satellite!lesions;! intertriginous!areas!show! erosions!and!macerations! Variable,!depends!where,! hair,scaling,!hair!loss,! pustules,!skin!!red,!scaly! patch,!central!clearing,!Feet! !vesicles!or!bullae! Variable!colored!white!to! pink!brown!scaling,!round! or!oval!macules!of!varying! sizes;!coalescing!to!form! large!areas!of!discoloration!

Fungal#Infections# Distribution/Progression!
Diaper!in!infants,!body!folds,! mucosal!surfaces,!nails,!and! nail!folds! Skin,!hair,!feet,!nails!

Associations!
Immunocompromised,! diabetes,!steroid,!inhalants,! pregnancy,!oral! contraceptives,!antibiotics,! systemic!&!topical!steroids! Immunocompromised,! systemic!corticosteroids,! farmers,!animal!contact,! hot!humid!w/!tight! clothing,!occlusive!shoes! Heat,!humidity,!tropical! climates,!exercise,!systemic! corticosteroids,!seborrheic! dermatitis!

Diagnostic!Labs!
KOH,!culture!

Tinea!

KOH,!culture!

Pityriasis! (Tinea!Versicolor)!

Upper!trunk,!axillae,!neck,! upper!arms,!abdomen,!thighs,! genitals!

KOH!shows!hyphae!and! spores!in!spaghetti!and! meat!balls!pattern!

! Condition!
Eczema/Atopic!Dermatitis!

Immunological/Inflammatory#Eruptions# Characteristics! Distribution/Progression! Associations!

Erythema,!papules,!vesicles,! Symmetrical;!infant!,!face,! scaling,!excoriations,!crusts,! flexures;!Child!!flexural! pruritus!always!present! creases;!Adults!!discrete! round!patches!or!regionalized! Vesicles,!erosion!edema,! Localized,!can!be!asymmetric,! inflammation!then!crusts,! generalized!with!airborne! lichenification;!pruritus! allergens/poison!ivy;!linear! with!plant!dermatitis! Well!demarcated,!ham! Favors!elbows!&!knees,!scalp;! colored!plaques!&!papules! intertriginous!areas,! w/!silvery!scale;!chronic,! sometimes!nails! recurrent!pruritus!common! Chronic!scaling,!flaking,! Areas!sebaceous!are!more! erythematous!dermatitis,! active:!face,!scalp,!eyebrows,! variable!pruritus! eyelashes,!body!folds,!ear! folds,!presternal,!mid/upper! back,!genitalia! Personal!or!FHx!!Astma,! seasonal!allergies,!and! eczema;!2nd!colonization!S.! Aureus!or!HSV! Occupational,!recreational! pursuits! Strep!infection,!arthritis,! HIV,!medications,!alcohol,! FHx! Atopic!Hx,!HIV!!

Diagnostic!Labs!
Serum!IgE;!culture!for! bacteria;!HSV!if!indicated! Patch!testing!

Contact/Allergic!dermatitis!

Psoriasis!

ASO!titer,!strep!culture,!HIV! test,!Biopsy! HIV!if!indicated!

Seborrheic!dermatitis!

! ! Rashes!&!Lesion!Lesions!,!6!

Condition!
Erythema!Multiforme! Urticaria!

Characteristics!
Hypersensitivity!Reaction,! annular!target!or!iris!lesion! Transient!wheals,!acute!or! chronic!(>6!wks)!individual! lesions!come!and!go!in!hrs;! pruritic!

Allergic#Reactions# Distribution/Progression!
Begins!upper!extremities!&! trunk! Localized,!regional!or! generalized!

Associations!
Herpes!virus,!mycoplasma! pneumoniae,!drugs! (sulfonamides)! May!have!angioedema,!LIFE! THREATENING,!chronic! infection,!SLE,!lymphoma!

Diagnostic!Labs!
Skin!Biopsy!if!caused!by! Toxic!epidermal!Necrolysis! (SJ!syndrome)! Biopsy;!general!workup!for! systemic!disease!in!chronic! urticaria!

! Condition!
Malignant!melanoma! Basal!cell!carcinoma! Squamous!cell!carcinoma!

Characteristics!
Asymmetrical!border,! irregular,!color!variations,! >6mm!(ABCDE)! Papular,!nodular!lesions,! raised!pearly!border,! telangiectasia! Indurated!papule,!plaque!or! nodule;!may!be!eroded,! crusted!or!ulcerated!

Neoplastic#Eruptions# Distribution/Progression!
Anywhere!in!the!body! including!scalp! Sun!damaged!areas,!covered! areas!when!genetic! disposition!to!BCC! Sun,damaged!areas,! radiodermatitis!areas,!old! burn!scars,!anywhere!

Associations!
Usually!asymptomatic,! unless!bleeding,!ulceration,! discharge!present! Usually!asymptomatic! Usually!asymptomatic,! associated!HPV,! immunosuppression,! topical!nitrogen!mustard,! oral!PUVA,!chronic!ulcers,! industrial!carcinogens,! arsenic!

Diagnostic!Labs!
Skin!biopsy,!excisional! biopsy! Skin!biopsy! Skin!biopsy,!excisional! biopsy!

! !

Rashes!&!Lesion!Lesions!,!7!

Skin,#Hair#&#Nails##Minor#Examination# ! Competencies# 1.#Inspect#Skin#color# 2.#Inspect#color#of#sclera# 3.#Palpate#skin#moisture# 4.#Palpate#Skin#temperature# 5.#Palpate#Skin#texture# 6.#Palpate#skin#mobility#&#turgor# 7.#Identify#Lesion#ABCDE# 8.#Palpate#Hair#qty.#&#distribution# 9.#Palpate#Hair#texture# 10.#Inspect#Nail#color# 11.#Inspect#Nail#Shape# 12.#Inspect#Nail#Lesions#

Normal# Well!perfused,!even!color! Sclera!is!white! Skin!is!well!hydrated!&!smooth! Skin!is!warm! Skin!soft!&!supple! Mobility,supple/movable! Turgor,return!rapidly! ABCDE,!macule,!papule! Full!evenly!distributed! Strong,!well!hydrated! Pink!,!well!perfused! Firm!rectangular!angle<180! Lesions!absent!

Abnormal# Skin!Pallor,Arterial!Insufficiency! Yellow,Jaundice,Hepatitis! Dryness,Hypothyroidism! Coldness,Hypothyroidism! Moist,!Velvety,Hyperthyroidism! Mobility!!edema! Turgor,dehydration! Scaly,!macule,!Psoriasis,extensor! surfaces!knees!&!elbows! Round!bald!patches!,!Tinea! capitis! Fine,!Silky!!hyperthyroidism! Bluish,peripheral!cyanosis!!CHF! Clubbing!!CHF! Pitting,psoriasis!

Rashes!&!Lesion!Lesions!,!8!

02#$#Earache# ! Life!Threatening!Conditions!(RED!FLAGS)! 1. Nasopharyngeal!Cancer! 2. Mastoiditis! 3. Cholesteatoma! ! Is!this!an!acute!condition?! 1. Age!!AOM!declines!after!age!6.!Increased!age!raises! the!likelihood!of!secondary!otalgia!caused!by!head,! face,!and!neck;!by!sinus!or!periodontal!disease;!and! by!malignancy.! 2. Fever!!Present!in!60%!of!children!with!AOM,!<2! mo.!is!uncommon.!High!fever!is!more!likely!to! indicate!systemic!illness! 3. Upper!Respiratory!(!Obstruction!of!eustachian!tube! from!URTI!in!nasopharynx!or!sinuses.!Inflammation! of!the!adenoids!can!block!them!too.!Mucus!creates! the!mechanical!obstruction!and!serves!as!a!medium! for!bacterial!growth.! 4. Previous!Infections!!Infant!<3mo!with!AOM!has! high!risk!of!recurrence.!Chronic!OM!can!result!from! anatomical!changes!to!the!tympanic!membrane!&! ossicles.! 5. Family!History!!FHx!of!chronic!OM!makes!it!twice! as!likely.!Child!care!practice,!milk!bottle!propping,! environmental!exposure!such!as!2ndary!hand! cigarette!smoke.! ! ! ! ! ! !

! ! What!environmental!conditions!might!suggest!increased! risk?! 1. Smoke!Exposure!!2(3x!increased!risk!to!OM.!Leads! to!functional!eustachian!tube!obstruction!and! decrease!protective!ciliary!action!in!the!tube.! 2. Attending!Day!Care! 3. Bottle!propping!!Nasopharyngeal!fluid!enters! middle!ear.! 4. Swimming!!loss!of!cerumen!&!chronic!! 5. Airplane!Travelers,!Divers!(!Barotrauma! ! Could!this!be!related!to!a!systemic!disease?! 1. Diabetes!Mellitus!!Pre(disposes!to!malignant!OM! involving!cellulitis,!OM!and!mastoiditis.! 2. History!of!Seborrheic!Dermatitis!or!Psoriasis!! Chronic!inflammatory!dermatitis!from! overproduction!of!sebum!can!occur!in!the!external! ear!and!cause!OE.! 3. Cleft!Palate!!Non(repaired!anomalies!anatomically! predisposes!to!OM!due!to!functional!obstruction!of! the!eustachian!tube.! ! What!does!the!presence!of!pain!tell!me?! 1. Location!of!Pain! a. OE!!Outer!ear/opening!tenderness!worse! with!pinna!manipulation,!bilateral! b. Mastoiditis!!Severe!pain!or!tenderness! over!mastoid! c. Referred!or!AOM!(!unilateral! d. Infants!!Show!irritability,!lethargy,!poor! appetite,!vomiting,!diarrhea!on!ear!pain.! Earache!(!1!

! What!does!the!presence!of!discharge!or!itching!tell!me?! 1. Infection,!inflammation!of!external!canal!!itching,! drainage! 2. Herpes!Zoster!of!CN!V!!itching! 3. TM!rupture!!Drainage! 4. Secondary!Mastoiditis!!exudate!! 5. Cholesteatoma!!TM!perforation!and!foul!smelling! discharge! ! ! ! ! !

2. Quality!of!Pain! a. AOM!(!Deep!or!Blockage!of!ear!! b. Serous!Otitis!!often!painless,!bubbling,! popping!or!stuffy!sensation.! c. OE!!tenderness!outer!ear!and/or!itching! d. Cerumen!Impaction!!Milder!pain,!vague! discomfort!of!stuffed!ears! 3. Severity!of!Pain! a. AOM!!can!interfere!with!sleep,!suddenly! relieved!if!eardrum!perforates.!! b. Chronic!Ear!Pain!!unresponsive!to!treatment! may!indicate!tumor.! 4. Onset/Timing/Duration!of!pain! a. TMJ!!Severe,!lasting!a!few!minutes,!recurring! 3(4x/d,!Headache,!worse!in!the!morning!due! to!teeth!grinding!while!sleeping! b. Dental!Malocclusion!or!Rheumatoid!arthritis! !Chronic!pain! c. OM!!crying!when!sucking!due!to!increased! pressure,!nocturnal!due!to!position!

What!does!a!history!of!trauma!or!injury!tell!me?! 1. Ear!trauma!!ear!drum!perforation!due!to!blunt!or! penetrating!trauma,!q(tip,!sharp!object.! 2. Head!Trauma!(!Fracture!of!petrous!temporal!bone! 3. Cerumen!impaction!!accumulation!from!q(tip!use! leads!to!hearing!loss,!tinnitus,!pressure!sensation,! vertigo,!&!infection.! 4. Foreign!body!!feathers,!beads!&!insect! (cockroaches)!can!produce!ear!pain!and! inflammation.!Children!self(inserted!objects.! 5. Insect!bites!!acute!pain,!tenderness!of!external! canal,!may!develop!secondary!infection.! 6. Loud!Noise!!High(pitched!sounds/loud!noise!for! long!periods!destroys!cochlear!hair!cells,!leads!to! hearing!loss.! ! Is!hearing!loss!a!clue?! 1. Difficulty!in!Hearing! a. Blockage!of!ear!canal!!cerumen,!foreign! body,!inflammation!of!middle!ear!or! neoplasm.! b. Chronic!OM!!Destroys!ossicles,!spread!to! mastoid,!labyrinth,!and!intracranial! structures.! c. Chronic!ear!pain!!Hearing!loss!&!discharge! secondary!to!perforated!non(healing!TM! 2. Hearing!Loss!in!Children! a. Chronic!OM!with!effusion!!conductive! hearing!loss!in!children! 3. Dizziness,!Ringing!in!Ear! a. Serious!Inner!ear!condition!Hearing!loss,! dizziness,!vertigo,!tinnitus.! ! ! Earache!(!2!

Condition!
External!Otitis! Acute!Otitis!Media!

History!

Common!Causes!of!Ear!Pain! Physical!Findings!
Discharge;!inflamed,!swollen! external!canal;!pain!with!movement! of!pinna;!TM!normal!or!not!visible! Red,!bulging!TM;!fever;!decrease! light!reflex;!opaque!TM;!decreased! TM!mobility! Fluid!line!or!air!observed!behind! TM;!conductive!hearing!loss;! decreased!TM!mobility! Pearly!white!lesion!on!or!behind!TM! Swelling!over!mastoid!process;! fever,!palpable!tenderness,!and! erythema!over!mastoid! Visualize!foreign!body!or!cerumen;! may!detect!foul!odor;!conductive! hearing!loss! Retraction!or!bulging!of!TM;! perforation!of!TM;!fluid!in!canal! Perforation!of!TM! Enlarged,!tender,!cervical!lymph! nodes;!may!see!early!onset!of!AOM! in!children! Dermatome!evaluation!for!cervical! nerve!involvement! Test!function!of!CN!V,!VII,!IX,!and!X;! ear!examination!normal! Malocclusion;!bruxism;!normal! external!and!middle!ear!structures! and!function;!jaw!click;!abnormal! CN!function;!ear!examination! normal! None!

Diagnostic!Labs!

Otitis!Media!with!Effusion!

Cholesteatoma! Mastoiditis! Foreign!body!or!cerumen! impaction! Barotrauma! Trauma! Cervical!lymphadenitis! Cervical!nerves!II!&!III! Referred!pain! Cranial!Nerves! Referred!pain! TMJ!disorder!

More!common!in!adults,!especially!those! w/!diabetes,!ear!pickers,!or!swimmers;! bilateral!itching;!pain! More!common!in!children!<6!yo;!those! with!smoke!exposure,!recent!URTI;!severe! or!deep!pain;!unilateral;!sensation!of! fullness! More!common!in!children!but!occurs!in! adults!with!recent!URTI;!unilateral!pain;! sensation!of!crackling!or!decreased! hearing! Hearing!loss;!recent!perforated!TM! History!of!recent!otitis!media;!chronic! otitis!pain!behind!ear! Both!children!and!adults!have!pain!or! vague!sensation!of!discomfort;!decreased! hearing! History!of!flying,!diving;!severe!pain;! hearing!loss;!sensation!of!fullness;!history! of!recent!nasal!congestion! History!of!blunt!trauma,!penetrating! trauma! History!of!cervical!node!swelling;!pain!in! ear!common!in!children! Pain!in!skin!and!muscles!of!neck!and!in! ear!canal! History,!depending!on!CN!involved! More!common!in!adults;!50%!related!to! dental!problems;!discomfort!to!severe! pain;!unilateral;!pain!worse!in!morning!

None!initially!

Tympanogram!

Immediate!Referral! Radiograph!of!mastoid!sinuses! reveals!cloudiness;!referral! None! Tympanogram! Radiographs/CT!scan!as!directed! by!injury! Throat!culture!if!indicated;!in! adolescents!Monospot!if!indicated! None! Radiography/CT!scan,!directed!by! CN!involvement! None!

Earache!(!3!

Ears#Examination# # Competencies# 1.#Inspect#auricle#&#surrounding# tissue# 2.#Palpate#and#move#the#Auricle# (Pinna)# 3.#Palpate#Tragus# 4.#Palpate#Pre#and#Post#lymph# nodes# 5.#Palpate#the#Mastoid#process# 6.#Inspect#opening#of#external#ear# canal# 7.#Inspect#Ear#canal#$#otoscope# 8.#Inspect#Ear#Drum#with#osseous# landmarks#

Normal# Well!formed! Painless! Painless! Small,!mobile,!discrete,!non! tender!or!none!palpable! Normal!hard!

Abnormal# Gouty!tophi!!gout! Pain!!Otitis!externa!

9.#Identify#cone#of#light#pars# flaccida#and#tensa# 10.#Perform#Whisper#Test# 11.#Perform#Weber#Test#

12.#Perform#Rhine#Test# !

Pain!!Otitis!externa! Tender!nodes!behind!ear!!Otitis! media! Pain,!softness,!tender!! Mastoiditis! Normal!no!discharges! Discharge!and!inflammation!! Otitis!externa! Normal!(!Cerumen!! Localized!Redness!&!Swelling!! Furuncle! Pinkish(grey! Red!&!Bulging!!Otitis!Media! Malleolus!lying!posterior!the! Prominent!handle!more! superior!part!of!the!drum.!Short! horizontal!!retracted!ear!drum!! process!superior,!Handle!inferior! Serous!Otitis!Media! Cone!of!light!inferior!anterior.! Displaced!cone!of!light!!Otitis! Pars!flaccida!superior.!Pars!tensa! media! inferior! Normal!!Hear!nine(four! Inability!to!hear!!Conductive! hearing!loss,!Cholesteatoma! Normal!!Hear!equal!both!ears! Sound!unilateral!!Ipsilateral! Conductive!hearing!loss!!acute! otitis!media! Normal!!AC!>!BC!(2x)! BC=>AC!Conductive!Hearing!Loss!

Earache!(!4!

03##Sore#Throat# ! Is!this!an!emergency!condition?!(RED!FLAGS)! 1. History!!Epiglottitis,!person!to!ill!to!talk.!! 2. Associated!symptoms! a. Epiglottitis!*!drooling,!unable!to!swallow,! unable!to!lie!down,!restless,!unable!to!stay! still,!unable!to!talk,!dyspnea,!inspiratory! stridor.!H.!influenza!most!common!pathogen.! b. Peritonsillar!abcess!!sever!sore!throat,! odynophagia,!trismus,!medial!deviation!of! soft!palate!and!peritonsillar!fold.! ! Is!the!sore!throat!related!to!an!infectious!cause?! 1. Exposure!!Day!care,!School,!Home,!Work! 2. Onset!!GABHS!is!sudden!while!EBV!requires! intimate!contact! 3. Severity!!Strep!infection!is!intense,!Influenza!&! adenovirus!is!severe!with!prominent!edema.! Peritonsillitis!sever!throat!pain!with!trismus!and! refusal!to!speak.!Non*infectious!is!scratchy!or! annoying.!Young!children!may!refuse!to!drink!or!eat! when!in!pain!and!indicates!epiglottitis,!laryngitis,! abscess,!diptheria!or!scarlatina.! ! What!does!the!presence!of!fever!tell!me?! 1. GABHS!!almost!always!present!>38.5C,!with! malaise,!headache,!painful!swallowing.!Fever!also! present!in!children!&!adults!with!epiglottitis! 2. Influenza!!abrupt!onset!37.8*40C!! 3. Adenovirus!*!>40C! 4. EBV!!Low!grade!fever! ! !

! ! 5. Peritonsillar!abcess!!Fever!7d!no! fever!recurrent!fever!or!continued! 6. Absence!!non*infectious!cause! ! What!does!the!presence!of!URT!symptoms!tell!me?! 1. Cough!and!Rhinorrhea! a. Strep!pharyngitis!!cough,!rhinitis,! conjunctivitis,!hoarseness!rare! b. Influenza!!Several!days!fever,!cough,!and! rhinorrhea.! c. Viral!Pharyngitis!!sore,!scratchy!throat,! nasal!congestion,!rhinorrhea!and!cough! d. Allergic!pharyngitis!!Clear!nasal!discharge,! possible!post*nasal!drip!that!causes!sore! throat.! 2. Conjunctivitis!!rare!with!Strep!pharyngitis,!Mild! with!viral!infection.!Watery,!itchy!eye!with!allergic! exposure.! 3. Sneezing!!Viral!infections!&!allergic!exposure.! Seasonal! 4. Hoarseness!!Not!uncommon!in!allergy*associated! sore!throat,!may!be!present!in!viral!infection.!Not! associated!with!GABHS.! ! What!does!the!associated!symptoms!tell!me?! 1. GABHS!*!Systemic!complains!&!myalgia! 2. Strep!pharyngitis,!influenza!*!>2yo,!Headache,! vomiting,!abdominal!pain.! 3. Influenza!!Fever,!systemic!symptoms!(myalgias,! cough,!rhinorrhea)! ! Sore!Throat!*!1!

Does!the!presence!of!risk!factors!help!me!narrow!cause?! 1. Age! a. GAS!!5*15yo,!GABHS!rare!in!<3yo.!! b. Influenza!!all!ages! c. Parainfluenza,!RSV!!children! d. Adenovirus!!exudative!pharyngitis!in! younger!children! e. Adenovirus!Type!4!(also!3,!7,!21!to!lesser! extend)!!Military!populations! f. EBV!(mononucleosis)!!Adolescents!&!young! adults.!In!older!patients!occurs!without! pharyngitis,!adenopathy,!or!splenomegaly! 2. Irritant!exposure! a. Tobacco,!smog,!dust,!allergens!can!cause!sore! throat.! b. People!who!work!outdoors! c. House!keepers!!dust!mites!&!chemical! irritants! 3. Sexual!behavior! a. Chlamydia!Trachomatis!or!Neisseria! Gonorrhoeae!!Oro*genital!sexual!activity! b. Gonococcal!Pharyngitis!!10%!of!patient!with! anogenital!gonorrhoeae! 4. Medications!&!Chronic!Health!Problems! a. Immunosuppression!!viral!agents!that! produce!pharyngeal!ulcers!(herpangina,! herpes!simplex)! b. Diabetes!!Candidiasis!susceptibility! c. Broad!spectrum!antibiotics!!Candidiasis! susceptibility! d. GERD!!Sore!throat!from!gastric!reflux! e. Immunizations!!Children:!DTaP!! Diphtheria,!tetanus,!pertussis,!Hib!!H.! !

influenza!Type!B!(Epiglottitis);!Adults:!Td! every!10!years.!Unimmunized!children!and! adults!are!at!higher!risk!for!infection.! ! Group!A,!*Hemolytic!Streptococcus!Risk!Groups! ! Risk#Factors# Diagnostic#Test# High#Risk# None;!treat!on!basis!of!risk! Tonsillar!exudate! factors! Temp>38.5C! Cervical!lymphadenopathy! Existing!Valvular!rheumatic! heart!disease! Presumed#Strep# None;!treat! Scarlet!fever! Strep!endemic! Antibiotics!already!started! Medium#Risk# Rapid!Strep!Screen! Exudates,!nodes,!fever! If!positive,!treat! Prior!rheumatic!fever! If!negative,!do!culture! Low!Risk!PE,!<25yo,!No!URI! Do!not!treat!if!culture! Diabetes! negative! Recent!strep!exposure! Low#Risk# Rapid!Strep!Screen! No!exudates,!nodes,!or!fever! If!positive,!treat! ! If!negative,!do!culture! Do!not!treat!if!culture! negative! ! !

Sore!Throat!*!2!

Condition!
Epiglottitis! Peritonsillar!Abcess! Viral!pharyngitis! GABHS! Mononucleosis!!EBV! Gonococcal!pharyngitis! Inflammation!

Common!Causes!of!Sore!Throat! History! Physical!Findings!

Pharyngitis!without!Ulcers! Sore!throat,!difficulty!with!secretions,! Respiratory!distress,!drooling,!toxic! odynophagia!<2yo,!unable!to!lie!flat,!talk! appearance,!DO!NOT!EXAMINE! Hx!of!tonsillitis,!sore!throat,!dysphagia,!RT! Orthopnea,!dyspnea,!symmetrical! symptoms,!fever,!malaise! swelling,!abscess,!trismus! Scratchy,!sore!throat,!malaise,!myalgias,! Erythema,!throat!edema,!tender!post! headache,!chills,!cough,!rhinitis! cervical!nodes! 5*15yo;!exposure;!Fall/winter;!sudden! Temp>38.5C;!exudate;!anterior! fever,!sever!sore!throat,!malaise,!no! cervical!lymphadenopathy! cough,!URT!symptoms! Young!adults;!slow!onset!malaise;!low* Presence/absence!pharyngeal!exudate,! grade!fever;!mild!sore!throat! palatine!petechiae,!post!cervical! lymphadenopathy;!splenomegaly! Hx!orogenital!sex,!may!be!asymptomatic! Pharyngeal!exudate;!bilateral;!cervical! lymphadenopathy! Exposure!to!irritants;!postnasal!drip;! Sinus!tender;!pale,!swollen!pharynx,! allergic!symptoms! postnasal!drain;!no!fever!or!lymphaden! Pharyngitis!with!Ulcers! Common!in!children;!immunosuppressed,! Lymphadenopathy;!small!gray!papulo* painful!throat;!fever;!malaise! vesicular!lesion!soft!palate!&!pharynx;! progress!to!shallow!ulcer!<5mm! Poor!oral!hygiene;!painful!ulcers,!foul! Grey!necrotic!ulcers!w/o!vesicles!on! breath,!bleeding!gums! gingival!margins!or!interdental!papilla! Oral!trauma,!ill*fitting!dentures;!painful! Shallow!ulcers,!no!vesicles;!indurated! ulcers!varying!size;!absences!of!other!sxs.! papules!1!cm!ulcers!w.!yellow! membrane,!red!halo;!no!fever!or!nodes! Hx!of!trauma!to!mucosa;!pain,!fever,!HA! Perioral!lesions;!lymphadenitis;! vesicles!on!palate,!pharynx,!gingiva! Immunosuppressed;!taking!antibiotics,! Curd*like!white!plaques!that!bleed! with!diabetes;!sore!mouth/throat! when!scraped!off!

Diagnostic!Labs!
Refer!immediately! Refer!immediately;!CT!scan;! H&N!X!ray;!laryngoscopy! None! Positive!Rapid!Strep!Test;! culture! Positive!Monospot;!CBC!w/! differential,!>50%!leukocytes! Gram;!culture! Eosinophils!in!nasal!secretion! with!allergies! Serology! Gram!stain!reveals!spirochetes! None! Viral!culture! KOH!smear!shows!hyphae;! culture!

Herpangina!!Coxsackie! Furospirochetal!infection! Aphthous!stomatitis! Herpes!simplex!infection! Candidiasis!

! ! ! ! !

Sore!Throat!*!3!

Nose,#Sinuses,#Mouth#Examination# # Competencies# 1.#Inspect#Nose# 2.#Test#for#Nasal#Tenderness#&# Obstruction# 3.#Palpate#for#Sinus#Tenderness# 4.#Sinus#transillumination# 5.#Inspect#Nasal#Mucosa#&#Septum#P# otoscope# 6.#Inspect#Lips# 7.#Inspect#Oral#Mucosa,#Hard#&#Soft# palate# 8.#Inspect#Gums#&#Teeth#

Normal# Symmetrical! Painless,!Effortless!breathing! Non*tender! Light!shines!through!the!sinuses! Pink*red! Pink*red,!smooth!texture! Pink! Gums!Pink,!Teeth!white!

9.#Inspect#Pillars#&#Tonsils# 10.#Test#symmetry#of#rising#Uvula# 11.#Inspect#&#note#symmetry#of# Tongue# 12.#Palpate#Tongue# #

Pillars!same!color!as!oral! mucosa,!tonsils!normal!size!2+! Uvula!raises!symmetrically! Symmetrical! Soft,!even!color!

Abnormal# Asymmetry!!Fractured!to!nasal! bone!due!to!trauma! Pain!!Local!infection,!furuncle! Obstruction!!Congestion!!Viral! Rhinitis! Tenderness!!Acute!sinusitis! Obstruction!of!light!!Acute! sinusitis! Redness!&!swelling!!Viral! Rhinitis! Blister!!Herpes!labialis! White!patches!!Thrush!*! Candidiasis! Red!&!Swollen,!Marginal! Gingivitis!! Lingual!Surface!Erosion!! Bulimia! Swell!3+,!Exudates!!Tonsillitis! Contralateral!deviation!*!CN!X! (Vagus)!paralysis! Ipsilateral!deviation!!CN!XII! (Hypoglossal)! Nodule!or!ulcer,!red!or!white!at! the!base!!Tongue!Cancer!

Sore!Throat!*!4!

04##Nasal#Symptoms#and#Sinus#Congestion# ! Life!Threatening!Conditions!(RED!FLAGS)! 1. Osteomyelitis!of!frontal!bone! ! What!symptoms!will!help!me!narrow!the!possibilities?! 1. Duration!of!Symptoms/History!of!problems! a. Acute!rhinitis/sinus!congestion!!Symptoms! last!48(72!hrs.!due!to!edematous!mucosa! obstructing!the!sinus!ostia.! b. Viral!Rhinitis!!Same!as!above!and!systemic! symptoms!(fever,!myalgias,!and!chills)!caused! by!rhino/parainfluenza!virus! c. Chronic!rhinitis!!week/years!rarely! infectious;!rather!anatomical!abnormalities! that!impair!the!sinus!drainage!even!when! muco(ciliary!clearance!is!normal.! 2. Seasonal!Occurrence!of!Symptoms! a. Allergic!rhinitis!!seasonal!occurrence!of! symptoms,!sneezing,!wheezing,!itchy!or! burning!eyes.! b. Perennial!Allergy!!allergen!present!in!their! environment!year(round!basis,!animal! dander,!house!dust,!mold,!feathers,!and! cockroaches.! c. Seasonal!Allergy!!Early!spring!!tree!pollens,! early!summer!!grass!pollen,!Early!fall!!weed! pollen! 3. Family!History! a. Allergic!Rhinitis!!FHX!of!asthma!or!allergies.! Other!symptoms!head!stuffiness,!ear! discomfort,!fatigue,!and!scratchy!or!mild!sore! throat.! !

! ! If!I!suspect!sinus!problems,!what!do!I!need!to!know?! 1. Acute!symptoms!!acute!sinusitis!has!abrupt!onset,! usually!after!URTI,!with!sore!throat,!irritated!by! postnasal!discharge,!face!or!tooth!pain,!headache! over!sinus,!morning!periorbital!swelling,!fever,!and! malaise.!Less!common,!adenoid!hypertrophy,!dental! abcess!or!periorbital!cellulitis.! 2. Location!of!pain!(!prolonged!cold!with!symptoms!of! nasal!congestion!and!facial!pain.!! a. Maxillary!sinusitis!!maxillary,!dental!pain.!! b. Frontal!sinusitis!!frontal!headache,!worse! waking!up.! c. Ethmoid!!vertex,!forehead,!occipital,! temporal!referred!pain.!! d. Sphenoid!sinusitis!!Top!of!the!head!! 3. Position!change!(!Maxillary!sinusitis!has!pain!that! worsens!bending!or!leaning.!Postnasal!discharge! produces!cough!worse!lying!down.! 4. Chronic!Symptoms!!can!be!caused!by!prolonged! obstruction!of!osteomeatal!complex.!Due!to!adenoid! hypertrophy,!conchae!bullosa,!nasal!polyps,!foreign! bodies,!and!nasal!deviations.!Adults!>3!weeks!with! molar!pain,!headache,!postnasal!drip,!and!rarely! fever.!Children!>30!days.! ! Do!associated!symptoms!provide!any!clues?! 1. Other!acute!symptoms! a. Purulent!discharge!!Bacterial!infection! b. Acute!rhinitis!!Bacterial!or!viral!with! systemic!symptoms!(fever,!myalgia,!chills)!

Earache!(!1!

! Is!it!viral!or!bacterial?! 1. Acute!rhinitis!!bacterial!or!viral,!yellow!or!green! purulent!discharge.! 2. Allergic!!watery!or!clear!discharge! 3. Viral!!persists!5(10!days!the!gradually!subside.! ! Are!symptoms!unilateral!of!bilateral?! 1. Bilateral!!Infectious!&!allergic!rhinitis! 2. Unilateral!!Anatomical!cause,!polyps,!septal! deviation,!or!foreign!body.! ! Are!there!risk!factors!that!will!narrow!the!diagnosis?!

c. Allergic!Rhinitis!!Sneezing,!nasal!congestion,! clear!and!profuse!rhinorrhea,!nose/!palate/! pharynx/middle!ear!pruritus.!Conjunctival! irritation,!itching,!erythema,!tearing.!Ear! fullness,!popping.!Sinus!pressure,!Cheek/! forehead/!behind!the!eyes!pain,!! d. !Acute!sinusitis!!in!Children!<30!days,! persistent!cough,!fever!>39C!>3days,! malodorous!breath,!maxillary!&!ethmoid! most!common,!frontal!occasionally,!sphenoid! rare.! 2. Chronic!symptoms!!Long!episodes!of!inflammation! or!repeated!infections!that!lead!to!anatomical! changes.!Interfere!with!daily!activities,!not!relieved! with!non(pharmacological!measures,!OTC! medications.!Cold!that!does!not!goes!away,!eye!pain,! halitosis,!chronic!cough,!fatigue,!anorexia,!and! malaise!

1. Smoking!History!!increased!risk!of!sinusitis.!More! tenacious!mucus,!ciliary!paralysis.!Passive!exposure! increases!risk!of!URTI!&!LRTI! 2. Trauma!history!!Nasal!trauma!or!fracture!may!lead! to!nasal!congestion.!Post!trauma!CSF!rhinorrhea.! 3. Diving!and!swimming!!Sinusitis!from!diving!or! swimming!secondary!to!barotrauma,!contaminated! water,!or!allergic!response!to!chlorine.! 4. Exposure!!Day!care,!school,!work,!home! 5. Pregnancy!!Hormonal!changes!can!cause!nasal! congestion! ! Is!the!patient!using!any!drugs!that!would!cause!nasal! congestion?! 1. Nasal!Spray!!topical!sympathomimetics!sprays!or! drop!can!cause!rebound!nasal!congestion.! Decongestants!&!antihistamines!can!cause!excessive! dryness!&!impaired!ciliary!function.! 2. Drug!use!!chronic!or!acute!use!of!cocaine!can!cause! rebound!congestion.!Sometimes!associated!with! conjunctivitis!and!irritation!of!the!eye! 3. Medications!!Oral!contraceptives,!phenothiazines,! ACE!inhibitors,!&!beta(blockers!may!cause!nasal! congestion.! ! Is!there!systemic!disease!present?!!Cystic!fibrosis,!ciliary! dyskinesia!syndrome,!immunoglobulin!deficiency!can!cause! decreases!muco(ciliary!clearance.!DM,!Leukemia,!AIDS,!CF! increased!risk!of!sinusitis.!Hypothyroidism,!acromegaly,! Horner,!neoplasm,!and!granulomatosis!can!cause!nasal! symptoms.! ! !

Earache!(!2!

Condition!
Infectious!Rhinitis! Allergic!Rhinitis! Nonallergic!rhinitis! Rhinitis!medicamentosa! Acute!sinusitis!

Common!Causes!of!Nasal!Symptoms!and!Sinus!Congestion! History! Physical!Findings!

Perennial!but!more!common!in!winter! months;!recent!URTI! Family!history!of!allergies;!sneezing;! recurrent!pattern;!more!common!in! children!and!young!adults! No!allergenic!cause!identified! History!of!medication!use,!contraceptives,! nasal!sprays,!antihypertensives;!nasal! congestion! Smoker;!recent!URTI;!winter!months;! frontal!headaches!worst!forward!bending;! sensation!of!fullness,!or!pressure! History!of!previous!sinus!infections;!dull! ache!or!no!pain;!persistent!symptoms! History!of!asthma,!aspirin!intolerance;! foreign!body!in!children,!tumor!in!adults;! infants!with!choanal!atresia;!difficulty! feeding;!cyanosis!if!bilateral! History!of!asthma,!aspirin!intolerance! History!of!head!trauma,!diving! Red,!swollen!mucosa;!purulent! discharge! Pale,!boggy!mucosa;!rhinorrhea! with!clear,!watery!mucous! Similar!to!allergic!rhinitis! Swollen!mucosa;!clear!mucus!or!dry! mucosa! Purulent!discharge;!maxillary! toothache!on!percussion,!postnasal! drainage,!decreased! transillumination! Same!as!acute!sinusitis;!decreased! or!no!transillumination;!obstruction! such!as!deviated!septum,!polyps! Increased!pain!with!forward!motion! or!Valsalva;!pain!with!percussion! and!palpation!of!sinuses;!no! transillumination;!septal!deviation! Presence!of!polyps! Appears!severely!ill;!periorbital!and! frontal!edema!

Diagnostic!Labs!
Nasal!smear!for!neutrophils,! intracellular!bacteria! Nasal!smear!for!eosinophils;! allergy!testing! None! None! None!

Chronic!sinusitis! Obstruction!

CT!scan;!nasal!endoscopy;!allergy! testing! Sinus!radiographs;!CT!scan!

Nasal!polyposis! Osteomyelitis!of!frontal! bone!

Nasal!endoscopy;!may!require! biopsy! Sinus!and!skull!radiograph;!blood! culture!

! ! ! ! ! ! ! ! ! !

Earache!(!3!

!
Nose,#Sinuses,#Mouth#Examination# # Competencies# 1.#Inspect#Nose# 2.#Test#for#Nasal#Tenderness#&# Obstruction# 3.#Palpate#for#Sinus#Tenderness# 4.#Sinus#transillumination# 5.#Inspect#Nasal#Mucosa#&#Septum#J# otoscope# 6.#Inspect#Lips# 7.#Inspect#Oral#Mucosa,#Hard#&#Soft# palate# 8.#Inspect#Gums#&#Teeth# Normal# Symmetrical! Painless,!Effortless!breathing! Abnormal# Asymmetry!!Fractured!to!nasal! bone!due!to!trauma! Pain!!Local!infection,!furuncle! Obstruction!!Congestion!!Viral! Rhinitis! Tenderness!!Acute!sinusitis! Obstruction!of!light!!Acute! sinusitis! Redness!&!swelling!!Viral! Rhinitis! Blister!!Herpes!labialis! White!patches!!Thrush!(! Candidiasis! Red!&!Swollen,!Marginal! Gingivitis!! Lingual!Surface!Erosion!! Bulimia! Swell!3+,!Exudates!!Tonsillitis! Contralateral!deviation!(!CN!X! (Vagus)!paralysis! Ipsilateral!deviation!!CN!XII! (Hypoglossal)! Nodule!or!ulcer,!red!or!white!at! the!base!!Tongue!Cancer!

Non(tender! Light!shines!through!the!sinuses! Pink(red! Pink(red,!smooth!texture! Pink! Gums!Pink,!Teeth!white!

9.#Inspect#Pillars#&#Tonsils# 10.#Test#symmetry#of#rising#Uvula# 11.#Inspect#&#note#symmetry#of# Tongue# 12.#Palpate#Tongue# #

Pillars!same!color!as!oral! mucosa,!tonsils!normal!size!2+! Uvula!raises!symmetrically! Symmetrical! Soft,!even!color!

Earache!(!4!

05##Vision#Change# ! Life!Threatening!Conditions!(RED!FLAGS)! 1. Injury,!Chemical/Thermal!burn,!trauma! 2. Retinal!detachment!! 3. Close!angle!Glaucoma! 4. Sudden!loss!of!vision! ! What!is!the!extent!of!the!vision!change?! 1. Total!absence!of!vision!!Disease!that!affects!optic! nerve!or!retina!such!as!retinal!detachment.! 2. Blurring!of!vision!,!Distinguish!between!vision!loss! and!visual!acuity.!Most!common!is!refractive!error.! 3. Ability!to!focus!,!Vision!loss!is!common!cause!of! nystagmus!in!children,!and!wandering!nystagmus!in! adults! 4. Visual!fixation!,!Infants!will!demonstrate!visual! interest!in!human!face.!Parental!concerns!are! important!history!finding.!!! ! Is!this!an!emergency!that!requires!immediate!intervention?! 1. Onset!!Sudden!vision!loss!suggest!central!retinal! artery!occlusion.!Unilateral!vision!loss!suggest!optic! nerve!problem!anterior!to!chiasm.! 2. Pain!!Sudden!vision!loss!with!eye!pain!&! photophobia!suggest!pathology!of!the!cornea,!iris!&! ciliary!body.!Sudden!vision!loss!with!red!and!painful! eye!may!indicate!close!angle!glaucoma.!Pain!on! movement!of!the!eye!due!to!inflammation!of!the! orbit!or!optic!nerve!in!retrobulbar!neuritis.!! 3. Other!symptoms!!In!children!acute!optic!neuritis! rarely!occurs!isolated,!usually!a!manifestation!of! neurological!or!systemic!disease!such!as!meningitis,! !

viral!infection,!or!demyelinating!diseases,!lead! poisoning,!long!term!of!chloramphenicol!or! vincristine.! 4. Flash!of!Light!with!Vision!Loss!!shortly!before! retinal!detachment,!a!veil!over!the!eye!just!before!or! after!the!flash.!When!the!retina!is!pulled!away!or! tear!patients!do!not!experience!the!flash!of!light,!but! may!experience!partial!loss!of!vision!on!affected!eye.! 5. Transient!vision!loss!!Migraine!headaches!patient! may!experience!scotoma!before!onset.!Positive! scotoma!is!perceived!as!scintillating!flashes;! negative!scotoma!is!experienced!as!a!blind!spot.!May! be!prodromal.!Profound!anxiety!can!cause!a! transient!or!perceived!vision!loss.! ! Can!I!rule!out!trauma?! 1. Head!trauma!!Vision!loss!after!trauma!to!the! occiput,!skull!fracture,!hemorrhage.!In!children,! trauma!is!most!common!cause!of!retinal!detachment! (shaken!baby)! 2. Eye!Trauma!!Sharp!trauma,!lacerations,!small! penetrations.! 3. Chemical!or!Thermal!Trauma!!Alkaline!burns!from! household!cleaners!&!lawn!products.!Exposure!to! heat!or!flame.! ! Is!the!vision!loss!because!of!a!chronic!problem?! 1. Progressive!loss!of!visual!acuity!and!color!vision!in! optic!gliomas,!most!common!in!childhood,!history!of! neurofibromatosis.!Glaucoma!may!cause!chronic! vision!loss,!Age,related!macular!degeneration!is! related!to!decreased!reading!vision.! ! Vision!Change!,!1!

Is!this!related!to!a!genetic,!familial,!or!intrauterine!risk?! 1. Family!History!!Retinoblastoma,!congenital! cataracts,!metabolic!or!genetic!disease!are!risk! factors!for!visual!and!ocular!abnormalities.! 2. Maternal,!Intrapartum,!and!neonatal!!Premature!on! oxygen!may!develop!retinal!detachment!and!vision! loss!due!to!vascular!neogenesis.!AIDS!&!TORCH!can! produce!blindness!at!birth!or!loss!of!vision!later!in! life.!Down!syndrome!and!galactokinase!deficiency! are!associated!with!cataracts.! ! Is!the!loss!because!of!a!systemic!disease?! 1. Chronic!Disease!!Diabetic!retinopathy!is!a!leading! cause!of!vision!loss,!due!to!micro,infarctions!and! hard!exudates!leaking!into!retina.! Neurodegenerative!disease!and!juvenile!rheumatoid! arthritis!can!cause!visual!changes.!Prolonged! systemic!steroids!treatment!can!lead!to!formation!of! posterior!subcapsular!cataracts!Marfan!syndrome! may!cause!dislocated!lenses.! ! Could!this!be!an!anatomical!problem?! 1. Eye!alignment! a. Strabismic!amblyopia!!one!eye!out!of! alignment,!brain!suppresses!the!image!to! avoid!diplopia.!! b. Refractive!amblyopia!!different!refraction!of! each!eye,!child!uses!one!that!focuses!best,! poor!development!of!affected!eye.! c. Deprivation!amblyopia!!due!to!ptosis,! congenital!cataracts,!vitreous!opacity.! 2. Squinting!!Often!occurs!with!strabismus.!Excessive! squinting!in!bright!light!may!indicate!glaucoma.! !

3. Exophthalmus!!Bilateral!in!hyperthyroidism,! Unilateral!in!tumor!behind!the!eye.! 4. Enophthalmus!!Caused!by!starvation,!dehydration! or!trauma.! 5. Ptosis!!drooping!of!eylid!may!indicate!a!lesion!of! the!oculomotor!nerve!(CN!III),!a!neuromuscular! weakness!(Bel!palsy!syndrome),!or!a!congenital! condition! ! Is!there!a!pattern!of!vision!loss?! 1. Retinitis!pigmentosa!!night!vision!loss! 2. Low!blood!pressure!or!impending!shock!!Diming!of! vision!when!standing! 3. Myopic!!reduced!night!vision! 4. Vitamin!A!deficiency!!night!blindness,!can!be!from! retinotoxic!drugs!such!a!quinine.! ! Can!I!associate!the!vision!loss!with!the!age!of!the!patient?! 1. Vision!Loss!with!aging!!Age,related!macular! degeneration!leading!cause!of!blindness!in!older! adults.! 2. Developmental!delay!!Decreased!vision!can!result! in!developmental!delays.!Motor!development! requires!good!vision.!Poor!school!performance! might!be!an!indication!of!refractory!problems!or! craniopharyngiomas.! ! ! ! ! ! ! ! Vision!Change!,!2!

Condition!
Strabismus! Amblyopia! Refractive!errors! Cataracts! Optic!neuritis! Optic!Nerve!hypoplasia! Injury! Retinoblastoma! Nystagmus! Retinopathy!prem.! Retinal!artery!occlusion! Glaucoma! Open/Close!angle! Retinal!Detachment! Macular!degeneration! Diabetic!Retinopathy! Uveitis! Optic!nerve!glioma! Craniopharyngioma! Chemical!burn! Thermal!burns! Congenital!infections!

Common!Causes!of!Vision!Change! History!
Family!reports!childs!eyes!cross,!family!history! May!have!history!of!premature!birth,!down!syndrome,! cerebral!palsy,!hydrocephalus! Sitting!close!to!television,!squinting! Blurred!vision,!glare,!distortion,!change!in!color;!increased! age,!history!of!infection,!trauma,!chronic!disease!(DM)! History!of!MS,!viral!infection,!pain!with!eye!movement,! rapid!vision!loss! History!of!vision!loss,!central!vision!without!peripheral! vision! History!suggesting!head/eye!trauma!(blunt/sharp)! Family!history,!<2yo! History!of!eye!searching! Premature!<36wks.,!1500g,!O2!administered,!twin! Sudden!onset,!painless!vision!loss,!may!come!and!go! Can!be!painless,!gradual!vision!loss,!blurring,!halos,!more! common!in!older!adults! Flashing!light,!floaters,!history!of!trauma!to!head/face! >60yo.!Decreased!central!vision,!blue!eyes,!!unilat.!image!

Physical!Findings!

Exams!
Refer!!Cover! uncover! Refer! Snellen! Refer! Fundoscopy! Refer! Fundoscopy! Refer! Fundoscopy! Refer,!Fundos.! Refer,!Fundos.! Refer,!H,Test! Refer,!Fundos.! Refer,!Fundos.! Refer,!Tang.! Light,!Tonom.! Refer,!Fundos.! Amsler!grid! Refer,!Fundos.! Refer! Refer,!Fundos.! Refer,!Fundos.! Eye!irrigation! Refer! Screen! TORCH,!refer!

Extraocular!movements!abnormal,! cover/uncover!test!positive! Vision!decreased!in!one!eye!

Loss!of!visual!acuity! Whitish!appearance!of!pupil,!bilateral!or! unilateral! Decreased!acuity,!reduced!color!percep,! afferent!pupil!defect,!central!scotoma! Optic!nerve!,1/3!size,!pale!to!gray!color,! surrounded!yellow!halo! Directed!by!history! Partial!or!absent!red!reflex,!strabismus! Rhythmic,!repetitive!oscillation!of!eyes! Abnormalities!of!retinal!vessels! Macular!edema,!cherry!red!spot,!vessel!nar! Decreased!visual!acuity;!may!have! intraocular!pressure!on!palpation! Retina!elevated,!gray,!dark!vessel,!folds! Drusen!deposits!near!macula,!gray,green! areas!on!retina!,decrease!acuity!! History!of!DM,!floaters,!gradual!vision!loss! Venous!dilation,!retinal!hemorrhages! History!of!infection/chronic!inflammation,!mild/moderate! Varies!according!to!cause!&!severity! pain,!photophobia,!tearing! Dimness,!loss!of!fields,!may!be!unilateral!rapid!vision!loss! Visual!field!defects,!optic!atrophy! Unilateral!vision!loss,!Headache,!child/adult! May!have!normal!fundoscopy! History!of!alkaline/acid!exposure! Treat!first!then!examine! History!of!exposure!to!high!heat/occupational!exposure! Corneal!opacities! TORCH,!maternal!exposure!to!measles! Retinitis,!optic!nerve!hypoplasia!

! ! ! ! ! ! Vision!Change!,!3!

Eye#Examination# # Competencies# 1.#Inspect#the#eyes#&#surrounding#area# 2.#Inspect#eyebrows#&#eyelids# 3.#Inspect#Conjunctiva#&#Sclera# 4.#Inspect#Cornea,#Lens#&#Iris# 5.#Inspect#Pupils# 6.#Inspect#Reflection#in#Cornea# 7.#Perform#Pupillary#Reaction#to#light# 8.#Perform#Pupil#near#Reaction# 9.#Test#for#convergence# 10.#Test#for#Acuity# 11.#Test#for#Visual#Fields# 12.#Test#extraocular#movements# 13.#Perform#Cover/Uncover#Test# 14.#Identify#Red#Reflex# 15.#Inspect#Optic#Disc# 16.#Inspect#Physiologic#Cup# 17.#Inspect#Arteries#&#Veins# 18.#Inspect#Retina# 19.#Inspect#Macula#&#fovea# !

Normal# Upper!lid!covers!part!of!iris,!not!protruding!or! sunken! Eyebrows!even!distribution!medial!to!lateral.! Eyelids!color!consistent!with!face,!able!to!close! White!sclera,!pink!conjunctiva,!normal! vasculature! Normally!transparent! Light!cast!no!shadow!on!Iris! Round!3,5mm,!Symmetrical! Visible!reflections!slightly!medial!symmetrical! Direct!&!consensual!result!in!pupil!contraction! DilatedFar!gaze,!Constricted!near!gaze! Normally!eyes!converge! Normal!Vision!20/20! 50 up,!70 down,!90 temporal,!60 nasal! Follow!pencil!without!being!dysconjugate! Steady!conjugation!directed!to!object! Seen!in!normal!lens! Yellow!Orange!!Round!Symmetrical! Size!!Optic!disk! Visible!column!of!blood! Red/Orange,!No!exudates! Macula!Lateral!to!optic!disc! Fovea!Center!of!Macula!

Abnormal# Exophthalmos!!Hyperthyroidism! Sty!,!Painful,!tender!and!red!inflammation!of!gland! at!margin!,!infection! Yellow!sclera!!Jaundice,!Hepatitis,!Inflammation!of! episcleral!vessels!!episcleritis! Opacity!!Cataracts! Medial!Shadow!!Acute!Narrow!Angle!Glaucoma! Mydriasis!!Adies!Tonic!Pupil! Asymmetry!!Dysconjugate!gaze,!Accommodative! esotropia! Dilated!Pupil!direct!or!consensual!!CN!III!Paralysis! Dilated,Near!gaze!!CN!III!Paralysis! Failure!to!converge!!CN!III!paralysis! Hyperopia!!farsighted! Both!Eyes!Temporal!Sides!absent!!Bitemporal! hemianopsia! Lateral!Dysconjugate,!Lateral!rectus,!CN!VI,! Abducent!Nerve! Dysconjugate!gaze!!Strabismus! Lack!of!Red!Reflex!!cataracts! Swelling!!Papilledema,!blurred!edges! >!,!Glaucoma!cupping! Nicking!!Hypertension! White!Cotton!Wool!Spots!!Malignant! Hypertension! Drusen,!Yellow!spots!!Macular!Degeneration!

Vision!Change!,!4!

06##Red#Eye# ! Life!Threatening!Conditions!(RED!FLAGS)! 1. Chemical!Injury/Trauma!!See!04!Vision!Loss! 2. Orbital!Cellulitis! 3. Retinal!detachment!'!Vision!Loss,!Floaters! 4. N.!gonorrhoeae!!copious!discharge! 5. Glaucoma!'!Pain! ! Could!this!be!caused!by!an!orbital!infection?! 1. Swelling,!Redness,!and!Fever!!'!Orbital!or! infraorbital!cellulitis!can!present!with!conjunctivitis.! Can!be!complication!os!sinusitis.!! 2. Pain!with!attempted!motion!of!the!eye!!Collection! of!pus!during!orbital!cellulitis!causes!this.! Inflammation!of!all!tissues!of!the!orbit,!and! proptosis!and!impairment!of!ocular!motility.! 3. Recent!sinus!infection!!Predisposes!to!orbital! cellulitis.!Ethmoid!sinuses!most!commonly,! maxillary!sinuses!next!most!common.! ! Can!I!rule!out!trauma?! 1. Lid!swelling,!discoloration,!subconjunctival!bleeding,! hyphema!(intraocular),!lacerations,!abrasions,!! ! Is!this!an!acute!or!chronic!condition?! 1. Onset! a. Abrupt!!Trauma,!chemical!burn,!foreign! body,!UV!exposure,!contact!lens! b. Few!Hours!!infection!from!adjacent! structures! c. Few!days!!Conjunctivitis,!infection!of! eyelids,!conjunctiva!!Staph!a.,!Strep! !

! Can!I!narrow!the!problem!by!location?! 1. Unilateral!!Trauma,!infection,!Hordeolum!(sty),! chalazion,!acute!glaucoma!(painful,!inflamed,! photophobia,!foreign!body!sensation!without! trauma)! 2. Bilateral!!Allergy,!Systemic!process.!Blepharitis!! inflammation!of!eyelids,!itching,!crusting!on!lash! line.! 3. Start!unilateral!then!bilateral!!Conjunctivitis,! Subconjunctival!hemorrhage,!Herpetic!infection.! ! What!does!the!presence!or!absence!of!pain!tell!me?! 1. Location!of!pain! a. Common!source!of!Pain!!Lid,!conjunctiva,! cornea,!uveal!tract! b. Seldom!a!source!of!Pain!!Retina,!vitreous,! optic!nerve! c. Referred!pain!!contiguous!structures,! inflamed!structure!innervated!by!meningeal! branches!of!ophthalmic!nerve.! 2. Severity!of!pain! a. Minimal!!Bacterial!conjunctivitis! b. Itching,!Burning!!Allergy! c. Moderate!!Iritis! d. Severe!!Corneal!abrasion,!ulcer! e. Constant,!boring,!throbbing!pain,!can! interfere!sleep!!from!ocular!inflammation! assoc.!with!iritis,!acute!glaucoma!and!scleritis! Red!Eye!'!1!

pneumoniae,!Strep!A,!H.!influenza,!N.! gonorrhea! 2. Recurrence!!Allergic!conjunctivitis,!Iritis!from! systemic!causes!due!to!collagen!destruction.!

3. Foreign!Body!sensation! a. Viral!!gritty!sensation! b. Sjogren!Syndrome!!scratchy,!dry!eye! c. Overwear!contact!lenses!!pain!from!corneal! hypoxia!several!hours!after!removing!them.! !

Red#Eye#Symptom#Patterns# No!Pain! Painful! No!Vision!Loss! Vision!Normal! Vision!Impaired! Conjunctivitis! Episcleritis! Iritis! Subconjunctival!hemorrhage! Keratitis! Glaucoma! Episcleritis! Cluster!HA! Orbital!Cellulitis! ! Corneal!Abrasion! Scleritis! ! Cornel!ulcer! Keratitis! ! ! Cornel!Ulcer!

5. Floaters!!and/or!flashing!lights!!vitreoretinal! traction!or!detachment.!Detachment!also!has! blurred!or!blackened!vision.! ! What!does!the!presence!or!characteristic!of!the!discharge! tell!me?! 1. Watery,!non'purulent!!Allergic!conjunctivitis,! bilateral!also!Mucoid!Stringy,!Ropy! 2. Mucopurulent/purulent!!Bacterial!conjunctivitis,! bilateral.!Copious!purulent!!N.!gonorrhoeae! 3. Watery!!Viral!conjunctivitis,!unilateral! 4. Neonate!24hrs!old!mucoid/purulent!!from!silver! nitrate,!other!medications.!Bilateral!3'7days!old!'! gonococcal,!5'30days!!chlamydial!conjunctivitis.! ! What!does!the!presence!of!photophobia!tell!me?! 1. Ocular!inflammation/irritation!!Intraocular!!iritis,! uveitis.!None!in!bacterial!conjunctivitis.!In!young!! juvenile!arthritis,!intraocular!tumors,!congenital! glaucoma,!herpetic!keratitis,!or!trauma.! ! What!other!things!do!I!need!to!consider?! 1. Swelling!!Dacryocystitis!!medial!canthus,!Lids!! infla.,!local!infection!or!trauma.!Periorbitalcellulitis.! 2. Tears!!nasolacrimal!duct!obstruction.!Epiphora'! viral!conjunctivitis,!corneal!abrasions,!infantile! glaucoma,!nasolacrimal!duct!stenosis.! 3. Itching!and!tearing!!Allergic!conjunctivitis! 4. Cough!and!Fever!!No!fever!in!bacterial! conjunctivitis.!Otitis'Conjunctivitis!syndrome!!low! grade!fever,!mucopurulent!rhinorrhea,!and!cough.!3' 4!days!after!fever!crusted!eyelashes,!ear!complains.! Viral!conjunctivitis!!slight!crusting!with!URTI! Red!Eye!'!2!

! Do!I!need!to!worry!about!vision!change?! 1. Vision!loss!'!Distinguish!from!blurry!vision!in! conjunctivitis.!No!Vision!decrease!!Bacterial!or! allergic!conjunctivitis! a. Mild!decrease!!Iritis! b. Marked!decrease!!Glaucoma,!corneal! abrasions,!ulcers! 2. Blurring!!From!hazy!cornea,!lens,!humor,!vitreous,! often!dazzle!in!bright!light.!Refractive!&!double! vision,!conjunctivitis!heavy!discharge!described!as! blurry.! 3. Double!Vision!!Sudden!onset!indicate!neurological! problem.!Ocular!muscles!conditions!can!cause! chronic!diplopia.!Monocular!diplopia!indicates! corneal!or!lens!changes.! 4. Halos!!Prismatic!effects.!Corneal!edema,!abrupt!rise! in!pressure!(glaucoma).!Can!be!water!drops!in! cornea!or!lens!(Corneal!edema,!cataracts)! !

Condition!
Dacryocystitis! Blepharitis! Hordeolum/Sty! Chalazion! Entropion/Ectropion! Unilateral,!acute;!pain! Bilateral,!gradual,!no!pain! Unilateral;!pain!

History!

Common!Causes!of!Red!Eye! Physical!Findings! Eyelids/Lacrimal!Sac!

Swelling,!redness!lacrimal!sac;!tearing,!pus!thru!punctum! Lids!inflamed;!acuity!ok,!loss!lashes! Swelling!eyelid;!indurated!lesion,!central!pus,! surrounding!erythema! Tarsal!plate!indurated!lesion,!pruritus,!redness!of! eye/eyelid! Lid!turned!in!or!out,!local!irritation,!tearing,!peripheral! injection!

Diagnostic!Labs!
CBC,!leukocytosis! None! None,!diabetes!if!repeated! None! None!

Unilateral,!chronic;!painless! Unilateral!or!bilateral!

Conjunctiva!
Bacterial!Conjunctivitis! Viral!Conjunctivitis! Allergic!Conjunctivitis! N.!gonorrhoeae!Conjunctivitis!! Chemical!Conjunctivitis! Subconjunctival!hemorrhage! Hyphema!!Ant.!Chamber! Gradual,!unilateral!bilateral,!scratchy,!no! pain;!photophobia! Gradual,!unilateral!bilateral.!Scratchy,!no! pain! Chronic;!seasonal;!bilateral;!itchy,!no!pain! Bilateral;!newborn! Bilateral! Unilateral;!no!pain,!cough;!strain! Unilateral;!trauma!to!eye! Peripheral!injection;!purulent!discharge;!matted!eyelids;! acuity!ok! Peripheral!injection;!watery!discharge;!acuity!ok;! follicular!! Peripheral!injection;!mucoid!disch;!cobblestone!mucosa,! acuity!ok! Purulent!disch;!48'72!hrs!after!birth! Neonate,!<24hrs! Splash!of!blood!in!conjunctiva!or!sclera;!acuity!ok! None!if!treatment!ineffective!obtain! culture,!gram!stain! Same!as!for!bacterial!conjunctivitis! Fluorescein!stain,!hypertrophy! Culture!Thayer'Martin!plate;!Gram! None! None! Refer!to!ophthalmologist!

Anterior!Chamber!
RBC!ant.!Chamber;!acuity!,!pupil!irregular,!poorly! reactive!

Sclera!
Episcleritis! Scleritis! Keratitis! Corneal!Abrasion! Herpetic!Keratitis! Periorbital!cellulitis! Orbital!cellulitis! Bilateral;!mild!stinging! Unilateral,!deep,!boring!pain! Bilateral;!moderate!severe!pain! Unilateral!pain;!photophobia! Uni/bi'lateral;!pain;!photophobia! Unilateral! Unilateral;!pain! Peripheral!injection;!no!disch;!acuity!ok! Ciliary!injection;!tear;!acuity!ok;!photophobia! Disch;!pupil!normal;!cornea!cludy;!acuity!! Diffuse!injection;!tear;!acuity!variable! Ciliary!flush;!disch;!acuity!! None! Asoc.!Systemic!Immune!Disease! Test!fungal,!viral,!bacterial!inf.! Fluorescein!Stain!+! Fluorescein!Stain!!!dendrites! CBC,!Leukocytosis;!blood!cultures! CBC,!blood!culture;!CT!scan;!life! threatening! Refer! Tonometry;!emergency!referral!

Orbit!
Lid!Swelling;!Fever;!redness;!conjunctiva!clear;!eye! moves!freely;!vision!not!impaired! Proptosis;!lid!swelling,!chemosis;!conjunctivitis;!limit!eye! motion!

Uveal!Tract!
Iritis! Acute!closed'angle!Glaucoma! Unilateral;!moderate!aching!pain;!photophobia! Unilateral;!deep!pain;!photophobia;!halos! Tearing;!pupil!smaller;!cornea!normal;!ciliary!flush!

Glaucoma!

! ! ! ! !

Ciliary!injection;!tears;!acuity!!

Red!Eye!'!3!

!
Eye#Examination# # Competencies# 1.#Inspect#the#eyes#&#surrounding#area# 2.#Inspect#eyebrows#&#eyelids# 3.#Inspect#Conjunctiva#&#Sclera# 4.#Inspect#Cornea,#Lens#&#Iris# 5.#Inspect#Pupils# 6.#Inspect#Reflection#in#Cornea# 7.#Perform#Pupillary#Reaction#to#light# 8.#Perform#Pupil#near#Reaction# 9.#Test#for#convergence# 10.#Test#for#Acuity# 11.#Test#for#Visual#Fields# 12.#Test#extraocular#movements# 13.#Perform#Cover/Uncover#Test# 14.#Identify#Red#Reflex# 15.#Inspect#Optic#Disc# 16.#Inspect#Physiologic#Cup# 17.#Inspect#Arteries#&#Veins# 18.#Inspect#Retina# 19.#Inspect#Macula#&#fovea# Normal# Upper!lid!covers!part!of!iris,!not!protruding!or! sunken! Eyebrows!even!distribution!medial!to!lateral.! Eyelids!color!consistent!with!face,!able!to!close! White!sclera,!pink!conjunctiva,!normal! vasculature! Normally!transparent! Light!cast!no!shadow!on!Iris! Round!3'5mm,!Symmetrical! Visible!reflections!slightly!medial!symmetrical! Direct!&!consensual!result!in!pupil!contraction! DilatedFar!gaze,!Constricted!near!gaze! Normally!eyes!converge! Normal!Vision!20/20! 50 up,!70 down,!90 temporal,!60 nasal! Follow!pencil!without!being!dysconjugate! Steady!conjugation!directed!to!object! Seen!in!normal!lens! Yellow!Orange!!Round!Symmetrical! Size!!Optic!disk! Visible!column!of!blood! Red/Orange,!No!exudates! Macula!Lateral!to!optic!disc! Fovea!Center!of!Macula! Abnormal# Exophthalmos!!Hyperthyroidism! Sty!'!Painful,!tender!and!red!inflammation!of!gland! at!margin!'!infection! Yellow!sclera!!Jaundice,!Hepatitis,!Inflammation!of! episcleral!vessels!!episcleritis! Opacity!!Cataracts! Medial!Shadow!!Acute!Narrow!Angle!Glaucoma! Mydriasis!!Adies!Tonic!Pupil! Asymmetry!!Dysconjugate!gaze,!Accommodative! esotropia! Dilated!Pupil!direct!or!consensual!!CN!III!Paralysis! Dilated'Near!gaze!!CN!III!Paralysis! Failure!to!converge!!CN!III!paralysis! Hyperopia!!farsighted! Both!Eyes!Temporal!Sides!absent!!Bitemporal! hemianopsia! Lateral!Dysconjugate'!Lateral!rectus,!CN!VI,! Abducent!Nerve! Dysconjugate!gaze!!Strabismus! Lack!of!Red!Reflex!!cataracts! Swelling!!Papilledema,!blurred!edges! >!'!Glaucoma!cupping! Nicking!!Hypertension! White!Cotton!Wool!Spots!!Malignant! Hypertension! Drusen,!Yellow!spots!!Macular!Degeneration!

Red!Eye!'!4!

07##Cough# ! Is!this!cough!related!to!a!life'threatening!condition?!(RED! FLAGS)! 1. Shortness!of!breath!!Physical!obstruction,!acute!asthma.! Heart!Failure!!orthopnea,!paroxysmal!nocturnal!dyspnea,! cough,!frothy!sputum,!weight!gain,!swollen!feet,!ankles!hx! of!heat!disease.! 2. History!of!asthma!!Acute!exacerbating!asthma!!irritating! non'productive!cough!tachypnea,!dyspnea,!wheezing,! grunting,!cyanosis,!fatigue!respiratory!&!cardiac!failure.! Viral!infection,!RSV,!parainfluenza!&!rhinovirus!are! common!triggers!for!asthma!in!children.! 3. Foreign!Body!!Chocking,!gagging,!coughing.!Foreign!body! in!LRT!can!produce!emphysema!or!atelectasis.!If!mobile! can!produce!paroxysmal!cough,!cyanotic!episodes,!and! stridor!and!subglottic!impaction.!If!on!the!esophagus!it!can! produce!airway!obstruction,!cough,!dysphasia!to!solid! foods! ! What!type!of!cough!is!this?! 1. Acute!(<3wks)!!Viral!or!bacterial!infection,!allergy! 2. Subacute!(3'8wks)!&!Chronic!(>8wks)!!COPD,!CF,!C.! Bronchitis,!Asthma,!postnasal!drip,!Heart!Failure,! Pertussis,!C.!sinusitis.!GERD!&!foreign!body!in!ear!canal! ! What!do!I!need!to!know!if!the!cough!is!acute!(<3weeks! duration)?! 1. Nasal!Congestion!!May!present!with!facial!pain.!Mainly! infectious!type!conditions.!!! a. Bronchitis!'!Runny!nose!with!cough,!mild!fever,! persistent!cough!>1wk,!clear'white!mucus! <morning!

b. Mycoplasma!pneumonia!present!in!older!children,! adolescent,!adults!with!sore!throat,!fever,! headache,!and!malaise! c. Chlamydia!trachomatis!!from!mother!at! childbirth,!3d!to!8wks!after!childbirth,!afebrile! cough!with!nasal!congestion.! 2. Fever! a. Viral!'!<38.3C!in!adults,!with!small!amounts!of! yellow!sputum,!nasal!congestion,!sore!throat,! malaise.!Most!common!in!children!with!nasal! congestion!and!little!appetite/activity.! b. Bacteria!Pneumonia!'!>38.3C,!chest!pain,!SOB,! purulent,!dark!sputum.! c. Non'infectious!(Heart!Failure,!pulmonary! embolism)!!lacks!fever,!chills,!purulent!sputum! 3. Headache!'!Sinusitis! ! What!does!the!nature!of!the!sputum!tell!me?! 1. Malodorous!!anaerobic!infection!of!lungs!&!sinuses! 2. Bronchiectasis!!Very!thick,!tenacious,!dark!sputum! 3. LRTI!!Cloudy,!thick!sputum! 4. Asthma!!Cloudy,!thick!sputum!with!increased!eosinophils.! 5. Viral!bronchitis!'!<2tbls!mucopurulent!sputum/day! 6. Bacterial!bronchitis!!purulent!sputum!>2tbls/day! 7. Bacterial!Pneumonia,!Acute!inflammatory!bronchitis,!CF,! tumor,!foreign!body!!hemoptysis,!uncommon!in!children.! 8. Infectious!Lung!Disease!!In!children!with!persistent! cough,!and!purulent!sputum.! ! What!does!the!nature!of!the!cough!tell!me?! 1. Severity!and!progression!of!cough! Pertussis!has!cough!that!becomes!progressively!worse!in!3! stages.!1st!is!mild!with!rhinorrhea,!conjunctivitis,!and!low! grade!fever!1'2wks.!2nd!stage!has!paroxysms!!whooping!

Cough!'!1!

2.

3. 4. 5.

cough.!No!whooping!on!young!infants!and!older!adults.!In! convalescent!stage!has!decrease!paroxysm!cough.!But! persist!for!3!mo.! Brassy!sound!cough!with!history!of!mild!URTI!in!children! might!indicate!Croup.!Cough!is!worse!at!night.!As! obstruction!increases,!stridor!becomes!continuous,!with! nasal!flaring,!supra/infrasternal!and!intercostal!retraction.! Child!agitated.!Requires!hospitalization.! Persistent!paroxysmal!coughing!is!associated!with!asthma.! Timing!of!cough! Awakens!person!at!night!!Asthma,!Chronic!bronchitis,! GERD,!Heart!Failure.!Asthma!12'2AM!due!to!low! glucocotisol.!! Severe!cough!early!morning!!Post!nasal!drip,!CF,! bronchiectasis! Worst!at!night!!Croup,!post!nasal!drip,!LRTI,!and!allergic! reaction! Disappear!with!sleep!!habit!cough! History!of!Choking!episode!!Foreign!body!aspiration! >3wks!in!child!then!sudden!re'occurrence.! Occupation!!Asbestos,!coal!dust!exposure!can!lead!to!lung! cancer!! Nature!of!Cough! Throat'clearing!!Post!nasal!drip!due!to!irritation! Dry,!brassy!'!pharyngeal,!tracheal!irritation,!allergy,!habit.! Loose,!moist!!Lung!disease!(CF,!asthma)! Paroxysmal!'!Asthma!,pertussis,!CF,!foreign!body! Barking,!croupy!!irritation!of!glottic/sub!glottic!area.! Sudden!short!burst!(Stacatto)!!Chlamydia!trachomatis.! Harsh,!dry!!TB,!fungal!infection! Loud,!bizarre!!psychogenic!origin!

! !

Is!the!cough!related!to!any!event!that!would!help!me!narrow! down!the!cause?! 1. Eating!!Inhalation!due!to!lack!of!esophageal!motility,! GERD,!congenital!malformations,!pneumonia! 2. Season!'!Chronic!cough!during!winter!due!to!viral! infections.!Exacerbation!during!spring,!summer,!and!fall! due!to!allergic!disease.!Croup'fall!(parainfluenza!1)!and! winter!(influenza!B);!RSV'!winter;!Warmer!Months!! Parainfluenza!3! 3. Exercise'!Asthma,!Heart!disease! ! Is!this!something!that!is!going!around?! 1. Day!Care,!School,!workplace!!viral,!Mycoplasma! pneumoniae! ! Is!there!anything!that!would!lead!me!to!suspect!allergies!or! reactive!airway!disease?! 1. Family!History!!Allergy!prone,!Hx!allergic!dermatitis,! asthma,!allergic!rhinitis.!Pets!allergy.! 2. Environmental!exposure!'!irritants! 3. Smoke!exposure!!Asthma,!emphysema,!COPD! 4. Getting!better!or!worse!!Chronic!cough!changes!in!a! smoker!may!indicate!pneumonia!or!lung!cancer.! ! Does!the!patient!have!any!risk!factors!for!systemic!disease! that!could!present!with!cough?! 1. Chronic!Health!problems!!Chronic!lung!and!heart!disease! can!present!with!cough.!ACE!inhibitor!induced!dry,! hacking!cough! 2. Immunocompromised!!Cancer!therapy,!HIV,!Steroids.! High!risk!lung!problems! 3. Tuberculosis!!FHx!of!exposure,!international!travel.! ! !

Cough!'!2!

Condition!
Nasopharyngitis! COPD!exacerbation! Pertussis! Pneumonia!

Common!Causes!of!Acute!Cough! History! Physical!Findings!

Acute!onset,!low!grade!fever,!rhinorrhea,! cough!at!night! Worsening!dyspnea,!increased!wheezing! or!coughing,!smoker! Persistent!hacking!cough;!inspiratory! whoop;!vomiting! Noisy!cough,!dyspnea,!pleuritic!chest!pain,! sputum!(yellow,!green,!red);!chills! Cough,!nasal!congestion,!sore!throat,! fever,!chills,!myalgias! Child!or!young!adult;!dry!cough,! headache,!malaise,!sore!throat! Paroxysmal!staccato!cough!in!infant!4' 12wks.!old! Grunting,!sneezing!cough,!anoxia,! exposure!to!passive!smoke! Nasal!mucosa!red,!swollen;!pharynx! mild!red;!otherwise!negative! Purulent!sputum,!fever,!tachycardia! Fever!absent,!coryza! Fever,!tachycardia,!tachypnea,! inspiratory!crackles,!irregular! breathing,!vocal!fremitus,!percussion! dull!over!consolidation! Fever,!pharyngitis,!enlarged!ant! cervical!node,!normal!TM,!nasal! mucosa!erythema,!normal!chest!exam! Fever,!rales!and!ronchi!on!auscultation! Afebrile,!conjunctivitis'50%,! Tachypnea!40'80!bpm,!crackles,!no! wheezing! Fever,!wheezing!on!auscultation,! prolonged!expiratory!phase,!tachypnea! 60'80!bpm,!tachycardia!>200bpm!

Diagnostic!Labs!
None! Chest!X'Ray,!spirometry! Nasopharyngeal!aspirate!+,! Chest!X'ray!to!R/o!pneumonia! Chest!X'Ray,!CBC,!sputum/nasal! cultures,!O2!saturation,!blood! cultures.! None,!Rapid!Influenza!test! during!outbreaks! Cold!agglutinin,!chest!X'Ray! Chest!X'ray!!Lung! Hyperexpansion,!diffuse! interstitial!infiltrates! WBC!5000'24,000/mm3,! PMN;!Chest!X'ray:! Hyperinflation.!Infant!<2mo!old,! and!!progressive!respiratory! distress!refer.! Chest!X'ray!negative!R/o! pneumonia! None!

Viral!URI! Mycoplasma!pneumonia! Chlamydial!pneumonia! Bronchitis!(RSV)!

Acute!bronchitis! Croup!

Duration!<3mo,!winter,!URI!3'4days;! loose!hacking!cough!productive,!afebrile! History!of!URI,!brassy,!barking!cough,!at! night!

Coarse,!fine!crackles!on!auscultation;! low!grade!fever!or!afebrile! Lo!grade!fever,!inspiratory!stridor,! flaring!nares,!prolonged!expiratory! phase,!retraction!of!accessory!muscles,! breath!sounds!diminished!

! ! ! ! ! ! !

Cough!'!3!

Condition!
Postnasal!drip! Asthma! GERD!

Common!Causes!of!Chronic!Cough! History! Physical!Findings!

Cough,!sore!throat! Dry,!hacking!cough,!<at!night,!<feeding,! <laugh! Cough!<Night,!mouth!sour!taste,! heartburn,!Hx!esophagitis,!smoker,! alcohol!abuse,!overweight,!<18mo!!FFT,! dysphagia,!cough!ater!eat/lying!down,! vomit! Cough,!mild!dyspnea,!Hx!COPD,!smoker,! yellow!sputum! Hrs'Mo.!!After!ACEI,!nonproductive!dry! cough,!scratching!sensation!in!throat! Cough!w/!hemoptisis;!smoker,!weight! loss,!SOB! FFT,!Chronic!cough,!bulky!stools,!FHx! Cough! Hx!environ.!hazard,!choking!episode! Hx!sneezing,!cough! Rinorrhea>7'10!days! School!age!child,!gradual,!Headache,! malaise,!sore!throat,!hacking!cough! Hx!expose,!High!risk,!weak,!malaise! Hx!smoker/around!smoker,!prod.!sputum! School!age/adolescent,!dry!hacking!cough! during!waking!hours!only! Mucoid!secretions!in!post!pharynx,! cobblestone!appearance!post!pharynx,! sinuses!tenderness,!normal!chest!exam! End!expiratory!wheeze,!prolonged! expiratory!phase! Normal!chest!exam,!normal!URT,! possible!epigastric!pain,!normal!abd.! Exam! Hacking,!rasping!cough,!normal!breath! sounds/ronchi!that!clear!coughing,! resonant!to!dull!chest,!barrel!chest,! prolonged!expiration,!possible!wheeze! Normal!examination! Enlarged!supraclavicular!nodes,!dull! chest!percussion!over!tumor,!increased! breath!sounds!distal!to!tumor! Nasal!polyps,!nail!clubbing,!sputum! Cerumen!in!ears,!hairs!in!contact!TM!or! opposite!wall!external!auditory!canal! Asym.!Finding!decreased!breath! sounds,!wheezing! Allergic!shiners,!salute,!rhinorrhea! clear!and!watery! Mucopurulent!rhinorrhea! Red!pharynx,!slight!enlarged!lymph! nodes,!rales!often!fine!and!crackling! Brassy!cough,!weight!loss,!can!have! fever,!night!sweats! Yellow!teeth/fingers,!smoke!odor,!! None!

Diagnostic!Labs!
Sinus!X'Ray,!Sinus!CT,!Allergy! testing! PFT,!Chest!X'Ray,!O2!saturation,! Methacholine!Test,!Allergy!test! Esophageal!pH,!blood!count!for! anemia,!aspiration!pneumonia! X'ray,!endoscopy;!manometry! Chest!X'Ray,!PFT!

Chronic!Bronchitis!

ACE!inhibitor!induced! Broncogenic!carcinoma! Cystic!Fibrosis!(CF)! Foreign!Body!in!ear!canal! Foreign!Body!aspiration! Allergic!Rhinitis! Chronic!Sinusitis! Mycoplasma!pneumonia!

Trial!off!ACEI! Chest!X'Ray,!CT! Sweat!test!positive! None! Asymmetric!Chest!X'Ray!with! forced!expiratory!view! Chest!X'ray!negative,!Allergy! testing!positive! Waters!in!Sinus!X'Ray! X'Ray'interstitial!pneumonia,! cold!agglutinins+,!ESR,!CBC,!O2! Sat,!sputum/blood!culture! Mantoux!Test,!CXR'Apical,! hyaline!atypia,!sputum!culture+! Chest!X'Ray!+!interstitial!marks! As!indicated!to!rule!out!other! causes!

Tuberculosis! Smoking! Psychogenic!

Cough!'!4!

Thorax#and#Lungs#Examination# ! Competencies# 1.#Inspect#posterior@anterior#chest# 2.#Inspect#Skin#and#lip#color# 3.#Inspect#shape#and#color#of#nails# 4.#Inspect#position#of#trachea# 5.#Inspect#breathing#pattern#&#accessory#muscle# 6.#Note#any#audible#breathing#sounds# 7.#Palpate#posterior#chest# 8.#Evaluate#chest#expansion# 9.#Perform#tactile#fremitusBlue#Ballon# 10.#Percuss#posterior#chest# 11.#Perform#diaphragmatic#excursion# 12.#Auscultate#posterior#chest# 13.#Evaluate#transmitted#sounds# #######Whisper#Pectoriloquy##1,2,3# #######Bronchophony##blue#ballon# #######Egophony##EE# 14.#Palpate#supraclavicular#lymph#nodes# 15.#Palpate#Anterior#Chest# 16.#Evaluate#chest#expansion# 17.#Perform#Tactile#fremitus##Blue#Ballon# 18.#Percuss#anterior#chest# 19.#Auscultate#anterior#chest# ! !

Normal# Anterior'posteriorTransverse! Well!perfused,!normal!color! Pink,!well!perfuse,!angle!of!phalange! and!nail!less!than!180! Midline! Regular,!14'20!bpm,!no!prominent! contraction!or!retraction!of!SCM! Breathing!is!quiet! Non'tender! Symmetric!expansion! Increased!in!'!Intra!scapular!&! Right!2nd!intercostal! Resonant'!Loud,!low!pitch,!Long! 5'6!cm,!right!a!little!higher!dt!Lv! Normal!Vesicular!sounds! Muffled,!indistinctive!

Abnormal# Barrel!Chest!APT!'!COPD,!Emphysema! Bluish!skin!'!Pleuritis! Clubbing!!CHF! Deviated!contralateral!'!pneumothorax! Deep!!Kussmaul!!Diabetic!Acidosis! Stridor!'!Epiglottitis! Tenderness!!Fractured!rib! Unilateral!delay!!Lobar!Pneumonia! Decreased!'!Pneumonia! Dullness!!Medium!Loud,!Medium!pitch,!Medium! duration!!Lobar!Pneumonia! Decreased!'!Pneumonia! Adventitious!sounds!!'!Late!Inspiratory!Crackles! (Rales)!!'Cystic!Fibrosis! Louder!!Lobar!consolidation!'!Pneumonia!

None!found! Non'tender! Symmetric!expansion! Decreased!or!absent!over! precordium! Resonant,!dullness!near!heart!area! Vesicular!&!Bronchovesicular!over!1! &!2nd!ICS!

Enlarged,!rubbery!!Lung!Squamous!Cell!Carcinoma! Intercostal!tenderness!!Pleuritis! Unilateral!delay!!Lobar!Pneumonia! Increased!!Lung!cancer! Hyperresonant!!COPD! Pleural!rub!'!Pleuritis!

Cough!'!5!

08##Shortness#of#Breath#(Dyspnea)# ! Life!Threatening!Conditions!(RED!FLAGS)! 1. See!Table!of!Emergent!conditions! ! Is!this!an!emergency?! 1. Onset!! a. New!Acute!w/o!previous!Hx!of!heart!or!lung! disease!aspiration!of!foreign!object,!anaphylaxis,! pulmonary!embolism,!pneumonia,!ventricular! dysfunction.! b. Children:!blocked!airway,!foreign!object,!epiglottitis! (drooling,!dysphonia,!dysphagia,!stridor,!anxious,! jaw!open,!toxic!look),!or!croup! c. Status!asthmaticus!!fever,!respiration,!pulse,! wheezing,!hypoxia,!hypercapnia,! acidosis!cardiopulmonary!arrest! 2. Foreign!Body!aspiration!!while!eating!foods,!or!while! alcohol!intoxicated,!sudden!onset!choking,!children!! toys,!small!objects! 3. Anaphylaxis!!Insect!bites,!medications,!allergens.! Primary!symptoms!are!flushing,!pruritus,!fear,!faint,!and! sneezing.!Lead!to!shock,!cardiac!arrhythmia,!laryngeal! edema,!leading!to!death!in!minutes.! ! Is!the!SOB!caused!by!a!secondary!obstruction!in!the!LRT?! 1. Cough2!obstructions!leads!to!imbalance!between! ventilation!and!perfusion! a. Intraluminal!!foreign!objects,!asthma! b. Intramural!!edema,!bronchomalacia,!bronchiolitis! c. Extramural!!compression!from!tumor,!lymph!nodes! 2. History!of!Asthma!2!FHx,!PHx,!! ! !

! ! Is!the!SOB!caused!by!trauma!to!the!chest?! 1. Trauma!!pan!and!or!trauma!limit!motion!of!thoracic! cage,!pneumothorax!!young!persons!during!strenuous! activity,!spontaneous!loss!of!volume,!hypoxia,! hypercapnia,!SOB!to!reduce!acidosis.!Other!trauma! causes!include!blunt!chest!trauma,!fall,!or!vehicle! accident.! ! Is!the!SOB!caused!by!a!pulmonary!embolus?! 1. Generals!!acute!distress,!SOB,!localized!pleuritic!pain,! apprehension,!bloody!sputum,!diaphoresis,!hx!of! conditions!causing!risk:!age>60,!pulmonary! hypertension,!CHF,!chronic!lung!disease,!ischemic!heart! disease,!stroke,!and!cancer.!Predisposing!factors:! venous!stasis,!hypercoagulability,!endothelial!injury! with!vessel!lining!inflammation!(atherosclerosis)!! 2. Confinement,!Surgery,!and!fracture!!DVT,!prolonged! immobility,!vascular!lung!disease!has!reduced! pulmonary!vascular!bed.!!Dyspnea!from!PE!has!fever,! chest!pain,!and!restlessness.! 3. Trauma!to!Leg!!In!adolescent!with!trauma!to!lower! limbs! 4. Anxiety!!feel!impending!doom! 5. Oral!contraceptives/Estrogen!!increased!coagulation! leading!to!PE,!smoking!and!contraceptives!in!>35yo! 6. Medications!!Hx!of!hypercoagulability!state,!taking! anticoagulants,!Heart!disease!medication!(ACEI,!,! digitalis)!due!to!chronic!heart!failure.!Tamoxifen,! raloxifene!(Serum!estrogen!receptor!modificators)!! risk!for!PE! ! Shortness!of!Breath!(Dyspnea)!2!1!

Is!the!SOB!related!to!a!pre2existing!disease?! 1. Past!History!of!Disease2!CAD,!Heart!Failure,!Valvular! disease,!COPD,!Asthma! a. MI!!sudden!SOB! b. COPD!2!Progressively!SOB,!<morning,!clear/yellow! sputum,!exercise!intolerance,!fatigue! c. Hx!Heart!failure,!valvular!disease!!Chronic! Progressive!SOB,!peripheral!edema,!ascites,!cough,!,! frothy!sputum,!chest!pian,!fatigue! d. Heart!Failure!!Orthopnea,!paroxysmal!nocturnal! dyspnea.! e. Congenital!structure!anomaly!!children! f. Sarcoidosis,!Rheumatoid!lungs,!CF,!Goodpasture!! Chronic!progressive!SOB!with!lung!involvement! disease! g. Asthma!!Periodic!recurrent!SOB,!wheezing! h. Hematological!disease,!CO/Cyanide!poisoning2!SOB! due!to!reduce!O2!carrying!capacity! 2. Hyperventilation!!SOB!from!pulmonary,!cardiac! conditions!<exertion,!>rest.!When!due!to!stress!it!does! not!changes!with!exertion!or!rest.! ! What!factors!precipitate!or!aggravate!the!SOB?! 1. Precipitating!factors! a. Smoke!!Lung!conditions! b. Exertion!!COPD,!Asthma! c. RTI!2!COPD! 2. Medication!Use! a. Bronchodilators!!Amel.!asthma!! 3. Allergies! a. Exposure!to!cold,!allergens,!Viral!RTI!!Agg.!asthma! 4. Alleviating!Factors!2!Sitting!upright,!diuretics,! bronchodilators,!resting! !

Is!the!SOB!caused!by!a!neuromuscular!problem?! 1. Neuromuscular!effects!!Systemic!MSK!diseases,!Neural! abnormalities,!Poliomyelitis,!tetanus,!CNS!insult! 2. Immunizations!!lack!of!vaccination!for!polio,!tetanus! 3. Honey!!Botulism!in!infants!&!children,!few!hours,! Nausea,!vomiting,!diarrhea,!cranial!nerves,!diplopia,! weak!suck,!facial!weakness,!absent!gag!reflex.! 4. Farm!residence!!Organophosphate! chemicals!myasthenia2like!syndrome!in!children! 5. Neuromuscular!affects!!Myasthenia!gravis,!myopathies,! insecticides!&!lead!poisoning! 6. Secondary!causes!!Disease!affecting!CNS,! Meningoencephalitis,!seizures,!CNS!lesions! ! Does!the!patient!have!any!pertinent!risk!factors!that!will! point!me!in!the!right!direction?! 1. Risk!factors!!Hx!of!pulmonary,!Heart!disease,!smoking,! passive!smoking,!noxious!environment,!predisposition! to!allergies!or!asthma! 2. Work!!Occupational!exposure,!asbestos,!silicon,!paint,! fumes,!coal!dust;!risk!for!lung!disease! 3. Obesity!!SOB!on!exertion! 4. Eczema!History!!Asthma!20240%!of!children!with!hx!of! atopic!dermatitis! ! ! ! ! ! ! ! ! ! Shortness!of!Breath!(Dyspnea)!2!2!

Condition!
Pulmonary!Embolus!

Emergent!Conditions!Manifested!by!Shortness!of!Breath!(Dyspnea)! History! Physical!Findings!

Acute!onset!SOB,!cough,!mild/sever!chest! pain,!sense!of!doom,!hemoptysis,!HX!DVT,! recent!surgery,!oral!contraceptive,! smoker,!hypercoagulability!state! Acute!onset!SOB,!Hx!alcohol;!Children:!Hx! small!object!in!mouth;!possible!cough! Restlessness,!fever,!tachycardia,! tachypnea,!breath!sounds,!crackles,! wheezing,!pleural!friction!rub!

Diagnostic!Labs!
ABG,!Chest!X2Ray,!ECG,! Ventilation!can,!d2dimer,!CT2 Pulm.!Angiog.!(CTPA)! Lateral!neck/Chest!X2ray,! bronchoscopy! None;!emergency!measure! necessary!!EpiPen! Chest!X2ray,!ABG!

Foreign!body!aspiration! Anaphylaxis! Pneumothorax!

Croup! Acute!Epiglottitis! Bacterial!Tracheitis! Status!Asthmaticus! Botulism!

Apnea/tachypnea,!restlessness,! suprasternal!retraction,!intoxication,! inspiratory!stridor,!localized!wheeze! Acute!onset!SOB,!Hx!insect!sting,!ingestion! Angioedema,!tachypnea,!clammy!skin,! of!drug,!allergen! hypotension,!bilateral!weakness,! tachycardia! Acute!onset!SOB,!sharp,!tearing!chest! Tachycardia,!breath!sounds,tactile! pain,!can!radiate!to!ipsilateral!shoulder! fremitus,!hyperresonance;! Hypertension,!contralat.!tracheal!shift!! Hx!URTI! Hoarse,!seal2bark!cough,!fever! Positional!sitting!forward,!sore!throat,! High!fever,!drooling,!stridor,!muffled! anxious,!toxic!child! voice! Recent!Viral!infection! Fever,!stridor,!purulent!sputum! Recent!URI,!allergen!exposure,! breathlessness! Honey!in!infant,!contaminated!food!ingest! Wheezing,!coughing,!tachycardia,! tachypnea! Hypoventilation,!drooling,!weak!cry,! ptosis,!ophthalmoplegia,!loss!of!head! control!

None!init.;!pulse!oximeter,!refer! Life!threatening;!refer! Airway!X2ray,!WBC,!Tracheal! Culture! Peak!flow,!Chest!X2Ray,!ABG! PFT,!Chest!X2ray,!Fluoroscopy,! Stool!culture!

! ! ! ! ! ! ! ! ! ! !

Shortness!of!Breath!(Dyspnea)!2!3!

Condition!
Pneumonia!

Non2Emergent!Conditions!Manifested!by!Shortness!of!Breath!(Dyspnea)! History! Physical!Findings!

SOB,!cough,!sputum!(green,!rust,!red),! pleuritic!chest!pain,!chills! Fever,!tachycardia,!tachypnea,! inspiratory!crackles,!asynchronous! breathing,!vocal!fremitus,!dull/flat! percussion!over!consolidation,! bronchophony,!egophony! Restlessness,!anxiety,!normal!CV!exam! Inspiratory!stridor,!normal!cough,!cry! Inspiratory!stridor,!expiratory!wheeze! Altered!LOC,!restless,!JVP!distention,! tachypnea,!use!accessory!muscle,!rales,! ronchi,!wheezes,!tachycardia,! peripheral!pulses,!cool!extremities,! displaced!PMI,!S3,!S4,!ascites,!Hepatom.! Pallor,!tachypnea,!cool!dry!skin! extremities,!possible!orthostatic! hypotension! Overweight,!tachycardia!

Diagnostic!Labs!

Chest!X2ray,!sputum!cultures,! ABG,!WBC!

Hyperventilation!syndrome! SOB,!lightheadedness,!palpitations,! paresthesias!(perioral,!extremities)! Laryngomalacia! Neonate,!infant,!Hx!stridor,!Hx!URI! Vascular!ring!(infant)! SOB,!brassy!cough,!difficult!swallow! Heart!Failure! Chronic!progressive!SOB,!cough,!frothy! sputum,!fatigue,!lightheaded,!syncope,! weight!gain,!ankle!swell,!palpitation,!PND,! orthopnea,!Hx!heart!disease! Anemia! Poor!physical!condition! Asthma! SOB!on!exertion,!fatigue,!palpitations,! lightheaded,!Hx!chronic!disease! SOB!on!exertion,!weight!gain,!palpitation! on!exertion,!sedentary!lifestyle,!smoking! SOB,!paroxysmal!cough,!audible!wheeze,! Hx!asthma,!allergies!

Chest!X2Ray! Refer,!larynx!visualization! Barium!swallow,!echocardiog.! ECG,!Chest!X2ray,!ABG,! echocardiogram!

CBC,!iron!studies! Cardiac!stress!test!

COPD!

Chronic!progressive!SOB,!SOB!on! exertion,!persistent!cough,!minimal! sputum,!easy!fatigue,!Hx!of!smoking!

Restless,!tachypnea,!use!accessory! Spirometry,!chest!X2Ray,!ABG! muscles,!intercostal!retractions,!vocal! fremitus,!breath!sounds,!inspiratory!&! possibly!expiratory!wheezes! Rapid!shallow!respirations,!reddish! Chest!X2ray,!PFT,!Exercise!tests,! complex,!chest!barrel!chest,!use!of! ABG! accessory!muscles,!pursed2lip! breathing,!tactile!fremitus,!excursion! bilateral,!hyperresonant,!distant!breath! sounds,!prolonged!expiration,! occasional!wheezes,!possible! tachycardia,!muffled!heart!sounds!

! ! ! !

Shortness!of!Breath!(Dyspnea)!2!4!

!
Thorax#and#Lungs#Examination# ! Competencies# 1.#Inspect#posteriorGanterior#chest# 2.#Inspect#Skin#and#lip#color# 3.#Inspect#shape#and#color#of#nails# 4.#Inspect#position#of#trachea# 5.#Inspect#breathing#pattern#&#accessory#muscle# 6.#Note#any#audible#breathing#sounds# 7.#Palpate#posterior#chest# 8.#Evaluate#chest#expansion# 9.#Perform#tactile#fremitusBlue#Ballon# 10.#Percuss#posterior#chest# 11.#Perform#diaphragmatic#excursion# 12.#Auscultate#posterior#chest# 13.#Evaluate#transmitted#sounds# #######Whisper#Pectoriloquy##1,2,3# #######Bronchophony##blue#ballon# #######Egophony##EE# 14.#Palpate#supraclavicular#lymph#nodes# 15.#Palpate#Anterior#Chest# 16.#Evaluate#chest#expansion# 17.#Perform#Tactile#fremitus##Blue#Ballon# 18.#Percuss#anterior#chest# 19.#Auscultate#anterior#chest# ! ! Normal# anterior2posteriorTransverse! Well!perfused,!normal!color! Pink,!well!perfuse,!angle!of!phalange! and!nail!less!than!180! Midline! Regular,!14220!bpm,!no!prominent! contraction!or!retraction!of!SCM! Breathing!is!quiet! Non2tender! Symmetric!expansion! Increased!in!2!Intra!scapular!&! Right!2nd!intercostal! Resonant2!Loud,!low!pitch,!Long! 526!cm,!right!a!little!higher!dt!Lv! Normal!Vesicular!sounds! Muffled,!indistinctive! Abnormal# Barrel!Chest!APT!2!COPD,!Emphysema! Bluish!skin!2!Pleuritis! Clubbing!!CHF! Deviated!contralateral!2!pneumothorax! Deep!!Kussmaul!!Diabetic!Acidosis! Stridor!2!Epiglottitis! Tenderness!!Fractured!rib! Unilateral!delay!!Lobar!Pneumonia! Decreased!2!Pneumonia! Dullness!!Medium!Loud,!Medium!pitch,!Medium! duration!!Lobar!Pneumonia! Decreased!2!Pneumonia! Adventitious!sounds!!2!Late!Inspiratory!Crackles! (Rales)!!2Cystic!Fibrosis! Louder!!Lobar!consolidation!2!Pneumonia!

None!found! Non2tender! Symmetric!expansion! Decreased!or!absent!over! precordium! Resonant,!dullness!near!heart!area! Vesicular!&!Bronchovesicular!over!1! &!2nd!ICS!

Enlarged,!rubbery!!Lung!Squamous!Cell!Carcinoma! Intercostal!tenderness!!Pleuritis! Unilateral!delay!!Lobar!Pneumonia! Increased!!Lung!cancer! Hyperresonant!!COPD! Pleural!rub!2!Pleuritis!

! ! Shortness!of!Breath!(Dyspnea)!2!5!

09##Chest#Pain# ! Is!this!a!life!threatening!condition!(LTC)?!(SEE!TABLE)! 1. Characteristics!of!Pain! a. Angina!!substernal!heaviness,!pressure,!squeezing! sensation;!provoked!by!exertion,!>rest,! >nitroglycerin;!radiates!to!the!left!shoulder!and! down!the!arm,!can!extend!to!the!neck!and!jaw.! b. Dissection!!Abrupt!tearing!pain,!anterior!or! posterior!chest,!can!migrate!to!the!arms,!abdomen,! back,!or!legs.! c. PE+!can!point!to!area!of!pain!over!affected!lung,! gripping,!stabbing!pain,!moderate!intensity;!radiates! to!the!neck!or!shoulders.! d. Pneumothorax!!Mild!to!severe!chest!pain,!sudden! onset,!lateral!thorax,!radiating!ipsilateral!shoulder;! sharp,!tearing! e. Pneumonia!!Not!life!threatening,!chest!pain!over! consolidation!area,!does!not!radiate;!burning,! stabbing;!associated!cough.! 2. Onset!of!Pain! a. Angina!!during!exercise,!exertion,!emotional!stress.!! b. MI!!Any!time,!not!relieved!by!rest!or!nitroglycerin.! Most!occur!in!morning!hours,!peak!on!Mondays.! c. PE!!Sudden,!with!SOB! d. Pneumothorax!!Severe!coughing,!exertion,!or! straining!precipitated!the!chest!pain.! e. Pneumonia!!Chest!pain!occurs!gradually! f. GERD!!Pain!that!occurs!usually!when!lying!down! g. Trauma!!fall!or!strenuous!activities,!fractures,! contusions.!

3. Duration+!Life!threatening!conditions!will!be!acute,!the! more!chronic,!less!likely!a!specific!cause!will!be!found,! Intermittent!chest!pain!might!indicate!angina! 4. Associated!Symptoms! a. Acute!MI!!nausea,!vomiting,!diaphoresis,!SOB,! syncope! b. PE!!SOB,!apprehension,!hemoptysis,!chest!pain!that! increases!with!deep!breathing.! c. Pneumonia!!Fever!cough,!and!thick!sputum!with! chest!pain.! ! Does!the!patient!have!a!risk!factor!for!CAD?! 1. Uncommon!in!male!<40yo,!premenopausal!females! 2. Smoking,!Hypertension,!diabetes,!High!cholesterol,! obesity,!FHx!of!heart!disease! 3. Major!Risk!Factors!for!CAD! a. Smoking! b. Hypertension! c. Low!HDL!(<40mg/dL)! d. FHx!of!premature!CAD! e. Age:!Male>45yo,!Female>55yo! 4. Other!factors:!Optimal!LDL!<100mg/dL,!TC<200mg/dL! ! If!this!is!not!a!life+threatening!condition,!what!does!a! description!of!the!pain!tell!me?! 1. Acute!or!Chronic!!After!LTCs!are!ruled!out,!sudden! onset!can!be!associated!with!trauma,!MSK!injury,!or! inflammation.!Chronic,!gradual!onset!is!rarely!a!LTC.! Chest!pain!can!be!due!to!URTI,!GERD!at!night!or!after!a! large!meal.! 2. Location!and!Character!of!pain! a. Thoracic!skin!!Furuncles,!contusions,!abrasions!! sharply!localized! Chest!Pain!+!1!

b. Intercostal!nerves!!neuritis,!sudden!onset!of!a! stabbing.!Severe!when!the!patient!breathes!deeply,! coughs!or!moves!suddenly.!Easy!to!locate! c. Dorsal!root!irritation!!herpes!zoster,!intense! burning!or!knifelike!pain!along!the!spine!to!the! lateral!thoracic!wall.!Can!restrict!movement!of!the! trunk!and!respiration.!Continuous!and!increases!in! severity.! d. Nerve!root!!mechanical!irritation!or!edema!of!nerve! root.!Felt!at!point!of!irritation!but!also!to!referred! points.!Thoracic!spinal!segment!root!pain!is!referred! to!lateral!and!anterior!wall! e. Costal!cartilage!!Localized!dull!pain,!aching,! tenderness!over!8,9,10!ribs.!Acute!paroxysmal!or! stabbing.! f. MSK!+!irritation!of!muscles!! g. Bone!!irritation!of!sensory!nerves!in!periosteum,! intense!and!well!localized.!Chronic!bone!marrow! poorly!localized!pain,!ribs!are!common!place!for! metastatic!malignant!deposits! h. Nerve!dermatome!!intense,!aching,!boring! i. Tumor!!in!the!mediastinum!produces!chronic! aching!or!dull!substernal!chest!pain! j. Lung!!Involvement!of!adjacent!structures.!Trachea! and!bronchus!are!innervated!by!Vagus!nerve.!Finer! bronchi!and!lung!parenchyma!are!free!of!pain! innervation.!! k. Pleural!Pain!!loss!of!normal!lubrication,!irritation!of! serous!membranes.!Constant!localized,!cutting! sensation!accentuated!by!respiration.!Diaphragmatic! pleural!pain!is!referred!to!the!neck!or!abdomen.!

3. Sleep!!Awakening!because!of!pain!indicates!a!more! serious!problem!such!as!cardiac!ischemia.!Psychogenic! pain!can!involve!sleep!disturbances! ! What!do!associated!symptoms!tell!me?! 1. Cough!and!sputum!production!!Pneumonia,!Pain!from! pleural!effusion,!LRTI!can!be!caused!by!congenital!heart! diseases.!Asthmatic!can!develop!chest!pain!from! straining!caused!by!tachypnea,!coughing!or!retraction! 2. Fever!!Pneumonia,!Myocarditis!or!PE.!Elderly!&! immunosuppressed!may!not!have!fever! 3. Lightheadedness,!Dizziness,!or!Fainting!!Arrhythmias! due!to!hypoxia,!trauma,!or!electrical!shock!can!cause! coronary!insufficiency!and!chest!pain.!Most!cases!of! syncope!are!due!to!cardiac!problems.! 4. Palpitations!!Caffeine,!stress,!and!hormonal!changes.! Mitral!valve!prolapse!can!present!with!history!of! palpitations.!Theophylline!&!+adrenergic!agents!can! cause!arrhythmias.! ! Is!the!pattern!of!pain!related!to!activity!and!position! change?! 1. Recent!activities!!strenuous!activities!can!cause!MSK,! rib!fractures!that!result!in!chest!pain.!Decrease!exercise! tolerance!can!result!from!heart!disease.! 2. History!of!Chest!Trauma!!Blunt!injury!can!cause! pneumothorax.!A!rupture!spleen!can!cause!irritation!of! phrenic!nerve!&!produce!shoulder!pain.! 3. Pain!with!movement!!Except!for!pericarditis,!cardiac! origin!pain!is!not!affected!by!respiration.!Pain!on! inspiration!suggests!pleural!involvement.!In!Pericarditis! the!pain!is!sharp,!pleuritic!relieved!by!sitting!upright! and!leaning!forward.!Esophagitis!!increased!lying!flat,! Chest!Pain!+!2!

! Is!there!a!gastrointestinal!origin!for!patients!chest!pain?! 1. Esophagitis!+!Pain!from!esophagitis!and!cardiac!origin! can!be!similar.!Nitroglycerin!can!relieve!both!the!pain!of! an!angina!and!the!pain!of!esophagitis.!Esophagitis!pain! is!more!related!to!eating!particular!foods,!includes! mouth!sour!taste,!mild!nausea,!and!dull!burning! sensation!in!the!retrosternal!area.! 2. Esophageal!tear!or!spasm!!more!acute!severe!chest! pain,!tearing!or!crushing!sensation.! 3. Peptic!Ulcer,!Cholecystitis!!intermittent!pain.! Hematemesis/hematochezia!in!ulcer.!Cholecystitis!is! reported!right!anterior!chest!pain!radiates!to!shoulder! or!upper!back! 4. Pancreatitis!!Constant,!excruciating!chest!pain,!lower! left!upper!quadrant!radiating!to!chest,!shoulder!and! arm.!Often!with!hypotension.! ! Could!this!pain!be!from!a!systemic!cause?! 1. Skin!symptoms!!Unilateral!chest!pain,!pruritic,!burning! or!stabbing!can!be!herpes!zoster.!A!vesicular!rash!is! common!several!days!after!the!chest!pain.! 2. Systemic!conditions!!Chest!pain!from!inflamed!muscles! due!to!polymyositis,!fibromyalgia,!SLE.!Arthritic! changes!of!thorax!and!cervical!spine!can!produce!chest! pain.!! ! What!does!the!family!history!tells!me?! 1. Family!history!!Hypertension!and!CAD!have!a!strong! family!pattern.!Watch!for!anyone!in!the!family!with!

consuming!alcohol,!taking!aspirin,!spicy!meals,!wearing! tight!clothes!<!lying!down!after!meal.!

! What!is!the!emotional!state!of!the!patient?! 1. Panic!Disorder!!In!the!past!6!months!have!you!felt! suddenly!frightened,!anxious!or!very!uneasy?!Or!felt!the! heart!rising!for!no!apparent!reason,!felt!faint,!could!not! catch!breath?! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Chest!Pain!+!3!

hypercholesteremia,!Hx!of!CAD!or!genetic!heart! conditions.!

Condition! Acute!myocardial! infarction!

Aortic!dissection!

Common!Causes!of!Emergent!Chest!Pain! History! Physical!Findings! Sever,!oppressive,!constricting! Hypertension!or!hypotension,! retrosternal!discomfort,!radiating!to! cardiac!arrhythmias,!paradoxical!S2! the!left!or!right!arm,!neck,!and!or!jaw,! >30mins.,!diaphoresis,!dyspnea,! nausea,!Hx!CAD,!smoking,!positive! family!Hx!CAD,!Hx!elevated!lipids! Sudden!tearing!pain,!ant.!or!post.! Pulse!deficits,!hypertension;! Chest;!migrates!to!arms,!abdomen,! possible!neurological!changes!in! and!legs! legs;!aortic!diastolic!murmur! Sever,!constricting!retrosternal!chest! pain,!>30mins,!anxiety,!diaphoresis,! dyspnea,!prior!Hx!of!angina!or!MI.! Acute!onset;!sense!of!doom;!pleuritic! pain,!restlessness;!mild!to!sever!pain;! hemoptysis;!Hx!DVT,!recent!trauma! to!lower!extremity,!surgery;!oral! contraceptives.! Sharp,!tearing!pain,!can!radiate!to! ipsilateral!shoulder;!dyspnea;! children!with!asthma,!CF,!or!Marfan! syndrome! Palpitations,!dizziness,!forceful! heartbeats;!Hx!of!CHD,!fever,!and! medications!(sympathomimetics!and! +adrenergic!agents)! !

Diagnostic!Labs! ECG,!Cardiac!Enzymes,! Nuclear!Scan,!Troponin,!T!&! I,!Chest!X+ray,! Echocardiogram,! angiography.!

Acute!Coronary!Artery! Insufficiency! Pulmonary!Embolus!

Echocardiogram,! angiography,!CT,!MRI,! emergency!referral,!Chest!X+ ray,!ECG,!isoenzymes.! Restlessness,!cool!and!clammy!skin,! ECG,!isozymes! tachycardia! Fever,!dyspnea,!cough,!tachycardia,! tachypnea,!diminished!breath! sounds;!crackles,!wheezing.! Tachycardia;!diminished!breath! sounds;!crackles,!wheezing! SVT=Tachycardia!150+250!bpm,! sinus!or!ventricular!tachycardia,! irregular!pulse! PT/aPTT,!ABG,!Chest!X+Ray,! Ventilation/perfusion!scan,! CT,!pulmonary!angiography! Chest!radiograph,!ABG!

Pneumothorax!

Arrhythmias!

ECG!during!episode,!Holter! 24hr!ECG!

! !

Chest!Pain!+!4!

Condition! Stable!angina!

Myocarditis! Pericarditis!

Aortic!stenosis!

Mitral!regurgitation!

Pneumonia!

Mitral!Valve!prolapse!

Pleuritis! Esophagitis! Chest!trauma!(rib! fracture)!

Common!Causes!of!Nonemergent!Chest!Pain! History! Physical!Findings! Substernal!chest!pressure!following! Normal!exam;!possible!transient!S4! exercise!or!stress!and!relieved!by!rest! or!nitroglycerin;!nausea,!SOB,! diaphoresis,!sternal!chest!pressure! Chest!pain,!Hx!of!fever,!dyspnea! Heart!murmur,!friction!rub,!fever! Sharp,!stabbing!pain,!referred!to!left! Fever!before!onset!of!pain,! shoulder!or!traps.!Ridge,!worsen! tachycardia,!pericardial!friction!rub! during!cough!or!deep!breathing,! relieved!by!sitting!forward;!Hx!of! infection,!autoimmune!disease! Chest!pain!on!exertion,!substernal! Radial!pulse!dim,!narrow!pulse! and!anginal!in!quality;!fatigue,! pressure;!loud!harsh,!crescendo+ palpitations,!DOE,!dizziness,!syncope! decrescendo!murmur@2nd!R+ICS! with!patient!leaning!forward;!thrill! Exertional!chest!pain,!fatigue,! Holosystolic!murmur,!blowing,! palpitations,!dizziness,!DOE,!syncope! often!loud,!@apex,!decreases!with! inspiration,!murmur!radiates!to! axilla!&!back! Productive!cough!of!yellow/!green/! Fever;!tachycardia,!tachypnea;! rust!sputum,!dyspnea,!pleuritic! inspiratory!crackles;!vocal!fremitus;! percussion!dull!or!flat!over! consolidation;!bronchophony;! egophony! Chest!pain,!varies!in!location!&! Arrhythmias,!possible!midsystolic! intensity;!palpitations;!anxiety;!non+ click!over!apex;!heard!best!while! exertional!pain!short!duration;!Hx!of! patient!is!sitting!or!squatting;! Marfan!syndrome! thoraco!sternal!deformity! Mild,!localized!chest!pain,!worse!with! Shallow!respirations,!local! deep!breath,!recent!URI! tenderness,!pleural!friction!rub! Substernal!pain!worse!after!eating!or! Epigastric!pain!with!palpation! lying!down;!sour!taste!in!mouth! Hx!injury,!trauma;!pain!with!deep! Shallow!respirations;!chest!wall! breaths;!splinting!of!chest!wall! pain!on!palpation!

Diagnostic!Labs! ECG!during!episode!of!chest! pain! ECG.!Chest!X+ray! WBC,!ESR,!ECG,!chest! radiograph!

Echocardiogram,!ECG,!Chest! X+ray! Chest!X+Ray,!ECG,! Echocardiogram! Chest!X+ray,!sputum!cultures,! ABG!

ECG,!Echocardiogram!

None!initially! Esophageal!pH! Chest!X+Ray!

Chest!Pain!+!5!

!
Diagnostic#Labs# Costochondritis# Herpes#Zoster# Peptic#Ulcer#Disease# Common#Causes#of#Nonemergent#Chest#Pain# Diagnostic!Labs! Diagnostic!Labs! Pain!along!sternal!border,!increases! Pain!with!palpitation!over! with!dep!breaths;!Hx!of!exercise,!URI,! chostocondral!joints;!normal!breath! or!physical!activity! sounds! Unilateral!chest!pain;!painful!rash! Normal!breath!sounds;!vesicular! rash!along!dermatome! Epigastric!pain!!to!2!hrs!after!eating,! Tenderness!to!palpation!in! can!be!relieved!by!antiacids;! epigastric!area;!signs!of! hematesis!and!melena;!risk!factors! hypovolemia! include!smoking!&!alcohol!abuse! Right!upper!quadrant!abd.!Pain! Positive!Murphy!sign;!palpable! radiating!to!right!chest,!often!after! gallbladder! eating!high!fat!meal;!nausea!and! vomiting! Severe!left!upper!quadrant!abd.!Pain! Left!upper!abd.!Pain!with!palpation;! radiating!into!left!chest;!worse!in! hypotension! supine;!nausea,!vomiting,!fever! Cheat!pain,!SOB,!cough,!hemoptysis,! Normal!exam!or!dim!breath!sounds! Hx!of!smoking,!Hx!of!pneumonia! &!dull!percussion!over!tumor!! Chest!pain,!SOB,!cough,!hemoptysis,! Tachycardia,!hypertension! Hx!of!smoking,!Hx!of!pneumonia! Precordial!chest!pain,!Hx!of!stressful! situations! Severe!acute!onset,!stabbing,! paroxysmal,!pleuritic!pain!over!lower! rib!cage!and!substernal!edge;! headache,!malaise,!non+productive! cough! Sudden!sharp,!non+distressing!pain! near!apex!of!heart;!seen!in! adolescents! Normal!exam! Pleural!friction!rub!25%!of!time,! chest!exam!normal,!fever!usually! present! Diagnostic!Labs! None! None! Upper!GI!radiograph,!upper! endoscopy,!CBC!

Cholecystitis#

Gallbladder!ultrasound!

Acute#pancreatis# Lung#Tumor# Cocaine#use# Psychogenic#origin# Pleurodynia#

Serum!analysis,!pancreas! ultrasound,!CT! Chest!X+ray!,Chest!CT,! Bronchoscopy! ECG,!serial!cardiac!enzymes,! drug!screen!ECG,!chest! radiograph! ECG,!Chest!X+Ray! None!

Precordial#catch# syndrome# !

Normal!exam!

None!

Chest!Pain!+!6!

Cardiovascular#System##D#Major# ! Competencies# 1.#Calculate#pulse#pressure# 2.#Inspect#skin#color# 3.#Inspect#face# 4.#Inspect#neck#for#Jugular#vein#distention# 5.#Measure#JVP#

6.#Palpate#Carotid#Pulse# 7.#Auscultate#carotid#pulse# 8.#Inspect#Anterior#Chest# 9.#Palpate#for#Apical#impulse,#diam.,# amplitude,#thrill# 10.#Palpate#Right#Ventricular,#Pulmonic,# Aortic#Area## 11.#Percuss#L#Ventricle#border# 12.#Auscultate#Apex#w/#Diaphragm# 13.#Auscultate#LLB,#Pulmonic#&#Aortic# w/Diaphragm# 14.#Auscultate#Apex,#Aortic,#Pulmonic,#LLB# with#Bell# 15.#Auscultate#in#Left#lateral#decubitus#D#Bell# 16.#Auscultate#with#Valsalva# 17.#Auscultate#Leaning#forward,# exhale#completely#&#hold# 18.#Auscultate#Squatting# 19.#Check#Orthostatic#hypotension#

Normal# Systolic+diastolic=30+40!mmHg! Normal,!uniform!pigmentation,!pink,!well! perfused! Symmetrical!&!well!perfused! Normal!!not!distended! @30,!3+4cm!from!sternal!angle! Biphasic!undulating!pulse! Occluded!by!pressure! 2+!Brisk,!normal! No!bruit! No!scars! 2+!brisk,!<2.5cm,!no!thrill! No!Thrill!or!Heaves! Resonant!!Normal! S1>S2! S1>S2!on!Apex!&!LLB! S2>S1!on!Aortic!&!Pulmonic! S1>S2!on!Apex!&!LLB! S2>S1!on!Aortic!&!Pulmonic! No!murmurs! No!murmurs! No!murmurs! No!murmurs! Normally!systolic!drops!and!diastolic! rises!slightly!

Abnormal# >50mmHg!!Aortic!Regurgitation! Bluish!skin!!Pulmonary!Valve!Stenosis! Face!Edema!!CHF! Distended!!Right!sided!CHF! Increased!3+4!cm,!Cardiac!Tamponade!

3+!Bounding!!Aortic!Insufficiency! Bruit!!Atherosclerosis! Scar!from!Open!Heart!Surgery! PMI>3cm!LVH! Aortic!Thrill!!Aortic!Stenosis! Dullness!far!left!!LVH! PSM!!Mitral!Insufficiency! Aortic!CD+MSM!+!Aortic!Stenosis! Apex!+!C+MDM!+!Mitral!Stenosis!! Apex!+!C+MDM!!Mitral!Stenosis! Apex!+!Strain!+!CD+MSM,!Aortic!Stenosis,!HCM! Apex!+!D+EDM!+!Aortic!Insufficiency! Apex!+!Squatting!+!CD+MSM!+!Aortic!Stenosis,! HCM! Systolic!decrease>20mmHg! Diastolic!decrease>10mmHg! Atherosclerosis!

Chest!Pain!+!7!

10#$#Hypertension# ! 1) Elevated!blood!pressure!is!a!sign,!Hypertension!is!a! diagnosis! 2) Hypertension! a) Fear,!panic!attacks,!stress!cause!HBP!but!that!is!not! HT! b) To!establish!with!diagnosis!you! i) Do!not!rely!on!one!reading! ii) 3!readings,!supine,!different!visits! c) Silent!killer! i) First!sign!is!a!HA!or!stroke! ii) For!long!period!of!time!runs!asymptomatic! d) Does!not!goes!unnoticed!!it!has!to!be!treated!once! found! e) Approach! i) Identify! ii) Evaluate/Assess! iii) Treat! 3) Definition!&!epidemiology! a) Sustained!systolic!and!or!diastolic!BP>140/90! b) Classification!.!>18yoa! i) Normal!120/80.!recheck!2!yr! ii) PreHT!120.139/80.89!!recheck!1!yr! (1) Not!a!disease!yet! (2) If!it!is!on!the!upper!range!you!have!to!work! with!prevention.! (a) Exercise! (b) Diet! (3) Diabetes!&!renal!dysfunctions!130/80! iii) HT!Stage!1!!140.159/90.99,!recheck!2!mo! iv) ISH.Isolated!Systolic!HT!.!>140/<90! Athrosclerosis! !

v) HT!Stage!2!.!>160/>100! vi) ISH!Stage!2!!170/82! vii) Not!aHT!drugs,!acutely!ill! viii) Pulse!pressure!!indicative!of!pathological! conditions! (1) Valve!diseases!!aortic!insufficiencies! (2) Wide!or!narrow!extreme!are!pathological! findings! c) Most!significant!risk!factor!for!CVD!!HBP! i) HT!&!Diabetes! d) Most!common!cause!for!a!visit!to!a!physician! e) Uncontrolled!HT! i) Kidneys!!renal!failure! ii) Brain!!aneurysm,!TIA,!strokes! iii) Heart! iv) Eye!!HT!retinopathy! 4) What!is!Blood!pressure! a) Cardiac!output!(CO)!!contractions!of!the!heart! i) Increased!with!sympathetic!discharge!from! stress!for!metabolic!demand!and!increased! vascular!volume! ii) Increased!with!HT! b) Peripheral!vascular!resistance! i) Increased!by!smooth!muscle!contraction! ii) Arterioles! iii) Intrinsically!elevated!through!blockages! iv) Athero!or!Artheriosclerosis! (1) Stiff!arteries! c) Systolic!hypertension! i) Isolated!phenomenon! ii) In!association!with!diastolic!hypertension! iii) Isolated!Systolic!Hypertension! (1) Advanced!age! 10!Hypertension!.!1!

(2) Lowers!PR!(Nutritional!deficiencies)! (3) Increased!CO!(anemia,!Thyrotoxicosis)! 5) High!Blood!pressure!Algorithm! a) Patient!BP!out!of!range! b) Determine!whether!the!patient!is!truly!hypertensive! i) Wrong!reading! c) Classification! d) HT!emergency!>200/120! 6) Risk!Factors!for!HT!(associated!with!coronary!arterial! disease)! a) Increasing!age! b) Genes! c) Smoking!!Free!radicals!damage!the!vessels!causes! plaque!formation.!Vasoconstrictor.!Malignant!HT,! adrenal!Failure! d) Male!sex! e) Obesity!!BMI,!Diabetes?!Increased!blood!volume,! stroke!volume,!increased!cardiac!output! f) FHx!!absence!does!not!rules!out! g) Psychological!stress!!catecholamines!excreted! h) Sodium!intake!!water!retention,!1!NA!retain!2! Water! i) Etoh!!Deposition!of!lipids?! j) Race!(African.american>whites;!more!sodium! sensitivity)! k) Contraceptive!pills!!oxidation!of!Angiotensin. Tensin!pathway! l) Diet!!increased!fat!intake! m) Metabolic!syndrome!!Dislipidemia,!increased!liver! TG,!decrease!Liver!HDL,!increase!Liver!LDL,!high! glucose! 7) Pathogenesis! a) Renin.Angiotensin!System! !

i) Increases!blood!pressure! (1) Vasoconstriction! (2) Sodium!retention!!Aldosterone!(water! retention)! ii) Kidney!Juxtaglomerular!system!!Renin! (extremely!sensitive!to!blood!supply)! iii) Liver!!Angiotensinogen! iv) Renin!convert!Angiotensinogen!to!Angiotensin!I! v) Kidney,!Lungs!!Angiotensin!I!!!Angiotensin!II! by!ACE!(Ang!Converting!Enzyme)! vi) ANGII!increase!secretion!of!Aldosterone!by! adrenal!cortex! vii) ANGII!systemic!vasoconstriction!of!arterioles! ! Primary!Hypertension! 1) Essential,!idiopathic! 2) Unknown!cause! 3) Most!common!in!adults!!95%! 4) Not!related!to!other!diseases! 5) Males!>females! 6) Blacks>whites! 7) Diagnosis!of!exclusion! ! Secondary!hypertension! 1) Underlying!disease! 2) Less!common!!5%! 3) Most!frequent!in!young!age<35! 4) Severe,!rapid!onset! 5) No!FHx! 6) Does!not!respond!to!std.!Tx! 7) Most!are!surgically!treated! !

10!Hypertension!.!2!

Recommended!Work.up!for!a!HT!pt.!!any!newly!diagnosed! pt! 1) CXR!malignancies! 2) ECG!!arrhythmia,!hypokalemia! 3) Urinalysis!!kidney!diseases! 4) Serum!creatinine,!sodium,!potassium!!kidney!function! 5) Other!test! ! Secondary!HT! 1) Parenchymal!renal!disease! a) Glomerulonephritis! b) Chronic!pyelonephritis! c) Diabetic!nephropathy! d) Polycystic!kidney! 2) Renovascular!disease! a) Atherosclerotic! b) Thrombotic!or!embolic!obstruction! c) Aneurysm!or!dissecting!aneurysm! 3) Coarctation!of!the!Aorta! a) Narrowing!of!the!aorta! 4) Epistaxis,!headache!!elevates!the!pressure!above!on! the!carotids!and!arteries!that!feeds!the!head.! 5) Cold!peripheral!extremities!!lower!pressure!leads!to! insufficient!circulation!to!the!extremities.!Has!to!be! bilateral.!If!unilateral!is!a!local!process.! 6) Claudication!!insufficient!blood!supply!when!required! for!walking,!thus!causes!pain!when!walking.! a) Femoral!pulses!absent,!delayed!or!markedly! diminished! b) Low!arterial!pressure!in!the!legs!but!HT!in!the!arms.! c) Aortic!Dissection!possible! i) Life!threatening! ii) HT,!syphilis,!trauma,!bacterial!infections! !

! Endocrine!Diseases! 1) Hyperaldosterism!!water!retention.!Adrenal!cortex! tumor,!production!of!aldosterone,!proximal!muscle! weakness,!Hyperglycemia,!polyuria,!polydyspia!(thirst),! frontal!HA,!muscle!cramps.! a) Hypokalemia!!Lab!test!explains!muscle!weakness! b) Aldosteronoma!!tumor!in!the!adrenal! 2) Cushings!Disease!!increased!cortisol!!adrenal!cortex! 3) Moon!facies!!red!and!round! 4) Central!obesity! 5) Mnemonic!.!CUSHING! a) C!.!Central!obesity,!Cervical!fat!pads!(Buffalo!hump),! Collagen!fibre!weakness,!Comedones!(acne)! b) U!.!Urinary!free!cortisol!and!glucose!increase! c) S!!Striae(purple,!abdominal,!arm!pit),!Suppressed! immunity! d) H!.!Hypercortisolism,!Hypertension,!Hyperglycemia,! Hypercholesterolemia,!Hirsutism!(!excessive!hair!in! women)! e) I!.!Iatrogenic!(Increased!administration!of! corticosteroids)! f) N!!Non.iatrogenic!(Neoplasms)! 10!Hypertension!.!3!

iii) Intima!interrupted! iv) Diastolic!murmurs!due!to!aortic!insufficiency! v) Fatal!if!left!untreated! vi) Pulses!asymmetric! vii) Legs!weakness! viii) Sudden,!severe,!tearing,!tends!to!persist! ix) Pain!b/w!shoulder!blades! x) Retrosternally,!neck,!abdomen! xi) Treatment:!Control!BP!&!HR!to!prevent! dissection!

g) G!.!Glucose!intolerance,!Growth!retardation! 6) Bruising! 7) Pheochromocytoma!!is!a!neuroendocrine!tumor!of!the! medulla!of!the!adrenal!glands!(originating!in!the! chromaffin!cells),!or!extra.adrenal!chromaffin!tissue! that!failed!to!involute!after!birth!and!secretes!excessive! amounts!of!catecholamines,!usually!noradrenaline! (norepinephrine),!and!adrenaline!(epinephrine)!to!a! lesser!extent.!Attacks!that!come!and!go.!If!you!increase! abdominal!pressure!it!causes!the!release!of!the! catecholamines.!! 8) Palpitations! 9) Anxiety!often!resembling!that!of!a!panic!attack! 10)Diaphoresis!(excessive!sweating)! 11)Headaches! 12)Estrogen!containing!oral!contraceptives! 13)Acromegaly!.!GH! ! Types!of!Strokes! 1) Ischemic!!85%! a) Not!enough!blood!circulating,!accumulation!of! metabolic!waste.!Causes!infarction!of!tissue!(death)! b) Stenosis!!constriction! c) Thrombose!!blood!lot!blocks!the!vessel! 2) Hemorrhagic!!15%! a) Rupture!vessel!under!highly!elevated!pressure! b) Subarachnoid!hemorrhage!!berry!aneurysm! associated!with!polycystic!kidney!disease! 3) Early!Warning!signs! a) Sudden!onset!deficit!in!! i) Vision! ii) Speech!!slow!or!slurred! iii) Sensation! !

iv) Coordination! v) Intense!headache!or!dizziness! (1) With!one!or!more!of!above!sxs! b) Transient!ischemic!attacks! i) 15.30!mins.! ii) Complete!recuperation! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 10!Hypertension!.!4!

Condition! Primary# Hyperaldosteronism#

Common#Causes#of##Secondary#Hypertension! Symptoms/Signs# Physical#Examination# Proximal!muscle!weakness,!polyuria,! ! nocturia,!polydipsia,!tetany,!muscle! paralysis,!frontal!headaches.! Patients!may!present!in!a!wide!variety! of!clinical!settings!including!transient! ischemic!attacks,!stroke,!headache!! (usually!pounding!and!severe).! Palpitations!with!or!without! tachycardia!and!excessive!sweating.! Less!common!symptoms!include! tremor,!pallor,!nausea,!weakness,! fatigue,!weight!loss,!and!chest!or! abdominal!pain! Epistaxis,!throbbing!headache,!leg! fatigue,!cold!extremities,!and! occasional!claudication.! Postural!hypotension!occurs!in!50!! 75%!of!patients.!Paroxysmal!episodes! of!hypertension!occur!in!about!one! third!of!patients.!Sweating!and! muscular!weakness!may!be!evident.!

Pheochromocytoma#

Laboratory#Features# Hypokalemia,!Metabolic!alkalosis,!! ratio!of!plasma!aldosterone!to!plasma! rennin!(>20)! Hyperglycemia!may!also!be!present! 24hrs!urine!for!metanephrines! Hyperglycemia!and/or!hyperalcemia! may!be!present.!

Coarctation#of#the# Aorta#

Cushings#Syndrome#

Menstrual!disorders,!loss!of!libido,! hirsutism,!acne,!striae,!muscle! weakness,!easy!bruising,!polyuria! Uremia!and!anemia;!associated!with! renal!failure!

Renal#Parenchymal# Disease#

Disparity!in!the!pulsations!and!blood! pressure!between!the!arms!and!legs.! The!pulsations!in!the!upper!extremities! are!pounding:!those!in!the!lower! extremities!are!weak,!delayed,!or! absent.!! The!blood!pressure!in!the!arms!exceeds! that!in!the!legs.!!There!is!collateral! arterial!circulation.!! Murmurs!are!usually!present!but!vary! in!location.! Hirsutism,!acne,!striae,!muscle! weakness!and!wasting,!purpura,! bruising,!edema,!and!poor!wound! healing! If!any!findings,!those!associated!with! renal!failure.!

Chest!x.ray!may!show!prominence!of! the!left!ventricle,!notching!of!the! inferior!border!of!the!ribs!from! collateral!vessels,!and!poststenotic! dilation!of!the!aorta.!

24!hrs!urine!for!cortisol! Hyper!glycemia,!impaired!glucose! tolerance,!neutrophilia,!lymphopenia,! and!hypokalemia.! 24!hrs!urine!for!protein!and!create!ine! clearance.!Several!laboratory! abnormalities!may!be!present.!!These! include!elevation!of!the!BUN!and! creatine!levels,!anemia,!hypocalcemia,! hyperphosphatemia,!hyperkalemia,! metabolic!acidosis,!proteinuria,!and! hematuria.!

10!Hypertension!.!5!

Renal#Vascular# Hypertension#

Hypertension!in!the!absence!of!family! history,!Age!less!than!25!years!or! greater!than!45!years, Cigarette! smoking, White!race! ! Abrupt!onset!of!moderate!to!severe! hypertension! Sudden!onset!of!hypertension! following!abdominal!trauma! Recent!acceleration!of!severity!of! hypertension! Headaches! Resistance!or!escape!of!blood!pressure! control!with!usual!therapy! Development!of!severe!or!malignant! hypertension! Retinotherapy!out!of!proportion!to! severity!of!blood!pressure! Excellent!antihypertensive!response!to! angiotensin.converting!enzyme! inhibitor! Blood!pressure!unaffected!or!increased! with!diuretic!therapy!

Abdominal!or!flank!systolic.diastolic! bruits.! Carotid!bruits!or!other!evidence!of! large.vessel!disease!

Unprovoked!hypokalemia! Hypokalemia!in!response!to!thiazide! diuretic! Elevated!peripheral!plasma!renin! activity!in!absence!of!alternative! explanation!

10!Hypertension!.!6!

11""Weight"Loss" ! Has!the!patient!lost!weight?!Is!the!weight!loss!really! unexplained?! 1. Measuring!Weight!!Normal!clothes!are!too!loose.! Significant!if!>4B5%/yr.!BMI<22!F,<23.5M.!>10%!in! diseased!patient!increases!mortality.! 2. Age!!Elderly!medications,!appetite!suppression,! functional!limitations!(prepare!food,!chew,!shop!food).! Social!isolation.! 3. Appetite!!Can!be!suppressed!in!acute!or!chronic! illnessB!cachexia.!Psychological!factors!can!decrease! appetite.! 4. Eating!Habits/Nutritional!Adequacy/Physical!Activity! ! Are!emotional!issues!contributing!to!weight!loss?! 1. Psychosocial!factors!!Emotions,!stress,!Anorexia! nervosa,!bulimia,!!can!cause!electrolyte!imbalances! 2. Failure!to!Thrive!!Caretaker!conditions!(work,!stress,! parenting!skill)! ! What!cues!indicate!a!pathologic!process?! 1. Acute!or!Chronic!Conditions! a. Acute!B!Infectious!(Fever,!Fatigue,! lymphadenopathy),!ie.!HIV! b. Chronic!!Cough,!SOB,!nausea,!vomiting,!anemia,! fatigue,!weakness,!change!in!moles,!pain,!abnormal! menstrual!bleeding,!breast!discharge,!headaches! c. Red!Flag!for!cancer!occurrence!and!reoccurrence!! Appetite!loss,!decreased!caloric!intake,!inability!to! absorb!nutrients! 2. Diabetes!!if!untreated!causes!weight!loss,!increased! hunger,!excessive!thirst,!and!frequent!urination.!

! ! 3. Endocrine!Disorders!!Hyperthyroidism!(trembling,! insomnia,!hair!loss)!speeds!metabolism!! 4. Appetite/Activity!Level!Change!!Appetite!can!decrease! with!an!inactive!lifestyle!or!the!presence!of!chronic! pain,!IBS,!or!other!conditions!that!might!be!exacerbated! by!eating!(nausea,!vomiting,!diarrhea,!constipation,! ulcers)! ! What!other!symptoms!might!help!narrow!the!possibilities?! 1. Cancer!screening!!Varies!by!gender!and!age.!Include! colon!cancer,!skin!exams,!for!femalesBmammogram!and! pap!smears.! 2. Diet!!Malabsorption,!maldigestion!syndromes,!lactose! intolerance,!celiac!disease! 3. Family!History!!Cystic!Fibrosis! ! What!selfBtreatment!or!medications!is!the!patient!using?! 1. Medication!History!!ephedrine!for!weight!loss,!drugs!or! treatments!that!cause!nausea,!vomiting,!chemotherapy,! Interferon!in!Viral!Hepatitis!C.! ! How!serious!is!this!situation?!Is!this!a!recent!change?! 1. Validate!Weight!Change! 2. Concern!about!weight!loss! 3. Ideal!or!Usual!Weight! ! ! ! ! ! !

Condition!
Cancer! Diabetes!Mellitus! GERD!(infants)! Addison!Disease! Hyperthyroidism!

Common!Causes!of!Unintentional!Weight!Loss! History! Physical!Findings!

Loss!of!appetite! Polyuria,!polyphagia,!polydipsia! Hx!of!regurgitation! Salt!craving,!fatigue! Tachycardia,!heat!intolerance,!sweating! None!or!may!look!cachetic! Truncal!obesity;!xanthomas! None! Darkening!of!the!skin! Exophthalmos,!warm!skin,! onycholysis,!thinning!hair,! pretibial!myxedema,!enlarged! thyroid,!brisk!DTRs! Muscle!wasting,!loss!of! subcutaneous!fat,!ascites! Perirectal!fissure,!anal!skin!tag! Digital!clubbing,!FTT,!growth! retardation! Cough,!Percussion!dull!over! consolidation!areas! Redness!or!swelling!of!tissues!or! lymph!nodes! Cachexia,!hair!loss,!dry!skin,! orthostatic!hypotension! May!have!poor!personal!hygiene! May!have!poor!personal!hygiene! May!have!poor!personal!hygiene!

Diagnostic!Labs!
Imaging,!CT,!MRI,!XBRay,!CBC! FBG,!HbA1C,!GTT! Upper!GI,!Barium!swallow! Serum!electrolytes,!Aldosterone!24hrs! TSH,!T4!

Malabsorption! Crohns!Disease!! Cystic!Fibrosis! Tuberculosis! Infection! Anorexia!Nervosa! Dementia! Depression! Psychological!Factors!

Intolerance!to!gluten,!chronic!diarrhea,! growth!retardation! Fever,!diarrhea,!FHx! Cough,!chronic!diarrhea,!FHx!! Contact!with!infected!person,!travel!to! endemic!area,!HIV! Fever,!fatigue! 10F:1M,!perfectionist,!achiever,! amenorrhea! Disorientation!to!person,!time!or!place! Loss!of!appetite/!interest!in!food! Alcoholism,!social!isolation,!financial! resources!

Colonoscopy,!stool!culture,!fecal!fat! CBC,!colonoscopy,!barium!enema,! small!bowel!followBthrough! Sweat!test! PPD,!HIV,!Chest!XBray! Purified!protein!derivative! Blood!or!tissue!culture,!CBC! TSH,!T4,!Serum!Electrolytes! MMSE!Mini!Mental!Stage!Eval! TSH,!T4,!Refer!for!Psychological!eval! Liver!Function!Test!(GTT,!ASP,!AST)!

12##Abdominal#Pain# ! Some!Causes!of!Pain!Perceived!in!Anatomical!Areas!
Right#Upper#Quadrant# Left#Upper#Quadrant# Duodenal!ulcer! Ruptured!spleen! Hepatitis! Gastric!ulcer! Hepatomegaly! Aortic!aneurysm! Pneumonia! Perforated!colon! Cholecystitis! Pneumonia! # # # Periumbilical# ! ! ! Intestinal!obstruction! ! ! ! Acute!pancreatitis! ! ! ! Early!appendicitis! ! ! ! Mesenteric!Thrombosis! ! ! ! Aortic!Aneurysm! ! ! ! Diverticulitis! Right#Lower#Quadrant# Left#Lower#Quadrant# Appendicitis! Sigmoid!diverticulitis! Ovarian!Cyst! Ovarian!cyst! Ruptured!ectopic!pregnancy! Rupture!ectopic!pregnancy! Renal/urethral!stone! Renal/Urethral!stone! Strangulated!hernia! Strangulated!hernia! Merckel!diverticulitis! Perforated!colon! Regional!ileitis! Regional!ileitis! Regional!ileitis! Ulcerative!colitis! Perforated!cecum!

Features#of#Peritonitis# P# ain;!front,!back,!sides! E# lectrolytes!fall;!shock!ensues! R# igidity!or!rebound!of!anterior!abdominal!wall! I# mmobile!abdomen!and!patient! T# enderness!with!involuntary!guarding! O# bstruction! N# ausea! I# ncreasing!pulse!rate;!decreasing!blood!pressure! T# emperature!falls!and!then!rises;!tachypnea! I# ncreasing!girth!of!abdomen! S# ilent!abdomen!(no!bowel!sounds)!

! Is!this!an!acute!condition?! 1. Onset/Duration!!Progressively!worse!or!sever!pain!6, 24!hrs!after!onset!signal!a!surgical!emergency.!Sudden! onset!!colic,!perforation,!acute!ischemia!(torsion,! volvus).!Slower!onset!!Inflammatory!conditions! appendicitis,!pancreatitis,!cholecystitis.!Comes!and!goes! !intestinal!peristalsis.!Hrs!after!meal!!duodenal!ulcer,! after!eating!,!esophagitis.!Emergencies!below:! a. Perforation!!look!for!signs!of!peritonitis!

b. Ectopic!pregnancy:!in!any!woman!of!childbearing! age! c. Obstruction:!in!the!elderly! d. Ruptured!abdominal!aortic!aneurysm:!when!back! pain!is!present! e. Intussusception:!in!infants! f. Malrotation:!in!infants!usually!less!than!1!month!old! 2. Severity!and!Progression!!Evaluate!with!1,10!intensity! scale.! a. Acute!requires!immediate!attention,!chronic!or! recurrent!might!be!handled!in!a!more!temperate! manner.!! b. Pain!that!causes!one!to!awaken!from!sleep!!serious! c. Causing!Fainting!!Perforated!ulcer,!ruptured! aneurysm,!and!ectopic!pregnancy.! d. Knifelike!!emergency! e. Tearing!!aortic!aneurysm! f. Colicky!becoming!steady!!appendicitis,! strangulating!intestinal!obstruction! 3. Last!Bowel!Movement!!obstipation!with!complete! obstruction,!diarrhea!might!be!present!with!partial! obstruction.!Lack!of!bowel!movement!>3day!signals! constipation! Abdominal!Pain!,!1!

4. Previous!Pain!Chronic!pain!>1yr!generally!not!caused! by!neoplasm,!instead!look!for!IBS,!colorectal,! endometrial,!or!inflammatory!causes.!Recurrent!attacks! !inflammation,!exacerbation!of!chronic!condition!(IBS,! cholecystitis,!chronic!pancreatitis,!diverticulitis,!ulcer).! Acute!pain!!recurrent!infection!(pyelonephritis,! cystitis,!urinary!tract!stones)! ! Will!the!location!of!pain!give!me!any!clues?! 1. Location!of!pain!! a. Visceral!!midline,!dull,!diffuse,!epigastric,! periumbilical,!hypogastric,!from!intraabdominal! extraperitoneal!organs!(pancreas,!kidneys,!ureters,! great!vessels,!pelvic!organs)!or!referred.! b. Parietal/peritoneal,!localized,!sharp,!from! intraabdominal!and!intraperitoneal!organs! c. Inflammation!!Visceral!&!Peritoneal.!Initially! limited!to!serosa!covering!organ!visceral,!as!it! progresses!parietal!
Pain#Location#and#Involved#Structures# Esophagus,!stomach,!duodenum,! liver,!gallbladder,!pancreas,!spleen! Upper#abdominal## Esophagus,!stomach,!duodenum,! pancreas,!liver,!gallbladder,!or! thorax! Right#upper#Quadrant## Esophagus,!stomach,!duodenum,! pancreas,!liver,!gallbladder,!thorax! Left#upper#quadrant# Spleen! Periumbilical# Jejunum,!midgut,!ileum,!appendix,! ascending!colon;!inflammation,! ischemic!spasm,!abnormal! distention! Lower#abdominal# Colon,!sigmoid!colon,!rectum,! genitourinal!structures,bladder,! uterus,!prostate! Epigastric#

Right#lower#quadrant# Left#lower#quadrant# Flanks# Localized#

Generalized#

Appendix,!fallopian!tube,!ovary! Sigmoid,!fallopian!tube,!ovary! Kidney(s)! Local!inflammation!of! skin/peritoneum,appendicitis;! lateralized!occurs!in!paired!organs! !kidneys,!ureters,!fallopian!tubes,! gonads! Diffuse!inflammation!GI!tract,! peritoneum,!abdomen!wall!

2. Radiation!of!Pain! a. Biliary!colic!!under!right!scapula! b. Renal!colic!!same!side!testicle! c. Ruptured!spleen!!Top!left!shoulder! ! What!do!the!pain!characteristics!tell!me?! 1. Character! a. Colicky/Cramping!!Obstruction,!rhythmic,! peristaltic!with!intermittent!cramping.!Painful! episodes!patient!is!agitated,!restless,!often!pale!and! diaphoretic.!Increased!frequency!!proximal! intestine! b. Steady!pain!!perforation,!ischemia,!inflammation,! and!blood!in!the!peritoneal!cavity! c. Burning!!esophagitis.! d. Burning/Gnawing!!duodenal!ulcer! e. Steady,!epigastric,!prostrating!!pancreatic! f. Pricking,!itching!or!burning!!Superficial!!Herpes! zoster! g. Dull!,!deep! 2. Precipitating!or!Aggravating!Factors! a. Lying!down/Bending!forward!!esophagitis! b. Alcohol!!can!aggravate!gastritis! c. Deep!inspiration!agg./amel.!pause!!pleuritic! Abdominal!Pain!,!2!

d. Increase!on!deep!inspiration!!peritonitis,! intraperitoneal!abscess,!obstruction! e. Inhibition!of!diaphragm!movement!!biliary!colic! 3. Relieving!Factors! a. Food/Anti,acids!!ulcer,!gastritis! b. Analgesics!!inflammatory,!colicky,!not!vascular! ! Are!there!any!precipitating!events!that!will!narrow!my! diagnosis?! 1. Relation!to!other!events! a. Intestinal!!relieved!by!defecation,!flatus,!laxatives! or!diet!change! b. GI!tract!!Associated!with!meals! c. Sexual!Activity!(dyspareunia)!!pelvic!origin! d. Position!change!!spine,!hips,!sacroiliac!joint,!pelvic! bones,!abdominal!muscles.! e. Exertional!,!cardiac! ! What!does!the!presence!of!vomiting!or!diarrhea!tells!me?! 1. Vomiting!!preceding!onset!of!abdominal!pain!is! unlikely!emergency,!Anorexia!absence!makes!serious! disease!less!likely.!Vomiting!with!acute!condition!of! abdomen!is!from:! a. Severe!irritation!of!nerves!in!peritoneum!or! mesentery! b. Obstruction!of!an!involuntary!muscular!tube,! dilation!before!obstruction,!tension!increased!with! peristaltic!waves.!Colic!in!spasm,!vomit!at!height!of! pain! c. Action!of!absorbed!toxins!on!medullary!center.! Stimulated!by!cardiac!glycosides,!ergot,!alkaloids,! and!morphine,!uremia,!diabetic!ketoacidosis,! general!anesthetics! !

2. Pain!with!Vomiting! a. Sudden!and!severe!stimulation!of!peritoneum!or! mesentery!!vomit!after!pain.! b. Vomit!is!early!,!acute!obstruction!urethra,!bile!duct! c. Timing!indicates!how!high!in!gut!is!obstruction! d. Onset!of!pain!vomit!!duodenum! e. Late!or!infrequent!vomit!!obstruction!of!large! bowel! f. No!vomit!!ectopic!pregnancy,!gastric!or!duodenal! perforation,!intussusception.! g. Vomit!before!pain!!gastroenteritis! h. Pain!preces!vomit!!appendicitis!most!time! 3. Vomitus!Appearance! a. Clear!!gastric!fluid! b. Bile,colored!!Upper!GI! c. Feculent!!distal!obstruction! d. Food!particles!eaten!recently!!gastric!outlet! obstruction,!later!turns!clear! e. Pyloric!stenosis!!no!bile!seen!in!vomit! f. Duodenal!atresia!!infants,!bilious! 4. Stool!characteristics! a. Diarrhea!!IBD,!diverticulitis,!early!obstruction,! precedes!perforation!of!appendix!due!to!irritation! of!sigmoid!colon!or!inflammatory!mass! b. Blood!!Intestinal!tract!neoplasm,!intussusception,! or!inflammatory!lesions! c. Defecate!without!relief!!appendicitis! d. Diarrhea!(children)!!with!onset!of!pain,!acute! gastroenteritis!(large!liquid!stools),!early! appendicitis! ! ! ! Abdominal!Pain!,!3!

Are!there!any!clues!to!implicate!a!particular!organ!system?! 1. Cardiovascular!!Exertional!!CAD,!Angina,!RUQ!!CHF,! Abdominal!MI,!pericarditis! a. Does!the!pain!occur!with!exertion?!! b. Do!you!have!any!chest!pain,!palpitations,!fast! heartbeat,!or!pain!that!goes!to!the!arm!or!jaw?! 2. Gastrointestinal! a. Do!you!have!any!GI!symptoms!(gas,!diarrhea,! constipation,!vomiting,!heartburn)?! b. Have!you!had!any!changes!in!your!bowel!habits,! stools,!or!eating!pattern?! c. Is!the!pain!relieved!by!defecation!or!burping?! 3. Genitourinary! a. When!was!your!last!menstrual!period?!Was!it! normal!for!you?!Could!you!be!pregnant?! b. Do!you!have!any!vaginal!symptoms!or!problems! such!as!unusual!discharge,!unusual!bleeding,!or!pain! with!sexual!intercourse?!PID,!STIs,!cancer! c. Do!you!have!any!menstrual!irregularity!or!unusual! bleeding?!PID;!pain!before!menses!endometriosis;! mid,cycle!pain!ovulation;!always!consider!ectopic! pregnancy! d. Sexual!history!in!regards!to!STIs?! e. Do!you!have!any!urinary!symptoms!(frequency,! urgency,!dysuria,!blood!in!urine,!change!in!urine! color)?! f. Do!you!have!pain!in!the!back!(flank)?!Can!you!point! to!it?!Pyelonephritis,!renal!calculi.!Upper!abdominal! radiating!to!groin!ureterolithiasis! 4. Musculoskeletal! a. Does!the!pain!occur!with!change!in!position!or! movement?!MSK,!Costochondritis,pain!with! vigorous!respiration.! !

b. Do!you!have!any!joint!pain,!heat,!swelling,!noises,!or! limitation!in!range!of!motion?!Rheumatoid!arthritis! c. Do!you!have!any!difficulty!walking! 5. Respiratory! a. Do!you!have!cough!or!difficulty!breathing?! Pneumonia,lower!lobe!!!refer!pain!to!abdomen.! Pleurisy!pain!on!deep!inspiration!persistent!cough! can!cause!MSK!soreness.! b. Do!you!have!any!shortness!of!breath?!See!SOB! chapter! ! Is!the!pain!psychogenic,!organic!or!functional?! 1. Do!you!feel!unhappy,!sad,!depressed?! 2. Are!you!able!to!eat,!sleep,!and!engage!in!usual!activities?! 3. Have!you!had!recent!problems!with!diarrhea!or! constipation?! 4. How!is!your!energy!level?! 5. Have!you!ever!been!diagnosed!with!or!treated!for! mental!health!or!psychiatric!problem?! ! What!else!do!I!need!to!consider?! 1. Medications!!GI!distress!!due!to!adverse!reaction,! Erythromycin,!tetracycline! 2. Surgery!!Prior!surgery!can!produce!adhesions!that! cause!intestinal!obstruction.!Adhesion!of!organ!to! abdominal!way!can!cause!pain.!Prior!appendectomy! does!not!precludes!appendicitis,!stump!can!be!inflamed! 3. Involuntary!Weight!loss!!Colon!cancer,!neoplasms,! check!for!change!in!bowel!habit,!FHx!colonrectal/! gynecological!cancer,!presence!of!blood!in!stool! 4. Camping!or!Day!Care!!intestinal!parasites! ! ! Abdominal!Pain!,!4!

Condition!
Appendicitis!

Common!Causes!of!Acute!Abdominal!Pain! History! Physical!Findings!

10,20yo!more!prevalent,!sudden!onset!of! coliky!pain!constant!pain.!Epigastric!or! periumbilicar!RLQ;!movement/cough! agg.,!vomit!after!onset!of!pain! Childbearing!age,!sudden!onset!spotting!&! persistent!cramping!in!lower!quadrant! shortly!after!missed!period! Sudden!onset!of!severe!intense,!steady,! epigastric!pain!that!radiates!to!the!sides,! back,!or!right!shoulder,!Hx!burning,! gnawing!<empty!stomach! Most!frequent!in!elderly!especially! Hypertensive;!sudden!onset,!excruciating,! chest/abd,!radiates!to!legs/back! >50yo,!upper/diffuse,!abd!pain,!can!have! nausea,!vomiting,!dyspepsia! More!often!elderly,!sudden!onset,!severe,! diffuse,!<movement/coughing! Hx!Cholelithiasis/Alcoholism,!steady,! boring,!unrelieved!by!change!in!position,! LUQ!radiates!to!back;!nausea,!vomiting,! diaphoresis! Fever,!RLQ,!symptoms!suggestive!of! appendicitis! More!in!adults!F>M,!colicky,!progression! to!constant,!RUQ!right!scapular,!falling! gradually;!nausea,!vomiting,!Hx!of!dark! urine!and/or!light!stools! Sudden!onset;!excruciating!intermittent! colicky!progress!to!constant;!Lower! abd.,!flank,!radiates!to!groin;!nausea,! vomiting,!abd.!Distention,!chills,!fever;! increased!urinary!frequency! Urinary!symptoms!with!UTI,!back!pain!w/! pyelonephritis;!infants,FFT,!irritability! Lying!still;!involuntary!guarding;! RLQ!tenderness;!rebound! tenderness;!Rovsing/Psoas!sign! positive.! Hemorrhage,!shock,!lower!abd.! Peritoneal!irritation!can!be! lateralized,!enlarged!uterus! Lying!still,!epigastric!tenderness,! rebound!tenderness,!abd.! Muscles!rigid,!bowel!sounds!can! be!absent! Appears!shock,!vital!signs!reflect! impending!shock,!deficit!or! difference!in!femoral!pulses! Hyper/hypotension,!cardiac! arrhythmia,!paradoxical!S2! Guarding;!rebound!tenderness,! decrease/absent!bowel!sounds! Appear!acutely!ill,!Abd.! Distention,!bowel!sounds,! diffuse!rebound!tenderness;! upper!abd!muscle!rigidity;! diaphragmatic!excursion!lungs! Palpation!pain!RLQ;!can!have! pharyngitis,!cervical!adenopathy! Tender!on!palpation/percussion! RUQ,!gallbladder!palpable!! cases!cholecystitis,!Murphy!Sign!! CVA!tenderness;!lumbar/groin! increased!sensitivity;!hematuria!

Diagnostic!Labs!
CBC!w/differential,!ultrasonography,! CT,!laparoscopy! hCG,!U/S,!Surgical!emergency! Upright/Lateral!decubitus!X,Ray!air! under!diaphragm/peritoneal!cavity!! Surgical!Emergency! CT/MRI,!ECG!,Cardiac!Enzymes,! Surgical!Emergency! Serial!ECG/Cardiac!Enzymes! CBC!w/differential,!Abd.!X,Ray! CBC!w/differential,!Serum!amylase/! lipase/!TG/!Ca,!Liver!enzymes,!U/S,!CT!

Ectopic!pregnancy! Peptic!Ulcer!perforation!

Dissecting!aortic!aneurysm! Myocardial!Infarction! Peritonitis! Acute!Pancreatitis!

Mesenteric!adenitis! Cholecystitis/Lithiasis!

CBC!w/differential,!Adenovirus!in! tissue!of!surgical!specimen! CBC!w/!differential,!U/S,!X,Ray,!Serum! amylase/lipase! U/A,!non,contrast!enhanced!helical!CT!

Ureterolithiasis!

UTI/pyelonephritis!

Altered!voiding!pattern,! malodorous!urine,!fever!

U/A,!culture!

Abdominal!Pain!,!5!

Condition!
PID!

History!

Common!Causes!of!Acute!Abdominal!Pain! Physical!Findings!

Diagnostic!Labs!
WBC,!ESR!elevated;!cultures;!gram! stain! CT,!Abd.!X,ray!

Lower!Abd,!pain,!progressively!severe,! can!have!irregular!bleeding,!vaginal! discharge,!vomiting;!m/c!sex!active!

Obstruction!

Ileus! Intussusception! Malrotation/volvus! Henoch,Schonlein!purpura! Incarcerated!Hernia! Pneumonia! IBS!

Lactose!intolerance! Diverticular!disease! Simple!Constipation! Habitual!Constipation! Dysmenorrhea!

Abd/adnexal!(bilateral!usual)! tenderness,!CMT,!w/peritonitis! can!have!guarding/rebound! tenderness;fever!&!vaginal!disch.! Sudden!onset,!crampy,!umbilical! Hyperactive,!high,pitched!bowel! area/epigastrium;!vomiting!early!with!SI! sounds,!palpation!fecal!mass,! obstruction,!late!with!LI!;!obstipation!or! abd.!distention;!empty!rectum!on! diarrhea! DRE! Abd.!Distention,!vomiting,!obstipation,! Minimal!or!absent!peristalsis!on! cramps! auscultation! Sudden!onset!pain!in!infant;!occurs!with! Fever,!vomiting,!currant!jelly! sudden!relief,!then!pain!again! stools! Seen!in!infants!up!to!1!mo.!old;!irritability,! Bilious!emesis,!abdominal! pain! distention! Seen!in!children!2,8!yo! Rash!on!lower!extremities/! buttocks;!arthralgias;!hematuria! More!common!elderly;!constant!sever! Hernia!or!mass!that!is!non, pain!RLQ/LLQ!<coughing/straining! reducible! Child!2,5yo.!Can!be!present!only!with!abd.! Tachypnea,!retractions,!pallor,! pain!and!fever! nasal!flaring,!crackles! Begins!in!adolescent,!young!adult!years,! Normal!exam,!heme,negative! hypogastric!pain;!crampy,!variable! stool! infrequent!duration;!associated!with! bowel!function,!gas!bloating,!distention;! relief!with!passage!of!flatus/feces! Crampy!pain!after!eating!milk/products! Negative!physical!exam! Localized!pain;!older!patient! Abdominal!tenderness;!fever! Colicky/dull!steady!pain,!does!not! progress!or!worsens! Lifelong!hx;!younger!patient! Typi.!Premenstrual!pain!onset!soon!after! menarche,!gradually!diminishing!with!age! Fecal!mass!palpable,!stool!in! rectum! Normal!Exam,!heme,negative! stool! Normal!pelvic!exam!

Gases!distention!sections!shown!on! Intestines!X,rays! Abdominal!films! Abdominal!films! CBC,!ESR,!Serum!IgA! MRI,!CT,!U/S! CBC,!Chest!X,ray! Proctosigmoidoscopy,!colonoscopy!if! onset!middle!age/older,!stool!blood,! FHx!of!colorectal!cancer/polyps,! failure!to!improve!after!6,8!wks! therapy! Trial!elimination!of!offending!foods! CT,!contrast!enema,!cystography,!U/S,! endoscopy!sometimes!usefull! None! Sigmoidoscopy,!anorectal!manometry,! colonoscopy!if!alarm!symptoms! GYN!consult;!Pelvic!U/S!if!secondary! dysmenorrhea,!disability,!abnormal! pelvic!exam! !

Abdominal!Pain!,!6!

Condition!
Uterine!Fibroids!

Common!Causes!of!Acute!Abdominal!Pain! History! Physical!Findings!

Pain!related!to!menses,!intercourse! Palpable!myomas;!no!suspicion! of!other!pelvic!disorder! Physical!exam!documents!hernia! Adnexal!pain,!palpable!ovarian! cysts,!especially!in!late!cycle!! (corpus!luteum)! Visible!ecchymosis!or!swelling;! palpable!hernia,!pain!with!rectus! muscle!stress;!no!GI/! genitourinary!symptoms! Physical!exam!negative,!in! infants:!weight!loss,!in!some! cases!aspiration!pneumonia! Can!be!epigastric!tenderness!on! palpation!

Hernia! Ovarian!Cysts! Abdominal!wall!disorder!

Localized!pain!that!increases!with! exertion!or!lifting! Young!woman! Hx!trauma!

Diagnostic!Labs! Pelvic!U/S!if!ovarian/uterine! neoplasm!cannot!be!excluded;!GYN! consult!if!abnormal!bleeding!or!severe! symptoms! MRI,!CT,!US,!BE!if!suspect! strangulation!or!bowel!obstruction! Pelvic!U/S!

CT!if!internal!disease!cannot!be! excluded! Endoscopy!if!severe!or!not!responsive! to!therapy,!manometry,!pH! monitoring! C,UBT,!stool!antigen!test,!endoscopy!if! no!response!to!therapy.!

Esophagitis/GERD!

Peptic!Ulcer!

Gastritis!

Gastroenteritis!

Functional!dyspepsia! Recurrent!Abdominal!Pain!

Burning,!gnawing,!mid!epigastrium,! <recumbency;!water!brash;!after!eating,! can!be!>antiacids;!in!infant!FTT,! irritability,!postprandial!spitting,!vomiting! Burning,!gnawing,!soreness,!empty! feeling,!hunger;!occurs!most!often!with! empty!stomach,!stress,!and!alcohol,!>food! intake;!pain!steady,!mild/severe,! epigastrium;!atypical!in!children,!minimal! in!elderly.! Constant!burning!pain!in!epigastric!area! can!be!accompanied!by!nausea,!vomiting,! diarrhea,!or!fever;!alcohol,!NSAIDs,!and! salicylates!make!pain!worse.! At!any!age,!produces!diffuse!crampy!pain,! nausea,!vomiting,!diarrhea,!fever;!can! have!Hx!of!recent!travels,!family!members! ill! Vague!reports!of!indigestion,!heartburn,! gaseous!or!fullness;!belching,!abdominal! distention,!and!occasionally!nausea! Child!5,10yo,!Hx!of! environmental/psychological!stress!

Physical!examination!negative!

No!diagnostic!testing!necessary!if! patient!responds!to!therapy! No!diagnostic!testing!needed!

Physical!examination!negative!

Physical!examination!negative! Physical!examination!negative!

C,UBT!(Carbon!13!Urea!Breath!Test!),! Stool!antigen!test! CBC,!U/A,!ESR,!FOBT!or!FIT,!stool!for! O!&!P!

Abdominal!Pain!,!7!

Abdominal!Examination! !
Competencies!
1. Inspect skin 2. Inspect umbilicus 3. Inspect contour/symmetry 4. Inspect peristaltic waves/pulsations 5. Auscultate for bowel sounds 6. Auscultate for bruit 7. Percuss abdomen (general patterns) 8. Palpate LIGHTLY 9. Palpate DEEPLY 10. Percuss and assess 2 liver spans

Assessment!Techniques#
Scars,!striae,!dilated!veins!rashes,!lesions,!inflam,!hair!distr,!color!(bruising)!around! umblicus!(Cullen's!sign)!or!flank!(Gray,Turner's!sign)! Contour,!location,!color!(bruising)! Observe!side,!then!stand!at!pt's!feet/shine!light!onto!abdomen! Use!penlight!at!oblique!angle.!Observe!for!normal/exaggerated!pulsations! Start!w/!RLQ.!If!no!sounds!in!2,5!minutes,!follow!w/!other!quadrants;!note! frequency/character!of!sounds.!N=!high!pitched!clicks,!gurgles,!borborygmi!5,30/min! w/!BELL;!at!aorta,!renal!arteries,!iliac!arteries,!femoral!arteries! Percuss!in!zig,zag!and!circular!pattern! Palpate!lightly!to!assess!for!guarding,!rebound,!and!tenderness.! Palpate!deeply!to!assess!for!masses!or!tenderness! Mark!resonance!dullness!w/!stickers.!Measure.!! Mid!clavicular!!!N=!6,12cm.! Midsternal!!!N=!4,8cm! Hook!under!R!costal!margin.!Pt!takes!breath!in!!!pt!exhales,!press!deeper!and!try!to!feel! smooth!liver!edge.! &Murphies-test:!while!hooked,!pt!inhales.!Watch!pts!face!for!pain/!stop!inhale! &Traube's-space!,Percuss!interspace!of!rib!8,10!anterior/midaxillary!lines! &Splenic-percussion-sign:!Percuss!lowest!IS!in!L!ant!axill,!pt!take!deep!breath!and!percuss! again.! Pt!supine,!R!hand!lifts!back,!L!presses!under!L!costal!margin!to!capture!SP.!Normally!cant.! ,Palpate-from-RLQ!LUQ-if-enlarged!! "capture"!KD;!Pt!takes!breath!in;!lift!from!behind!w/!L,!R!on!top.!Ask!pt!to!breathe!out!and! stop!breathing!briefly,!feeling!for!KD!movt!back!into!place.! CVA!=!costovertebral!angle! "KD!punch"! ! Use!fingers!to!feel!pulse,!measure.! Fluid!wave!tap!of!1!side!w/!pts!hands!in!midline&Rovsing's-sign,!Press!deeply!and!evenly!in!the!LLQ!!!then!quickly!w/draw!your!fingers.! &Psoas-sign,!Place!your!hand!just!above!pt's!R!knee.!Ask!pt!to!raise!thigh!against!your!hand.! RUQ!Pain!&!tenderness;!Hook!left!thumb!or!fingers!of!right!hand!under!the!costal!margin.! Ask!patient!to!take!deep!breath.!Positive!Murphys!Sign!!sudden!top!in!inspiration!

Abnormalities!
,Purple!striae!a/i!Cushing's!Syndrome! ! ,Cullen's!sign!a/i!intra&!peritoneal!bleeding! ,protuberant!abdomen!w/bulging!flanks!a/i!ascites! ,exaggerated!aortic!pulsation!a/i!!abdominal!aortic! aneuryism!(AAA)! ,increased!bowel!sounds!a/i!diarrhea!or!early! intestinal!obstruction! ,bruits!w/!both!syst/dia!a/i!renal!stenosis!as!the! cause!of!HT!! ,dullness!in!both!flanks!a/i!ascites! ,involuntary!rigidity!a/i!peritoneal!inflam! ,mass!in!abdominal!cavity!could!indicate!a!bowel! obstruction! ,!increased!liver!span!in!hepatomegaly! ,!tender/firm!liver!a/i!hepatitis!or!CHF! ,pain!is!+ve!for!acute!cholecystitis! ,!Traube's-space!dullness!a/i!splenomegaly! ,from!tympany!!dullness!on!inspiration!a/i! splenomegaly! ,palpable!spleen!usually!suggests!splenomegaly! ! ,!bilateral!enlargement!suggests!polycystic!KD!dz!! N=L!rarely!palpable,!R!lower!but!usually!not! palpable! ,!pain!a/i!pyelonephritis! N=!painless/hear!a!thud! ,>3cm!a/i!risk!of!AAA! ,!dullness!shifts!to!more!dependent!side!in!ascites! ! ,!pain!in!RLQ!a/i!appendicitis! ! ,!pain!a/i!appendicitis! Positive!Murphys!sign!,!Cholecystitis!

11.

Palpate liver

12.

Percuss spleen

13. 14.

Palpate spleen Palpate kidneys

15.

Assess CVA tenderness

16. 17. 18.

Evaluate aortic width Evaluate ascites Evaluate appendicitis: any 2 tests

19.

Evaluate acute cholecystitis

! !

Abdominal!Pain!,!8!

13##Diarrhea# ! What!does!the!patient!mean!by!diarrhea?! 1. Frequency!of!stools!!Normal!1*3x/d!2*3X/wk! 2. Stool!volume!and!consistency!!SI!conditions!large! volume!watery!relatively!infrequent,!LI!(bacteria! induced!inflammation)!conditions!more!frequent!less! watery! 3. Intervals!!Malabsorption!(Lactase!Deficiency)!Acute,! continuous*intermittent,!loose.!Intermittent!alternating! constipation!IBS! 4. Proximal!Colon!Symptoms!!Large!volume,!less! frequent,!more!homogeneous,!without!urgency!or! tenesmus!food!intolerance,!infectious,!inflammatory.! 5. Distal!Colon!Symptoms!!Small!volume,!frequency,! urgency,!tenesmus,!incontinence,!mucus!proctocolitis,! colon!cancer,!diverticular!disease,!or!IBS.! ! If!this!is!an!infant,!is!there!a!risk!of!dehydration?! 1. Wet!diapers!!Dehydration!in!infants!and!young!can! occur!quickly!and!be!fatal.!<!6!wet!diapers/24hr!or! >4hrs!without!urination.! 2. Thirst!*!Irritability,!crying,!eagerness!to!drink!fluids.! Stuporous,!unresponsive,!unable!to!manifest!thirst*! sever!dehydration! 3. Tears!!In!mild!dehydration,!tears!present,!in!sever!no! tears.! ! If!this!is!an!adult,!is!there!risk!for!dehydration?! 1. Urination!frequency,!volume!*!reduced! 2. Thirsty!*!increased! 3. Dry!mouth/eyes!*!increased! ! !

! ! Is!this!an!acute!or!chronic!problem?! 1. Acute!diarrhea!in!adults!!M/C!of!viral!origin,!self*! limited!<2wks.!Abd.!Pain,!diarrhea,!nausea,!vomiting,! fever,!tenesmus!common.! 2. Acute!diarrhea!in!children!!Loose,!liquid!stools,.!Large! qty.!of!electrolytes!lost.!Sever!protected!can!lead!to! metabolic!acidosis,!dehydration,!azotemia!(high!BUN),! oliguria!(low!urine!output).!Serious!in!neonates! associated!with!infection!or!congenital!abnormality! 3. Chronic!diarrhea!in!adults!*!>2wks,!unless!bloody!or! systemic!illness!parasites,!medication,!IBS,!lactose! intolerance,!IBD.! 4. Chronic!diarrhea!in!children!*!>!3wks,!causes!change! with!age.!!Infants!Intolerance!to!formula,!protected! enteritis!after!viral!infection,!Giardia.!Children!&! Adolescents!!!malabsorption!disorders,!IBD.! ! Does!the!presence!or!absence!of!blood!help!me!narrow!the! cause?! 1. Blood!in!stools! a. Bright!red,!small!spots!in!toilet!!hemorrhoids! b. Blood!in!stools!!Acute!diarrhea!Shigella! c. Infants!&!children!!Cow!milk!intolerance!or!anal! fissures.! d. Newborn!!hemorrhagic!disease,!lack!Vit!K.! e. Chronic!bloody!*!!IBD,!dysentery,!colitis,!invasive! organism.! f. Red!blood!!lower!GI!tract!origin! g. Dark/Black/tarry!(melena)!!Upper!GI!origin! ! ! 13!Diarrhea!*!1!

2. Color!of!stools! a. Black!!Iron,!Charcoal,!bismuth,!licorice,! huckleberries,!lead! b. Red/Pink!!Beets,!cranberries,!tomatoes,!peppers,! food!coloring,!drugs!(anticoagulants,!salicylates,! rifampin,!diazepam).! c. Green*black!!grape,!iron! d. Dark!grey!!cocoa,!chocolate! e. Pale!gray!/White!!cholestasis,!obstructive!jaundice,! malabsorption,!excessive!milk!ingestion,!antacids.! f. Green!*!bile!salts,!chlorophylls!in!veggies!(spinach)! ! What!does!the!presence!or!absence!of!pain!tell!me?! 1. Occurrence!of!pain!!Malabsorptive!disorder!! Flatulence,!pain,!diarrhea.!Self!Limiting!viral!! combination!of!pain,!diarrhea,!nausea,!vomiting,!fever,! tenesmus.!Food!poisoning,!Giardia,!contaminated!water! !crampy!abd.!pain,!seen!in!children,!infants!in!day!care! 2. Location!of!pain!!Generalize,!diffuse!!IBD,!abd.!cramp! from!infective!cause.!UC!entire!abd!or!localized!to!LQ.! IBS!LQ,!sigmoid!colon.!LI!pain!LQ,!SI! pain!epigastric/umbilical! 3. Severity!of!pain!!See!abdominal!pain!examinations! 4. Sleep*related!pain!!Awakens!from!sleep!organ! disease!(diabetes!enteropathy,!HIV!enteropathy),! IBS!waking!hours.! ! What!do!associated!symptoms!tell!me?! 1. Fever!!GI!tract!&!respiratory!cause!80%! 2. Vomiting!!Presents!early!on!viral!gastroenteritis,!food! poisoning,!food*borne!bacterial!infection.!Viral!agents! cause!delayed!gatric!emptying!&!luminal! distention!induces!vomiting!before!diarrhea.! !

3. Occurrence!of!vomiting!and!diarrhea!!Bacterial! ! Could!this!be!caused!by!exposure!to!others!or!to! contaminated!food?! 1. Day!Care!attendance!!Children!at!greater!risk!of! bacterial!infections!thru!feco*oral!route.! 2. Others!with!similar!symptoms!!Social!gatherings! where!food!is!served! ! Could!this!be!the!result!of!exposure?! 1. Animals!!C.!jejuni!!dogs!or!cats.!Salmonella!turtles! 2. Recent!travel!!Outside!US/Canada!risk!of!ETEC,!less! commonly!G.!lambia,!Salmonella,!Shigella,!C.!jejuni,!E.! histolytica.!! 3. Camping!!Giardia,!C.!jejuni!from!untreated!water! 4. Urban!water!contamination!!Cryptosporidium!! ! !Could!sexual!activities!explain!the!diarrhea?!Suspect! Shigella!with!anal!sex,!particularly!in!homosexual!males.! Tenesmus,!passage!of!mucus!proctitis! ! Could!this!be!the!result!of!an!immune!problem?!IgA,!IgG! deficiencies!are!frequent!cause!of!diarrhea!in!children.!Aids,! Chemotherapy!can!develop!enteropathy.! ! Could!this!be!caused!by!medications?! 1. Recent!treatment!with!antibiotics!!C.!difficile!!! pseudomembranous!enterocolitis!using!ampicillin,! clindamycin,!cephalosporins.! 2. Medications!!Antacids,!magnesium,!antibiotics,! methyldopa,!digitalis,!b*blocker,!systemic!anti* inflammatories,!colchicine,!quinidine,!high!dose! salicylates,!laxatives.! 13!Diarrhea!*!2!

! Could!this!be!related!to!surgical!procedures?!!Surgery!can! cause!dumping!syndrome!after!the!ingestion!of!meals.!Due! to!inadequate!mixing!and!digestion.!Stagnant!loops!after! operation!lead!to!bacterial!overgrowth.!Extensive!bowel! resection!can!produce!short!bowel!syndrome!diarrhea! from!malabsorption.! ! Is!this!diet!related?! 1. Excessive!Intake!of!Carbohydrates!fluids!!apple!juice,! nonabsorbable!fillers!(sorbitol)!malabsorptive! diarrhea.!Bacterial!contamination!of!non*pasteurized! apple!juice.! 2. Cows!Milk!Protein/Soy!Protein!Hypersensitivity!! Diarrhea,!vomiting,!colic,!occult!or!grossly!blood,!2*3! wks!after!starting!cow/soy!formulas.! 3. Celiac!Sprue!(Gluten!enteropathy)!!Increased! frequency,!looseness,!paleness,!and!bulkiness!of!stool,!3* 6!mo!within!dietary!intake!of!wheat,!rye,!barley,!oats.! 4. Starvation!stools!!Liquid!low!fiber!diet!used!to!treat! diarrhea!continued!for!too!long.!Start!feeding!soon!after! re*hydration!is!achieved.! ! Could!this!be!caused!by!food!preparation!problems?! 1. Dietary!exposure!to!infectious!agents!!Undercooked! poultry!(Salmonella,!C.!jejuni).!Beef,!unpasteurized!milk,! juices!(ECO157:H7).!Raw!shellfish!(Norwalk),! contaminated!cooking!surfaces! 2. Other!ill!persons!!Food!poisoning!to!be!considered! ! ! ! ! !

Is!there!any!family!predisposition!that!can!point!to!a!cause?! 1. Cystic!Fibrosis!Family!History!!Most!common!genetic! disease!in!Caucasians.!Fat!malabsorption,!fatty,!foul! smelling!diarrhea.! 2. Diarrheal!Illness!Family!History!!IBD!is!genetically! linked.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 13!Diarrhea!*!3!

Condition!
IBS!

Common!Causes!of!Chronic!Diarrhea! History! Physical!Findings!

Intermittent!diarrhea!alternating!constipation;! mucus!stool;!seldom!at!night!or!awakens!patient;! common!morning;!rectal!urgency;!triggered!by! stress!or!ingestion!of!food;!M:F=1:3! Hx!severe!diarrhea!w!gross!blood,!no!growth! retardation;!few!report!pain;!2nd*3rd!age!onset,! small!peak!in!adolescence;!Fhx! Hx!chronic!bloody!diarrhea,!abdominal! cramping,!tenderness,!rectal!bleeding;!in! children!a!hx!of!retardation,!weight!loss,! moderate!diarrhea,!abd.!pain,!anorexia! Bloating,!flatus,!diarrhea!exacerbated!by! ingestion!of!disaccharides!(milk,!lactose,!milk! prods.);!can!follow!viral!gastroenteritis! Greasy,!fatty,!malodorous!stools;!associated!with! Vit!A,D,K!deficiencies;!CF! Increased!frequency,!looseness,!paleness,! bulkiness!within!3*6!mo!of!dietary!onset;! children!lethargic,!irritable;!anorectic;!peak! frequency!9*18mo.! Watery,!foul!diarrhea;!common!in!day!care;! among!travellers!and!in!male!homosexuals! Recurrent!episodes;!variable!amounts!watery;! non*bloody!diarrhea;!amounts!can!be!massive! Follow!GI!surgery,!diarrhea!after!meals!due!to! increased!transit!of!food!thru!colon! Nocturnal!diarrhea,!postprandial!vomiting,!fatty! stools!from!malabsorption! Insidious!onset,!recurrent!large!qty!nonbloody! diarrhea,!mild/moderate!nausea,!vomiting! Mild/moderate!severe,!nonwatery/nonbloody! Tender!colon!on!palpation,!abd.! distention;!no!weight!loss;!afebrile! Overt!!rectal!bleeding;!initially!no! fever,!weight!loss,!or!pain!on! palpation!of!abd.;!moderate!colitis:! weight!loss,!fever,!abd.!tenderness! Weight!loss;!rare!gross!rectal! bleeding;!fistulas!common! Diffuse!abd.!pain! Rectal!prolapse,!poor!weight!gain,!abd.! distention! FTT,!abd.!distention,!irritability,! muscle!wasting! Low*grade!fever,!weight!loss;!chronic! form:!fatigue,!growth!retardation,! steatorrhea! Weight!loss,!severe!RUQ!abd.!pain!w/! biliary!tract!involvement! Diaphoresis,!tachycardia! Finding!associated!with!DM! Finding!associated!with!HIV! No!specific!findings!

Diagnostic!Labs! Diagnosis!of!exclusion;! sigmoidoscopy,! proctoscopy!

CBC!shows!leukocytosis! or!anemia;!ESR!elevated;! stool!to!r/o!other! causes;!colonoscopy! Colonoscopy!with! biopsy! Trial!elimination!of! offending!foods! 73hr!fecal!fats,!sweat! test! C/F;!improvement!on! gluten*free!diet,!CBC,! anemia,!folate! deficiency,!X*Ray,!biopsy! Giardia!Ag!test! Stool!for!Ova!&!Parasite! Test!(O!&!P)! Upper!GI!series! Diagnosis!of!exclusion!in! diabetic!person! Testing!for!HIV! Usually!one!needed!

UC!

Crohns!Disease!

Carbohydrate!malabsorption! Fat!malabsorption! Celiac!Disease!

Giardia!parasite! Cryptosporidium! Postgastrectomy!dumping! Diabetic!enteropathy! HIV!enteropathy! Medication!Induced!

13!Diarrhea!*!4!

14##Breast#Mass#(Lumps#&#Discharge)# ! Is!this!lump!malignant?! 1. Duration!and!Growth! a. Malignant!!single,!hard,!painless,!unchanged!by! cyclic!hormonal!milieu,!show!progressive!size! increase!alteration!of!breast!contour! b. Benign!!Unchanged,!long!duration,!!of!cysts! resolve!within!two!or!three!menstrual!cycles.! 2. Unilateral!vs.!Bilateral! a. Bilateral!!More!likely!benign,!identical!quadrants! b. Unilateral!!Usually!a!cyst,!fibroadenoma!or!lipoma! (rare)!raises!suspicion! 3. Postmenopausal! a. Cyclic!cyst!!less!common!after!menopause! b. Post!menopausal!unilateral!mastalgia!5!cancer!risk! c. Perimenopausal,!postmenopausal!5!cancer!risk! d. New!lump!in!postmenopausal!5!cancer!risk! 4. Nipple!Discharge!with!a!lump!5!Ductal!cancer! 5. Infection!!residual!masses!after!antibiotic!are! suspicious!for!malignancy.! ! Does!the!person!have!additional!risk!factors!for!breast! cancer?! 1. Female!Gender! 2. Age!!75%!cases!>50yo,!no!plateau!w/!age! 3. PHx!of!Breast!Cancer!or!Cancer!in!situ! 4. PHx!of!breast!biopsies!for!non5malignant!breast!disease! a. Fibrocystic!!moderate!risk!! b. Severe!hyperplasia5!1.552X!risk! c. Atypical!Hyperplasia!!5X!risk! d. Lobular!carcinoma!in!situ5!8510X!risk,!Cancer! marker!! !

! ! 5. Genetic!!BRCA1,!BRCA2!gene!mutation! 6. PHX!of!Cancer!!Ovarian,!endometrial,!colon,!thyroid! 7. FHx!of!breast!cancer!5!1st!degree,!>2!relatives! ! Is!this!condition!likely!to!be!benign?! 1. Age! a. Fibrocystic!changes!20!to!30!yo! b. Fibroadenomas!!15!to!39!yo! c. Intraductal!papilloma,!ductal!ectasia!!35555!yo! d. Breast!carcinoma!!40!to!70!yo! 2. Timing,!consistency,!and!duration!!Most!frequent:! painful,!mobile!lump,!size!&!tenderness!as!menstrual! cycle!approaches,!discrete!borders,!measurable.! !fibrocystic! 3. Previous!mammograms!or!biopsies!!Cyclic!changes,! presence!of!glandular!tissue!supports!evidence!of! benign!disease.!If!clear!fluid!aspirate!from!the!cyst!is! obtained!with!no!residual!or!recurring!lump!!more! convincing!evidence!to!be!benign! 4. Breast!Implants!!ruptured!implant,!augmented!breast! tissue!is!pushed!away!from!chest!wall.! ! Could!this!lump!be!mastitis!related!to!lactation?! 1. Childbirth!!Congestive!mastitis!day!2!or!3!after! delivery.!Breast!mass!in!lactating!woman!!mastitis.! Most!common!in!primiparous.!Inflammatory!breast! cancer!is!rare!in!lactating!woman! 2. Sore,!cracked,!or!pierced!nipples!!can!lead!to!infection! 3. Painful!or!Hot!breast!!Mastitis.!In!non5lactating!woman! can!be!the!result!of!insect!bite,!sunburn,!or!allergic! reaction.!Most!common!cause!for!inflamed!breast!in! Breast!Mass!(Lumps!&!Discharge)!5!1!

non5lactating!is!cancer.!All!breast!swollen,!heavy!and! edematous.! 4. Fever!!Infectious!mastitis!in!association!with!lactation! and!breastfeeding.!High!fever!not!due!to!breast! engorgement!in!postpartum,!does!not!usually!occurs! cancer,!rare!in!dermatitis!reactions.! ! Discharge! Is!this!normal!lactation?! 1. Menstrual!Cycle!!fibrocystic!breast!most!marked! before!menses,!spontaneous!multiple!duct!discharge! unilateral!or!bilateral! 2. Pregnancy!and!lactation!!Breast!tenderness,!clear!or! milky!discharge.!Bloody!discharge!can!be!vascular! engorgement!and!clears!within!weeks.!Recent! pregnancy!or!breastfeeding!can!account!for!prolonged! clear!or!milky!discharge,!suppressed!by!stimulation!or! dopamine!agonist!therapy!(bromocriptine!or! pergolide).!In!prolonged!lactation!prolactin!may!be! normal.! 3. Color!of!discharge! a. Normal!lactation!is!milky!and!non5purulent.! Mastitis!due!to!breastfeeding!can!produce! purulent!discharge.!Mastitis!&!abscesses! producing!purulent!discharge!are!suspicious!for! inflammatory!cancer,!or!by!remission!with! antibiotic!therapy.! b. Oral!Contraceptives!can!cause!clear,!serous!milky! discharge,!from!single!or!multiple!ducts.! c. Ductal!ectasia!and!papillomatosis!can!produce! green/brown!discharge.!Serous/serosanguinous! from!single!duct!indicates!intraductal!papilloma!

or!intraductal!cancer.!Bloody!discharge!can!be! benign!or!cancerous.! 4. Duration!of!discharge!!Breastfeeding!can!cause! discharge!long!after!it.!New!onset!on!non! pregnant/lactating!warrants!further!investigation! ! Is!the!discharge!related!to!high!prolactin!levels?! 1. Medicines!!Tranquilizing!medications!have!discharge,! discontinuation!clears!it.!! 2. Behavioral!activities!!Nipples!stimulation,!marijuana! increases!prolactin!levels.!13%!men!with! hyperprolactinemia!gynecomastia!&!galactorrhea.! Woman!with!prolactin!experience!galactorrhea!&! amenorrhea! 3. Other!causes!for!galactorrhea! a. Genetic!disorders! b. Medical!conditions!!Chronic!renal!failure,! sarcoidosis,!Cushing,!Cirrhosis,!Hypothyroid! c. CNS!lesions!!pituitary!adenoma,!empty!sella,! hypothalamic!tumor,!head!trauma! 4. Newborn!! ! Can!the!nipple!discharge!be!a!sign!of!malignancy?! 1. Spontaneous!vs.!Expressed!discharge!!Spontaneous! more!concerning!than!expressed.!Bilateral!related!to! lactation!or!systemic!cause!(prolactin),!Unilateral! spontaneous!!intraductal!papilloma!(IDP)! 2. Unilateral!vs.!Bilateral!discharge!!Unilateral!IDP,! cancer,!Bilateral!!lactation,!rarely!cancer! 3. Single!duct!vs.!Multiple!ducts!discharge!!Single!duct! more!suspicious!for!IDP!or!cancer,!Multiple!prolactin! 4. Associated!mass!!Benign!or!malignant,!solid!vs.!cystic! 5. Postmenopausal!5!cancer!incidence,!unilateral,!spont.! Breast!Mass!(Lumps!&!Discharge)!5!2!

Condition! Cancer!

Cysts! Fibroadenoma! Abscess! Fat!necrosis! Lipoma! Tuberculosis! Ruptured!implant! Mastitis!&!acute!abscess! Inflammatory!breast!cancer!

Common!Causes!of!Breast!Lumps!and!Nipple!Discharge! History! Physical!Findings! Single!Breast!Mass! Usually!older!than!35yo;!unilateral!new!lump! Single,!hard,!non5tender,!fixed!lump;! irregular!borders;!erythema,!dimpling;! vessel!patterns,!nipple!discharge!possible! Younger!age,!often!<35yo,!often!multiple! Round!or!elliptical;!soft!or!fluctuant;!mobile! Common!in!adolescence! Hx!of!mastitis! Single,!sharply!circumscribed,!mobile!lump! Single!mass;!irregular!shape;!chronic! abcess,!can!be!non5tender! Single,!fixed,!often!irregular!tumor! Single!tumors;!smooth,!well!defined,! fluctuant!consistency! Single;!irregular!shape;!non5tender!

Diagnostic!Labs! Diagnostic!mammogram;! ultrasound;!tissue!biopsy! CE;!FNA:clear!aspirate;! mammogram,!U/S:!cysts! Mammogram,!U/S,!biopsy! Biopsy! Biopsy! Biopsy! Biopsy! Mammography,!U/S!;MRI! Culture!S.!Aureus,!E.!coli,!Strep;! WBC! Biopsy!

Fibrocystic!changes!

Intraductal!papilloma! Fibrocystic!changes! Duct!ectasia! Neonatal!discharge! Hyperprolactinemia!

Acute!Mastitis! Cancer! !

Can!have!Hx!injury!at!site! Can!have!others!on!arms,!trunks,!buttocks,!or! back,!usually!non5tender! Hx!tuberculosis,!positive!PPD,!Chet!X5Ray,! Immunocompromised! Hx!augmentation;!change!size!or!shape! Nodule!palpated!best!when!sitting! Inflammatory!Breast!Mass! Primigravidas>multigravidas;!>1wk!after! Red,!warm,!tender;!usually!unilateral,!! deliver;!breast!feeding,!tender!nipples! breast!or!one!lobule,!engorgement,!fever;! nipple!discharge;!pus! Hx!mastitis,!breast!inflammatory!process! Entire!breast!swollen,!fever!rare,!axillary! lymphadenopathy! Multiple!or!Bilateral!Breast!Lumps! Multiple!lumps!both!breast;!cyclic!changes! Bilateral!nodularity,!dominant!lumps;! <menses! tender,!mobile! Nipple!Discharge! Bloody!nipple!disch,!40550yo! Unilateral,!subareolar! Milky!disch,!cyclic!changes!<!menses! Spontaneous,!clear,!milky;!bilateral,!multi5 duct;!multiple!breast!lump!both!! Green!nipple!discharge! Green/brown!discharge! Milky!disch!152wk!after!birth! Enlarged!breast! Milky!clear!disch.,!amenorrhea;!hx! Spontaneous,!unilateral!or!bilateral,! medications:!estrogenic,!dopamine!depleters,! multiduct;!clear!or!milky!discharge! hypothyroid;!pregnancy;!postabort;!nipple! stim.,!visua!changes! Male!Breast!Disease! Hx!clothing!rubbing!(jogging);!swelling!or! Red,!warm,!tender;!usually!unilateral,!1/4! lump;!tenderness! brest,!one!lobule,!engorgement;!fever,! discharge/pus! FHx!male!breast!cancer,!painless!lump! Induration,!nipple!retraction,!mass,!fixed,! non5tender;!lymphadenpathy!

FNA;!U/S;!mammogram!

Mammogram;!U/S;!ductogram! Mammogram;!U/S;!ductogram! Mammogram;!ductogram! None! Serum!prolactin;!TSH;!MRI!if! indicated!

Culture:!S.!aureus,!E.!Coli,!Strep,! WBC! Mammogram;!FNA;!biopsy!

Breast!Mass!(Lumps!&!Discharge)!5!3!

Breast!Examination!
!

Competencies! 1. Inspect#breasts# 2. Inspect#nipples# Demonstrate!patient!positions! 3. Arms#at#side# 4. Arms#raised# 5. Hands#against#hips# 6. Patient#bends#forward# Palpation! 7. Palpate#breasts#(bilateral)#

Assessment!Techniques! Symmetry,!size,!contour,!skin;!color,!thickening! Size,!shape,!direction,!discharge! Looking!for!nipple!retraction,!skin!dimpling!with! different!arm!movts! Above!head! On!hips!w/!pecs!flexed! Support!pts!arms!with!yours,!pt!leans!forward,!look!at! sides!too! Pillow!behind!sh,!arm!raised!above!head,!expose!1! breast!only!(entire!area)5!palpate!w/!3!depths! 5Demo!parallel!line5!start!in!midsternal!move!up!and! down!to!axillae.!Explain!concentric!circles,!radial!lines! 5Nodules,!cysts,!ropey!consistency,!tender,!nipple!d/c! Press!down!on!areola,!squeeze!w/!index!and!middle! finger,!pull!up,!5Elasticity,!thickness,!d/c! Central5!pt!sitting!raise!arm!to!insert!hand!deep!into! axilla;!lateral5!along!upper!humerus;!pectoral5!ant! chest!wall;!subscapular5!post!axillary!fold! Supra5!sh!shrug;!infra5!sh!relaxed!

Abnormalities! Prominent!pores!!underlying*cancer* Ulceration!from!nipple!out!!Pagets*dz* Dimpling!!underlying*cancer*attached*to* suspensory*ligg* ! ! !

Nodule!in!the!tail!of!Spence!!enlarged*LN*

8. Palpate#nipples#(bilateral)# 9. Palpate#axillary#lymph#nodes! 10. Palpate#supra#and# infraclavicular#nodes! When!a!nodule!is!found,!discuss:! 11. Location# 12. Size,#shape# 13. Consistency# 14. Delineation,#mobility,# tenderness# 15. Menstruation,#family#history# 16. Referral#to#family#doctor#
!

Thickened,!loss!of!elasticity5!cancer* Enlarged!LN!!ixn*of*hand/*arm** Fixed,!non5tender,!hard!node!5!malignancy#

Using!clock!positions,!how!far!from!nipple! Diameter,!round,!oval,!irregular! Soft,!spongy,!hard! Irregular!edges,!movable,!tender! Irregular!Menstruation,!Abnormal!bleeding,!Fhx!1! Always!

# # # # # #

Breast!Mass!(Lumps!&!Discharge)!5!4!

15A$$Pelvic$Pain$(Vaginal$Discharge/Itching)$ ! What!kind!of!vaginitis!this!might!be?! 1. Characteristic!Discharge! a. Trichomonas!V.!5!Green,!copious,!offensive!smell! b. Gonorrhea,!Chlamydia!!Mucopurulent,!purulent! c. Candida!!White,!curd5like! d. Bacterial!!Thin,!white,!gray! 2. Itching,!Swelling,!and!redness! a. Vaginitis!inflammation,!redness!of!vulva!and! vagina! b. Candidiasis!!Itching! c. Scratching!!excoriation,!satellite!lesions! d. Bacterial!!no!inflammatory,!discharge!with!little! vulvovaginal!erythema!and!edema!! 3. Odor! a. Bacterial!5!Fishy!odor!by!amines,!accentuated!by! KOH!!whiff!test! b. Trichomonas!V.,!retained!tampons,!foreign!bodies!! foul!odor! ! Is!this!likely!a!sexually!transmitted!disease?! 1. Sexual!History!!Early!onset!activity,!multiple!partners,! nonuse!of!barrier!contraceptives!increase!risk!of!vaginal! infections.!New!Partner,!childbearing!age!(12550yo),! frequent!partner!change,!risky!sexual!practices,!sexual! abuse,!mother!infection!of!neonate!!STI! 2. Recent!treatment!for!a!sexually!transmitted!infection!! Treatment!failure!or!co5infection!that!was!not!covered! by!prescribed!drug,!or!recent!exposure.! 3. Lesions! a. Herpes5vesicles,!external!typ.! ! !

! !

b. Condylomata,!molluscum!!papular!(warts),!labia,! perineum,!anal! c. Syphilis!painless!ulcer,!solitary!

! ! Can!this!be!vaginitis!that!is!not!related!to!an!STI?! 1. Immunocompromised!state! a. Diabetes!5!Refractory!fungal!infection! b. HIV,!Organ!transplant,!cancer! 2. Recent!illness!!chicken!pox,!scarlet!fever,!and!measles! !vaginitis! 3. Medications!or!Chemotherapy!5!Candida!! Contraceptive!pills,!corticosteroids,!antibiotics,! chemotherapy! 4. Night!itching!!pinworms! 5. Activities!!Bicycle,!polls,!hot!tub,!tight!fitting!clothes!! Candidiasis,!Bacterial! 6. Premenarche!!non5estrogenized!vagina,!lack!of!labial! development,!hair!growth!!prone!to!infections! ! Is!this!condition!acute,!recurring,!or!chronic?! 1. Chronology!of!Symptoms! a. Acute!STI!5!After!Having!New!partner! b. Sensitivity!5!Use!of!condoms/Spermicidal!!! c. Chronic!Candidiasis!!worse!after!menses/!recurs! monthly! ! If!this!is!acute,!could!it!be!related!to!a!previous!infection?! 1. Adequate!diagnosis!!based!on!color/appearance!of! discharge!may!be!incorrect,!or!missed!comitant!infx.!Self! Diagnosis/treatment!!in!candidiasis! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!1!

2. Adequate!treatment!!non5compliant!to!treatment!with! onset!of!menses!or!with!early!sxs.!Relief.! 3. Drug!interactions!!inadequate!therapy,!alter!diet! ! If!this!is!chronic,!what!should!I!suspect?! 1. Transmission! a. Poor!hygiene!!Caregivers,!parents,!and!siblings!can! spread!inf.!(Candidiasis,!Molluscum,!herpes,!lice,! pinworms)!to!children! b. Autoinoculation!!Herpes,!warts,!molluscum! 2. New!or!untreated!partner!5Re5infection! 3. Sexual!practices!!Herpes,!gonorrhea! 4. Chronic!vulvovaginitis!!3!episodes!of!candidiasis! within!a!year!!Diabetes,!HIV/AIDS.!Contraceptives,! HRT,!antibiotics,!steroid,!CHO!diet,!artificial! sweeteners,!tight!clothing!!Candidiasis! ! What!are!other!possible!causes!for!this!vaginitis?! 1. Hygiene!practices! a. Contamination!5!Inappropriate!feminine!hygiene! practices!(clean!rectum!vagina)! b. !Allergic!5!perfumes,!douches,!sprays,!lubricants,! bubble!bath! c. Children!!Unsupervised!wiping!technique! 2. Dyspareunia!and!pain! a. Vaginal!atrophy,!genital!warts,!vaginal!infections! !introital!dyspareunia.! b. Endometriosis,!PID,!fibroids!5!Deep!dyspareunia! c. STI!!cervicitis!PID!Abd.!Pain! 3. Eye!infection!!In!newborn,!mother!has!gonorrhea,! chlamydia! 4. Cough!!Pneumonia!of!newborn,!chlamydiosis! ! !

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!2!

! Condition!
Physiological! Bacterial!vaginosis! Candida!vulvovaginitis! Trichomoniasis! Atrophic!vaginitis! Allergic!vaginitis! Foreign!body! Chlamydia! Gonorrhea! Pelvic!Inflammatory!Disease!

! Common!Causes!of!Vaginal!Discharge!and!Itching! History! Physical!Findings!

Discharges! discharge;!no!foul5odor/itching/edema! Clear/mucoid;!pH<4.5! Foul5smelling!discharge! Pruritic!discharge! Watery!discharge;!foul!odor! Dyspareunia;!vaginal!dryness! New!bubble!bath,!soap,!douche,!etc.! Homogenous!thin!white/gray!pH>4.5! White,!curd!like;!pH!455! Profuse,!frothy!green!discharge;!red! friable!cervix!(strawberry);!pH556! Pale,!thin!mucosa;!pH>4.5! Foul!smell,!erythema,!lost!tampon! pH<4.5! Bloody,!foul5smelling!discharge!

Diagnostic!Labs!
Up!to!355WBC/HPF;!epith.!cell,! lactobacilli! KOH!whiff!test,!few!lactobacilli! KOH!prep! Round/Pear!protozoa,!motile! gyrating!flagella! Folded/clumped!epith.!Cell,!FSH! WBC! WBC! DNA;!NAAT;!>10!WBC/HPF,PAP! Gram;!culture;!DNA,!NAAT,!PAP! WBC;!culture;!DNA;!NAAT,! Gram,!PAP! Serology:!VDRL,!RPR! Acetic!acid!test:!white! Viral!culture,!Tzanck!smear!

Syphilis! Genital!warts!(HPV)! Herpes!

Molluscum!contagiosum!

Red/swollen!vulva;!discharge;!hx! tampon,!condom!diaphragm! Partner!with!non5gonoc.!urethritis;!asxs.! May/may!not!have!purulent!discharge! Partner!with!STI;!often!asxs! Purulent;!inflammation!of!glands! CMT!and!adnexal!tenderness;!guarding,! Bleeding,!abd.!pain,!fever,!discharge,! rebound!tenderness! bleeding!after!intercourse! Itching!and!Lesions! Hx!painless!ulcer;!rash!on!palms!and! Chancre!1+,!painless;!condylomata!flat,! soles;!warty!growth!vagina/anus! whitish!papule/plaque;!maculopapular! rash!palm,!soles,!body! Mild/moderate!itching,!foul!disch.,!child:! Moist,!pale5pink!verrucous!lesion!on! sex!abuse!hx;!adult:!new/multiple! base,!vulva,!vagina,!cervix,!perianal! partners,!hx!warts! Hx!prodromal!sxs,!paresthesias,! Grouped!vesicles!red!base,!erode!to! burning,!itching;!mucoid!disch.! ulcer;!if!on!mucous!exudates!forms;!if! on!skin,!crusts!forms,!tender!inguinal! nodes! Hx!contact!with!infected,!if!inflamed! Flesh!colored,!dome5shaped!papules,! itching! some!umbilication;!255!mm!diameter!

None!

! ! ! ! ! !

! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!3!

15A$$Pelvic$Pain$(Vaginal$Discharge/Itching)$ ! What!kind!of!vaginitis!this!might!be?! 1. Characteristic!Discharge! a. Trichomonas!V.!5!Green,!copious,!offensive!smell! b. Gonorrhea,!Chlamydia!!Mucopurulent,!purulent! c. Candida!!White,!curd5like! d. Bacterial!!Thin,!white,!gray! 2. Itching,!Swelling,!and!redness! a. Vaginitis!inflammation,!redness!of!vulva!and! vagina! b. Candidiasis!!Itching! c. Scratching!!excoriation,!satellite!lesions! d. Bacterial!!no!inflammatory,!discharge!with!little! vulvovaginal!erythema!and!edema!! 3. Odor! a. Bacterial!5!Fishy!odor!by!amines,!accentuated!by! KOH!!whiff!test! b. Trichomonas!V.,!retained!tampons,!foreign!bodies!! foul!odor! ! Is!this!likely!a!sexually!transmitted!disease?! 1. Sexual!History!!Early!onset!activity,!multiple!partners,! nonuse!of!barrier!contraceptives!increase!risk!of!vaginal! infections.!New!Partner,!childbearing!age!(12550yo),! frequent!partner!change,!risky!sexual!practices,!sexual! abuse,!mother!infection!of!neonate!!STI! 2. Recent!treatment!for!a!sexually!transmitted!infection!! Treatment!failure!or!co5infection!that!was!not!covered! by!prescribed!drug,!or!recent!exposure.! 3. Lesions! a. Herpes5vesicles,!external!typ.! ! !

! !

b. Condylomata,!molluscum!!papular!(warts),!labia,! perineum,!anal! c. Syphilis!painless!ulcer,!solitary!

! ! Can!this!be!vaginitis!that!is!not!related!to!an!STI?! 1. Immunocompromised!state! a. Diabetes!5!Refractory!fungal!infection! b. HIV,!Organ!transplant,!cancer! 2. Recent!illness!!chicken!pox,!scarlet!fever,!and!measles! !vaginitis! 3. Medications!or!Chemotherapy!5!Candida!! Contraceptive!pills,!corticosteroids,!antibiotics,! chemotherapy! 4. Night!itching!!pinworms! 5. Activities!!Bicycle,!polls,!hot!tub,!tight!fitting!clothes!! Candidiasis,!Bacterial! 6. Premenarche!!non5estrogenized!vagina,!lack!of!labial! development,!hair!growth!!prone!to!infections! ! Is!this!condition!acute,!recurring,!or!chronic?! 1. Chronology!of!Symptoms! a. Acute!STI!5!After!Having!New!partner! b. Sensitivity!5!Use!of!condoms/Spermicidal!!! c. Chronic!Candidiasis!!worse!after!menses/!recurs! monthly! ! If!this!is!acute,!could!it!be!related!to!a!previous!infection?! 1. Adequate!diagnosis!!based!on!color/appearance!of! discharge!may!be!incorrect,!or!missed!comitant!infx.!Self! Diagnosis/treatment!!in!candidiasis! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!1!

2. Adequate!treatment!!non5compliant!to!treatment!with! onset!of!menses!or!with!early!sxs.!Relief.! 3. Drug!interactions!!inadequate!therapy,!alter!diet! ! If!this!is!chronic,!what!should!I!suspect?! 1. Transmission! a. Poor!hygiene!!Caregivers,!parents,!and!siblings!can! spread!inf.!(Candidiasis,!Molluscum,!herpes,!lice,! pinworms)!to!children! b. Autoinoculation!!Herpes,!warts,!molluscum! 2. New!or!untreated!partner!5Re5infection! 3. Sexual!practices!!Herpes,!gonorrhea! 4. Chronic!vulvovaginitis!!3!episodes!of!candidiasis! within!a!year!!Diabetes,!HIV/AIDS.!Contraceptives,! HRT,!antibiotics,!steroid,!CHO!diet,!artificial! sweeteners,!tight!clothing!!Candidiasis! ! What!are!other!possible!causes!for!this!vaginitis?! 1. Hygiene!practices! a. Contamination!5!Inappropriate!feminine!hygiene! practices!(clean!rectum!vagina)! b. !Allergic!5!perfumes,!douches,!sprays,!lubricants,! bubble!bath! c. Children!!Unsupervised!wiping!technique! 2. Dyspareunia!and!pain! a. Vaginal!atrophy,!genital!warts,!vaginal!infections! !introital!dyspareunia.! b. Endometriosis,!PID,!fibroids!5!Deep!dyspareunia! c. STI!!cervicitis!PID!Abd.!Pain! 3. Eye!infection!!In!newborn,!mother!has!gonorrhea,! chlamydia! 4. Cough!!Pneumonia!of!newborn,!chlamydiosis! ! !

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!2!

! Condition!
Physiological! Bacterial!vaginosis! Candida!vulvovaginitis! Trichomoniasis! Atrophic!vaginitis! Allergic!vaginitis! Foreign!body! Chlamydia! Gonorrhea! Pelvic!Inflammatory!Disease!

! Common!Causes!of!Vaginal!Discharge!and!Itching! History! Physical!Findings!

Discharges! discharge;!no!foul5odor/itching/edema! Clear/mucoid;!pH<4.5! Foul5smelling!discharge! Pruritic!discharge! Watery!discharge;!foul!odor! Dyspareunia;!vaginal!dryness! New!bubble!bath,!soap,!douche,!etc.! Homogenous!thin!white/gray!pH>4.5! White,!curd!like;!pH!455! Profuse,!frothy!green!discharge;!red! friable!cervix!(strawberry);!pH556! Pale,!thin!mucosa;!pH>4.5! Foul!smell,!erythema,!lost!tampon! pH<4.5! Bloody,!foul5smelling!discharge!

Diagnostic!Labs!
Up!to!355WBC/HPF;!epith.!cell,! lactobacilli! KOH!whiff!test,!few!lactobacilli! KOH!prep! Round/Pear!protozoa,!motile! gyrating!flagella! Folded/clumped!epith.!Cell,!FSH! WBC! WBC! DNA;!NAAT;!>10!WBC/HPF,PAP! Gram;!culture;!DNA,!NAAT,!PAP! WBC;!culture;!DNA;!NAAT,! Gram,!PAP! Serology:!VDRL,!RPR! Acetic!acid!test:!white! Viral!culture,!Tzanck!smear!

Syphilis! Genital!warts!(HPV)! Herpes!

Molluscum!contagiosum!

Red/swollen!vulva;!discharge;!hx! tampon,!condom!diaphragm! Partner!with!non5gonoc.!urethritis;!asxs.! May/may!not!have!purulent!discharge! Partner!with!STI;!often!asxs! Purulent;!inflammation!of!glands! CMT!and!adnexal!tenderness;!guarding,! Bleeding,!abd.!pain,!fever,!discharge,! rebound!tenderness! bleeding!after!intercourse! Itching!and!Lesions! Hx!painless!ulcer;!rash!on!palms!and! Chancre!1+,!painless;!condylomata!flat,! soles;!warty!growth!vagina/anus! whitish!papule/plaque;!maculopapular! rash!palm,!soles,!body! Mild/moderate!itching,!foul!disch.,!child:! Moist,!pale5pink!verrucous!lesion!on! sex!abuse!hx;!adult:!new/multiple! base,!vulva,!vagina,!cervix,!perianal! partners,!hx!warts! Hx!prodromal!sxs,!paresthesias,! Grouped!vesicles!red!base,!erode!to! burning,!itching;!mucoid!disch.! ulcer;!if!on!mucous!exudates!forms;!if! on!skin,!crusts!forms,!tender!inguinal! nodes! Hx!contact!with!infected,!if!inflamed! Flesh!colored,!dome5shaped!papules,! itching! some!umbilication;!255!mm!diameter!

None!

! ! ! ! ! !

! Pelvic!Pain!(Vaginal!Discharge/Itching)!5!3!

15C$$Pelvic$Pain$(Penile$Discharge)$ ! Is!this!likely!a!sexually!transmitted!infection?! 1. Sexual!History!!Multiple!partners!STI,!Ureaplasma! urealyticum.!New!partner!or!partner!that!has!other! sexual!partners!is!risk!factor.! 2. Unprotected!sex!!vaginal,!oral,!anal!increases!risk!of! STI! 3. Number!of!days!between!exposure!and!symptom!onset! !short!incubation!(246d)!N.!gonorrhea,!longer!period! (243wks)!C.!trachomatis.!IF!multiple!partners!or! unknown!exposures,!incubation!period!not!useful.!! ! Are!there!any!risk!factors!that!point!me!in!the!right! direction?! 1. History!of!drug!or!Substance!abuse!!Risk!factor!for! unprotected,!indiscriminate!sexual!activity! ! What!do!the!characteristics!of!the!discharge!tell!me?! 1. Color,!consistency,!amount!!Copious!yellow4 greenish!gonococcal!infection,!scant! mucoid!nongonococcal!infection.!Whitish!substance! or!drug!abuse! ! Is!this!a!local!infection!or!process?! 1. Red,!inflamed,!Glans!Penis!!Beefy!red!yeast!or!drug! reaction!(tetracycline).!Lubricated!condoms!contact! dermatitis! 2. Hygienic!practice!!Poor!or!aggressive!with!harsh! cleaners!!local!irritation! ! Is!this!complicated!urethritis?!

1. Symptoms!that!may!indicate!complicated!urethritis!! frequency,!urgency,!and!nocturia!urethritis!spreading! to!other!structures,!Prostate.!Perirectal,!testicular!or! low!back!pain!vas!deferens,!epididymitis!or!orchitis.! 2. Symptoms!that!may!indicate!Reiter!Syndrome!! complication!of!NGU!arthritis,!conjunctivitis,!oral! mucosa!ulcers!and!dermatitis.!Joint!an!tendon! involvement!C.!trachomatis!also!reported!in!HIV! patients.!Less!common!in!non4Caucasians.!144wks!after! urethritis!onset.! 3. Disseminated!Systemic!Urethral!infection!! Disseminated!gonococcal!papules!or!petechiae! progress!into!pustules!on!skin!of!hands,!arms,!legs.! ! Is!this!an!upper!urinary!tract!problem?! 1. Fever!!ascending!(pyelonephritis)/descending! (prostatitis,!epididymitis)!infection.! 2. Hematuria!!Pyelonephritis,!lithiasis.!Painless! hematuria!in!elder!bladder!tumor!late!symptom!conf! kidney!carcinoma.! 3. Acute!Pain!!Abd,!flank,!CVA!bladder/ureter/kidney! involvement.!Referred!pain:!testicles!renal!calculi.!! ! What!else!could!this!be?! 1. Scrotal!pain!or!fever!!Epididymitis!often!febrile.! 2. Recent!treatment!or!instrumentation!4!Risk!infection! especially!in!elderly!secondary!to!BPH.! 3. Recent!Treatment!from!an!STI!!treatment!failure,! coinfection,!not!covered,!reinfection.!Noncompliance! 4. Immigrant!Patient/partner!or!Recent!Foreign!Travel!! STI!not!normal!of!NA,!refer!to!urologist/Public!health.! ! ! 15C!Pelvic!Pain!(Penile!Discharge)!4!1!

Condition!
Balanitis! Gonococcal!urethritis!

Common!Causes!of!Penile!Discharge! History! Physical!Findings!

Not!circumcised;!poor!hygiene!practice! Localized!erythema,!edema;!smegma;! foul!smelling!discharge! Unprotected!sex;!abrupt!onset!345d! Yellow4green!discharge;!spontaneous! after!exposure;!yellow4green!discharge;! or!copious!amounts!with!stripping!of! frequency,!urgency,!dysuria!>beginning! penis! of!urination! Unprotected!sex;!longer!incubation!(84 Thin!mucoid!discharge!may!be! 12d);!meatal!itching,!irritation;!scant! absent!or!minimal!with!penile! mucoid4like!discharge,!before!first! milking!or!stripping.! voiding!of!day;!symptoms!vary;! urgency,!frequency,!dysuria! Chills,!fever;!30450yo;!onset!over!days;! May!have!fever;!painful!prostate;!do! pain!in!rectal,!perianal!area,!low!back,! not!massage! and!abdomen! Abrupt!onset!several!hrs.,!febrile,!pain! Tender,!swollen!epididymis!and/or! in!scrotum!and/or!testicles! testicles;!elevation!of!affected!testicle! lessen!discomfort,!may!have!fever! Joint!and!tendon!involvement;! Decreased!ROM;!skin!and!mucous! urethritis! lesions;!conjunctivitis!

Diagnostic!Labs!
None;!Hx!&!physical!exam! Collect!specimen!144!hr!after!last! voiding;!gram!stain,!culture;!urine! DNA!test!for!gonococcus!(NAAT)! Gram!stain;!culture;!urine!DNA! testing!for!Chlamydia!(NAAT)!

Nongonococcal!urethritis!

Acute!bacterial!prostatitis! Epididymitis/Orchitis! Reiter!Syndrome! Reactive!Arthritis!

Segmental!urine!specimens;! culture!and!sensitivity! Doppler!flow!studies!with!color! Blood,!synovial!fluid,!HLAB27!Ag;! X4ray!

15C!Pelvic!Pain!(Penile!Discharge)!4!2!

16##Dysuria#(Females)# ! !Are!there!systemic!or!upper!urinary!tract!symptoms! present?! 1. Fever!and!chills!!Systemic!inflammatory!response,! acute!<!Pyelonephritis,!upper!UT!lithiasis,!UTI! 2. Nausea!and!vomiting!!Systemic!inflammatory!response! <!UTI,!pyelonephritis,!lithiasis.! 3. Acute!pain!!Back,!abdomen!!Upper!UTI,! pyelonephritis.!Flanks!!pyelonephritis,!infection,! obstruction,!primary!renal!disease.! 4. Immunocompromised!patients!!Overwhelming! infection!common!and!atypical!organisms.! ! Is!there!hematuria?! 1. Hematuria! a. Red!to!brown<!infection,!trauma,!urinary!tract! stones.!Renal!disease,!systemic!disease,!medication,! coagulopathies.! b. Gross!hematuria!!pyelonephritis,!urinary!tract! stones,!cystitis.!60<90%!bladder!tumors.!Bladder!&! renal!neoplasm!more!common!in!men.!! c. Platelet!disorders,!hemophilia!!gross!&!microscopic! hematuria.! d. Urinary!frequency,!urgency,!dysuria,!suprapubic! pain!!hematuria!confined!to!lower!urinary!tract.! e. Initial!hematuria!at!urination!!urethra! f. Terminal!hematuria!!posterior!urethra!or!bladder! g. Total!hematuria!!Kidney,!ureter,!bladder! 2. Pain!!Hematuria!w/o!Pain!!renal!disease,!tumor!of! bladder!or!kidney,!stones,!polycystic!kidney,!renal!cyst,! sickle!cell,!hydronephrosis.!With!Renal!colic!!ureteral!

stone.!Hematuria!+!dysuria!bladder!infection!or! lithiasis.! 3. Bleeding!without!urination!<!Bladder!lesions!! 4. Strenuous!exercise!!transient,!proportional!to!amount! of!exercise!and!trauma!sustained.!Direct!trauma!to! kidneys/bladder!or!ischemic!injury.!Shifting!of!blood! from!kidney!to!heart,!lungs,!skeletal!muscles!during! high!O2!demand! ! Can!the!symptoms!be!localized!to!the!lower!urinary!tract?! 1. Primary!Symptoms!!Dysuria!suggest!inflammation!of! the!bladder!neck!or!urethra!bacterial!infection!(can! lea!to!urgency!and!frequency),!acute!bacterial!cystitis,! urethritis!(if!accompanied!by!vaginal!discharge).! External!dysuria!vulvovaginitis!(also!has!discharge,! odor,!itching),!active!herpes!lesion.!Interstitial!cystitis!<!! diminished!bladder!capacity,!frequent!urination,! hematuria!might!be!present.!Increased! frequency!stone!or!tumor.! 2. Suprapubic!Discomfort!and!Urinary!incontinence!! bladder!neck!irritability,!impaired!bladder!muscle,! pelvic!relaxation.! ! Could!this!be!the!result!of!trauma?! 1. Recent!injury!!Blow!to!the!flank!!hematuria!from! kidney.!Straddle!injury!pain!during!urination.!10%!of! injured!kidney!has!abnormalities!!hydronephrosis,! horseshoe!shape.! 2. Trauma!!Victim!of!domestic!violence!hematuria! secondary!to!trauma!with!or!w/o!pain.! ! ! !

Could!this!be!genitourinary!in!origin?! 1. Sexual!Activity!!Frequent!intercourse,!diaphragm,! spermicidal!!bacterial!cystitis.!Urethritis!new! partner,!partner!with!urethritis,!multiple!partners.! Dysuria!masturbation!due!to!introduction!of! organisms!that!produced!lower!UTI.!Urethritis,!STI!(C.! trachomatis,!N.!gonorrhoea,!Trichomonas!vaginalis,! herpes).!Active!herpes!dysuria! 2. Diaphragm!Use!!Mechanica!compression!of! urethra!urinary!retention!cystitis! 3. Vaginal!Discharge!and!Hormone!Therapy!!Vaginal! infections,!Atrophic!Vaginitis!dysuria.!Postmenopausal! women!not!in!hormone!therapy!Atrophic!vaginitis! ! Are!there!any!specific!risk!factors!to!point!me!in!the!right! direction?! 1. History!of!similar!problems!!Increased!risk!of!chronic! relapsing!conditions!unresolved!infection,!resistant! strains,!reinfection! 2. Recent!instrumentation!!Increase!risk!of!infections! 3. Family!history!of!urinary!problems!!increased!risk!of! UT!disorders.!FHx!of!deafness!or!renal! insufficiency!hereditary!nephritis!or!Alport!syndrome.! 4. History!of!Diabetes!Mellitus!!Recurrent!bacterial! cystitis! 5. Types!of!food!Consumed!!Dysuria!spicy!foods,! carbonation,!alcohol! 6. Decreased!Fluid!Intake!!Concentrated!urine!dysuria! w/o!pyuria,!bacterial!cystitis.! 7. Urge!to!urinate!!postponing/ignoring!urge!bacterial! cystitis.!! 8. Bubble!bath!and!Hygiene!Products!!Chemical! irritation!dysuria!without!infection!

9. Constipation!!compression!of!bladder!neck!UTI,! incomplete!bladder!emptying.! ! What!else!could!this!be?! 1. STI!!Vaginitis,!if!have!had!recent!then!treatment!may! have!failed,!coinfection!not!treated!by!medication!or! reinfection.! 2. Excessive!urination!!polyuria!Diabetes!mellitus! (prone!to!UTI)! 3. Recent!streptococcal!infection!!Post!streptococcal! glomerulonephritis!1<3!wks!latency!following! pharyngitis!or!skin!infection!with!certain!strains!of! GABHS.!Peak!age!7yo.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Condition!
Uncomplicated!UTI! Urethritis! Vulvovaginitis! Interstitial!cystitis! Pyelonephritis!

Common!Causes!of!Urinary!Problems!in!Females! History! Physical!Findings!

Dysuria,!frequency,!mild!nausea,! nocturia,!urgency,!voiding!small!qty.,!! Dysuria,!vaginal!discharge,!hx!new!sex! partner,!frequent!sex,!multiple!partner! Hx.!Vaginal!itching,!discharge,!burning,! dryness;!postmenopausal! Frequent!painful!urination,!hematuria,! middle!aged,!long!standing!symptoms! Fever,!chills,!back!pain,!N/V,!toxic! appearance;!some!patients!also!have! frequency!and!dysuria! Pain,!hematuria,!may!have!symptoms!of! 2nd!infection;!renal!colic!pain!that! radiates!to!inner!tight;!nausea,!vomiting! Hx!skin/throat!infection!1<3!wks!prior;! lethargy,!anorexia,!vomiting,!abd.!pain! Hx!of!bubble!baths,!soaps,!lotions,! sprays,!urgency,!dysuria!

Urolithiasis! Poststreptococcal! glomerulonephritis! Chemical!irritant!

Diagnostic!Labs! Urine!dipstick:!RBC,!WBC!esterase,! +nitrites;!microscopic!analysis:!RBC,! WBC,!no!casts;!urine!C&S! Dipstick:!RBC,!WBC!esterase,!nitrites;! urines!culture;!DNA!testing!vaginal! specimen! Inflamed!or!atrophic!labia;! Microscopic!exam,!vaginal!cultures,! vaginal!or!cervical!discharge! molecular!testing! Appears!well,!no!physical!finds,! Urinalysis!negative;!X<ray,! May!have!suprapubic!tenderness! Cystometric!studies;!cystoscopy! Feels!and!looks!ill;!fever;!CVA! Dipstick:!RBC,!WBC!esterase,!nitrites;! tenderness;!abd.!may!be!tender! microscopic!exam:!WBC!or!bacterial! casts;!urine!C!&S:!Ecoli,!Klebsiella,! Proteus!Mirabilis,!Enterobacter;!blood! cultures! CVA!tenderness,!looks!ill!during! Urinalysis:!gross/micro!hematuria;! periods!of!pain;!may!have!abd.! WBC!w!or!w/o!bacteria;!crystalline! distention! structures;!non!contrast!helical!CT! Hypertension,!periorbital!edema,! U/A:!proteinuria,!hematuria,!ASO! CVA!tenderness;!may!have! titer;!serum!C3!low!early!disease! dyspnea,!cough,!pallor! No!fever;!erythematous!labia,! Hematuria!common,!gross!hematuria! urethral!opening! usual!and!casts!never!seen!
Appears!well,!No!fever,!no!CVA! tenderness,!may!have! suprapubic!tenderness,!! Appears!well,!no!CVA!tenderness! or!fever!

16B$$Dysuria$(Male$Genitourinary)$ ! Are!systemic!or!acute!symptoms!present?! 1. Fevers!and!Chills!!Suggest!systemic!inflammatory! response,!patient!acutely!ill.!Suspect!pyelonephritis!or! lithiasis!of!upper!UT,!or!prostatitis,!orchitis,! epididymitis!of!lower!UT.! 2. Immunocompromised!Patients!!Susceptible!to! infections!by!common!and!atypical!organisms.! 3. Acute!Pain!!Abd.!or!flank!!bladder,!ureter!and!kidney! involvement.!Acute!pain!in!the!scrotum!or!testicles!may! indicate!infection!or!pathology!of!the!scrotal!content!or! referred!pain!from!other!urinary!sites.!Scrotum!pain!is! characteristic!of!inflammation!of!the!testicle,!epididymis! or!torsion!of!a!testicle.! 4. Anuria!!Sudden!decrease!!!compromised!renal!blood! supply!(prerenal),!damaged!interstitia,!glomeruli,!or! tubules!(intrarenal);!or!obstructed!urine!flow! (postrenal).!! a. Prerenal!failure!6!usually!have!hx!of!volume! depletion!or!reduction!in!blood!volume!with!low! cardiac!output.!! b. Intrarenal!failure!!Hx!renal!damage!from! nephrotoxic!agents! c. Postrenal!failure!!least!likely!cause!of!anuria,!but! should!be!investigated!before!permanent!nephron! damage!occurs.! d. Elderly,!diabetics,!renal,!heart!or!liver!disease!at! greatest!risk.! ! Is!there!hematuria?! 1. Hematuria!!blood!can!enter!urinary!tract!at!any!point.! Most!is!extrarenal.!Lower!UT!or!bladder!lesion!660%.!! !

! 2. Timing!!Anterior!urethral!lesions!(urethritis,!stricture,! meatal!stenosis)!!becomes!clear!during!voiding.! Prostatic!or!prostatic!urethra!!terminal!hematuria! (clear!initially!bloody).!Kidney,!ureters!lesions!!Total! hematuria.!Bladder!lesions,!recent!kidney!trauma!! bleeding!independent!of!micturition.!Gross!hematuria!is! often!transient!but!may!continue!microscopically.! 3. Pain!!With!hematuria!!passing!stone!or!sloughed!renal! papilla,!often!with!concurrent!infection.!Painless! hematuria!upper/lower!tract!tumor,!systemic! coagulopathy,!excessive!anticoagulant.!Less!common,! acute!necrosis!or!sloughing!of!papilla.!In!elderly! painless!hematuria!renal!cancer.! ! Can!the!symptoms!be!localized!within!the!urinary!tract?! 1. Hesitancy,!slow!urinary!stream,!and!dribbling!of!urine!6! >50yo,!gradual!onset!!BPH! 2. Low!back,!Flank,!or!Abdominal!Pain!!Ureteral/Kidney! involvement.!Dislodged!kidney!stone!!colicky,!cyclic! ureteral!pain,!can!radiate!to!abd,!testes,!and!penis.!Renal! disorders!do!not!frequently!cause!pain.!If!pain!is!present! it!is!from!calyces!or!renal!pelvis!6!!stretching!of!capsule,! interstitial!edema,!inflammation!of!capsule.! 3. Aching!in!the!perianal!area!!Prostate!pain,!infection! (usual),!prostatic!stones!with!infection.! 4. Suprapubic!discomfort!and!urinary!incontinence!! Suprapubic!6!Bladder!involvement,!incontinence!!

! ! From!kidney!!nephropathy!and!polycystic!kidney! disease.!No!cause!10615%.!

15D!Pelvic!Pain!(Male!Genitourinary)!6!1!

Bladder!neck!irritability!by!inflammation.!Bladder!pain! !infection,!obstruction,!distention!by!tumor!or!stones.! 5. Penile!discharge!with!frequency,!urgency,!and!dysuria!! STI,!See!dysuria!(discharge,!male)!! 6. Nocturia!!Primary!Bladder!disease!from!infection,! stones,!or!tumors.!Prostate!enlargement! characteristically!produces!nocturia.! 7. Polyuria!6!>3L!urine/d,!early!indication!of!renal!disease! progression!due!to!inability!to!concentrate!urine.! Pseudopolyuria!!excess!fluid!intake.!Alcohol!ingestion! inhibits!ADH!!causes!polyuria;!glycosuria!promotes! excess!solute!excretion.!Diabetes!insipidus;!CHF!due! to!mobilization!of!fluid.! ! Are!there!any!specific!risk!factors!to!point!me!in!the!right! direction?! 1. History!of!similar!problems!!risk!of!chronic!relapse6! unresolved!infections,!resistant!strains,!reinfection.! 2. Family!History!of!Urinary!problems!!Renal,!Kidney!or! prostatitis!increases!risk!for!urinary!problems.!Familial! disorders!implicated!n!kidney!disease!!DM,! hypertension,!collagen!vascular!disease,!nephrolithiasis,! and!polycystic!kidney!disease.! 3. Age!!Occurrence!increases!with!age.!Prostatic! obstruction!m/c>50yo,!painless,!difficulty!starting! urine!stream,!less!stream!force,!continues!to!dribble! after!voiding.!Chlamydia!prostatitis,!epididymitis,!and! nongonococcal!urethritis,!>40yo.!Adolescent!STIs!risk.! 4. Confinement!to!bed!!Elderly!prone!to!infections!due! to!urinary!stasis/reflux! 5. Sexual!Activity!!risk!for!STIs!urethritis.!Increased! risk!with!multiple!partners!

6. Bicycle!riding!!Perineal,!penile!numbness,!w/o! pain!long!distant!cyclist!due!to!stretching!of!pudental! nerve.! ! What!else!could!this!be?! 1. Recent!instrumentation!!indwelling!catheters! !increased!risk!of!infections.! 2. Recent!STI!!Treatment!failure,!coinfection!not!covered! by!prescribed!drug,!reinfection.! 3. Drug!review!or!History!!nephrotoxic!drugs!! Aminoglycosides,!NSAIDs,!iodated!radiocontrast,!ACEI,! AMphtericin!B,!chemotherapy!agents,!cocaine,!H2! recptor!agonist,!sulfonamide,!Volatile!HC.! 4. Toxic!exposures!!occupational!hazards!!Volatile!HC,! benzene,!aniline,!xylene,!heavy!metals,!ionizing! radiation.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 15D!Pelvic!Pain!(Male!Genitourinary)!6!2!

Condition!
Cystitis/Urethritis!

Common!Causes!of!Genitourinary!Problems!in!Males! History! Physical!Findings!

Frequency,!urgency,!dysuria;!nocturia! with!low!back!pain! Fever,!chills,!back!pain,!n/v,!toxic! appearance,!frequency,!dysuria! Pain,!hematuria;!may!have!symptoms!of! 2nd!infection;!renal!colic:!pain!radiate! inner!thigh;!n/v! Chills,!high!fever,!frequency,!urgency;! perineal!pain,,!low!back!pain;!varying! obstructive!symptoms,!dysuria,!burning,! nocturia,!hematuria,!arthralgia,!myalgia! c/c!recurrent!cystitis,!!same!pathogen!in! prostate!secretion;!asymptomatic;!c/! low!back!pain,!perianal!pain,!frequency,! painful!urination! Pelvic!Pain!3!out!of!6!preceding!months,! no!bacterial!cause,!dysuria,!urgency,! frequency,!backache,!obstructive! voiding!symptoms! Symptoms!of!another!GU!problem;!no! pain! Abrupt!onset!several!hours;!febrile;! testicle/scrotal!pain! Sudden!onset!testicle!pain,!radiates!to! groin;!lower!abd.!pain! Hesitancy,!slow!urine,!dribbling,! nocturia! Hesitancy,!slow!urine,!dribbling,! nocturia,!low!back!pain!

Pyelonephritis! Urolithiasis! Acute!Bacterial!Prostatitis!

Diagnostic!Labs! Urine!dipstick:!+!leukocyte!esterase;! hematuria,!U/A!w/!microscopic!exam;! segmented!urine!collection;!Gram! stain;!C!&!S;!urine!DNA!test!(NAAT)! Microscopic!exam,!WBC!white!cell! Feels!&!looks!ill;!T>38.3C;!CVA! casts/!bacterial!casts;!urine!C!&!S;! tenderness;!abd.!may!be!tender! blood!culture! May!have!CVA!tenderness;!looks! Urinalysis:!gross/micro!hematuria;! ill!during!acute!pain;!may!have! WBC!w/!w/o!bacteria;!crystalline! abd.!distention! structures;!X6ray,!U/S! Urinalysis;!urine!culture;!prostate! T>38.3C;!prostate!tender,! swollen,!indurated,!warm;!do!not! secretion!culture! massage!can!cause!bacteremia!
Discharge!may!be!present;!may! have!suprapubic!tenderness! Infection!can!involve!scrotal! content!epididymitis;!prostate! palpation!nonspecific;!moderate! tender,!irregular!indurated,! boggy,!copious!secretion! Normal!prostate!exam! Culture!prostatic!secretion;!culture! post!massage!urine;!WBCs!present!in! EPS!&!VB3! Inflammatory:!absence!of!bacteria!and! presence!of!WBC!in!semen,!EPS!or!VB! 3! WBC!found!expressed!in!prostatic! secretions! Doppler!blood!flow!studies!with!color! Scrotal!U/S!!surgical!emergency!

Chronic!Bacterial!prostatitis!

Chronic!Pelvic6Syndrome/! Prostatitis;!infl/noninfl.! Asymptomatic!inflammatory! Prostatitis! Epididymitis/Orchitis! Testicular!torsion!

Specific!for!another!GU!disorder! Tender,!swollen!epididymis/! testicle;!elevation!of!testicle! lessen!discomfort;!fever.!! Exquisitely!tender!testicle;!may! ride!high!due!to!shorten! spermatic!cord;!cremasteric! reflex!absent! Prostate!rectum!protusion;! median!sulcus!reduced;!boggy!! Prostate!rectum!protusion;! prostate!hard!

BPH! Prostate!Cancer!

TRUS;!PSA! TRUS;!PSA;!biopsy!

15D!Pelvic!Pain!(Male!Genitourinary)!6!3!

Condition!
Bladder/Kidney!Tumor! Perineal!compression! Syndrome!

Common!Causes!of!Genitourinary!Problems!in!Males! History! Physical!Findings!

Often!Hx!smoking,!alcohol!abuse! Genital!numbness,!no!pain,!increase!in! training,!miles,!change!in!bicycle/equip! Usually!no!sign!other!than!silent! hematuria! Usually!no!visible!signs!

Diagnostic!Labs!
U/A:!hematuria! Rule!out!cauda!equina!syndrome!or! other!neuropathy;!refrain!from!biking! for!3!weeks,!refit!bicycle!saddle.!

15D!Pelvic!Pain!(Male!Genitourinary)!6!4!

17##Low#Back#Pain# ! Is!this!potentially!serious!cause!of!Acute!Low!Back!Pain! (ALBP)?! 1. Fever!!Inflammatory!condition!Spondyloarthropathy,! systemic!infection!(Fever,!chills,!weight!loss,!hx! infection,!IV!drug!use,!immunosuppressed).!Ewing! Sarcoma!(malignant!tumor)!can!mimic!spinal!infection! (back!pain,!fever,!refuse!to!walk).! 2. Trauma!!Fracture,!dislocation,!misalignment!of! muscles,!ligaments!&!discs!from!blunt!impact,!repetitive! injury,!lifting,!pulling.!Most!common!occupational! injury.!Usually!contusion!and!abrasions!but!can!cause! spinal!fracture!(vehicle!accident,!or!fall).!In!elderly!with! osteoporosis!fracture!from!strenuous!lifting.!Suspect! spinal!injury!is!impaired!LOC!after!accident.!! 3. Age!!in!absence!of!trauma,!sudden!onset!of!severe,!low! or!middle!back!pain,!>30yo!might!suggest!dissecting! aneurysm.!Pain!not!alleviated!by!rest.!>50yo! compression!fracture,!cancer! 4. Systemic!Disease!!Metabolic!disease,!inflammatory! disorders,!fibromyalgia.!Hx!of!cancer!spinal!tumor.! May!have!unexplained!weight!loss! 5. Bowel!and!Bladder!Symptoms!!loss!of!urinary!or!stool! continence!cauda!equina,!s1!or!S2!nerve!root! compromised!secondary!to!herniated!disk,!entrapment,! spinal!stenosis,!infection,!or!tumor.!Lumbar!puncture! with!saddle!anesthesia,!urinary!retention,!fecal! incontinence!cauda!equina!syndrome!(Emerg.)! 6. Medications!!Long!term!use!of! corticosteroids!Compression!fractures!of!vertebrae.!! ! ! !

! What!does!the!location!of!pain!tell!me?! 1. Location!of!pain! a. Trauma!!cervical!and!lumber!regions!more! motion,!less!protection! b. Overuse,!Inflammatory!!Generalized!pain,!over! wide!area! c. Sciatica!!Sharp,!burning!radiates!down!the! posterior!and!lateral!leg!to!foot,!ankle! d. Cervical!osteomyelitis!!back!pain!with!stiff!neck! e. Rheumatoid!arthritis!!upper!back!and!neck!pain! f. Spondylolysis,!tumors!!localized! g. Flank!!kidney!infection!(pyelonephritis)! h. Gallbladder!disease!!radiates!to!right!subscapular! area! i. Osteoporosis,!Malignancies!!compression!fractures,! mid.thoracic!pain! ! What!does!the!pattern!of!pain!tell!me?! 1. Onset!!normally!is!sudden!and!resolves!with! conservative!treatment!in!4!weeks,!X.ray,!other!studies! not!recommended!until!then.! 2. Duration!!Subacute!6.12!wks,!Chronic!>3mo.!>40yo! can!be!postural,!congenital!(scoliosis,!ankylosing! spondylitis).!In!older!indicates!degenerative!disease! (spinal!stenosis,!disc!herniation)! 3. Pain!Characteristics!!Intractable,!night! pain!neoplastic!disease.!Painful!scoliosis!and! stiffness!!spinal!tumor! 4. Night!Pain!!Tumor,!infection,!inflammation.!Muscle! pulls,!overuse!injuries,!spondylolysis,!spondylolisthesis,! have!less!pain!at!night.!! 5. Recurring!Pain!!compression!fracture!in!the!older.! 17!Low!Back!Pain!.!1!

! What!does!the!pain!in!relationship!to!activity!tell!me?! 1. Aggravating!factors! a. Exercise,!sports!!muscle,!tendons!contusions!and! sprains.!Fractures!of!pas!articularis!in!gymnastics! b. Activity!!MSK! c. Standing,!sneezing,!coughing!!Spinal!stenosis! d. Hyperextension!(tennis!serving,!back!handspring,! butterfly!stroke)!.!spondylolisthesis! 2. Alleviating!factors! a. Activity!!Ankylosing!spondylitis! b. Not!related!to!activity!or!not!relieved!by!rest!! tumor! c. Aspirin,!NSAID!!inflammatory! d. Rest,!Heat!!MSK! e. Flexion!of!spine!!spinal!stenosis! ! What!does!radiation!of!pain!tell!me?! 1. Referred!from!spine! a. Upper!lumbar!!radiates!anterior!aspect!of!tight,!legs! b. Lower!Lumbar!!gluteal!regions,!posterior!tight!and! calves.! c. Spondylolisthesis,!spondylolysis!!report!hamstring! tightness,!buttock!discomfort,!LBP! d. Sciatica!!sharp,!burning!radiates!down!lateral!or! posterior!leg!to!lateral!ankle,!foot!!from!disc! displacement.! 2. Referred!from!pelvic,!abdominal!viscera! a. From!visceral!disease!!usually!felt!within!abdomen! and!flanks.!Gallbladder!right!scapula.! ! ! ! !

! Are!there!signs!of!neurological!damage?! 1. Stumbling!!Spinal!cord!tumors!(astrocytoma,! ependymoma)!movement!disturbance!in!posture,! strength!in!spine!or!extremities.!Impairment!of! proprioception!or!sensation!from!an!UMN!lesion!foot! drop,!ataxia,!stumbling! 2. Numbness!and!Tingling.!Radiculopathy!(nerve!root! pain)!!sharp,!dermatomal!with!numbness!and!tingling! ! Is!there!a!family!history!of!back!pain?! 1. Family!History!!Spondylolysis!&!scoliosis!often!seen!in! families.! ! Could!a!systemic!disease!cause!this?! 1. Illness!!Female!PID!>moderate,!dull,!aching,!low!abd.! pain,!&!LBP.!Pyelonephritis!fever,!N/V,!headache,! back/flank!pain.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 17!Low!Back!Pain!.!2!

! Condition!
Spinal!Fracture! Tumor! Osteoblastoma! Osteoid!osteoma! Infection!(vertebral! osteomyelitis)! Diskitis! Herniated!Disc! Cauda!Equina! Syndrome! Sciatica! MSK!strain! Spondylolisthesis! Ankylosing!spondylitis! Spinal!Stenosis! Osteoporosis!

Common!Causes!of!Acute!Low!Back!Pain! History! Physical!Findings!

Potentially!Serious!Causes! Trauma!to!spine!or!back;!pain!is!felt!near! Palpable!tenderness!over!site!of!fracture! site!of!injury! Hx!cancer;!progressive!pain!is!unremitting;! Weight!loss,!fever,!tenderness!near!tumor! occurs!at!night!and!rest! Neck!or!back!pain!not!relieved!by!aspirin;! Local!tenderness;!may!have!scoliosis!with! occurs!in!older!adolescents,!young!adults! muscle!pain! Primarily!adolescents;!rare>40yo;!well! localized!pain!more!severe!at!night!relieved! by!aspirin!of!other!PG!inhibitor! Infection!Hx,!invasive!procedure;!continuous! dull!back!pain;!chronic!back!pain! Painful,!well.localized!scoliosis!may!be! present.!

Diagnostic!Labs!
Emergency;!immobilize! patient,!transport!for!X.ray! ESR;!bone!scan! Plain!film:!expansive!osteolytic! lesion!surround!think!rim!of! bone;!bone!scan;!CT!scan! Bone!scan! ESR;!blood!culture;!bone! biopsy;!CT!scan;!MRI! ESR! None! MRI,!surgical!emergency!

Acute!onset!presents!fever,!diaphoresis;! tenderness!over!affected!disc;!positive! SLR!(straight!leg!raise)! Pain!agg.!By!movement;!m/c!children! Tenderness!over!affected!disc! LBP!radiating!down!buttock!below!knee,!less! Positive!SLR! than!one!month! Constant!pain!in!saddle!distribution;!urinary! Positive!SLR,!abnormal!DTR,!motor! retention,!fecal!incontinence,!radiculopathy! weakness! Sciatica!&!Nonspecific!Back!Problems! Acute!back!pain!with!radiculopathy;!HX!of! Paravertebral!tenderness!and!spasm,!+! strain!or!trauma,!relief!when!sitting! SLR,!sitting!knee!extension,!sensory! findings! Pain!in!the!back,!buttocks;!Hx!new!activity!or! Paravertebral!tenderness,!scoliosis,! exertion,!relief!when!sitting! lumbar!lordosis,!no!neurological!sgn! Young!in!sports!(hyperflex.extend)!or! No!neurological!signs;!pain!localized!to! excessive!load!in!hyperestension! low!back,!below!iliac!crest;!tight! hamstring! <40yo,!insidious!onset;!progressive!morning! Painful!sacroiliac!joint,!reduced!spine! back!pain!relieved!w/exercise! mobility,!may!have!uveitis! Pain!worse!throughout!the!day;!agg.! Sign!of!osteoarthritis!of!joints;!may!have! Standing,!amel.!rest! neurological!signs! Chronic,!poorly!localized!back!pain;! Palpable!tenderness!over!area!of! postmenopausal;!slight!build;!hx!inactivity/! compression!fracture;!kyphosis!or! endocrine!disorder! lordosis;!loss!of!height!

EMG!if!chronic! None! Lumbar!spine!X.ray! ESR;!spinal!X.Ray! None! Bone!densitometry;!Spinal!X. ray!to!assess!fracture!

17!Low!Back!Pain!.!3!

Condition!
Aortic!aneurysm!

Common!Causes!of!Acute!Low!Back!Pain! History! Physical!Findings!

Non.spinal!Causes! Severe,!acute!onset!pain!not!related!to! Intact!aneurysm!pulsatile!midline!UQ! activity!or!movement;!increased!risk>30yo;! mass;!in!dissected!aneurysm!upper! pallor,!diaphoresis,!anxiety,!confusion! extremity!pulse!and!pulse!pressures!are! asymmetrical;!posterior!thoracic!pain! Increased!incidence!with!age;!steady,! Normal!physical!exam,!positive!Murphy! intense!pain!in!RUQ!radiation!right!scapula! sign!on!abdomen!palpation! or!shoulder;!belching,!bloating,!fatty!food! intolerance! Ill.appearance;!sweating,!nausea,!back!or! Fever;!cloudy,!malodorous!urine;!CVA! flank!pain,!headache! tenderness!on!percussion! Hx!of!recent!URI;!pleuritic!pain! Normal!examination!or!crackle!and! bronchial!breath!sounds! Sexually!active!female;!LB!and!abdominal! Cervical!and!uterine!motion!tenderness,! pain;!Hx!urinary!or!vaginal!symptoms,!STI,! adnexal!tenderness;!cervicitis,!fever! IUD,!multiple!sex!partner! Hx!psychosocial!stressors,!depression,! Exaggerated!or!inconsistent!reactions!to! exaggerated!expression!of!pain! testing;!normal!examination!

Diagnostic!Labs!
Emergency!surgical!referral!

Gallstones!

Surgical!referral!

Pyelonephritis! Pleuritis! PID! Psychological!

Urinalysis;!urine!culture! PPD;!chest!X.ray! Gonorrhea,!Chlamydia! cultures;!ESR! None!

! !

17!Low!Back!Pain!.!4!

18##Joint#Pain# ! Is!the!joint!pain!related!to!an!urgent!problem!that!needs! immediate!treatment?! 1. Constitutional!Symptoms!!generalized!symptoms!such! as!fever,!weight!loss,!generalized!malaise,!or!hot!swollen! joints!infection,!rheumatic!disease.! Fever!hematogenous!spread,!direct!invasion!as!a! result!of!trauma,!puncture!or!migration!from!adjacent! area.!Rheumatic!Fever!!!hemolytic!streptococcal! infection!precedes!joint!pain!1+3!weeks,!hip!joint!first! affected!before!polyarticular!involvement!occurs,!fever! is!sustained.!Intermittent!fever/spikes!chronic!forms!in! children.!!Polyarthritis!!bacterial!endocarditis,!Lyme,! syphilis,!Hep!B,!rubella,!CMV,!HIV,!EBP,!Varicella!Zoster.! 2. Severity!!Unrelenting!diffuse!pain,!often!at! night!Bone!cancer,!osteomyelitis,!septic!hip.! Claudication!and!neurogenic!pain!increase!with!activity! and!decreased!with!rest!vascular!causes,!more!slowly! for!neurogenic!causes.! ! Could!this!be!a!joint!disease?! 1. Intraarticular!pain!!inflammatory!radiates! diffusely!to!surrounding!tissues,!intense,!sharp,! burning,!boring,!or!pulsating!pain,!persist!during! rest,!and!at!night,!worse!in!the!morning!with! stiffness,!improves!through!out!the!day.! 2. Degenerative!!radiates!to!soft!tissue!structures! around!the!joint!(muscles!ligaments,!tendons).!It!is! dull,!boring,!gnawing!with!muscle!pain!or!sharp,! acute!with!overuse.! ! ! !

! ! What!does!stiffness!tells!me?! 1. Joint!stiffness!!inflammatory!arthropathy.!Worse!in!the! morning!with!SLE,!RA,!alleviated!by!activity.!! ! Is!this!caused!by!medications?! 1. Fluoroquinolones!!can!produce!tendonitis!or!tendon! rupture! ! Could!Lyme!disease!cause!the!pain?! 1. Lyme!disease!!Caused!by!Borrelia!burgdorferi.!Early! symptoms!include,!diffuse!arthralgias,!myalgias,!fever,! chills,!and!target!like!rash.!Usually!knee!affected.!Joint! manifestation!occurs!1!week!to!2!years!after!initial! illness.!Patients!may!recall!tick!bite!or!exposure! (camping)! ! What!does!Medical!history!tells!me?! 1. Chronic!diseases!such!as!sickle!cell!anemia,! inflammatory!bowel!disease,!Crohns!disease,! hypothyroidism,!hyperthyroidism,!collagen!vascular! diseases!skin!rashes,!psoriasis,!limb!and!joint!pain! 2. Gonorrhea!disseminates!to!MSK!in!1+3%!of!patients!of! which!more!than!80%!develop!arthritis.! ! ! ! ! ! ! ! ! 18!Joint!Pain!+!1!

Condition!
Osteoarthritis! Rheumatoid!arthritis! Septic!Arthritis! Gout!

History!

Common!Causes!of!Joint!Pain! Physical!Findings!

Diagnostic!Labs!
ESR;!X+ray:!osteophytes,!loss!of! joint!space! Increased!ESR,!+RF,!anemia!on! CBC;!X+ray:!bony!erosions! WBC,!culture!of!joint!aspirate,! ESR,!CRP,!!joint!U/S! Increased!serum!uric!acid,! ESR,!WBC! Kidney!function!tests,!ANA! test,!CBC! Serum!IgM,!IgG!Ab,!ESR! X+ray,!serum!alkaline! phospatase!

Systemic!Lupus! Erythematosus! Lyme!Arthritis! Osteogenic!sarcoma!

Joint!inflammation! Older!adults;!asymmetrical!joint!pain!and! DIP,!PIP!joints!enlarged;!Herberden! stiffness;!improves!throughout!the!day;!Hx! nodes;!limited!cervical!spine!ROM! of!repetitive!joint!trauma;!obesity! Morning!stiffness!small!joints;!symmetrical! Fever;!rheumatoid!nodules,!ulnar! involvement;!anorexia;!weight!loss! deviation!of!wrists! Hx!of!systemic!infection,!malaise,! Fever;!red,!swollen!joint;!limited!ROM! diaphoresis,!refusal!to!bear!weight(hip),! acute!joint!pain! Acute!pain!of!large!joint,!asymmetrical;! Inflamed,!swollen!joint,!tophi;!sodium! males!>30yo,!Hx!of!gout! urate!crystals! Systemic!Disorders! Female,!transient!arthritis!of!small!joints,! Normal!examination,!may!have!joint! malar!rash! tenderness!on!palpation! Hx!exposure!endemic!area!of!deer!tick;! Asymmetrical!swelling,!warmth!of!joint;! chills,!diffuse!joint!pian!and!swelling;!often! erythema!migrans;!may!have!myocardial! knee!is!affected! involvement! 10+25yo;!intermittent!pain!lower!femur,! Tenderness!over!affected!area! upper!tibia;!limp!

! !

18!Joint!Pain!+!2!

Musculoskeletal!Examination! !
Competencies! TMJ# 1. Inspect!and!palpate! 2. Perform!AROM! Shoulder# 3. Inspect!and!palpate! Assessment!technique! Swelling,!redness,!lesions,!masseter,!temporal!mm,!open!TMJ! Open,!close,!protrude,!retract,!lateral!movt! Inflammation,!redness,!Glenohumoral,!sternoclavicular,! acromioclavicular,!scapula!spine,!coracoid,!greater!tubercle,! biceps!tendon,!SITS!mm! Shrug,!flexion,!extension,!abduction,!adduction,!ext!rot,!int!rot! Inflamn,!redness,!lat/med!epicondyle,!olecranon! Flexion,!extension,!supination,!pronation! Swelling,!redness,!lesions,!distal!radius/ulna,!snuffbox,!mm! atrophy!of!thenar/!hypothenar,!MCP,!PIP,!DIP! Wrist+!flex,!ext,!ulnar!dev,!radial!dev! Hand+!fist,!ext,!abduction,!adduction! Thumb+!flex,!ext,!adduction,!abduction,!opposition! Posture,!head!position,!spine!curvature(kyphosis,!lordosis),!press! on!SP/!paravertebral!mm! Flex,!ext,!lat!flex,!rot! Support!pt!in!flex,!ext;!Hold!hips!w/!lat!flex,!rotation! Watch!gait,!iliac!crest,!iliac!tubercle,!ASIS,!PSIS,!ischial!tuberosity,! gluteal!fold,!greater!trochanter,!sacroiliac!jt! Pt!holds!table!w/!flexion,!ext,!abduction,!adduction,!ext!rot,!int!rot! Fxnal!!umbilicus!!!med!malleolus;!Struct.!+!ASIS!!!med!malleol.! Inflamn,!symmetry,!tibial!tendon,!med/lat!menisci,!behind!the! knee,!bursas,!femoral!condyles,!patella! Extension,!flexion! Abnormalities! Non+smooth!ROM!+!TMJ!syndrome! Pain!on!lateral!movt!!pterygoid!tension! Unilateral!elevation!+!scoliosis!

4. Perform!AROM! Elbow# 5. Inspect!and!palpate! 6. Perform!AROM! Wrist#,#Hand,#Fingers# 7. Inspect!and!palpate!! 8. Perform!AROM!

Pain!and!restricted!movt!!dislocated!shoulder! Inflamn!over!the!olecranon!+!bursitis! Pain!in!lat!side!!lateral!epicondylitis!(tennis!elbow)! PIP!nodules!!Bouchards!node! Reduced!ROM!common!in!elderly!+!arthritis!

Spine#(standing)! 9. Inspect!and!palpate!entire!spine! 10. Perform!AROM!+!neck! 11. Perform!AROM!!spinal#column! Hip#and#Sacroiliac#joint#(standing)! 12. Inspect!and!palpate!hip!and!SI! 13. Perform!hip!AROM! 14. Measure!leg!length!(lying)! Knee!(lying)! 15. Inspect!and!palpate! 16. Perform!AROM! Ankle#and#foot!(lying)! 17. Inspect!and!palpate!!

Increased!thoracic!kyphosis!with!age! Stiffness!!rheumatoid!arthritis! Lateral!curvature!and!uneven!ROM!+!scoliosis! Tender!SI!joint!!sacroiliitis! Reduced!ROM!+!common!location!for!OA!in!elderly! 1!leg!shorter!!hip/leg!fracture! Semi+membranous!bursa!behind!the!knee!!bakers! cyst! Reduced!ROM!and!pain!damage!to!ant!cruciate!ligg! Swelling!+!gout!! Limited!ROM!!common!w/!sprains!

Inflamn,!redness,!nodules,!corns,!calluses,!Achilles!tendon,! calcaneus,!MTP,!jts!of!phalanges! 18. Perform!AROM! Plantar!flexion,!dorsiflexion,!inversion,!eversion! PROM#and#RROM#(perform!only,!TA!chooses!1!of!each/!if!abnormal!AROM)!

! ! 18!Joint!Pain!+!3!

19##Headache# ! What!clues!indicate!this!is!a!potentially!serious,!life* threatening!headache?! 1. Mental!status!deficit!*!emergency!! 2. Onset!and!severity!*!Sudden!onset!w/o!hx!of!chronic! headache!suggest!intracerebral!hemorrhage!2nd! ruptured!aneurysm!or!vascular!anomaly,!specially! >50yo!treated!with!anticoagulant!therapy.!Sudden!onset! with!neurological!deficit!!emergency.!Worst!headache! of!my!life!!Subarachnoid!hemorrhage,!often! precipitated!by!activity,!stiff!neck,!nausea,!vomiting,! photophobia,!pupillary!dilation,!seizure.!Leaky! aneurysm!!worsening!headache!with!neurological! findings.!! 3. History!of!Trauma!!Subdural,!epidural!bleeding,!LOC!* Skull!fracture.!! 4. Associated!symptoms!!Infectious!origin!fever,! meningismus!(stiff!neck),!drowsiness!meningitis!or! encephalitis.!Intracranial!hemorrhage!thunderclap! headache,!confusion,!vomiting,!lethargy,!focal! neurological!sign! 5. Presence!of!Chronic!Disease!!AIDS!cryptococcal! meningitis,!encephalitis!and!generalized!sepsis.! Anticoagulation!therapy,!elder!ICH,!acute!glaucoma.! HA!2nd!metabolic!disorders!hyponatremia,!uremia,! hypoglycemia,!hypercapnia.! ! After!determining!the!headache!is!not!serious!how!can!I! narrow!the!causes?! 1. Characteristics!of!the!pain! ! ! !

2.

3.

4. 5.

! ! a. Moderate,!constant!throbbing!dilation!of!cervical! arteries.!Severe!expanding!lesion!such!as!tumor,! hematoma,!edema,!hydrocephalus.!! b. Migraine!!Steady,!throbbing!limited!to!same!side!of! arterial!pain!origin,!takes!3*4!hrs!to!peak.! c. Cluster!Headache!!Explosive!and!severe! d. Tension!Type!Headache!(TTH)!!at!school!or!work,! disappears!on!weekends,!vacations,!or!relaxation! Location! a. Trauma!!At!site!of!insult,!noxious!stimulation!from! any!type!of!disease!of!the!eye,!ear,!nose,!sinuses!may! spread!the!pain.! b. TTH!!Hatband!distribution! c. Cluster!!Sudden!sever!beginning!over!one!eye!and! spreading!to!same!side!of!face.! d. Orbital!Pain!!Intraocular!pressure!(glaucoma?)! e. Periorbital!!sinusitis,!migraine,!trigeminal! neuralgia,!ocular!disease! f. TMJ!!frontotemporal!regions,!unilateral!or!bilateral! g. Head,!neck!muscle!tension!!non*pulsatile!occipital! headache! Aggravating!Factors!!For!migraine!!sound,!odor,! menstrual!estrogen!fluctuations,!foods!(wine,!chocolate,! ripe!cheese,!high!in!tyramine!or!tryptophan),!worse! with!activity.!TTH!!able!to!continue!usual!routine.! Duration!!TTH,!migraine!*!<24hrs,!cluster!*!<3hr,!cyclic.! Subacute!persists!for!days,!weeks! Aura!and!prodrome!!Migraine!visual!symptoms!! nonspecific!blur,!scintillating!scotoma,!zigzag,!diplopia,! stars!and!flashes.!Prodromal!symptoms!fatigue,!

19!Headache!*!1!

! What!does!chronicity!of!pain!suggest?! 1. Frequency!!Persistent!HA!>3mo!may!demonstrate! physical!findings!such!as!papilledema,! bilateral/unilateral!CN!VI!palsies,!gait!or!balance! disturbances,!or!spasticity!of!lower!extremities.!In!the! absence!of!symptoms!it!is!rarely!structural!or!systemic! in!origin.!HA>4weeks!without!neurological!signs!or! symptoms!psychogenic! 2. Pattern!and!duration!of!headache!!TTH*during!the!day! only.!Sinus!HA!!after!arising!worsens!as!day!progress,! bends!forward,!less!painful!evening.!Sever!Hypertension! HA!!diastolic>130mmHg,!occipital,!worse!arising,!less! as!day!progress.!Meningeal!!fluctuates,!no!clear! pattern.!Migraine!HA!!episodic,!several!times!per!week! to!once!a!year.!Cluster!HA!!attacks!occur!daily!for! several!weeks!with!long!periods!of!remission,!<1!hr,! intense.! 3. Prior!History!of!Headache!!Acute!check!organic! causes.!Subacute,!Chronic!check!vascular!or!muscle.! Psychogenic!constant!diffuse,!difficult!to!describe.! 4. Age!of!Patient!at!First!Onset!!Migraines!as!early!as!5! yo.,!10*30yo!is!normal!range,!>50!unusual.!!TTH!8*12! yo.!Cluster!HA!20*40yo.! 5. Lifestyle!habits!and!medications!!Alcohol!is!trigger!for! migraines!and!cluster,!relieves!TTH.!Smoking!&!second! hand!smoke!can!trigger!Ha.!Medication!side!effect.! ! What!associated!symptom!does!the!patient!have?! 1. Nausea!and!Vomiting!!Can!be!a!sign!of!increase! intracranial!pressure!such!as!tumors!! !

depressed,!euphoric,!change!in!appetite,! constipation/diarrhea,!yawning.!

2. Vision!changes!!Migraine!have!aura!(see!Question!2).! Cluster!HA!!ipsilateral!conjunctival!injection,! lacrimation,!edema!of!eyelid! 3. Photophobia!!Often!with!migraine!and!meningitis,!but! not!with!TTH! 4. Dizziness!!1/3rd!of!patient!with!migraines!experience! vertigo.!! ! What!do!the!alleviating!and!aggravating!factors!suggest?! 1. Alleviating!factors!*!Meningeal!!recumbent,!lying! quietly.!TTH!!mild!analgesic.!Migraine!!sleep,!rest,! dark,!quiet!environment! 2. Aggravating!factors!*!Sneezing!!Benign!HA!or!lesion!at! the!foramen!magnum.!Exertion!!Migraines.!Cluster!HA! !Lying!down.!Tumor!HA!!worst!early!in!the!morning,! improve!on!arising.!Coitus!!Benign!exertional!HA.! Stimulation!of!affected!nerve!(Rubbing,!chewing)!! Trigeminal!neuralgia! ! What!does!family!history!indicate?!!TTH!have!no!FHx,! Migraine!have!FHx.! ! Is!there!anything!else!that!would!help!narrow!the!cause!or! causes?! 1. Recent!Health!History!!Iatrogenic!substance,!Radio! contrast,!antibiotics,!steroids,!lumbar!puncture.! Melanomas!metastasis!to!brain,!brain!abcess,!skull! fracture.! 2. History!of!Medications!!Tetracycline,!Vitamin!A,! Topical!Acne!preps.,!contraceptives,!OTC!analgesics,! Caffeine!withdrawal,!nitrates.! 3. Exposures!!Carbon!monoxide! ! 19!Headache!*!2!

Condition!
Tension!Type!(muscle)! Migraine!w/o!Aura!! Migraine!w/!Aura! Mixed! Cluster! Benign!Exertional!

Common!Causes!of!Headaches! History! Physical!Findings!

Primary!Headaches!without!Structural!or!Systemic!Pathology! M/C!adults,!bilateral,!general!or!local,! Normal!physical!exam;!tight!neck! bandlike,!Hx!anxiety,!stress,!depression! muscles,!fasciculations!palpable! M/C!Children,!unilateral,!throbbing,!nausea! Photophobia!and!phonophobia! Precipitated!by!environmental!stimuli,! N/V,!photophobia!and!phonophobia! visual!disturbances!(scintillating!scotoma)! before!pain! Throbbing,!constant,!during!waking!hours,! Mix!of!findings!related!to!tension!and! muscle!tightness,!FHx!migraines! migraine!headache!pain! Rare!children,!abrupt,!nighttime!onset,! Ipsilateral!rhinorrhea,!nasal!stuffiness,! unilateral!periorbital,!severe! conjunctival!injection,!sweating,!ptosis,! normal!physical!exam! Sudden!onset,!physical!exertion,!Valsalva!or! Normal!physical!exam! coitus! Secondary!Headaches!with!Structural!or!Systemic!Pathology!*!Infectious! Frontal,!upper!molar,!periorbital!pain,! Low*no!fever,!pain!on!palpation!of! cough,!rhinorrhea! sinuses,!purulent!nasal/postnasal!disch.! Localized!pain!in!jaw!or!top!of!head! Malocclusion,!caries,!abscess,!gum!diseas.! Sore!throat! Fever;!infection!posterior!pharynx! Ear!pain,!pain!w/!swallowing! Fever,!red,!bulging!tympanic!membrane! Severe!HA,!chills,!myalgias,!stiff!neck,!toxic! Positive!Kernings!and!Brudzinski!signs;! look! fever,!photophobia,!petechial!rash;! mental!status!changes! Secondary!Headaches!with!Structural!or!Systemic!Pathology!!Neurogenic! >55yo,!burst!of!sharp!pain!over!face;! Normal!physical!exam;!stimulation! triggered!by!stimulus! provoke!pain! Acute!onset!pain!with!extraocular! Diminished!visual!acuity,!decrease! movement!followed!by!blurred!vision! papillary!reflex,!hyperemia!of!optic!disc,! blurred!disc!margin;!pain!with!EOM.! Hx!trauma,!occipital!pain,!muscle!stiffness! Normal!physical!examination,!pain!on! neck!motion! >50yo,!sharp!localized,!temporal!pain;! Fever,!weight!loss;!tender!over!a!nodular! malaise,!anorexia,!Hx!polyalgia!rheumatica! temporal!artery!

Diagnostic!Labs!
None! None! None! None! None! CT!scan:!DDx!subarachnoid! hemorrhage! X*ray:!Waters!view! Dental!referral! Throat!culture! None! Lumbar!puncture!

Sinusitis! Dental!disorders! Pharyngitis! Otitis!Media! Meningitis!

Trigeminal!Neuralgia! Optic!Neuritis! Cervical!spine!disorder! Temporal!arteritis!

None! Ophthalmologic!referral! Cervical!Spine!X*ray! Elevated!ESR!(>50),!immediate! referral!for!treatment! ! ! !

19!Headache!*!3!

Condition!
Carbon!Monoxide! Severe!hypoglycemia! Drug!withdrawal! Dietary!ingestion! Intracranial!tumor! Hydrocephalus! Subdural!hematoma!

History!

Common!Causes!of!Headaches! Physical!Findings!

Diagnostic!Labs!
Blood!gasses,! carboxyhemoglobin!level! Blood!glucose;!may!need!elf! monitoring!to!establish! pattern! Blood!chemistry! Blood!chemistry! CT!scan! CT!scan;!referral! CT!scan;!neurosurgical!referral!

Pseudotumor!cerebri! Brain!abscess! Intracranial!hemorrhage!

Secondary!Headaches!with!Structural!or!Systemic!Pathology!!Metabolic! Hx!exposure,!throbbing!HA,!mild!dyspnea! N/V,!change!in!mental!status,!lethargy,! LOC! Hx!diabetes,!medication,!alcohol!and!food! Normal!physical!exam!or!pallor,!sweating! ingestion,;!generalized!HA,!dizziness,!sense! and!weakness! of!not!feeling!well! Pattern!of!HA!associated!with!stopping! Normal!physical!exam! medication!or!substance! Mild!to!Severe!HA!after!ingestion!of!foods! Normal!physical!exam! or!medication! Secondary!Headaches!with!Structural!or!Systemic!Pathology!!Cerebrovascular! Sudden!onset!HA,!progressive,!exacerbated! Papilledema,!vomiting,!asymmetrical! by!coughing,!exercise;!worse!morning,!Hx! reflexes,!weakness,!sensory!deficit!or! trauma!increases!risk! other!neurological!deficit! Progressive!HA,!vomiting,!irritability! Rapid!enlargement!of!head,!bulging! fontanelles! Hx!head!trauma,!bleeding!disorders,!child! Unequal!pupils,!photophobia,! abuse,!>35yo;!sudden!onset!of!worst! neurological!changes,!seizure! headache!ever,!often!over!one!eye;! transient!LOC! Teens,!menopausal!women,!Hx!Vit!A!or! Papilledema!might!be!present!! tetracycline!ingestion;!topical!acne! treatment,!progressive!HA! Hx!chronic!ear!infection,!cyanotic!heart! Fever,!seizures,!focal!neurological!deficits! disease! Risk!factors:!>50yo,!Aids,!anticoagulant! IF!conscious,!abnormal!neurological! therapy! findings!correlated!with!extent!of!lesion!

CT!scan,!neurology!referral!to! assess!risk!of!lumbar!puncture! CT!scan! Emergency!transport!for! immediate!evaluation!or!with! hypertension!(CT!scan)!and! possible!surgical!treatment.!

! !

19!Headache!*!4!

Cranial!Nerves!Examination! !
Competencies# Cranial#Nerve#I#=#Olfactory! 1. Check patency and smell (1 scent, eye closed) Cranial#Nerve#II#=#Optic# 2. Evaluate visual acuity (14 inches) 3. Evaluate visual fields Assessment#Technique# Abnormalities# patency*!Ask!pt!to!press!each!ala!nasi!closed!one!at!a!time! *loss!of!smell!a/i!frontal!lobe! and!inhale.! lesions.! smell*!pt!closes!eyes,!occlude!one!nostril!at!a!time;!pass! scent!under!nose!to!id.! *!blindness!a/i!optic!nerve!defect! *bitemporal!hemianopsia!a/i! pituitary!tumor!on!optic!chiasm! *disc!pallor!a/i!optic!nerve! atrophy! *bilateral!small!irregular!pupils! a/i!oculomotor!n!damage!from! CNS!syphilis!! ! *no!rxn!to!light!a/i!!damage!to! optic!n!from!CNS!syphilis! *lack!of!pupillary!constriction!a/i! damage!to!!Oculomotor!n!

Snellen!chart,!1!eye!closed!switch! fish!bowl!w/!1!eye!covered.!Ask!pt!to!tell!you!when!they! see!wiggling!fingers.!4!quadrants! 4. Perform fundoscopy 15o!lateral.!ID!the!red#reflex,!optic#disc,#physiological# cup,!BV,!fovea!and!macula.! Cranial Nerves II and III - Optic and Oculomotor 5. Evaluate pupil size and shape Measure!size!and!shape!of!pupils!w/!chart.!! N!=!3*5mm!and!round.!Compare!sides.! Ask!pt!to!put!edge!of!hand!in!middle!of!face.!Shine!light!in! one!pupil!and!observe!for!constriction!(direct!rxn)!and! constriction!of!other!pupil!(consensual!rxn)! 7. Evaluate pupil near reaction Have!pt!look!at!your!finger,!then!the!wall,!then!your! finger!again.!Eyes!should!constrict!when!looking!from!far! away!to!close!up.!! Cranial#Nerves#III,#IV,#and#VI#=#Oculomotor,#Trochlear,#and#Abducens# 8. Perform H test (indicate corresponding Have!the!pt!follow!your!finger!as!you!draw!a!large!H!in! nerve-muscle pair) the!air.!Testing!extraocular!mm!fxn;!CN!III!(sup/inf/med! rec,!inf!obl),!IV(sup!obl),!VI(lat!rec)!! 9. Check convergence Ask!pt!to!follow!your!pen!light!as!you!move!it!toward!the! bridge!of!their!nose.!N!=!eyes!follow!to!w/in!5*8cm!of! nose.! Cranial#Nerve#V#=#Trigeminal# 10. Palpate temporal and masseter While!palpating!temporal,!then!masseter!mm!in!turn,!ask! pt!to!clench!his!teeth!and!move!jaw!side*to*side.! 11. Test CN V for pain sensation Dull/sharp!sensation!performed!with!q*tip!cotton! /broken!end!(explain!1st).!Vary!rhythm!and!touch!all!3! areas!bilaterally*!opthalmic,/maxillary,/mandibular.!! 6. Evaluate pupil reaction to light

*impaired!adduction!mvmt!a/i! damage!to!CN!III!affecting!the! medial!rectus!mm! *poor!convergence!a/i! hypothyroidism!

*!unilateral!weakness!a/i!CN!V! pontine!lesions! *!isolated!sensory!loss!a/i! trigeminal!n!lesion!(define!the! branch)!

19!Headache!*!5!

Competencies# Cranial#Nerve#VII#=#Facial# 12. Inspect facial symmetry

Assessment#Technique# Symmetry,!tics,!other!abnormal!movt.!*raise!both! eyebrows,!show!upper!and!lower!teeth;!smile,!*puff!out! cheeks! ! Place!vibrating!fork!on!top!of!pt's!head.!Ask!pt!if!sound!is! heard!=!in!both!ears!(N)!

Abnormalities# *!unilateral!paralysis!a/i!!Bell's! Palsy!(inflam!of!Facial!n)! ! *!sound!heard!in!impaired!ear!a/i! unilateral!conductive!hearing! loss!!(cerumen/obstr)! *!BC!=!AC!or!BC!>!AC!in! conductive!hearing!loss! *obstruction!of!ear!canal!by! cerumen!may!cause!conductive! hearing!loss! *!palate!fails!to!rise!a/i!bilateral! lesion!of!CN!X! *unilateral!absence!of!gag!reflex! a/i!lesion!of!CN!IX,!possibly!CN!X! *!trapezius!weakness!w/!atrophy! &!fasciculations!indicates! peripheral/n!disorder! *bilateral!weakness!a/i!Accessory! n!injury!d/t!laceration!of!neck!!

CN VIII - Acoustic 13. Perform Weber test

Place!vibrating!fork!on!mastoid!bone!(BC).!When!pt!can! no!longer!hear!sound,!move!fork!close!to!ear!canal!and! ask!if!sound!can!be!heard!again!(AC)! 15. Perform otoscopic exam Pull!auricle!upward.!Brace!hand!holding!otoscope!on!pt's! head.!Note!cone#of#light,!tympanic#memb!and!short# process#and#handle#of#malleus.! Cranial#Nerves#IX#and#X#=#Glossopharyngeal#and#Vagus# 16. Evaluate rising of soft palate and explain 8soft/palate/and/uvula/rising*!pt!says!"ahhh"!and!use! gag reflex tongue!depressor!and!penlight!to!inspect!movt! 8gag/reflex*!Stimulate!the!back!of!pt's!throat!w/!a!cotton! swab;!test!on!each!side!.!Pt!should!gag.! Cranial#Nerve#XI#=#Accessory# 17. Test trapezius strength Ask!pt!to!shrug!both!shoulders!upward!against!your! hands.!Note!strength!and!symmetry!of!contraction.!Hold! for!5!seconds! 18. Test SCM strength Ask!pt!to!turn!his!head!to!each!side!against!your!hand.! Observe!contraction!of!opposite!SCM!and!note!force!of! movt! CN#XII#=#Hypoglossal# 19. Inspect tongue Ask!pt!to!protude!tongue.!Look!for!asymmetry,!atrophy! or!deviation!from!midline.! Ask!pt!to!move!the!tongue!side!to!side!and!note! symmetry!of!movt,!pressing!against!cheek! 14. Perform Rinne test

*tongue!deviates!to!affected!side! in!CN!XII!damage!

! ! ! !

19!Headache!*!6!

20##Fatigue# ! Is!this!really!fatigue?! 1. Fatigue!vs.!Weakness!vs!Sleepiness! a. Fatigue!!Does!not!improve!with!sleep,!rest! b. Weakness!!Involves!a!disease,! c. Sleepiness!!Improves!with!sleep! ! Is!the!fatigue!physiological?! 1. Lifestyle!habits!!Undernutrition,!high!levels!of!caffeine,! stress! 2. Sleep!Pattern!!Adults!require!8+9!hours!of!sleep.!Sleep! apnea!!men>45yo,!wake!up!not!refreshed.!Disturbed! sleep!from!heart!failure!(postural!dyspnea).!Early! morning!awakening,!excessive!sleeping!+!depression! 3. Last!normal!Menstrual!period!!Pregnancy,!post! childbirth,!menopause.!Perimenopausal!may!have! sleepiness!due!to!disrupted!sleep!from!hot!flashes,!night! sweats.! ! Do!I!Need!to!consider!an!organic!cause?! 1. Exposure!to!body!fluids!!Hepatitis,!HIV! 2. Medications!!Antihypertensive!and!cardiovascular! drugs,!psychotropic,!opiates!side!effect.!Sedatives,!and! antihistamines!side!effects.! 3. Alcohol!and!drug!use!!Alcohol!abuse,!marijuana! ! What!other!clues!can!help!me!rule!out!an!organic!cause?! 1. Appetite!!increased!in!hypoglycemia,!decreased!in! infectious!process! 2. Weight!loss!!malignancy,!infection,!poor!nutrition! related!to!depression!or!lack!of!information.! 3. Increased!urination!!DM!especially!type!2.! !

4. Joint!tenderness!!CFS!multiple!tender!points! including!over!joints.!Juvenile!RA!causes!fatigue!! 5. Associated!symptoms!!Psychological!fatigue! !nonspecific,!multiple!symptoms!(muscle!aches,!abd.! pain,!general!lethargy).!!Hypothyroidism!has!fatigue! with!dry!skin,!nails;!CHF!has!fatigue!with!SOB!on! exertion!or!lying!flat.! ! Could!this!have!an!environmental!cause?! 1. Occupational!exposure!!Heavy!metal!and!pesticides,! soldier!returning!from!combat!zones! 2. Camping!!Lyme!disease! ! What!else!do!I!need!to!know!about!the!fatigue?! 1. Onset!and!pattern! a. Psychological!+!Sudden,!related!to!stressful!event! b. Metabolic!!Slow,!progressive!onset! c. Significant!fatigue!+!>2weeks/25%!adults! 2. Severity!!Significant!fatigue!varies!thru!the!day!but! never!completely!disappears.!Limits!social!functioning! and!recreational!activities! 3. Aggravating/Alleviating!factors!!Psychological!fatigue! is!worst!in!the!morning,!better!with!physical!activity.! Organic!fatigue!is!not!associated!with!intensity!or! duration!of!activity!and!not!relieved!with!rest!or!sleep! 4. Fever!!infectious!disease,!malignancy! 5. Bleeding!!Heavy!menstrual!flow!anemia.!GI!ulcers,! polyps,!bowel!cancer!!occult!blood!loss!causes!fatigue.! ! If!I!suspect!a!psychological!cause,!what!else!do!I!need!to! know?! 1. Stress!!may!cause!anxiety,!depression! 2. Anxiety!and!depression!!Major!Depressive!Disorder! 20!Fatigue!+!1!

Condition!
Poor!sleep!and!rest! Poor!nutritional!status!

History!

Common!Causes!of!Fatigue! Physical!Findings!

Diagnostic!Labs!
None! Hematocrit!,!low!serum! ferritin! Depression!screening! instrument! None!

Depression! Anxiety!

Infection! Drugs!&!Alcohol! Anemia! Hypothyroidism! (myxedema)! Hyperthyroidism! (Graves!Disease)! Sleep!apnea! Medications! Heart!Failure! Cancer! Mononucleosis!(EBV)!

Physiological!Causes! Adolescent!&!young!adult;!Hx!overwork,! Normal!examination! psychological!stress,!disturbed!sleep! Depression,!decreased!appetite,!lack!of! BMI:!under/over!weight! balanced!nutrient!intake,!alcohol!abuse! Psychological!Causes! Loss!of!interest,!feeling!worthless,!sleep! Depressed!affect;!normal!exam! problems! Numerous!somatic!complaints,! Tachycardia,!palpitations,!diaphoresis! breathlessness! Organic!Causes:!Acute!Fatigue! Sudden!onset,!Hx!exposure,!recent!viral! Fever,!lymphadenopathy,!localized!signs! illness! of!erythema,!edema! HX!smoking,!alcohol!use;!antihistamines,! Bilateral!enhanced!or!decreased!DTR;! analgesics,!antihypertensive!medications! pupillary!changes;!reduced!attention! span,!judgment! Breathlessness!on!exertion;!menstruating! Increased!pulse!rate,!pale!mucosa;! female;!recent!surgery;!delivery! smooth!red!tongue! Poor!appetite,!fatigue,!weight!gain,!cold! Decreased!pulse!rate;!dry!skin,!coarse!dry! intolerance! hair;!thyroid!possibly!enlarged,! hoarseness! Hyperactivity,!heat!intolerance,!sleep! Lid!lag,!fine!thinning!hair,!tachycardia,! problems! exophthalmos! Organic!Causes:!Chronic!Fatigue! Male;!>mid+age;!partner!reports!periods!of! Hypertension,!obesity,!narrow!upper! no!breathing!during!sleep,!fatigue! airway! HX!allergies!treated!with!antihistamines,! Nasal!congestion,!cough,!injected! meds!for!hypertension,!heart!disease,! conjunctiva! chronic!pain! Dyspnea,!weight!gain,!fatigue,!cough! Anxiety,!JVP!distention,!displaced!PMI,! rales! Fatigue,!unexplained!weight!loss,!night! Observe,!palpate,!percuss!all!systems!for! sweat! lumps,!lesions,!consolidation;!physical! exam!may!be!normal! Young!adult;!slow!onset!malaise;!low+grade! Palatine!petechiae,!posterior!cervical! fever;!mild!sore!throat! lymphadenopathy,!splenomegaly!

CBC,!ESR,!Monospot! CAGE!alcohol!screening! CBC!with!indices,!serum!iron,! ferritin,!transferrin,!TIBC! TSH!elevated,!T3,!T4!low! TSH!depressed,!T3!T4! increased! Sleep!studies! Evaluate!medication!choices! ECG,!chest!radiograph,!ABG! CBC!to!r/o!anemia;!leukocyte! count! Monospot;!CBC!w/!differential;! >50%!leukocytes!

20!Fatigue!+!2!

Condition!
Hepatitis! Fibromyalgia! Chronic!Fatigue! Syndrome!

History!

Common!Causes!of!Fatigue! Physical!Findings!
Jaundice,!weight!loss,!arthralgia,!skin! rash! Palpation!of!trigger!points!will!produce! pain;!normal!physical!exam! Physical!exam!might!be!normal;!cervical! and!axillary!lymphadenopathy!

Jaundice,!anorexia,!fatigue;!may!have!fever! Female;!20+50yo,!Hx!depression,!sleep! disturbance,!chronic!fatigue,!general! muscle!and!joint!aches! Fatigue!lasting!longer!than!6!mo;!sudden! onset!of!flulike!symptoms!that!persists!or! recur!

Diagnostic!Labs! Bilirubin!increased;!Liver! panel! None!

CBC,!ESR!

! ! !

20!Fatigue!+!3!

Neurological!and!Sensory!Examination! !
Competencies! Assessment!Technique! Motor!System!(corticospinal,#basal#ganglia,#cerebellum)# 1. Inspect#body#position,#check#for#involuntary# Position!(rest,movt),!ticks,!tremors,!fasciculation,! movement#&#evaluate#muscle#bulk# paralysis,!mm!bulk/!atrophy! 2. Test#muscle#tone#bilaterally# PROM!of!shoulder,!elbow,!wrist,!fingers,!hip,!knee,!ankle,! toes! 3. Test#for#muscle#strength#bilaterally#(examiner# RROM+!Biceps!C5,6;!Triceps!C6,7,8;!wrist!ext!C6,7,8;!grip! chooses#any#2#joints#in#each#upper#and#lower# C7,8,!T1;!finger!abdn!C8,!T1,!ulnar;!thumb!oppn!C8,!T1,! extremities)# median;!hip!flex!L2,!3,4;!hip!addn!L2,3,4;!hip!abdn!L4,5,! S1;!hip!ext!S1;!knee!ext!L2,3,4;!knee!flex!L4,5,!S1,2;! dorsiflexion!L4,5;!plantar!flexion!S1! Coordination!(cerebellum)# 4. Check#rapid#alternating#movements! +Fast!hands! +Toe!heel!tap! 5. Evaluate#pointKtoKpoint#movements#(upper#and# +Finger!nose!finger+NDs!finger!(eyes!open!!closed)! lower#extremities)! +Heel+to+shin!test! Gait! 6. Evaluate#tandem#walking#(heelKtoe)# Heel+to+toe!walking!in!straight!line,!posture,!balance,! arm!swing,!leg!movt! 7. Evaluate#toe/heel#walking# +backward!on!heels!(dorsiflexion)! +walk!forward!on!toes!(plantar!flexion)! ! 8. Evaluate#hopping#(bilateral)# Hop!in!place!on!each!foot! Stance! 9. Perform#Rombergs#test## Feet!together,!eyes!open!closed!(30+60sec),!note! swaying! 10. Test#pronator#drift#(palms#up,#eyes#closed)# Feet!apart,!both!arms!straight!forward,!palms!up,!eyes! closed!(20+30sec),!tap!arms!down+!watch!for!arms!to! come!back!up!or!pronate!in! Sensory#(spinothalamic#tract,#posterior#column)# 11. Evaluate#pain#(bilateral,#3#dermatomes#upper# +Show!with!eyes!open!1st! &#lower#ext)# +Eyes!closed,!using!broken!tongue!depressor! Hand:!thumb!C6,!middle!finger!C7,!pinky!C8! Leg:!knee!L4,!big!toe!L5,!baby!toe!S1! +if!absent,!temp!sense! 12. Evaluate#light#touch#(bilateral,#3#dermatomes# +w/!fine!wisp!of!cotton,!ask!pt!to!respond!when!they!feel! upper#&#lower#ext)# it!and!point!to!where! Hand:!thumb!C6,!middle!finger!C7,!pinky!C8! Leg:!knee!L4,!big!toe!L5,!baby!toe!S1! Abnormalities! Atrophy!d/t!lesion!to!peripheral!nervous!system!! diabetic!neuropathy! Increased!resistance!in!ROM!d/t!damage!of!basal! ganglia!!Parkinsons!dz! Hemiparalysis!+!stroke!

Dysdiadochokinesis!(non+smooth!movt)!!Cerebrellar! dz! Clumsy,!unsteady,!inappropriate!movt!!Cerebellar!dz!

Swaying,!ataxia!(lack!of!coordination)!!intoxicated! patient!d/t!damage!to!cerebellum! Inability!for!heel!walk!!damage!to!corticospinal!track!

Difficulty!!cerebellar!dysfxn! Ataxia!(+ve!sign),!loss!of!position!senseJ!lesion!to! posterior!column! +ve!sign!!corticospinal!tract!lesion!

Analgesia!(absence!of!pain)!!spinothalamic!tract! lesion!

Anesthesia!(absence!of!touch!sensation)!posterior! column!lesion!

20!Fatigue!+!4!

Competencies# 13. Evaluate#vibration#sense#

14. Evaluate#proprioception#(position#sense)# 15. Evaluate#discriminative#sense#(sterognosis#or# 2Kpt#discrim)# Reflexes! 16. Evaluate#&#grade#all#DTRs#(biceps,#triceps,# brachioradialis,#patellar,#Achilles)# 17. Evaluate#abdominal#reflex#(above#&#below# umbilicus)# 18. Evaluate#Babinskis#

Assessment#Technique! Low!pitch!tuning!fork!on!big!toe!and!DIPs!of!1!finger! (BILAT)! +demo!1st,!eyes!closed,!ask!pt!to!say!when!vibration!stops! Grasp!big!toe!on!sides!demo!up!and!down! +eyes!closed,!ask!pt!if!up/down! Stereognosis+!eyes!closed,!put!object!in!hand!to!id!w/in!5! sec!(pen,!cotton)! Deep!Tendon!Reflexes!!bicep!C5,6(pt!over!thumb;! tricep!C6,7!(pt!in!scarecrow);!braciorad!C5,6!(flat,!2! above!wrist),!knee!L2,3,4!(flat),!Achilles!S1!(flat)! Use!back!of!reflex!hammer!to!swipe!in!4!quadrants;!2! above!umbilicus!(T8,9,10),!2!below!(T10,11,12)! Use!back!of!reflex!hammer!to!swipe!sole!of!!foot!up! pinky!and!across!ball! N=plantar!flexion! Neck!mobility+!lying!supine,!lift!head,!chin!to!chest!w.! smooth,!easy!movt!

Abnormalities! Lost!sense!!posterior!column!dz!

Loss!of!position!sense!!B12!def!d/t!effects!on! posterior!column! Astereognosis+!inability!to!recognize!object!d/t! sensory!cortex!lesion! Hyperreflexia!!central!nervous!system!lesion! ! Grade!0J4+!(2+!Normal)! Absent!reflex!!Central!nerve!system!disorder! Dorsiflexion!w/!big!toe!fanning!!lesion!in! corticospinal!tract! Stiffness!and!resistance!!bacterial!meningitis!

19. Evaluate#meningeal#signs#(Brudzinski,!Kernig)#

20!Fatigue!+!5!