Symptom & Background

Key Questions
Is this an acute infection?
How old are you?

Earache

Have you had a fever?

Generally an inflammatory Have you had an URTI?

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

Child: does the child attend day care?

Child: does the infant take a bottle lying down?
Have you been swimming recently?

What these questions will tell you

Acute otitis media (AOM) declines after 6

Physical Exam
Need to view TM and
external ear canal.

Fever present in 60% of children with AOM Lavage indicated if

(infants <2mo uncommon, high fever is
blockage. CI if history
systemic illness)
suggests perforation.
Organisms travel up eustatian tube -->
obstruction --> mucus and bact growth
High risk of recurrens of AOM
Having a sibling or parent with chronic OM
makes you 2x as likely. May be environ'tal

Note behaviours in
children: irritability, poor
feeding, congestion, fever.
Older infants may pull on
painful ear, bang head on
affected side.

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

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

2-3x inc risk. Leads to functional

eustachian tube obstruction, decreases
protective ciliary action in the tube

Inspect External Ears

Inc exposure to organisms

Swallowing lying down may allow
nasopharyngeal fluid to enter middle ear
Swimming causes loss of protective
cerumen and excessive moisture and
irritation to the canal

Hemorrhage over matoid - Mastoid Process

battle's sign - basal skull
Radiography fracture
radiographs of mastoid.
Pain in opening of ear or
inflamed skin suggests
bacteria

Have you recently been in an airplane or been scuba Barotrauma --> acute serous otitis. Failure Fungal and yeast
CT of temporal bone for
diving?
of eustachian tube to open and equilibrate infections are white or dark cholesteatoma and
--> fluid collection in middle ear.
patches
congenital syndromes
Palpate External Ears.
Also pre and postaruicular
Predisposition to malignant otitis externa (a lymph notes. Pre may be
Do you have diabetes?
enlarged in AOM and otitis
cellulitis), OM, and mastoiditis
externa. Post in
Have you ever had dermatitis, eczema, or psoriasis? Overproduction of sebum can cause otitis
mastoiditis.
externa
Child: does the child have a nonrepaired cleft palate? Can cause functional obstruction of the
Inspect Ear Canals with
eustachian tubes
Otoscope
Visualize any discharge,
What does the presence of pain tell me?
Where specifically is the pain felt? Is it in one ear or Otitis externa - pinna. Mastoiditis - mastoid. noting color, consistency,
and odor. Disharge usually
both?
Bilateral - otitis externa. Referred pain or
AOM is unilateral. Children may tug at ears means infection, however,
CSF must be kept in mind
with trauma.
How severe is the pain? Does it interfere with
AOM - deep pain or blockage of ear.
Inspect Tympanic
sleeping, eating, or other activities?
Serous otitis - bubbling, popping, or stuffy. Membrane noting light
Otitis externa - tender and may have
reflex. Normal:
itching. Cerumen impaction - vague
transluscent and pearly
discomfort
grey. Normally concave.
Could this be related to a systemic disease?

How long have you had this pain?

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

What does a history of trauma or injury tell me?

Have you had any recent trauma to the ear?
Have you had any head trauma?
How do you clean your ears? Do you use cottontipped swabs?
Do you have a history of excessive earwax?

TMJ - lasts a few minutes and occurs 3Bulging: increased

4x/day, sometimes with headache, worse in hydrostatic pressure
the morning (grinding). Chronic pain may
be dental malocclusion or RA.
Perform Pneumatic
Otoscopy (Insufflation)
Discharge seen after TM ruptures, can be
secondary to mastoiditis.
Itching indicates infection of the external
canal. Can also be precursor to herpes
zoster of CN V.

Tests mobility of the TM by

creating a seal - normal if
there is slight motion when
air is insufflated

Test hearing acuity:

Weber and Rinne
Trauma can perforate the eardrum.Fractur Examine Related Body
of the petrous temporal bone can destroy Systems: head and neck.
the inner ear. Cotton-tipped swabs can
Conjunctiva, mucosa and
scratch the canal.
patency of nose, sinuses,
larynx/tonsils, teeth and
Accumulation can cause hearing loss,
gums
tinnitus, pressure sensation, vertigo,
infection. Self-cleaning can cause harm.

Child: does the child have a history of putting objects can cause ear pain and inflammation
into ears?
Have you had any recent insect bites around the ear? Can lead to acute pain and tenderness of
the external canal and may develop
secondary infection.
Have you been exposed to any loud noise?

Is hearing loss a clue?

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

Perform an Intraotic
Manipulation. Face the
patient, insert a single
fingertip in each ear and
pull the patient toward you
as they are instructed to
Loud prolonged noise can destroy cochlear open and close their
hair cells.
mouth. Pain is elicited in
90% of patients with a TMJ
disorder.
Blockage, inflammation, neoplasm. Most
common cause of CHL is cerumen.
Chronic OM can cause hearing loss.
May indicate serious inner ear condition.

Page 1 of 52

Evaluate CN V, VII, and

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

DDX
Physical Findings

Condition

History

Earache DDX
External otitis

More common in adults, especially those with

diabetes, ear pickers, or swimmers. Bilaral itching;
pain.

Discharge; inflamed, swollen external canal; pain None

with movement of pinna; TM normal or not visible

Diagnostic Studies

Acute otitis media

More comon in children <6 years; those with smoke

exposure, recent URTI; severe or deep pain;
unilateral; sensation of fullness

Red, bulging TM; fever; decreased light reflex;

opque TM; decreased TM mobility

None initially

Serous otitis

More common in children but occurs in adults with

URTI; unilateral pain; senation of crackling or
decreased hearing

Fluid line or air observed behind TM; conductive

hearing loss; decreased TM mobility

Tympanogram

Cholesteatoma

Hearing loss; recent perforated TM

Pearly white leasion on or behind TM

Immediate referral

Mastoiditis

History of recent otitis media; chronic otitis pain

behind ear

Swelling over mastoid process; fever, palpable

tenderness, and erythema over mastoid

Radiograph of mastoid sinuses

reveals cloudiness, referral

Foreign body or cerumen

impaction

Both children and adults have pain or vague sensation Visualize foreign body or cerumen; may detect
of discomfort; decreased hearing
foul odor; conductive hearing loss

None

Barotrauma

History of flying, diving; severe pain; hearing loss;

sensation of fullness; history of recent nasal
congestion

Retraction of bulging of TM; perforation of TM;

fluid in canal

Tympanogram

Trauma

History of blunt trauma, penetrating trauma

Perforation of TM

Cervical lymphadenitis

Radiographs/CT scan as directed by

injury
Enlarged, tender, cervical lymph nodes; may see Throat culture if indicated. Monospot
early onset of AOM in children
if indicated in adolescent
Dermatome evaluation for cervical nerve
None

TMJ disorder

Test function of CNs V, VII, IX, X; ear examination Radiograph/CT scan directed by CN
normal
involvement
Malocclusion; bruxism; normal external and
None
middle ear structures and function; jaw click;
abnormal CN function; ear examination normal

History of cervical node swelling; pain in ear common

in children
Cervical nerves 2, 3 (referred Pain in skin and muscles of neck and in ear canal
pain)
Cranial nerves (referred pain) History, depending on CN involved
More common in adults, 50% related to dental
problems; discomfort to severe pain; unilateral; pain
worse in morning

Page 2 of 52

Is this an emergency?

Sore Throat
Most common
inflammation of the
mucosa of the
oropharynx. Less
commonly a symptom of
a systemic illness (i.e.
mono). Classified as
those with ulcers and
those without. Make sure
you idetify group A Bhemolytic strep (GABHS)
due to sequelae

Have you been drooling?

Have you been unable to swallow?
Have you been unable to lie down?
Have you been restless, unable to stay still?
Have you been unable to carry on a conversation?

All these symptoms signal acute

Assess degree of illness
epiglottitis. Rare but can cause airway
(emergency questions)
obstruction. Syptoms: sore throat, difficulty
swallowing, respiratory distress (drooling,
dyspnea, inspiratory stridor). MC due to H.
Inspect the mouth look for
influenzae type b, age 2-5.
ulcers.
Peritonsillar abcess also needs immediate
referral (sx of this and cellulitis are severe
sore throat, odynophagia, trimsus (diff
opening mouth), medial deviation of the
soft palate, and peritonsillar fold.)

Is the sore throat related to an infectious cause?

Is anyone else at home sick?
Are any of your friends or co-workers sick?
When did the pain start?

How severe is the pain?

What does the presence of fever tell me?

Have you had a fever?

When did it start?

How high has it been?
What does the presence of upper respiratory
symptoms tell me?
Do you have a cough?
Have you had a runny nose? What color is the
drainage?
Do you have mucus dripping from the back of your
nose and down your throat?
Do you have any eye redness or discomfort?
Have your eyes been itchy or watery?
Have you had any hoarseness?
Have you been sneezing?
What do associated symptoms tell me?
Do you have muscle aches?
Have you had any nausea, vomiting, or diarrhea?
Does the presence of risk factors help me to
narrow the cause?
How old are you?

What is your smoking history?

What kind of work do you do?
Do you engage in oral sex?
Are you taking any medications?

Increases likelihood of bact/viral infxn

Sudden onset of sore throat is caused by

GABHS. Gradual onset is mono. In viral
pharyngitis sore throat is a day after other
sx. Noninfectious - insidious onset.

Generally limited to
identification of GABHS

Rapid screening tests:

throat swap for strep
antigens. If positive: tx, if
negative: throat culture.
Inspect the posterior
Monospot is a rapit slide
pharynx and observe
swallowing: grade tonsils test that detects
heterophil Ab
(1: behind pillars, 2:
between pillars and uvula, agglutination, not specific
for EBV
3: touching uvula, 4:
beyond midline).
Do not examine the
parynx if you suspect
epiglottitis (may
Culture - "gold standard"
precipitate obstruction).
for GABHS. Can confirm
Beyond midline:
gonorrhea
peritonsillar abscess. Grey
exudate: diptheria. Yellow
exudate: GABHS.

Strep infxn pain is intense. Influenza/

adenovirus throat is severe with edema.
Noninfectious "scratchy or annoying"

"Doughnut lesions": red,

raised hemorrhagic lesions
with yellow center are
diagnostic for GABHS

ASO titer - for enzyme

streptolysin. Detects
previous strep infection.
Does not aid in diagnosis
but in associated
Present with GABHS (38.5C, malais, HA
Palpate the cervicofacial
infections (e.g. rheumatic
and painful swallowing) and epiglottitis.
lymph nodes: anterior
fever)
Adenovirus has high fever (more than 40C) enlarged in strep, posterior
if viral . Cardinal sign of
mono.
CBC with diff - 50%
Fever that recurrs may indicate peritonsillar
abcess.
lymphocytes and 10%
atypical lymphocytes
Inspect the nasal
confirms mono
mucosa: red, swollen
indicates infection. Pale,
Presense of these 2 are rare with strep and boggy indicate allergy.
CT scan - obstruction or
Purulent discharge:
suggest viral infection. Influenza is assoc
swelling
sinusitis
with several days of fever, cough and
rhinorrhea. Clear nasal discharge common Inspect the conjunctiva: Nasal smear - presence
to allergic pharyngitis.
red may indicate
of eosinophils on a nasal
Rare with strep, common to viral or
allergies

pharyngoconjunctival fever
caused by adenovirus. Non
purulent discharge. Watery
discharge: allergic

Viral or allergen exposure.

Viral or allergen exposure, can be
seasonal.
Myalgia common in GABHS, influenza.

GABHS is usually 5-15 years. Rare under

3. Influenza is all ages. Parainfluenza,
adenovirus and RSV is in children. Mono in
teenagers.
Musocal irritations
Irritants: working outdoors, housekeepers
(chemicals)
Pharyngitis from chlamydia trachomatis
and neisseria gonorrhea
Immunosuppression seen with meds

Do you have any chronic health problems?

Are your immunizations up to date?

Page 3 of 52

Inspect the tympanic

membrane - can have
nontypical H. influenza
AOM
Palpate the thyroid acute thyroiditis
Inspect the skin - scarlet
fever has maculopapular
erythema that spares
palms and soles
Auscultate the lungs could be mycoplasma
pneumoniae in
adolescents (adventitious)
Palpate the abdomen splenomegaly in mono

smear stained with

Wright's stain suggest
allergic, inflammatory
process

Sore Throat DDX:

Pharyngitis without ulcers:
Epiglottitis

Sore throat, difficulty with secretions, odynophagia

(seen in pediatric patients >2), unable to lie flat,
cannot talk

Respiratory distress, drooling, toxic appearance;

DO NOT EXAMINE PHARYNX

Refer immediately

Peritonsillar/ retropharyngeal
abscess

History of recurrent tonsilitis; sore throat, difficulty

swallowing, respiratory symptoms, fever, malaise

Orthopnea, dyspnea, asymmetrical swelling,

abscess, trismus

Rever immediately; CT scan; head

and neck radiographs; laryngoscopy

Viral pharyngitis

Scratchy, sore throat, malaise, myalgias, headache,

chills, cough, rhinitis

Erythema, edema of throat, tender posterior

cervical nodes

None

Group A B-hemolytic
streptococcal pharyngitis

Most common in persons 5-15 years; known

exposure; fall/winter season; sudden onset of fever,
severe sore throat, and malaise; absence of cough
and upper respiratory symptoms

Temp >38.5C (101.5 F); exudate; anterior cervical Positive rapid strep antibody screen,
lymphadenopathy
strep culture

Mononucleosis (EBV)

Young adults; slow onset of malaise, low-grade

temperature, mild sore throat
History of orogenital sexual activity; may be
asymptomatic
Exposure to irritants; postnasal drip; allergic symptoms

+/- pharyngeal exudate, palatine petechiae,

posterior cerv LN, splenomegaly
Pharyngeal exudate; bilateral cervical
lymphadenopathy
Sinus tenderness, pale or swollen pharynx,
postnasal drainage visible, no fever or
lymphadenopathy

Gonococcal pharyngitis
Inflammation

Pharyngitis with ulcers:

More common in children; immunosupressed; painful
Herpangina (coxsackie virus) throat; fever, malaise

Positive monospot; CBC with

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

Lymphadenopathy; small greyisk papulovesicular Serology

lesions of the soft palate and pharynx,
progressing to shallow ulcres, <5mm

Fusospirochetal infection
(Vincent's angina)

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

Gram stain reveals spirochetes

Apthout stomatitis

Oral trauma, ill-fitting dentures; painful ulcers vary in

size; absence of other symptoms

None

Herpes simplex infection

History of trauma to the mucosa; pain, fever, headache Perioral lesions; lymphadenitis; vesicles on
palate, pharynx, gingiva
Immunosuppressed; persons on antibiotics or with
Curdlike white plaques that bleed when scraped
diabetes; sore mouth/throat
off

Candidiasis

Shallow ulcers, no vesicles; indurated papules

that procress to 1cm ulcers; ulcer has yellow
membrane and red halo; no fever or nodes

Page 4 of 52

Viral culture
KOH smear shows hyphae; culture

Nasal
Symptoms
and Sinus
Congestion

What are the primary symptoms that will help me

narrow the possibilities?
How long have these symptoms been present?
Acute symptoms with fever/chills: acute
infectious rhinitis
Do you have a history of nasal or sinus problems?

Chronic: rarely infectious, associated with

anatomical abnormalities that impair the
sinus drainage system

Do the symptoms occur at any particular time of the

year or season?
Is there a family history of allergies or asthma?
Do you have other symptoms?
If I suspect sinus problems, what do I need to
know?
Do you have a history of sinus problems?
Do you have pain? Please point to the areas.
Do your symptoms change with position changes?

Allergic rhinitis if with sneezing, wheezing,

itchy/burning eyes that are seasonal. IgE
response. Early spring (tree pollens), early
summer (grass), early fall (weed pollens)

How long have you had these symptoms?

Do associated symptoms provide any clues?

Children: chronic sinusitis is >30 days

Acute bacterial infection: purulent nasal
discharge. Acute rhinitis: bacterial or viral
and has fever, myalgia, chills. Sinus
complaints: pressure/pain of the cheeks,
forehead, behind eyes.

Do you have other acute symptoms such as cough,

fever, or muscle aches?

Acute sinusitis: <30 days, persistent cough,

fever >39C for 3 days, malodorous breath.
MC maxillary and ethmoid sinuses,
occasionaly frontal and rarely sphenoid

Do you have other chronic symptoms, such as eye

pain, bad breath, or fatigue?
Is it viral or bacterial?
What color is your nasal discharge?

Seen with chronic sinusitis, not bettwe with

meds.

How long have you had these symptoms?

Are the symptoms unilateral or bilateral? Is it on
one side or both?
Are there risk factors that will narrow the
diagnosis?
Do you smoke?
Are you exposed to others who smoke?
Do you have any other health problems?
Have you had a recent history of head or facial
trauma?
Have you been diving or swimming?

Have you been exposed to infections in day care,

school, or work settings?
Are you pregnant?
Is the patient using any drugs that would cause
nasal congestion?
Are you using nasal sprays or drops?
Do you use cocaine or other drugs?
What medications are you taking?

Maxillary: toothache. Frontal: frontal

headache worse on wakening. Ethmoid
can refer to the vertex, forehead, occipital
or temporal regon. Sphenoid: top of head.
Maxillary sinusitis: worse with bending or
leaning forward. Postnasal discharge
worse with lying down with sinusitis

Yellow or green purulent is viral or

bacterial. Watery/clear is allergic.
URTI is 5-10 days then subsides
Infectious/allergic: bilatral. Unilateral are
MC anatomical cause: polyps, septal dev,
foreign body.

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

Sinus radiographs for

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

CT Scan

Periorbital cellulitis is the

most common serious
complication of severe
bacterial sinusitis.

Allergy skin testing

Perform a regional
examination of the head
and neck: eyes (visual
acuity), ears, LN.
Examine the mouth and
teeth: look for abscesses,
dental root infection.
Erythema of tonsils in
acute viral rhinitis.

Test for smell severe

nasal congestion or
ethmoid sinusitis causes
anosmia
Inspect condition of
nasal mucosa and
turbinates

Smoking has inc risk of sinusitis: more

Inspect for masses: nasal
mucus and paralysis of the nasal cilia. Risk polyps look like skinned
for upper and lower resp tract infections
grapes. Septal deviation
predisposes to infection.
Rare but serious post-trauma CSF
rhinorrhea may be present.
Secondary to barotrauma, infection from
Note the presence and
contaminated water, or allergic response to color of any discharge chlorine
pus in middle turbinate
suggests bacterial sinusitis.
CSF drainage will increase
in forward position
Hormonal changes may lead to nasal
congestion
Transilluminate the
sinuses - complete opacity
suggests infection
Use for more than 1 week can lead to
rebound nasal congestion.
Palpate and percuss
Also rebound nasal congestion
fornal and maxiallry
BCPs, ACE inhibitors, B-blockers may
sinuses for tenderness
cause nasal congestion

Cystic fibrosis can cause dec mucociliary

Is there a systemic disease present?
Have you noticed any other general body symptoms? clearance. Also: diabetes, leukemia, AIDS, Test for facial fullness
hypothyroidism, acromegaly, horner's
and pressure - bending
syndrom, neoplasm can cause nasal sx.
forward from the waist or
Do you have any chronic health problems?
valsalva will worsen
sumptoms of a partial or
complete sonus
obstruction
Examine the lungs
Perform neurological
testing if indicated severe complications from
sinusitis - brain
anbscesses

Page 5 of 52

Nasal smear eosinophils confirms

allergic rhinitis

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

Nasal symptoms DDX:

Infectious rhinitis
Allergic rhinitis

Perennial but more common in winter months; recent Red, swollen mucosa; purulent discharge
URI
Family history of allergies; sneezing; recurrent pattern; Pale, boggy mucosa; rhinorrhea with clear, watery
more common in children and young adults
mucus

Nasal smear for neutrophils,

intracellular bacteria
Nasal smear for eosinophils; allergy
testing

Nonallergic rhinitis

No allergenic cause identified

Similar to allergic rhinitis

Absence of eosinophilia on nasal

cytology

Rhinitis medicamentosus

History of medication use: oral contraceptives, nasal

sprays, antihypertensives; nasal congestion
Smoker; recent URI; winter months; frontal headaches
made worse with forward bending; sensation of
fullness or pressure

Sollen mucosa; clear mucus or dry mucosa

None

Purulent discharge; maxillary toothache on

percussion; postnasal drainage; decreased
transillumination

None

Chronic sinusitis

History of previous sinus infections; dull ache or no

pain; persistent symptoms

Same as above; decreased or no

transillumination; obstruction such as deviated
septum, polyps

Sinus radiographs; CT scan; sinus

aspiration and culture

Obstruction

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

Nasal polyposis

History of asthma. Aspirin intolerance.

Presence of polyps

May require biopsy

Osteomyelitis of the frontal

bone

History of head trauma, diving

Appear severely ill; periorbital and fronal edema

Sinus and skull radiograph; blood

culture

Acute sinusitis

Page 6 of 52

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

First, is this a life threatening condition?

Can you describe the pain? What does it feel like?
E.g. dull, sore stabbing, burning, squeezing?

When did it start?

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

Does the patient have risk factors for CAD?

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

Substernal heaviness, pressure or

squeezing provoked by exertion is anginal.
Tearing pain is aortic dissection. PE:
gripping, stabbing over lung.
Sudden onset and dyspnea is with PE.
Pneumonia is more gradual.
Determine if it is exercise related
Chronic pain is less likely to have a cause
MI: n/d/v SOB, syncope. PE: SOB,
apprehension, hemoptysis. Fever, cough,
think sputum in pneumonia.

Point to where the pain is located. Does it spread to

any other part of your body?
What seems to trigger the pain?
Does the pain awaken you from sleep?

Non emergent chest pain:

dull or sharp.
Submammary and
hemothorax areas. Pain
provoked by body
movements or breaths

What do associated symptoms tell me?

Do you have a cough or a change in your usual
cough?
Do you bring up sputum? If so, how much and what
colour?
Do you have a fever?
Are you lightheaded or dizzy?

Do you feel like your heart is racing?

Is the pattern of pain related to activity and
position change?
Describe your recent physical activities.

Have you had any injury to your chest?

Does chest movement or position make the pain
better or worse?

ECG - good to compare

previous ECG's. ST
elevation means injured
myocardium. T wave
inversion: ischemia.

Measure vital signs and

respiratory patterns
Aortic dissection:
hypotension and unequal
pulses.

Treatmill exercise
testing - tests risk of
severe CAD

Major risk factors for CAD: smoking, HT,

low HDL, family history, age (men >45,
women >55)

Inspect the skin. Cool,

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

Chronic pain is rarely emergent. May be

related to URTI or GERD.

Palpate trachea and

chest - pneumothorax.
Palpate for tenderness,
depressions, buldges.
Costochondritis is pain
where bone meets
cartilage.

What were you doing when the pain first occurred?

Emergent chest pain:

constricting, squeezing,
burning, heavy. It
radiates.

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

Localized pain is more likely non-emergent.

Awakening because of pain signals more

serious problems such as cardiac
ischemia.

Percuss the chest

Auscultate breath
sounds
Auscultate for
adventitious sounds

Usually infection.
Pneumonia sputum: green, rust color, or
red.
May indicate pneumonia, myocarditis,PE
MC caused by structural heart disease,
arrhythmias, and cornary insufficiency. MC
benign in children - breathing difficulties.

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

Arterial Blood gases detect resp alkalosis from

hyperventilation

Auscultate heart sounds

- MI cannot be ID'd
Observe spine for
Radiography evidence of scoliosis
pneumothorax and
pneumonia

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

CT Scan
MRI

Physical activities can cause muscle

strains, rib fracturs, contusions. Decreased
exercise tolerance: shunts, CAD, or
arrhythmias. Investigate any episode
during exercise.

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

Recent muscle strain,

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

Serum amylase and

lipase - pancreas.

Is there a GI origin for the patient's chest pain?

Bronchoscopy

Does the pain get better or worse from eating?

Pain of esophagitis and cardiac origin are

hard to ddx, both better with nitro.
Esophagitis is associated with meals.

CBC - elevated WBC's

with infection

Do you have blood in your stools?

Have you vomited any blood?
Could this pain be from a systemic cause?
Do you have any skin problems?

Peptic ulceration.
Pancreatitis has hypotension.

Esophageal pH - for
GERD
Endoscopy

Do you have any chronic health problems?

Local inflammation of muscles in

polymyositis, fibromyalgia, or SLE. Sickle
cell disease can cause chest pain. Marfan
syndrom: inc risk for aortic dissection

What does family history tell me?

Has anyone in your family had heart disease, chest
pain, or sudden death from cardiac arrest?
Has anyone in your family been born with heart
problems?
What is the emotional state of the patient?
In the past 6 months, have you had a spell or an
attack in which you felt frightened, anxious, or very
uneasy? Or has your heart begun to race, felt faint,
or you could not catch your breath?

consider herpes zoster: persistent

unilateral pain thet is pruritis, burning, or
stabbing.

Hypertension, hypertrophic
cardiomyopathy, CAD have strong family
history.

Panic disorder, anxiety, depression. May

have difficulty taking a deep breath.

Page 7 of 52

Nonemergent Chest Pain

DDX:
Stable angina

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

ECG during episode of chest pain

Myocarditis

Chest pain; history of fever, dyspnea

Heart murmur, friction rub, fever

ECG, chest radiograph

Pericarditis

Sharp, stabbing pain referred to left shoulder or

trapezius ridge, usually worse during coughing or
deep breathing; may be relieved by sitting forward;
history of viral or bacterial infection, autoimmune
disease

Fever before onset of pain, tachycardia,

pericardial friction rub

WBC, ESR, ECG, chest radiograph

Aortic stenosis

Chest pain on exertion, subsernal and anginal in

Radial pulse diminished; narrow pulse pressure;
quality; fatigue, palpitations, DOE, dizziness, syncope loud, hars, crescendo-decresc murmur heard at
2nd R ICS leaning forward; thrill

Mitral regurgitation

Exertional chest pain, fatigue, palpitations, dizziness,

DOE, syncope

Holosystolic, blowing, often loud murmur heard at Chest radiograph, ECG,

apex in L lateral position, which dec on
echocardiogram
inspiration; murmur may radiate to the axilla and
possibly the back

Pnemonia

Productive cough of yellow or green or rust sputum;

dyspnea; pleuritic pain

Fever; tachycardia, tachypnea; inspiratory

crackles; vocal fremitus; percussion dull or flat
over consolidation; bronchophony. Egophony

Chest radiograph; sputum cultures;

ABGs

Mitral valve prolapse

Chest pain, varies in location and intensity;

palpitations; anxiety; non-exertional pain of short
duration, history of Marfan's syndrome

Dysrhythmias, possible midsystolic click over

apex, hear best sitting or squatting;
thoracoskeletal deformity common in children

ECG, echocardiogram

Pleuritis

Mild, localized chest pain, worse with deep breathing;

recent URI

Shallow respirations, local tenderness, pleural

friction rub

None initially

Esophagitis

Substernal pain worse after eating and lying down;

sour taste in mouth

Epigastric pain with palpation

Esophageal pH

Chest trauma (rib fracture)

History of injury or trauma; pain with deep breaths;

splinting of chest wall
Pain along sternal border, increases with deep
breaths, distory of exercise, URI or physical activity

Shallow respirations; chest wall pain on palpation Chest radiograph

Pain with palpation over costochondral joints;
normal breath sounds

None

Herpes zoster

Unilateral chest pain; painful rash

None

Peptic ulcer disease

Epigastric pain 1-2hrs after eating, > antacits;

hematemesis and melena. Risks: smoking, alcohol
Right upper quadrant abdominal pain radiating to the
right chest, often following high-fat meal; nausea and
vomiting

Normal breath sounds; vesicular rash along

dermatome
Tenderness to palpation in the epigastric area;
signs of hypovolemia
Positive Murphy's sign; palpable gallbladder

Severe left upper quadrant abdominal pain radiating

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

Left upper abdominal pain with palpation;

hypotension
Normal exam or diminished breath sounds over
tumor and dull percussion over tumor

Serum amylase. Pancreas

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

Chest pain, SOB, diaphoresis, nausea; may relate to

substance use
Precordial chest pain, history of stressful situations

Tachycardia, hypertension

ECG, serial cardiac enzymes, drug

screen
ECG, chest radiograph

Pleurodynia

Severe, acute onset, stabbing, paroxysmal, pleuritis

pain over lower ribcage and substernal edge;
headache, malaise, nonproductive cough

Pleural friction rub 25% of time; chest

examination normal; fever usually present

Precordial catch syndrome

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

Costochondritis

Cholecystitis

Acute pancreatitis
Lung tumors

Cocaine use
Psychogenic origin

Normal exam

Page 8 of 52

Echocardiogram, ECG, chest

radiograph

Upper GI radiograph, upper

endoscopy, CBC
Gallbladder ultrasound

None

None

Is this a medical emergency?

Dyspnea

assess adequacy of the airway

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

Rule out epiglotitis in children: drooping,

dysphonia, looks toxic.
Anaphylaxis from insect bites or ingestion
of potential allergins (meds, food)

Is the dyspnea caused by secondary obstruction Obstruction may be intraluminal (foreign

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

CAD, valvular disease, CopD, or asthma

can cause dyspnea. Also MI. Also things
that dec oxygen capacity of blood (e.g.
anemia)

Do you have any numbness or tingling in your body? Hyperventilation syndrome: nonemergent.
Where?
Paresthesias around mouth and distal
extremities.
Have you noticed any other symptoms?
What factors precipitate or aggravate dyspnea?

> rest if lung/cardia orgin. < rest if from

anxiety
Smoking most frequently causes chronic
dyspnea. COPD > rest.

Note general appearance Transcutanous pulse

oximetry
and observe posture:
respiratory distress?
Chest radiography

Electrocardiography
Assess level of
consciousness

Echocardiography

Observe chest
movement: PE and
pneumothorax have
unequal expansion

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

Inspect shape and

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

Look for retractions

CT Scan
contractions of intercostals
Pulmonary angiography
Observe rate, rhythm and for PE
depth of respiration for 1 CBC with diff for
full minute - expiration
bacterial infection
longer in COPD.
Tachypnea: resp distress.
BUN and creatinine for
renal function
Listen for stridor
ABGs
inspiratory airway
obstruction
Listen for audible
wheeze and voice
changes
Take pulse, temperature,
and blood pressure.
Palpate pulses.

What activities are associated with SOB?

Do you take any prescription medication?
Do you have any known allergies? Trees? Dust?
Associated with asthma.
Pollen? Animals? Have you been exposed recently?

Inspect oral cavity foreign body.

Inspect the nose patency and flaring

Is there anything that makes your SOB better? Sit

up? Stay indoors? Lie down? Use meds?
Is the dyspnea caused by a neuromuscular
problem?
Are the patient's immunizations up to date?

Palpate the neck masses and trachea

Examine skin and
extremities: cyanosis,
pallor (anemia), clubbing,
peripheral edema,
angioedema (allergy), cap
refill, diaphoresis

Child: has the infant had honey?

Do you live on a farm?
Child: are they at risk for lead poisoning?
Do you have a headache, muscle weakness, or
visual changes?
Does the patient have any pertinent risk factors
that will point me in the right direction?
Do you or have you smoked? Are you exposed to
cigarette smoke frequently?
What type of work do you do?
Have you had recent weight gain?
Have you ever had eczema?

May result in paresis/paralysis of resp

muscles.
Can be caused by infections: poliomyelitis,
tetanus.
Botulism --> respiratory distress.
Organophosphate chemicals can cause a
myasthenia-like syndrome
Could also be: meningitis, seizures, CNS
lesion

Exposure to: asbestos, silicon, paint and

chemical fumes, coal dust.
Obese patients report SOB more frequently
than their counterparts.
Assoc with asthma

Page 9 of 52

Palpate the chest

Asses for vocal fremitus
- diminished in
pneumothorax, asthma,
emphysema. Inc in
pneumonia, heart failure,
tumor
Percuss the chest
Auscultate breath
sounds
Auscultate heart sounds

Sputum culture

Dyspnea DDX:
Emergent Conditions
Pulmonary Embolus

Acute-onset dyspnea, cough, mild to severe chest

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

ABGs, chest radiograph, ECG,

ventilation/ perfusion scan

Foreign body aspiration

Acute-onset dyspnea; history of eating or drinking

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

Lateral neck radiograph, chest

radiograph, bronchoscopy

Anaphylaxis

Acute-onset dyspnea; history of insect sting, ingestion

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

None; emergency measures

necessary
Chest radiograph, ABGs

Pneumothorax

Angioedema, tachypnea, clammy skin,

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

None initially; if respiratory distress

increases, pulse oximeter and
referral
Admit; life threatening

Croup

History of upper respiratory infection

Acute epiglottitis

Positional sitting forward; sore throat, anxious, toxic

child

High fever, drooling, stridor, muffled voice

Bacterial tracheitis

Recent viral infection

Fever, stridor, purulent sputum

Status asthmaticus

Recent URI, exposure to allergins, breathlessness

Wheezing, coughing, tachycardia, tachypnea

Botulism

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

Nonemergent conditions:
Pneumonia

Dyspnea, cough, sputum production (green, rust, or

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

Hyperventilation syndrome

Dyspnea, lightheadedness, palpitations, paresthesias Restlessness, anxiety, normal CV examination

(perioral and extremities)

Chest radiograph

Laryngomalacia

Neonate, infant: history of stridor, history of URI

Inspiratory stridor; normal cough, cry

Refer for visualization of larynx

Vascular ring

Infant: dyspnea, brassy cough, difficulty swallowing

Inspiratory stridor with expiratory wheeze

Barium swallow, echocardiography

Heart failure

Chronic progressive dyspnea, cough, frothy sputum,

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

Altered level of consviousness, restlessness,

jugular venous distention, tachypnea, use of
accessory muscles to breathe, rales, rhonchi,
wheezes, tachycardia, decreased peripheral
pulses, cool extremities, desplaced PMI, S3, S4,
ascites, liver enlargement

ECG, chest radiograph, ABGs,

echocardiogram

Anemia

Dyspnea on exertion, fatigue, palpitations, lightheadedness, history of chronic disease

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

Pallor, tachypnea, cool dry skin on extremities,

possible orthostatis hypotension
Overweight, tachycardia

CBC, iron studies

Restlessness, tachypnea, use of accessory

muscles to breathe, intercostal retractions,
decreased vocal fremitus, decreased breath
sounds, inspiratory and possible expiratory
wheezes

Spirometry, chest radiograph, ABGs

Chronic progressive dyspnea, dyspnea on exertion,

persistent cough, minimal sputum, easy fatigue,
history of smoking

Rapid shallow respirations, reddish complexion,

increased AP diameter of thorax, use of
accessory muscles to breathe, pursed lip
breathing, decreased tactile fremitus, decreased
respiratory excursion bilaterally, lungs
hyperresonant, distant breath sounds, prolonged
expiration, occasional wheezes, possible
tachycardia, muffled heart sounds

Chest radiograph, pulmonary

function test, exercise tests, ABGs

Poor physical conditioning

Asthma

COPD

Page 10 of 52

Radiography of airway, WBC

increased, tracheal culture
Peak flows, chest radiograph, ABGs
Pulmonary function testing, chest
radiograph, fluroscopy, stool culture

Cardiac stress test

Amenorrhea

Is there a pregnancy?
Are you sexually active?

Lack of menstruation that Are you using any birth control methods?
may be a result of 1o or 2o
causes.
Are you trying to become pregnant?
Is this primary or secondary?
Have you ever had a menstrual cycle?

Have you started pubertal development? Can you

show me how your breast and pubic hair look
compare with these pictures? (see pics in book
pg.314 3rd ed.)
At what age did you start you periods?
When was your last normal menstrual period?
What is the nature of your periods (amount of flow,
frequency, duration)?

Are there any constitutional delays causing the

amenorrhea?
Has there been a change in weight, % body fat, or
athletic training intensity?

Important to rule out pregnancy!

Note general
appearance: short stature,
Ask questions about having nonconsensual
under/overweight.
sex.
Contraceptive failures may account for
unintended pregnancy. Amenorrhea may
occur after discontinuation.

Pregnancy Test: rule out

pregnancy.

Thyroid stimulating
hormone: Identifies
hypothyroidism. Menses
resumes w/
Unintended or intended. Also may refer
Assess nutritional status supplementation.
amenorrheic patient to infertility clinic.
and plot measurements
on growth chart in
Age range for menarche is 9-17yrs. If
Prolactin levels: fasting
adolescents: under/
established menses (no outlet flow problem overnutrition. Height,
levels.
and HPO axis & endometrium functioning) weight, arm span.
If high or galactorrhea
at intervals of every 21-38 days then
RO adenoma or illicit
classification of secondary.
drugs.
Begins w/ growth spurt 1 yr before breast
buds at ~11yrs. Pubic hair at beginning of
menarche. Avg age for menarche 12 years
4months. Can look at peds growth chart to
see if normal dev.
Primary - lack of menses & 2o sex char. by
14 or lack of menses by 16 w/ 2o sex char.
Ask about mother/sister's menses onset if
delayed.
Secondary - Absence of menses for 6
months or cycle > 35days.

Screen for eating

disorders: Anorexia or
bulimia. Refer to DSM for
criteria.
Calculate BMI: 17%
(19kg/m2) body fat needed
for menses and 22% body
fat for ovulation.
BMI > 27% obesity =
imbalance in HPO axis

Severe stress of anorexia can produce

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

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

Are you under unusual stress at school, home or

Stress can disrupt normal cyclic menses.
work?
Do you or anyone in your family have any congenital Turner's syndrome- abnormality of
disorders or chronic diseases?
components necessary for menses.
Structural anomalies - prevent outflow.
Anorexia, DM, Crohn's, SLE, GN, CF,
pituitary adenoma, adrenal diseases &
thyroid dysfxn.

Perform head & neck

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

Could this be a thyroid dysfunction?

Have you noticed changes in the texture of your hair
or skin?
Are you bothered by hot or cold temperatures?
Have you had any changes in your energy level /
bowel function?

Palpate thyroid gland

and lymph nodes:
enlargement, bruits,
lymphadenopathy.

Hyperthyroidism - heat intolerant

Hypothyroidism - cold intolerant
Inc thyroid fxn - restlessness, diarrhea
Dec thyroid fxn - constipation, fatigue

Perform breast exam:

sexual maturation level,
axillary hair, galactorrhea.

Are you able to express a discharge or liquid from

your nipples?

Nipple d/c not associated with

breastfeeding or medications (dopamine
antagonists/ estrogens).

Is there increased stimulation to your nipples?

Galactorrhea - from clothing irritation,

sexual activity, LN dissection, herpes
zoster

Perform pelvic exam:

maturation of female
genitalia, secondary sex
characteristics.
Absence of vagina, cervix
or uterus.
Outlet problems, assess
vaginal walls.
Bimanual examination enlarged ovaries,
position/size of cervix /
uterus.

Could this be caused by hyperprolactinemia?

Have you had any surgery or disease of the breasts

or chest wall?
Could the hyperprolactinemia be caused by
medications?

Meds such as phenothiazines or

contraceptives cause amenorrhea (inc
prolactin, induce estrogenic effect, toxic to
ovaries)
What prescription medicines are you taking?
Heroin and methadone lead to menstrual
Have you used any street drugs? What kind of drugs abnormalities.
have you used?
Is a pituitary tumor causing the amenorrhea?
Hyperprolactin state - pituitary tumor -->
Have you experienced any visual changes?
may cause headache, visual defects (optic
Are you having an increased number of headaches?
chiasm & nerves compressed)

CNS Imaging: If both

FSH, LH low indicative of
pituitary problem. Use
contrast CT or MRI to
determine ABN.

Pelvic U/S & Vaginal

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

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

Is this a problem of the HPO Axis?

Have you experienced any problems with infertility?

Main cause = failure of ovulation.

PCOS b/w ages 15-30.

Do you have excess hair on your face or chest?

50% of women w/ PCOS are hirsute &

obese, difficulty conceiving. LH elevated.
Androgen excess - truncal obesity, acne,
male pattern baldness

Estrogen &
Progesterone
Challenge test: +ve if
flow w/in 2-7days,
indicates inadequate
estrogen production.

Are you having menopausal symptoms (Hot flashes, Estrogen deficiency - menopausal sx. May
vaginal dryness)?
see dyspareunia, dysuria. Prolonged may
lead to osteopenia.
Did you hemorrhage during childbirth?
Is this a problem of the uterus?
Have you had a miscarriage or abortion, uterine
infection, or any surgery or procedure involving your
uterus?
What symptoms support a structural outflow
problem?
Do you have a cyclic abdominal bloating or
cramping?
Have you been amenorrheic since you had a cervical
procedure?

May lead to amenorrhea - Sheehan's

syndrome.
Endometriosis, incomplete abortion, or
aggressive curettage of uterus can lead to
denuding of endometrial layer, scarring &
Asherman's syndrome.

Chromosome Analysis:
abnormalities in
development.

Incomplete outflow tract (imperforate

hymen/ cervical os) - dysmenorrhea w/
absence of menses

Endrometrial Biopsy

Stenosis of cervical os - can occur after

surgeries (cervical biopsies)

Basal Body Temp.

Charting
Progesterone Levels
Maturation Index

Page 11 of 52

DDX: AMENORRHEA
Pregnancy

Breast tenderness, morning sickness, urinary

frequency.

Globular, enlarged uterus; soft, bluish colour

cervix

Constitutional Problems:
Delayed puberty

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

Prolactin normal; TSH, T4 normal;

CBC, UA normal; chemistry profile
normal; bone age normal; skull
radiograph normal

Anorexia nervosa / bulimia

Mean age 13-14; fear of being fat; low self-esteem;

depression; isolation; overachiever; food is a parental
battleground; preoccupation; hair loss; abdominal
bloating, pain, constipation.

TSH normal; prolactin normal; FSH

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

Amenorrhea before or after weight loss; cachexia;

low body fat; short stature; yellow, dry, cold skin;
acrocyanosis; increased lanugo hair;
hypotension, systolic murmurs, often mitral valve
prolapse.

B-hCG pregnancy test positive; U/S

positive.

Exercise Induced Amenorrhea Began athletic training at young age; more common w/ BMI < 17% body fat
long distance runners, ballerinas, gymnasts.

TSH normal; prolactin normal.

Congenital or Chronic
Disorders:
Turner's syndrome

Congenital; short stature; infantile sexual development. Characteristics: webbed neck, low set ears,
shieldlike chest, short fourth metacarpal

Karyotype (45,X)

Cushing's syndrome

Weight gain; weakness; back pain

Moon face, acne, hirsutism, purple striae of

abdomen

Cortisol increased; 17-ketosteroids

increased; CT adenoma

Thyroid dysfunction

Hypothyroid: delayed growth, weight gain, fatigue,

constipation, cold intolerance; hyperthyroid: wt loss,
nervousness, heat intolerance

Hypothyroid: dry skin, fine hair, galactorrhea;

hyperthyroid: moist skin, hyperpigmentation over
bones, thin hair, goiter

Hypothyroid: TSH high;

Hyperthyroid: TSH low; T3 high; T4
high

Polycystic Ovary Syndrome

Infertility

Hirsutism; obese; enlarged ovaries

Uterine and Outflow Tract

Problems:
Imperforate hymen/ stenotic
cervical OS

Monthly bloating, cramping and pelvic pressure; no

menses; cryotherapy or other procedure to cervix

Fibrotic hymen without patent opening; stenotic

cervical os

U/S: enlarged overies w/ multiple

fluid filled cysts; Testosterone high.
Clinical diagnosis by history and
findings

Asherman's syndrome

History of uterine infection; tuberculosis,

Pelvic exam normal
schistosomiasis; uterine iatrogenic scarring; curettage,
irradiation

PCT negative; E and PCT negative;

hysteroscopy adhesions

Hypothalamic-pituitaryOvarian Axis Problem:

Menopause

Hot flashes, night sweats, insomnia, mood changes

Pale, dry vaginal mucosa; few rugae

FSH and LH high; estradiol low

Sheehan's syndrome

Recent history of postpartum hemorrhage and shock

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

Hair loss; depigmentation of skin; mammary and

genital atrophy
Nipple discharge: bilateral; multiduct; milky, clear
or yellowish discharge

Pituitary and end-organ hormones

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

Medications/ chest wall or

nipple stimulation

Pituitary adenoma

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

headaches

Page 12 of 52

Prolactin high; cone-down view of

sella turcica positive; MRI or CT with
contrast positive

Breast Lumps
& Nipple
Discharge

Is this lump likely to be malignant?

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

Malignant lesion = single, hard, painless

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

Cyclic cysts less common after menopause

therefore warrant investigation.
Peri/post menopausal at greater risk for
CA.
Is there any discharge from the nipple?
Ductal CA - nipple d/c w/ a lump (eg
Paget's - mass w/ bloody d/c.)
80-90% of breast lump
Have you recently been treated for a breast
Masses after ABC's suspicious for
found before diagnosis
infection?
malignancy & require biopsy.
through clinical breast
Does the person have additional risk factors for Inc risk of malignancy if:
exam. Risk of breast CA breast cancer?
- Hx of epithelial hyperplasia, ductal
acceralerates after age
carcinoma in situ (DCIS) or lobular
50. Nipple d/c associated Have you ever had breast cancer?
carcinoma in situ (LCIS)
Do you have a family history of breast cancer (first
w/ pregnancy, breast
- tumors in adolesents more likely to be
degree relative)?
feeding or estrogenic
metastasis than primary tumor
meds.
- 75% of all cases occur >50 yrs old
Have you ever had ovarian, endometrial, colon, or
- previous hx of breast biopsy for benign
thyroid cancer?
Do you have a family history of ovarian, endometrial, breast disease (LCIS)
- genetic mutation (BRCA1, BRCA2 genes)
colon or prostate cancer?
- Hx of CA (Ovarian, endometrial, colon,
Have you ever received radiation to the chest or had thyroid)
malignancy in childhood?
- Family Hx (First deg. relatives)
When was your last menstrual period?

Is this condition more likely to be benign?

How old are you?

Have you had lumps before? Do you have a history

of cystic breast changes or lumpy breasts?

Does this lump feel like other lumps youve had?

Do the lumps come & go or change with your
periods?
Have you ever had a mammogram or u/s? Why was
it done? What were the results?
Have you ever had a lump drained or biopsied?
What was the diagnosis?
Have you had breast implants?
Could this lump be mastitis related to lactation?
Have you recently had a baby?
Are you currently breast feeding/ suckling?
Are your nipples sore, cracked or pierced??
Is your breast painful or hot? Areas of redness?

Have you had a fever?

Is this normal lactation?
When was your last menstrual period? How frequent
are your cycles?
Is it possible you are pregnant? What are you using
for birth control?
When was your last delivery or miscarriage? How
long were you pregnant?
Did you breastfeed? For how long? When did you
stop?
Is the nipple discharge clear or milky?
How long have you had the nipple discharge?
Is the discharge related to high prolactin?
What medications are you taking?
Do you jog or run? If yes: Do you wear a sports bra?
Do your nipples rub on your clothing?
Are your breasts fondled, squeezed, or suckled
during sexual activity?
Do you have a thyroid condition?
What medical / health problems do you have?
If a newborn: has d/c been present since birth?
Can nipple d/c be a sign of malignancy?
Is the nipple d/c spontaneous or must it be
expressed?
Does it come from one or both nipples?
Does it come from one or multiple nipple ducts?
Do you also have a breast lump?
Are you post menopausal?

Fibrocystic breast changes b/w 20-30

Fibroadenomas b/w 15-39
Intraductal papilloma & ductal ectasia b/w
35-50
Breast carcinoma b/w 40-70
Fibrocystic breasts - Painful, mobile lumps
that increase in size & tenderness, discrete
borders changes correspond with
menstrual cycle
Cyclical changes correspond w/ benign
disease along w/ clear fluid aspirate from
cyst.
No changes of tissue on mammogram or
U/S.

Ruptured implant pushes augmented

breast tissue away from chest wall.
Breast masses in lactating women usually
associated w/ mastitis & a blocked duct.
Usually caused by Staph aureus.
CA in lactating women rare.
May be site for infection
Mastitis - painful, hot, red breast
Inflammatory BR CA - swollen heavy,
edematous breast (m/c in non lactating
women)
sign of infectious mastitis - associated w/
lactation & breast feeding
Fibrocystic changes manifest as
spontaneous multiple duct d/c.
Pregnancy - m/c cause of galactorrhea;
bloody d/c due to vascular engorgement
Normal lactation - milky, non purulent d/c
Mastitis/ sub aerolar abscess - purulent d/c
(DDx w/ inflammatory CA by use of ABCs)
BCP - clear, serous or milky d/c
Duct ectasia/ Papillomatosis - green/brown
d/c
Bloody d/c - benign or cancerous
New onset d/c requires further
investigation.
Discontinuation should elimate d/c
Stimulation inc. PRL levels along w/
marijuana.

responsible for galactorrhea (eg. hypoT, pit.

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

Page 13 of 52

Inspect breast & nipples:

arms at side, on hips,
elevated above head,
bending forward. Look for
dimpling, asymmetry,
inversion.

Ultrasound:
differentiates solid from
cystic.

Observe skin of breasts

and nipples: erythema,
prominent vessels,
eczema, pigmented lesions
(Paget's), crack, exudate,
retraction.

MRI: evaluates abnormal

lesions on mammogram,
good for dense breast
tissue

Palpate breasts &

nipples: feel for lumps,
nodules, feel tail of
Spence.
Palpate lymph nodes:
supra/infraclavicular,
axillary. Note size,
consistency and mobility.

Mammography: for
nonpalpable lesions

Fine needle aspiration

& Cytological Exam:
differentiates solid vs.
cystic (in-office)
Stereotactic or needle
localization biopsy: for
poorly defined masses

Assess nipple well:

depress nipple ino areola - Core needle biopsy: for
should move easily.
difficult to palpate
masses
Examine Nipple for
discharge: uni/bilateral,
single/multiple ducts, take Excisional biopsy: gold
standard for masses.
sample of d/c .

Transluminate breast
masses: solid mass will
not transluminate
(malignant)

Microscopy: of nipple
d/c reveals "fat cells" of
galactorrhea, leukocytes,
RBCs.

Characterize lump: depth

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

DDX: BREAST LUMPS & NIPPLE DISCHARGE

Single Breast Mass:
Usually older than 35; unilateral new lump
Cancer

Single, hard, nontender, fixed lump; borders

irregular or not discrete; may be erythema,
dimpling, increased vessel patterns; may have
nipple discharge

Diagnostic mammogram; ultrasound;

tissue biopsy

Cysts

Younger age, often younger than 35; often multiple

round or elliptical; soft or fluctuant; mobile

Clinical exam; FNA:Clear aspirate;

mammogram; U/S: cysts

Fibroadenoma

Common in adolescence

Single, sharply circumscribed mobile lump

Diagnostic mammogram; ultrasound;

biopsy

Abscess

History of mastitis

Biopsy

Fat necrosis
Lipoma

May have history of injury at site

May have others on arms, trunk, buttocks, or back;
usually nontender

Single mass; irregular shape; chronic abscess

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

Tuberculosis

History of Tb, Positive PPD, or chest radiography;

immunocompromised patient status

Single; irregular shape; nontender

Biopsy

Ruptured implant

History of augmentation; change in shape or size of

breast

Nodule palpated best when patient is sitting

Diagnostic mammogram; U/S; MRI

Mastitis and acute abscess

Primigravidas more often than gravidas; >1wk after

delivery; breast feeding; tender nipples

Red, warm, tender; usually unilateral, one fourth

of breast, or one lobule; breast engorgement;
fever; nipple discharge: pus

Culture positive for S. aureus, E.

Coli, Strep; Elevated WBCs

Inflammatory Breast cancer

History of mastitis or inflammory process of breast

Entire breast swollen; fever rarely present; axillary Biopsy

lymphadenopathy

Biopsy
Biopsy

Inflammatory Breast Mass:

Multiple or Bilateral Breast Lumps:

Fibrocystic breast changes
Multiple breast lumps of both breasts; cyclic changes
that worsen at time of menses

Bilateral nodularity; dominant lumps; tender,

mobile

FNA; Ultrasound; Mammogram

Nipple Discharge:
Intraductal Papilloma

Unilateral; subareolar

Diagnostic mammogram; ductogram

Fibrocystic breast changes

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

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

Diagnostic mammogram; ductogram

Neonatal Discharge (Witch's

milk)
Hyperprolactinemia

Milky d/c 1-2 wk after birth

None

Male Breast Disease:

Acute Mastitis

Hx of clothing rubbing nipple (eg. Jogging); swelling or Red, warm, tender; usually unilateral, one fourth
lump of chest wall; tenderness of site
of breast, or one lobule; breast engorgement;
fever; nipple discharge: pus

Culture positive for S. aureus, E.

Coli, Strep; Elevated WBCs

Cancer

Family Hx of male breast cancer; painless lump of

chest wall

Mammogram; FNA; tissue biopsy

Duct ectasia

Milky or clear nipple d/c; amenorrhea; Hx of meds:

estrogenic, dopamin depleters;hypoT; pregnancy;
postabortion; nipple stimulators; visual changes

Enlarged breast tissue, milky d/c lasting 1-2 wk

after birth
Spontaneous, unilateral or bilateral, multiduct;
clear or milky nipple d/c

Induration, retraction of nipple or mass in nipple

well; fixed, nontender; lymphadenopathy

Page 14 of 52

Diagnostic mammogram; ductogram

Serum Prolactin levels; MRI if

indicated

Diarrhea
Most cases are of viral
origin and are self-limiting.
Osmotic/ malabsorptive:
nonabsorbable water
soluble solutes.
Secretory: imbalance b/w
fluid secretion &
absorption. Exudative:
mucosal inflammation or
ulceration.

What does this px mean by "diarrhea"?

How frequent is the stool?
What is the volume of stools?

Are the stools formed or liquid?

At what intervals does the diarrhea occur?

Is this an infant, is there risk of dehydration?

How many wet diapers has the child produced in the
past 24 hours?
Does the infant seem thirsty?
Does the child have tears when crying?
If this is an adult, is there risk of dehydration?
How many times have you urinated in the past 24
hours?
Are you thirsty?
Do you have a dry mouth or dry eyes?
Is this an acute or chronic problem?
How long have you had diarrhea?
Have you had this problem before?
Does the presence or absence of blood help me
narrow the cause?

Typical 1-3x/day to 2-3x/week.

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

Inspect General
Appearance

Assess hydration status:

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

Observe abdominal
contour: distension
Related to rate of fluid loss
Auscultate Abdomen:
Ss/Sx: thirst, dry mouth, dry eyes,
detect presence of bowel
frequency & volume of urination, weakness sounds
Acute adults: infectious cause(viral), self
limited, <2wks
Acute children: loose/liquid d/t infection or
congenital anomaly
Chronic Adult: >2wks, parasites, meds,
IBS, lactose, IBD
Chronic children: >3wks, formula
intolerance, infex, Giardia, malabs, IBD

Fecal leukocytes: found

in inflammatory bowel
disease, UC, Crohn's

Fecal Immunochemical
Test (FIT): uses Anti-b's
to detect human blood
protein
Fecal fat: restrict fat &
collect stools.
D-Xylose Absorption
test: malabsorption vs.
maldigestion.

Palpate abdomen for

tenderness: peritonitis
Stool pH: 5 indicates
(rigid abdomen, rebound
malabsoption
tenderness, +ve iliopsoas,
obturator.
Wet mount: assess for
bacteria, cysts, ova,
larvae, trophozoites

Is there any noticeable blood in the stool or tissue?

How much?
What colour is the blood?

Hemorrhoids - bright red blood

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

Perform DRE: look for

fissures/lacerations, feel
for impacted stool

What colour are the stools?

Red: blood, food, drugs, food colouring

Green-black: grape drinks, iron
Dark gray: cocoa, chocolate
Pale gray/white: cholestasis, jaundice,
malabsorption
Green: bile salts, chlorophyll veggies

Palpate lymph nodes:

lymphadenopathy
associated w/ lymphoma
and AIDS

What does the presence or absence of pain tell

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

Malabsorptive - pain & flatulant stools

Self limiting viral - pain, D/N/V, fever,
tenesmus

Stool culture: detects

common bacteria

Generalized: diffuse inflammation

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

Stool for ova &

parasites: requires fresh
stool

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

Cardinal manifestation of disease (GI tract,

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

Campylobacter - infected dogs or cats

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

Pseudomembranous colitis (C.Difficile):

ABCs disturb normal flora of gut
Antacids (Mg), ABCs, methyldopa, Antiinflams, laxatives, B-Blockers, Colchicine,
salicylates

Page 15 of 52

C. difficile toxin assay:

toxin causes necrosis of
colonic epithelium

Giardia antigen test:

tests for antigen 65
Indirect hemagluttinin
assay: detects
antibodies
CBC w/ diff: may
indicate presence of
chronic disease, anemia,
inflammatory dz.

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

DDX: ACUTE Diarrhea

Viral gastroenteritis (eg.
Norwalk or rotavirus viral
agents)

Abrupt onset 6-12 hr after exposure; nonbloody,

watery diarrhea; lasts <1wk; nausea/vomiting, fever,
abdominal pain, tenesmus

In children may see severe dehydration;

hyperactive bowel sounds, diffuse pain on
abdominal palpation

None

Shigella (gram negative rod;

fecal-oral transmission;
common in day care setting;
common in gay bowel
syndrome)

Acute onset 12-24 hr after exposure; lasts 2-3 days;

large amounts of bloody diarrhea with abdominal
cramping and vomiting

Lower abdominal tenderness, hyperactive bowel

sounds, no peritoneal irritation

Fecal leukocytes, positive stool

culture

S.aereus food poisoning

(gram-positive cocci; from
improperly stored meats or
custard filled pies)

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

Clostridium perfrigens food

Acute onset 8-20 hr after ingestion; lasts 12-24hr;
poisoning (Gram-positive rod; large amounts of watery, nonbloody diarrhea;
from contaminated food)
abdominal pain and cramping

Hyperactive bowel sounds, diffuse pain on

abdominal palpation

Fecal leukocytes, negative

anaerobic cultures of stool

Salmonella good poisoning

(gram-negative bacilli;
ingestion of contaminated
food, poultry, eggs)

Acute onset 12-24 hr after exposure; lasts 2-5 days;

Fever of 38.3-38.9C (101-102F) common;
Fecal leukocytes, positive stool
moderate to large amounts of nonbloody diarrhea with hyperactive bowel sounds, diffuse abdominal pain culture, WBC count normal
abdominal cramping and vomiting

Campylobacter jejeni (gram

-ve rod; fecal-oral
transmission; household pet)

Acute onset 3-5 days after exposure; lasts 3-7 days;

moderate amounts of bloody diarrhea

Fever, lower quadrant abdominal pain

Fecal leukocytes; positive stool

culture

Vibrio cholera (gram -ve rod;

fecal-oral transmission;
ingestion of contaminated
water, seafood or food)

Acute onset 8-24 hr after ingestion of contaminated

food; lasts 3-5 days; large amounts of nonbloody,
watery, painless diarrhea; can be mild or fulminate

Cyanotic, scaphoid abdomen, poor skin turgor,

thready peripheral pulses, voice faint

Fecal leukocytes, negative stool

culture

Enterotoxic E.Coli (gram -ve

rod; fecal-oral transmission;
ingestion of contaminated
water or food)

Acute onset 8-18 hr after ingestion of contaminated

food/water; lasts 24-48hr; moderate amounts of
nonbloody diarrhea; pian, cramping, abdominal pain;
adults in US generally do not develop this

No fever; dehydration is major complication

Fecal leukocytes; positive stool

culture

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

Acute onset 12-24 hr after ingestion of contaminated

food or water; large amts of bloody diarrhea;
abdominal cramping & vomiting

Right lower quadrant abdominal pain; in small

number of cases hepatic abscess forms

IHA: Antibodies to E.Histolytica;

positive titer is > 1:128

ABC-induced (begins after

taking ABCs)

Mild, watery diarrhea: crampy abdominal pain

Diffuse abdominal pain on palpation; fever absent Usually not needed

Pseudomembranous colitis
(C.difficile ABC induced)

M/c ampicillin; Sx range from transient mild diarrheaactive colitis w/ bloody diarrhea, ab pain, fever

Lower quadrant tenderness, fever

CBC: leukocytes; sigmoido/

colonoscopy, C.diff toxin assay or
stool culture; C difficile toxin

Hemolytic uremic syndrome

(HUS)

Children < 4yr w/ Hx of gasteroenteritis; Hx of bloody

diarrhea, fever and irritability

Fever, irritability; may have oliguria or anuria

CBC, platelet count, renal fxn test,

periph. Blood smear; -ve stool
culture

Necrotizing enterocolitis

Premature or low birth we infant who presents w/

feeding intolerance
GI bleeding 2-3 days postnatal; Hx of lack on vit K
injection; Hx of mother on anti convulsants prenatally

Vomiting, abdominal distension, lethargy, loose,

Refer
bloody mucousy stools
Bruising, ecchymoses, mild to moderate bleeding Lab studies typically show elevated
PT & PTT w/ dec. levels of vit K
dependent factors

Hemorrhagic disease of
newborn

DDX: CHRONIC DIARRHEA: Intermittent diarrhea alternating w/ constipation;

Tender colon on palpation; may have abdominal
mucus w/ stool; seldom occurs at night or awaken px; distension; no weight loss; afebrile
IBS
commonly present in morning; may have rectal
urgency; episodes usually triggered by stress or
ingestion on food; affects women 3 times more

Diagnosis of exclusion;
sigmoidoscopy. Protoscopy

UC (distal colon most

severely affected & rectum
involved)

Hx of sever diarrhea w/ gross blood in stools, no

growth retardation; few complaints of pain; age of
onset 2nd & 3rd decades w/ peak I adolescence;
postive family history

CBC show leukocytosis or anemia,

ESR elevated; stool cultures to rule
out other causes of diarrhea;
colonoscopy

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

Hx of chronic bloody diarrhea w/ ab cramping, tender Wt loss, rare gross rectal bleeding, fistulas
& rectal bleeding; in children Hx of growth retardation, common
wt loss, mod.
Diarrhea,
pain, anorexia
Bloating,
flatus,
diarrheaab
exacerbated
by ingestion of Diffuse abdominal pain
certain disaccharides (lactose, milk products); may
follow viral gasteroenteritis

Overt rectal bleeding; initially no fever, weight

loss, or pain on palpation of abdomen; moderate
colitis: wt loss, fever, ab tenderness

Colonoscopy w/ biopsies
Trial elimination of offending foods

Greasy, fatty, malodorous stools; associated w/

deficiencies of vit K, A & D; cystic fibrosis
Toddler's diarrhea
3-4 stools/day; some contain mucus; rare >4-5 yrs
Celiac sprue/ PRO
Increased stool frequency, looseness, paleness &
hypersensitivity (rxn to protein bulkiness of stool w/in 3-6 mo of dietary onset;
in wheat, rye, barley & oats) children are lethargic, irritable and anorectic; peak
frequency 9-18mo

Rectal prolapse, poor wt gain, abdominal

distension
Physical exam & growth normal
Failure to thrive, abdominal distension, irritability,
muscle wasting

73 hr fecal fats; sweat test

Giardia parasite (primary

cause of chronic diarrhea in
children)

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

growth retardation, steatorrhea

Giardia antigen test

Fat malabsorption

Watery, foul diarrhea; common in daycare; among

travellers and in male homosexuals

Page 16 of 52

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

Could this be related to a surgical procedure?

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

Do you eat wheat products?

What have you had to eat in the past 3 days?
Could this be caused by food preparation
problems?
Have you recently eaten raw or undercooked poultry,
shellfish or beef?
Have you recently ingested unpasterized milk?
Do you prepare poultry and/or beef on the same
surface as other foods?
Is anyone else you know ill with similar sxs?
Is there any family predisposition that may point
to a cause?
Have you or anyone in your family been diagnosed
with cystic fibrosis?
Does anyone in your family have a history of chronic
diarrhea, UC, or IBD?

Surgery can result in dumping syndrome

after eating: inadequate mixing and
digestion
- also stagnation & bacterial overgrowth
High carb content drinks lead to
malabsorptive diarrhea
Malabsorptive osmotic diarrhea
Protein hypersensitivity: 2-3 wks after
starting cow's milk or soy formulas
Gluten enteropathy or hypersensitivity
Loose stools: low fiber diet

Salmonella/ C. jejuni: undercooked poultry

E.Coli: undercooked beef/ unpasterized
milk
Norwalk
virus: shellfish
Food
poisoning
if 2 or more persons ill from
same food; infected food or toxic
substances (lead, mercury)

CF leads to fat malabsorption & produces

fatty, foul smelling diarrhea
IBD genetically linked

Page 17 of 52

Cryptosporidium sp. /Isospora Recurrent episodes; variable amounts watery,

belli protozoan parasites
nonbloody diarrhea; amounts can be massive
(fecal-oral; ingestion of
contaminated water or direct
oral anal contact)

Postgastrectomy dumping
syndrome

Wt loss, severe right upper quadrant abdominal

pain with biliary tract involvement

Following GI surgery, diarrhea occurs after meals;

Diaphoresis and tachycardia
diarrhea occurs after meals b/c of increased transit of
food through colon

Diabetic enteropathy

Nocturnal diarrhea, postprandial vomiting, fatty stools Findings associated w/ diabetes

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

Mild to moderately severe nonwatery, nonbloody

diarrhea

No specific findings related to diarrhea

Page 18 of 52

Stool for O &P

Upper GI series

Diagnosis of exclusion in diabetic

persons
Testing for HIV

Usually not needed

Constipation
Complete failure to
evacuate the lower colon
associated with difficulty
defecating, infrequent
BMs, straining, ab pain,
pain on defecating. Can
be acute or chronic.

Is this really constipation?

How many stools are there per day?
What is the consistency of the stool?
Is the constipation acute or chronic?
When did the constipation start?
How long have you been constipated? Is this an
individual episode or is it chronic?
At what age did the constipation first begin?
If the constipation is acute, what conditions
should I consider?
Have you been ill recently? Have you have a fever?

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

Dehydration & fever cause hardening of

stools
Reflex ileus sometimes seen w/
pneumonia.

Do you have any chronic health problems?

Renal acidosis / Diabetes insipidus

Medical dz can cause constipation b/c of
neurological gut dysfxn (myopathies,
endocrine, electrolytes)

If the constipation is chronic or recurrent, what

should I consider?
What do you usually eat in a day?
How many glasses of liquid do you drink/day?
What are your usual bowel habits?
How active are you?
What medications are you taking?

Dec. peristalsis: diets that lack bulk,

roughage, inadequate fluids (<6
glasses/day), inc. calcium (formation of
calcium caseinate in stools)
High protein diets stimulate movement.
Postponing BM b/c of time constraints
Lack of PA reduces peristaltic reflex
Narcotics, imipramine, diuretics, Ca
channel blockers, anticholinergics
Use of stimulants to empty colon removes
peristalsis stimulus for 2-3 days.

Do you use laxatives? How often? How long have

you used laxatives?

Plot growth curve in

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

Perform focused neuro

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

Is there any pain with defecation?

Flexible sigmoidoscopy
& colonoscopy

Barium enema: contrast

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

constipation
IBS: crampy lower ab pain w/ distension
Diverticulosis: noncrampy dull pain on left
Hemorrhoids/fissures: pain w/ defecation
Is there any bleeding with defecation? How much?
Hemorrhoids /fissures - bright red blood
upper GI bleed - black, tarry stools
What colour are your stools? Are the stools very dark Red: laxatives or vegetables
coloured or black?
Black/ dark brown: iron & bismuth (from
drugs)

Anxiety

functional megacolon 2o to constipation:

involuntary passage of feces
Also fear of toilet/ coercive toilet training

Has the child recently started toilet training?

Does the child have urinary frequency?
Is there a family history or genetic
predisposition?
Is there a family Hx of constipation or IBS?
Have you experienced any of the follwing symptoms
WITH anxiety/worry more days than not for at least 6
months:
1) Restlessness, keyed up, on edge
2) Being easily fatigued
3) Difficulty concentrating or mind going blank
4) Irritability
5) Muscle tension
6) Sleep disturbance

Stool witholding develops sometimes

May result in constipation

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

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

Lack of fluids/fiber = dry hard stools

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

If this is a child, is there anything else I need to

consider?
Is there fecal soiling of underpants?
Is there crying with defecation?
If an infant: Is there a Hx of delayed passage of
meconium stool?
Has the child begun to drink milk?

Serum electrolytes:
hypokalemia,
hypocalcemia (causes of
constipation)

Urinalysis

How can I further narrow the causes?

What does your stool look like? Is the stool size large Aganglionic megacolon: infreq. Small, hard
or small? What is the general shape of the stool (eg. stools
Small, round, ribbonlike)?
Ribbonlike: IBS or narrowing of colon
Is the stool formed or liquid?
Have you had any involuntary loss of stool?
Does the constipation alternate with periods of
diarrhea?
What else do I need to consider?
Do you have the urge to defecate?
Do you have any urinary tract symptoms?
Do you have any nausea or vomiting?

CBC: Hematocrit & Hb

below normal

Crying w/ fissure or large hard stools

May indicate Hirschsprung's disease
Cow's milk common cause of constipation

Genetic predisposition seems to exist.

DSM IV criteria for Generalized Anxiety
Disorder
-Patients will often report sense of doom
and fear of losing control

Page 19 of 52

Ask: dyspnea, chest

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

None noted

Simple constipation

Low dietary fiber & bulk; inadequate fluid intake;

physical inactivity; pain before and w/ bowel
movements; anorexia

Normal abdominal and rectal examination; may

feel fecal masses in colon and rectum

None if resolved; consider

sigmoidoscopy if not resolved

Functional constipation

Preschool and school-age children; Hx of abdominal

pain and stool soiling.
Onset in young adulthood; alternating diarrhea and
constipation; mucus in stools
Passage of hard stool 3-5 day interval; diarrhea, small
stools; common in those confined to bed
Common in older adults; physical inactivity; decreased
stool frequency; stool dry & hard
Delayed passage of meconium at birth; no urge to
defecate

Palpable stool in LLQ; large dilated rectum w/

packed stool; external sphincter intact
May have tender, palpable colon

Abdominal radiography, unprepped

barium radiography
Sigmoidoscopy if indicated

Hard feces in rectal ampulla; may have palpable

feces filled bowel
Normal abdominal and rectal examination

Sigmoidoscopy if indicated

Empty rectal ampulla on examination

Colonoscopy

Anorectal lesions

Rectal pain on defecation; Hx of hemorrhoids; blood

on stool, on toilet tissue, or in toilet

On rectal exam: Hemorrhoids, fissures, tears,

abrasions; increased sphincter tone

Anoscopy

Drug induced

Hx of chronic laxative use; Hx of taking med that

produce constipation

Normal rectal and abdominal exams

None if resolved; consider

sigmoidoscopy, barium enema if not
resolved

Tumors

Diarrhea more common than constipation; recent

onset: pain & abdominal distension, stool leakage,
urgency; late onset: wt loss, anorexia; increased
increased incidence over age 40; uncommon in
children

May have palpable abdominal mass or

organomegaly

CBC, FOBT or FIT, sigmoidoscopy,

colonoscopy, barium enema

IBS
Obstipation/ impaction
Slow transit
Hirschsprung's disease

Page 20 of 52

FOBT or FIT to rule out tumors

Insomnia

Define the Nature of the Problem

What kind of sleep problem are you having?

Are you having difficulty falling asleep?

Inspect Ears and nose

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

Are you having difficulty staying asleep?

Sleep disrupted d/t physiological factors,

illness, depression, pain, meds or alcohol

How long has the problem been going on?

Acute/transient (few days) - d/t stress,

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

Is this a specific Sleep Disorder?

Do you have a creeping, crawling or uncomfortable
feeling in your legs that is relieved by moving the
legs?

Restless leg syndrome: sxs increase in evening, esp when person is

lying down and still

Does the bed partner report patients arms and or

legs jerk during sleep?

Common > 65yoa.

Periodic Limb movement disorder: b/l repeated, rhythmic jerking or
twitching

Do you snore loudly, gasp, choke, or stop breathing

during sleep?

Obstructive sleep apnea: loud snoring and restless sleep patterns. May
report insomnia and excessive daytime sleepiness
Passive parental smoking can be a risk factor for snoring in children
(smoke provoke mucosa --> narrowed pharynx --> snoring)

Do you have difficulty staying awake during the day

or doze off during routine tasks (driving)?

Narcolepsy: excessive daytime sleepiness.

Adults: fall asleep during tasks like driving
Child: difficulty getting up in am, when awakened appear confused,
aggressive (phys or verbal), fall asleep at school, doing hmwk, watching
TV

Do you have episodes of muscle weakness?

Cataplexy: episodes of sudden muscular

weakness and atonia; emotional trigger

Could the Sleep Problem be Secondary to an

Illness?
Have you been ill recently?
Do you have a chronic health condition?

Ask: Do you lean against

wall for support b/c legs
feel rubbery?

Children: OM, chronic otitis, upper airway obstruction

GERD, COPD, PUD, CHF - paroxysmal nocturnal dyspnea
Anything causing nocturia

What medications do you take?

anidepressants, decongestants, bronchodilators, b-blockers, thyroid

meds, phenytoin, methyldopa, corticosteroids, antihistamines
Do you have depression or anxiety?
Depression: early morning waking
Anxiety: trouble falling asleep
Could this be related to Sleep Hygiene?
What is your bedtime routine?
Is it consistent? - can cause disruptive rhythms
What else do you do in your bedroom?
Work or watching TV can cause disruptive envt
noice can
affect sleep,
decrease
REMexacerbate GERD and sleep
Do you consume alcohol, nicotine, caffeine, diet pills alcohol
shortens
total sleep
time and
(with ephedrine) before bed?
apnea
Alcohol
heavy
drinker can be assocaited with restlessness
Do you exercise before bed?
avoid forwithdrawal
1-2 hours in
before
bedtime
and
How do you put your child to sleep?
Childsleep
who disturbance
is put to bed when they are still awake will learn to use selfWhere does your child sleep?
Could this be lifestyle related?
Are you a shift worker?
Do you sleep in the same bed each night?
Do you travel frequently?
Could this be age related?
How old is patient?
What age was child when problem began?
Does your child wake up screaming at night?
Does your child have problems going to bed?
Does your child refuse to go to sleep?

comforting
methods
even
they wakeif in
the middle
Sleeping
with
parentssocan
beifdisruptive
parents
moveof night, they will
fall
backbe
asleep
Should
quiet and dark room
Toddlers
fearful
of
separation
must
establish
routine
Interruption of circadian rhythm
Affects quality of sleep, increase light sleep, shorter REM
Jet lag

Newborns: 20 min - 4 hrs

School age - 8 hrs/night
Night terrors - inconsolable for up to 30 min and then falls asleep again,
happen within first few hours of sleep, not readily awakened, no
recolleciton of event
Nightmares - can be consoled, child is awake, and dream is
Could this be conditioned insomnia?
remembered
Are you able to fall asleep easily in places other than Usually insomnia develops initially in response to psychosocial stressor
the bedroom?
Can fall asleep outside bedroom but awake in bed
If a child: what do they do when they wake up at
Children need to develop self-comforting behaviours
night?
Conditioned to feeding after waking at night, can prevent development
of more mature circadian rhythm
If a child: what do you have to do to get them back
asleep?
usually once/night and 15 min. Takes great effort to wake person and
they have little or no memory of episode
Sleep walking?

Page 21 of 52

Sleep diary: keep for 1-2

weeks. Record bedtime,
total sleep time, time until
sleep onset, times they
wake, quality of sleep, etc

Sleep labs
Polysomnography overnight sleep study for
1-2 nights

DDX Insomnia
Restless leg syndrome

Irresistable urge to move legs in bed

Normal

None

Periodic limb mvmt

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

None

Obsructive sleep apnea

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

sleep studies

Narcolepsy

Excessive sleepiness, cataplexy

refer to sleep specialist

Secondary to illness or
medications

GERD, COPD, PND, CHF, prostatitis, nocturea,

depression or anxiety

consistent with medical condition

consistent with medical condition

Poor sleep hygiene

routine, habits, env't not conductive to sleep

use of alcohol, caffiene, diet pills, nicotine

normal

sleep diary

Lifestyle

shift work, travel, jet lag

normal

sleep diary

Night terrors

Inconsolable awakening occuring early in sleep,

lasting 15 min, no memory of event

both normal

both none

Nightmares

Occur later in sleep cycle, dream is remembered

Night awakening

Single to repeated awakening at night

Use medical examination to eliminate associated depends on examination

illness

Sleep refusal

child refuses to sleep

normal

none

Conditioned insomnia

identify intial trigger with persistent problem

physical exam to r/o underlying condition

sleep diary

Somnanbulism

sleep walking in early sleep cycle

normal

None

Trained night crier

child unable to soothe self

normal

none

Trained night feeder

Hx of frequent feedings on awakening at night

normal

none

Page 22 of 52

HTN

HTN Dx: depend on two or more blood pressure

readings taken at each of two or more visits after
initial screening

Definition is 140/90

Stage 1 HTN is defined as a systolic blood pressure

of 140-159mmHg and a diastolic blood pressure of
120-139/80-89 is preHTN, 90-99mmHg
follow up annually
Stage 2 HTN is defined as a systolic blood pressure
greater or equal to 160mmHg, or a diastolic blood
pressure greater or equal to 100mmHg
Presenting Condition
What have previous blood pressure readings been?

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

A gradual rise in blood pressure with age is

normal, but a sudden increase could
suggest a secondary cause or malignant
hypertension

Have there been any symptoms or signs of clinically Episodes of weakness or dizziness
overt cardiovascular disease?
(cerebrovascular disease), angina pectoris
(coronary artery disease), or dyspnea
caused by pulmonary edema (congestive
heart failure). Such episodes could show
that hypertension is already causing target
organ damage and that it should be treated
more aggressively
Does the patient have diabetis mellitus?

Diabetic patients with hypertension are

particularly at risk of cardiovascular
disease and should be treated more
aggressively than nondiabetic patients

Have you been experiencing headaches?

Contrary to popular opinion, headache is

not a characteristic symptom of
hypertension, although it may be
associated with severe hypertension

Have you been experiencing heat or cold

intolerance, sweating, slow or fast heart rate, or
palpations?

Such symptoms may point to underlying

hyperthyroidism or hypothyroidism as a
cause of hypertension, or
pheochromocytoma

How much alcohol do you drink?

Excessive alcohol consumption can raise blood

pressure

Is your diet high in salt? Do you cook with a lot of salt?

How much salt do you add at the table? How much coffee
and tea do you drink?

Excessive consumption of sodium chloride

and caffeine can raise the blood pressure

Do you eat regular amounts of licorice?

Licorice has mineralocorticoid properties

similar to aldosterone, and excessive
intake can directly cause hypertension

Is the patient obese?

Obese patients are at an increased risk of

hypertension and should be encouraged to
lose weight

Do you smoke?

Smoking increases cardiovascular risk, and

a diagnosis of hypertension is a good
opportunity for advice on giving up

Do you have a history of anxiety?

Anxiety disorders, especially panic

disorder, can result in significant episodic
elevation of blood pressure

What medications do you take?

Specifically, estrogen therapy, such as oral

contraceptives, can be associated with
hypertension

Is there a family history of hypertension?

Essential hypertension has a strong

genetic component, and the lack of a
family history increases the likelihood of a
secondary cause

Is there a family history of other cardiovascular

disease?

Patients with a family history of

cardiovascular disease are at an increased
risk of complications of hypertension

Hypertension should be treated urgently and aggressively in the following emergencies:

Hypertensive encephalopathy
Intracranial hemorrhage
Unstable angina
Acute myocardial infarction
Acute left ventricular failure with pulmonary edema
Dissecting aortic aneurysm
Pregnancy-induced hypertension
Malignant hypertension

Page 23 of 52

Page 24 of 52

What Does the Patient Mean by Dizziness?

Describe how you feel when you are dizzy

Dizziness
Do you feel as though you or the room is spinning?
Do you feel your balance is off?
Includes vertigo,
lightheadedness, loss of
balance. Needs visual,
vestibular, and sensory
systems
Central: neopastic or
vascular, CNS
Peripheral: inner ear or
vestibular appraratus

Do you feel like you are about to faint?

Take VS and BP,

orthostatic HoTN
Vertigo - patient or env't is spinning
Neoplasms and progressive vetibule loss
produces changes in vestibular fuction.
Slow onset and manifest as imbalance
Loss of balance, lack of coordination with
General appearance: looks
absence of vertigo - result of degenerative,
ill (labyrinthitis)
neoplastic, vascular, or metabolic disorder
Acute nausea and vomit:
vestibular neuronitis
Vision exam: change in
visual acuity/ new
corrective lenses may
cause transient imbalance

In Children: parents may describe as trouble walking, Maybe peripheral neuropathy or

irritable, or behaviour differences
dysfunciton of vestibular or cerebellar
system
Do you feel lightheaded? Or about to faint?

Near syncope

In elderly: have you previously been diagnosed with

blood pressure irregularities?

orthostatic hypotension is most common

cause of dizziness in the elderly - d/t
abnormal BP regulation

Does the Vertigo Result from a Systemic Cause? CV problems common cause of vertigo.
May be vasomotor instability decreasing
systemic vascular resistance, venous
What other medical problems do you have?
return - can lead to transient decline in
cardiac output

Ear Exam: look for signs of

infection (serous otitis,
OM)
Cholesteatoma: shiny
white irregular mass, foulsmelling d/c
Look at TM: trauma
Rinne and Weber tests:
sensorineural loss
lateralizes to unaffected
ear; AC > BC (but both
reduced)

Would you describe yourself as anxious or nervous? Psychogenic dizziness. Sxs are vague and CN VIII - nystagmus
include fatigue, fullness in head,
lightheadedness, feeling apart from env't.
Do the episodes occur with any specific activity or
movement?

When turning, especially when rolling in

bed usually d/t vertigo.
Disequilibrium - unsteady while walking

Is the vertigo central (brainstem or cerebellar) or

peripheral (vestibular) in origin?
Do you have migraine headaches?
Do you have other symptoms that bother you?

H/a - vascular related cause of central

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

MRI brain - acoutis

neuroma or central cause
of vertigo. Order if
sudden onset or with
severed headaches,
direction-changing
nystagmus, or neurlogical
signs

CT - persistent vertigo
and in all cases with
additional sigsn of
neurological disturbance
With renal failure, HTN,
hematological
malignancy with sudden
onset

EEG - vertigo with

alterations of
consciousness
CBC - anemia
Glucose levels - DM
BUN - renal failure

Neurological exam: CN,

Syphilis - 2nd or 3rd like
cerebellar function (gait,
Meniere's diseases
balance), rapid-alternating
mvmts, sensory and motor
function

CV exam: HR and rhythm,

auscultate carotid and
temporal arterires for bruits
for CVS cause of vertigo

Do you have nausea and vomitting?

Suspect peripheral vestibular apparatus

problem
Common with vestibular neuronitis and
labyrinthitis

When do the episodes occur?

If first arising in morning, usually vestibular disorder

If turning in bed - benign positional vertigo (BPV)

What Do the Characteristics of the Episodes Tell

Me?

Few secs: BPV, d/t rapid head mvmt

Min - Hrs: Meniere's disease or recurrent vestibulopathy
Days - Wks: vestibular neuronitis. >lying completely still. Stroke can produce long-lasting
episodes.

How long do the episodes of dizziness last?

Is the onset sudden or gradual?

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

Do you have any hearing loss?

Meniere's triad: vertigo, hearing loss, tinnitus (also fullness in ears)

CN VII or lesions in inner ear: tinnitus, hearing loss, pain in ear
Hearing loss, no tinnitus: labyrinthitis
U/l hearing loss w/ tinnitus: acoustic neuroma

Do you have ringing in your ears?

What Else Should I Consider?

What medications are you taking?

Are you now or have you recently been ill?
Have you had any recent injury to your head? Did
you have dizziness before the head injury?
Have you had any previous ear surgery?

Salt retaining or oxotoxic: vertigo, lightheadedness, or unsteadiness

Psychotropic drugs - vertigo
AntiHTN drugs - HoTN
Sedatives, alcohol, anticonvulsants - disequilibrium

Vestibular neuronitis - recent viral infxn

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

Page 25 of 52

Central Causes
Brainstem/cerebellar problems elderly, acute onset, recurrent vertigo, tinnitus, hearing ataxia, double vision, coordination problems,
MRI
OK
sensory/motor deficits, nystagmus, impaired RAM
and finger-finger testing
HEARING OK
MS

30-40yog

maybe normal

MRI

Migraine

h/a hx, other migraine sxs

MRI

Peripheral Causes
BPV

adults, with position changes, recurrent episodes,

lasts sec-min, > no motion

maybe have sxws of vertebrobasilar vascular

abnormalities
nystagmus
NO tinnitus
HEARING OK

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

childhood

vomitting, pallor, sweating, nystagmus, no LOC,

neurological, audiological can be normal

hypoactive or abset response to

caloric testing

Meniere's Disease
Vestibular neuronitis

sudden onset, lasts hours, recurrent, tinnitus and

fullness in ears
sudden onset, previous viral infection

nystagmus, fluctuating hearing loss, low tones,

sensorineural
nausea and vomitting, nystagmus
NO HEARING LOSS

Labryinthitis

sudden onset, lasts hours to days

Acoustic neuroma

adults, gradual onset, mild vertigo, persistent tinnitus,

facial numbness, weakness

current illness, nystagmus, hearing loss

maybe tinnitus, n/v
u/l hearing loss, poor speech discrimination

Perilymph fistulas

history of trauma, hearing loss

nystagmus and vertigo, sensorineural hearing loss audiometry

Otitis/sinusitis

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

vertigo

serious otitis, OM, tenderness on sinus, purulent

nasal d/c, NO nystagmus

Systemic Causes
Psychogenic

vague sxs, recurrent, anxious, other psychiatric

diagnosis

normal neurological and auditory exams

hyperventilation to reproduce the

vertigo

CV

CV hx, antiHTN meds

depends on px and conditions

Neurosyphylis

vertigo, tinnitus, fullness in ears

orthostatic BP, dysrhythmias, carotid/temporal

bruits
Various clinical sxs, papilledema, aphasia,
monoplegia/hemiplegia, central nervous palsies,
pupillary abN, Argyll-Robertson pupil, focal
neurological deficits

Page 26 of 52

provoke position changes

audiometry
MRI

Is This Really Syncope?

Syncope

Did you lose consiousness?

Did you have any prodromal symptoms?

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

If you lost consciousness, how long did it last?

Was there any limb jerking during the event?

Did anyone see you faint?
Does This Require Immediate Referral?

Do you have a history of heart disease?

Do you have a congenital heart problem?

Are you having chest pain and/or shortness of
breath?
Did this occur after exercise?

What Do Associated Symptoms Tell Me?

What other Sx did you have or are you having?
Did you have/ have you been having palpitations?
Have you had headaches?

Distinguish syncope from dizziness,

vertigo and resyncope where loss of
consciousness and postural tone does not
occur
Prodromal symptoms of sweating, vertigo,
nausea and or yawning associated with
syncope. Aura and tongue biting
associated with seizures
Loss of consciousnes precipitated by pain,
exercise, urination, defecation or stressful
events is probably not a seizure. Breathholding spells in children causes syncope
and are usually precipitated by pain, anger,
a sudden startle or frustration. Syncope
that occurs with rest or in supine suggests
seizure or arrythmia. Syncope with no
warning suggests cardiovascular origin.
Disorientation after event, slowness in
returning to consciousness and
unconsciousness lasting longer than 5
minutes
seizure
Rhythmicindicate
movements
during event suggest
seizure, although they can occur with
syncope
History from witness give you useful info.
Presence of structural heart disease
increases risk of sudden death.
Hospitalization required if history of
coronary artery disease, congestive heart
failure or ventricular arrythmia. Aortic or
mitral stenosis or prosthetic valves may
cause syncope. Complete heart block is
leading cause of syncope.
Obstructive mechanical blockage may be
caused by pulmonary embolism, cardiac
ischemia or myocardial infarction with
pump failure
Syncope after exercise is of cardiac origin
until proven otherwise. Syncope after
exertion ina well-trained athlete who has no
heart disease is of vasovagal origin.
Supraventricuar and ventricular
tachycardia are associated with syncope
and sudden death.Ventricular fibrillation is
always fatal unless reversed with electrical
defibrillation.
Pain of migraine headaches can affect
brain stem and cause sycope. Headache
continues after consciousness has been
regained and is associated with other
migraine symptoms

Have you had vertigo, dizziness, diplopia or other

vision changes?
Is This Neurocardiogenic in Origin?
Did this occur in response to a specific situation (eg.,
stressful event, urination, defecation?)

May accompany migraine or transient

ischemic attack
vasovagal syncope is neurocardiogenic
and tends to occur in families. Often
precipitated by emotional stress, fear,
extreme fatigue or injury and can occur
without any antecedent cause. Warm
temperature, anxiety, blood drawing and
What position were you in when you fainted? Sitting, crowded rooms can cause peripheral
standing or lying flat?
vasodilation. Situational syncope can occur
in response to urination, defecation, cough
Are you an athlete? Do you have a history of any
or emotional stress. Post-tussive
heart problems?
syncopefollows paroxysmal coughing
Is This Orthostasis?
caused by increased intrathoracic
What medications are you taking?
10% of syncopal episodes are caused by
prescription medication, over the counter
medications, and recreational drugs that
Have you recently started taking blood pressure
produce orthostasis, bradycardia or
medicine or increased its dose?
prolonged QT interval.
What other health problems/conditions do you have? Diabetes may induce hypoglycemia. Also
anemias and chronic GI bleeding from an
ulcer can cause syncope. Pregnancy,
prolonged bed rest and dehydration can
lead to orthostatic hypotension.
Psychogenic syncope often associated
Is This Explained by Other Factors?
with repeated episodes in which
Have you had this before? How often?
unpredictable motor reflexes appear with a
Did it occur with suddden head turning?
lack of pathological reflexes. Carotid sinus
If a child: Has the child had Kawasaki disease?
hypersensitivity produces a cardioinhibitory
response that results in a profound drop in
heart rate or may induce an abrupt
vasopressor response with a drop in blood
pressure. Children who had Kawasaki
disease are at risk for coronary heart
disease which may present as chest pain
associated with exercise.
Do you have Lyme Disease?
Lyme Disease can cause dysrhythmia in
the form of heart block which can lead to
syncope.
A family history of idiopathic hypertrophic
What Other Things Do I Need to Consider?
subaortic stenosis is a risk factor for
sudden
death. Family member who had MI
Do you have a family history of sudden death?
before age 30 is also risk for sudden death.
Do you have a family history of fainting?

Neurogenic syncope is common in families

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

Page 27 of 52

Observe Hydration
Status
Dehydration leads to
syncope

Perform Heart and Lung

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

ECG to rule out cardiac

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

Cardiac Causes Organic

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

Refer, electrocardiogram, Holter,

echocardiogram, Doppler studies,
treadmill

Neurocardiogenic Causes
Vasovagal

Emotional event, standing for long periods, crowded

room, warm environment

none

tilt table test

Situational

occurs with cough, micturition, defecation, swallowing

none

None

Breath holding

infants 6 mo to 5 yrs, associated with anger, pain, brief cyanosis or pallor

cry. Breath is held, loss of consciousness, may have
twitching

None

Hyperventilation

Anxiety or fear induced event, shortness of breath

none

None

Couch syncope

History of asthma, coughing paroxysm awakens child

from sleep, becomes flaccid with clonic muscle
spasm, loss of consciousness

wheezes

None

Orthostasis
Orthostatic hypotension

Position change from lying/sitting to standing.

Pregnancy, prolonged bedrest

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

on standing

Medication Related
Prescribed medications
Drug induced

History of antidepressants, antiarrythmic agents, beta- Depends on underlying condition

blockers, or diuretics
History of use of illicit drugs
Arrythmia may be present

None

Neurological Causes
Migraine
Seizure

Headache, vomiting, photophobia, positive family

history
convulsion, incontinence, postical phase

Usually none, nystagmus, photophobia

usually none, nystagmus

None
electroencephalogram

Psychiatric Causes
Mental disroder

Symptoms consistent with depression, anxiety, panic

none

psychiatric evaluation

Hysterical reaction

Adolescent, event occurs with audience present.

Gentle fall, memory or incident exact

none

None

Unknown

no diagnostic characteristics

none

workup negative

Page 28 of 52

Toxicology screen

ABDOMINAL PAIN
subjective feeling of
discomfort.

Is this an acute Condition??

1.how long ago did the pain start?
Was the onset sudden or gradual??

3 processes produce:

How severe is the pain (1-10)

acute and severe could mean emergency

1. tension in the GI from

mm contraction or
distension

Child? What is their level of activity?

avoidance of favourite activities indicates

an organic problem

2. Ischemia

does the pain wake you from sleep?

serious!
An organic dz wakes a child from rest

Vitals
fever - acute inflam
condition, mc renal or lung
infection

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

3. Inflammation of the
perotineum

course of the pain? Getting worse/better?

pain that is severe and progressing = bad,

likely an emergency

Abdominal Musculature
rigid - perotineal irritation
may require surgery

Urine culture
suspect UTI

pain can also occur from

within or outside the
abdominal wall

last BM?

obstipation occurs with complete

obstruction but diarhea may present with
partial obstruction.

had this pain before?

chronic pain may be bc potential emerg

event is brought into check but is not
resolved. If >1yr consider IBS or
colorectal, endometrial or inflam causes

where is the pain?

1.visceral pain - perceived midline - dull

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

acute onset of pain that is getting

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

General Appearance
visceral pain = restless and
move about - obstr, stones,
gastroenteritis
parietal pain = lie still, don't
want to move appendicitis, rupture,
perforation
children - do they look sick,
lethargic withdrawn

Urine/serum HCG
to RO pregnancy
ESR inflam, or tissue injury,
pregnancy

Test for STI's

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

does it travel anywhere?

pain will radiate from distribution of nerves

that supplies affected area

describe pain

gives clues to the specific condition (ie.

colicky/cramping from a hollow viscus)

related to activity?/ triggers?

relieved by defecation or diet changes -->

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

vomiting?

if vomit precedes pain unlikely a surgical

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

Aucultate bowel sounds

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

Stool characterisitics

blood = in the intestinal tract

diarrhea may preceed perforation of
appendix
children - diarhhea may suggest acute
gastroenteritis

Percuss
unexpected dullness

Page 29 of 52

CBC
inc WBC infection/inflam
inc neutrophils - bacterial
infection

Abdominal Distention
"The F's": fluid, fat, feces,
fetus, flatus, fibriod, full
bladder, false pregnancy,
fatal tumour.

CT
Sigmoidoscopy,
colonoscopy, proctoscopy

ACUTE
1. Ectopic preg

women childbearing age

sudden spotting and cramping in lower quad after
missed period

hemorrhage, shock and lower abd peritoneal

irritation. Enlarged uterus and cervical motion
tenderness

HCG + ultrasound
ruptured
ectopic preg = sugical emerg

2. peptic ulcer perforation

sudden severe, intense, steady epigastric pain that

radiates to sides, back and shoulder.
Hx pain < empty ST

Pt lying still. Epigastric tenderness, rebound

tenderness, abd mm rigid, bowel sounds decr.

Radiograph - surgical emerg

3. dissection of aortoc
aneurysm

sudden excruciating pain in chest or abd. May radiate pt looks shocked, vitals indicate impending shock, CT or MRI and cardiac enzymes
to back.
decr femoral pulses.
surgical emergency

4. peritonitis

sudden severe pain, diffuse and worsens with

movement/cough

5. acute pancreatitis

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

6. mesenteric adenitis

fever, pain in RLQ, other sx suggestive appendicitis

7. cholecystitis/lithiasis

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

CBC with differential.

US
Abd radiograph
serum amylase and lipase

8. ureterolithiasis

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

Urinalysis
CT

9. UTI/pyelonephritis

Urinary sx of UTI. Back pain with pyelonephritis.

Urinalysis
Culture

10. PID

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

WBC, ESR elevated

cultures and gram staining.

11. Obstruction

sudden crampy pain in umbillical area of epigastrium,

vomiting

hyperactive, high-pitched bowel sounds, fecal

mass may be palp, abd distention, empty rectum
on DRE

abd radiograph

12. Ileus

abd distention, vomiting, obstipation and cramps

minimal/absent peristalsis on auscultation

gaseous distention of isolated

segments of small and large
intestines shows on radiographs

13. Intussusception

sudden onset pain in infants

fever, vomit, jelly stools

abd films

gaurding. Rebound tenderness, bowel sounds

decr.

pain in RLQ, may be pharyngitis and cervical

adenopathy

altered voiding pattern, malodorous urine, fever

Page 30 of 52

CBC with differential.

Abd radiograph

CBC with differential. Adenovirus

found in surgical specimen.

Clues to implicate organ??

Do you have GI symptoms?
changes in bowel habits/stools or eating habits?

gas, bloating, diarrhea, constipation, and

rectal bleeding - usu pain intestinal origin
heartburn and dysphagia - esophagitis

pain relieved by defecation/burping?

pain relieved by defecation/flatus - IBS

Pain or difficulty with movement, limited ROM,

swellings

pain produced by MSK and refered to abd

Pain with exertion, palpitations, chest pain, fast HR?

referred pain from chest not uncommon.

RO MI as cause.
On extertion - angina or CAD

cough or difficulty breathing/SOB?

Pneumonia - pain often perceived in abd

pleurisy - in abd with deep insp

Pain Psychogenic?

how do you feel? mood? Energy? Dx of mental

health disorder?
Other

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

Palpate for masses

neoplasm, obstruction,
hernia, feces.
Intussusception in infants.
not organic pain
Palpate groin

Meds?

Palpate Hernias

recent surgeries?

sugery can produce adhesions thatmay cz Percuss for flank

intest obtsr
tenderness
KI issue could be stone

weight loss?

colon cancer?

Test for peritoneal

irritation
1. obtrurator mm test
2. iliopsoas mm test
3. Rovsings test

camping recently or chikd in day care?

untreated water ingestion - parasite

parasites also transmitted in day cares

Perform pelvic Exam in

women/Genital prostate
exam on men

Check peripheral pulses

Page 31 of 52

14. malrotation/ vulvulous

infants

billous emesis

abd films

15. incarcerated hernia

MC elderly. Constant severe pain in RLQ or LLQ that

worsens with strain

hernia or mass that is non-reproducible

upper gastro series

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

Unremarkable

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

2. lactose intolerance

crampy pain after eating dairy

Unremarkable

trial elim of dairy

3. diverticular dz

older pt. localized pain

abd tenderness, fever

Barium enema, elevated ESR,

4. constipation

colicky or dull and steady pain. Does not progress or

worsen.

fecal mass palpable. Stool inrectum

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

5. dysmenorrhea

premenstrual pain. Decr with age.

normal pelvic exam

GYN consult

6. uterine fibroids

pain related to menses, intercourse

palpable myomas

7. hernia

localized pain incr with exertion

hernia noted

8. ovarian cysts

young

adnexal pain and palpable ovarian cysts

pelvic USG if neoplasm cannot be

excluded
proctoscopy, barium enema is
strangulation suspected
pelvic USG

9. abd wall disorder

trauma

bruising or swelling, no GI/GU sx

CT uf internal dz

10. esophagitis/GERD

burning, gnawing pain in mid epigastrium. Pain after

eating. May be relieved after antacids

Unremarkable

upper gastro series

radiogrpahy or endoscopy if sx
severe

11. Peptic Ulcer

burning, gnawing pain. Soreness. Empty feeling or

hunger. MC with empty ST, stress and alcohol.
Relieved with food. Pain steady, mild or severe in the
epigastrium

may have epigastric tenerness on papl

upper gastro series, endoscopy,

gastric analysis

12. Gastritis

constant burning pain the in epigastric are. May N/V

diarrhea or fever. Alcohol, NSAIDs and salicylates
agg

Unremarkable

pt should respond to therapy

13. Gastroenteritis

diffuse crampy pain with N/V diarrhea, fever

no dx test needed

14. Functional Dyspepsia

vague complaints of indigestion, heartburn, gas, abd

distention

hyperactive bowel sounds. Dehydration if very

severe.
Unremarkable

15. recurrent abd pain

children 5-10 yo. Enviro pr psycholog stress.

Unremarkable

CBC, urinalysis, ESR, FOBT

CHRONIC LOWER ABD

PAIN
1. IBS

UPPER ABD PAIN CHRONIC

Page 32 of 52

CBC, fecal occult blood test (FOBT)

Urinary
Problems in
Females and
Children

Have you had a fever or chills?

systemic inflammatory response - acute

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

Have you had nausea or vomiting?

Accompany a UTI, pyelonephritis, or

lithiasis. Systemic inflammatory response
indicating an acute presentation

Have you and acute pain in the abdomen or back?

Upper UTI and pyelonephritis. Urinary tract Vitals: Hypertension is

stones can cause localized back pain that seen in patients with
radiates to the thighs
nephritis

KOH and Wet Mount: if

you suspect
vulvovaginitis

Are you positive for HIV? Or receiving chemo?

immunocompromised individuals are

susceptible to infections

Palpate and Percuss: the

flanks and costovertebral
angle for pain, this may
indicate renal capsule
distention

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

In an infant: has the infant been irritable with

lethargy?

In babies, UTI may present as irritability,

anorexia and weight loss.

Pain the lower quadrant lower ureter involvemnet

Radiography: urinary
calculi

Have you had any recent injury?

Hematuria can be caused by injury to the

flanks

Suprapubic tenderness
lower UT

Have you been hit recently?

Domestic violence can cause blood in the

urine d/t trauma

Deep palpation for any

masses

Are you sexually active? And how frequently do you

engage in this behavior?

Acute bacterial cystitis d/t frequent sexual

intercourse, use of diaphragm or
spermicidal gel.

distended bladder rises

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

Page 33 of 52

Urine Dipstick: Specific

gravity, leukocyte
esterase, nitrites, protein,
glucose, ketones, blood

Also, neonates with UTI's Microscopic Urinalysis:

may present with Jaundice. color, sediment, RBC's,
WBC's, Casts

DDX Common causes of Urinary Problems in Females and Children

Uncomplicated UTI

Dysuria, frequency, mild Nausea, nocturia, urgency,

voiding small amounts; neonates and young infants
present with anorexia, irritability, fever

NO fever; appears well; no CVA tenderness; may

have suprapubic tenderness; Note: neonates and
young infants may present with failure to thrive,
bacteremia

Urine dipstick: + blood, +leukocyte

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

Urethritis

Dysuria; vaginal d/c, Hx of new sex partner, frequent

sex, partner with urethritis, multiple sex partners

Appears welll has no CVA tenderness or fever

Urine dipstick: may have + blood, +

leukocyte esterase, + nitrites, urine
culture; molecular testing vaginal
specimen

Vulvovaginitis

Hx of vaginal itching, dc, burning, dryness,

postmenopausal

inflamed or atrophic labia, vaginal or cervical d/c

Microscopic exam, vaginal cultures,

molecular testing

Interstitial cystitis

Frequent painful urination, hematuria, most often

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

urinalysis usually negative, x-ray and

cystometric studies to rule out other
urological disease, cystoscopy

Pyelonephritis

fever, chills, back pain, n/v, toxic appearance, some

patients also have frequency and dysuria

feels and looks ill, fever, CVA tenderness,

abdomen may be tender

Microscopic examination, WBC's

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

Urolithiasis

Pain, hematuria, may have symptoms of secondary

infection, renal colic, pain that radiates to inner thigh,
nausea, vomiting

may have CVA tenderness, loosk ill during

periods of acute pain, may have abdominal
distention

urinalysis, gross or microscopic

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

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

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

dysuria

No fever, erythematous labia, urethral opening

Page 34 of 52

U/A: +proteinuria, +hematuria,

+ASO titer, serum C3 low early in
disease
hematuria common, gross
hematuria, unusual and casts never
seen

Vaginal
Discharge
and Itching

What kind of vagnitis might this be?

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

Common vaginal
infections pospubertal:
Trichomonas, Candida
and bacterial vaginosis

Most common cervical

infections: Chlamydia,
Neisseria gonnorrhea,
and herpes simplex

Are you sexually active? Do you have multiple

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

Green, offensive smelling: T. vagnitis.

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

Note vital signs

Fever in serious infection
such as PID (uncommon in
vaginitis)

Fishy: BV (positive whiff). Foreign body.

MC in women of childbearing age (12-50)
with a new partner.

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

Test for pH - normal is

less than 4.5. Above this:
BV, trich, or atrophic

Perform an internal
vaginal examination look
at the cervix and vaginal
walls

Herpes culture
Tzank smear - for
herpes
Modified diamond's
culture - for trich (rarely
used)

Perform a bimanual
examination - POSITIVE
CERVICAL MOTION is
from PID and warents
immediate evaluation,
treatment, or referral to
prevent scarring, ectopic
pregnancy, and infertility

Thayer-Martin culture for gonorrhea

Perform a vaginal-rectal
exam

Scotch tape test - for

pinworms (Enterobius)
Acetic acid test for HPV

Recent treatment may indicate tx failure

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

Can this be vaginitis that is not related to an

STD?
Have you ever been told you have diabetes or
Could be immunocompromised
Cushing's syndrome or that you are positive for HIV?
Have you been ill recently?

Are you taking antibiotics, hormones, or BCPs?

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

Chickenpox, scarlet fever, measles can

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

Watch for self-diagnosis of a "yeast

infection"
Can have tx failure if stop taking meds.
May have drug interactions
Transmission of candida, M. contagiosum,
herpes, lice, pinworms. Also poor hygiene.

Consider diabetes or immunocompromised

state (HIV) if more than 3x candida/yr.

What are other possible causes for this vagnitis? local irritation, altered flora. Perfumes,
douches, sprays, lubricants, bubble baths
all are offenders in allergic vaginitis.
What are your personal hygiene practices?
Do you douche?

Changes flora and pH. Also

scented/coloured toilet paper can irritate.
Direction of wiping is also important
(microbes from anus to vagina)

Have you changed brands of contraceptive products? May cause allergic inflammation
Could you have forgotten to remove your diaphragm Itching, burning, foul, purulent discharge.
or tampon?
Also assoc with vaginal bleeding.
Are there any associated symptoms that point to
a cause?
Do you have burning or pain with urination?
Frequency, hesitation, nocturia?
Do you have painful intercourse?
Do you have any abdominal or pelvic pain?
Infant: is there an eye infection?
Infant: is there a cough?

Perform oral exam look

for oral thrush

Atrophic vaginitis: dysuria, dyspareunia,

vaginal dryness.
Endometriosis or PID, or fibroids. STIs
leading to PID.
Gonorrhea or chlamydia
Pneumonia assoc with chlamydiosis

Page 35 of 52

Potassium Hydroxide
(KOH) and wet mount.
Whiff test is + for BV.
Look for hyphae:
candida. Clue cells for
BV

Funal culture or
sabouraud agar culture

DNA probe for

Chlamydia, Gonorrhea,
and herpes
Serology for syph
Urinalysis
Microscophy and skin
scraping for scabies and
pubic lice

FSH - to determine premenopause

Vag Discharge DDX

Physiolocial discharge

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

Up to 3-5 WBCs; epithelial cells,

lactobacilii

Bacterial vaginosis

Foul-smelling discharge

Homogenous, thin, white or gray discharge, pH

>4.5

Presence of KOH "whiff" test,

presence of clue cells, <lactobacilli

Candida vulvovaginitis

Priuritic discharge

Whie, curdy, pH 4-5.0

KOH prep: mycelia, budding,

branching yeast, pseudohyphae

Trichomoniasis

Watery discharge; foul odour

Atrophic vaginitis

Dyspareunia; vaginal dryness

Profuse, frothy, greenish discharge; red friable

cervix; pH 5.0-6.6
Pale, thin vaginal mucosa; pH >4.5

Round or pear-shaped protozoa;

motile "gyrating" flagella
Folded, clumped epithelial cells

Allergic vaginitis
Foreign body

New bubble bath, soap, douche, etc.

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

Chlamydia

Pelvic inflammatory disease

(PID)
Itching and lesions DDX
Syphilis

Bleeding, abdominal pain, fever, and vaginal

discharge; increasing amount of dicharge and
bleeding after sex
History of painless ulcerative lesion; rash on palms
and soles; warty growth on vagina or anus

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

Cervical motion test and adnexal tenderness;

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

VDRL, RPR, FTA-ABS

Genital warts

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

Herpes

History of prodromal syndrome, paresthesias, burning, Grouped vesicles on a red base, erode to ulcer; if Viral culture; Tzank smear
itching, may have mucoid vaginal discharge
on mucous memb, exudate forms, if on skin,
crusts form; redness, edema, tender ing lymph
nodes
History of contact with infected person; if inflamed:
Flesh-coloured, dome-shaped papules, some
None
itching
with umbilication; usually 2-5cm in diameter

Molluscum contagiosum

Page 36 of 52

Acetic acid test: white

Was onset abrupt or gradual?

Does it chenge in a 24 hr. period?

Abrupt & shortlived = transient ischemic

attack. DEMENTIA = insidious onset
Sudden over a few hours = delirium

Is pateint alert and aware?

Yes = dementia and depression

No/decreased alertness = delirium

Confusion/
Forgetfulness

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

MENTAL STATUS EXAM CBC- infxn, or anemia

- What is the date?
may contirbute to
- Repeat words after me:
confusion
house,
car,
lake.
Fluctuating symptoms in delerium
What
is
this?
(pointing
to
More stable symptoms in depression and
pencil)
dementia
NEURO exam

Cranial nerves: i.e. sense

Hallucinations common in delirium
of smell often impired in
Uncommmon in dementia and depression dementia; slurred speech
(although can occur in late stage dementia) Rapid alternating Mvmt:
Rhomberg's, DTR
(hyperreflexia in dementia);
Numerous drugs, illicit and pharmaceutical Language (apahsia in
can alter mental states.
dementia)
Meds interactions

Tremor and gait disturbances at rest?

Associated with Parkinsons, HIV

encehalopathy, liver dz, medication rxns,
head trauma

H/A, fever, n/v?

H/A, N/V assctd. With stroke and tumor nd

trauma
Abdomen: inspect, percuss
Fever in infxn, OH withdrawl
for CVA tenderness. May
indicate
systemic cz of confusion
i.e.urinary retention- UTI
Delirium = global cognitive losses involving CVA tender-pyelonephritis
Large Liver= hepatic
memory, thinking, perception and
encephalopathy
judgement. Also irritability, disoriented,

What specific problems with mental abilities or

tinking have you noticed?

Serum folate and B12

deficiencies may cz
reversible dementia
S-syphilis
r/o neurosyphilis
Urinalysis - r/o infxn
Lumbar puncture - r/o
meningitis

fearful
Early Dementia = seletive cognitive losses,
poor hygiene, socially withdrawn,
Depression= fewer cognitive losses

Fatigue

Does patient have any chronic health concerns?

HIV, alcoholism, renal failure, liver disease,

severe anemia, COPD, CVD, predispose
elderly to the development of confusion

Is this really fatigue?

Discriminate b/w fatigue & weakness. Pxs

describe muscle weakness instead.

Psych screening for

depression & anxiety

adults; adolescents 8-9hrs; kids 10 hrs.

Early am waking/ Xs sleep = sx of
depression

orthostatic hypoT, BMI

Tell me what you mean by fatigue?

The sensation of profound
tiredness that is not
relieved by rest or sleep
and is not associated with
prolonged activity.
Chronic fatigue lasts more
than 6 months and onset
is slow & progressive.

Is the fatigue physiological?

Tell me about you lifestyle habits (Exercise & diet)?
Tell me about your sleep pattern.
Do you require naps?
Do you feel rested when you wake up in the am?
When was your last menstrual period?

CBC w/ diff: may

indicate presence of
anemia (Hb, hematocrit),
chronic blood loss
Erratic eating patterns, over/undernutrition, Note general appearance inflammation or infxn
missed meals, caffeine, stress,
-demeanor
employment.
Lack of adequate sleep. Need b/w 6-8 hrs Vitals - fever, inc. HR/BP,

Fatigue = early sx of pregnancy, post child

birth, perimenopausal (night sweats/ hot
flashes = disrupted sleep)

Inspect skin, hair & nails

- for signs of hypo/hyperT,
nail biting, skin lesions
(mono, Lyme dz)

1st sign of HIV, hep, AIDS - STI contracted Examine Nose, eyes,
from semen or blood. & through sex
mouth & throat practices that damage mucous membranes inflammation, lymph
nodes, mucous
Fatigue = side effect
membranes
alcohol , marijuana use result in fatigue CV exam - heaves, bruit,
CAGE questionnaire
heart sounds, PMI
What other clues can help me rule out an organic increased app may indicate hypoglycemia Examine LU - RR, A/P,
cause?
dec. app. May indicate infectious process fremitis, rales, wheezes
Wt loss - malignancy, infxn, poor nutrition Examine Abdomen Have you noticed a change in appetite?
Do you have any joint tenderness or pain?
seen in juvenile rheumatoid arthritis (JRA) bowel sounds, Palpate
Have you noticed increased urination?
DM type 2 = fatigue, poly dypsia/phagia/uria (light & deep); rigid
Sx such as muscle aches, abdominal pain, abdomen (peritoneal
What other symptoms have you experienced?
general lethargy, dry skin & nails, SOB w/ irritation), LV, KI, SP for
tenderness
exertion
Do I need to consider an organic cause?
Do you practice saf sex (if sexually active)?
Have you ever had hepatitis?
Do you take any medication?
Do you drink alcohol or use street drugs?

Could this have an environmental cause?

Where do you work?
Have you been exposed to any toxins?
Have you been camping?
What else do I need to know about fatigue?
Describe the onset & pattern of your fatigue. When
did you first notice this?
How severe is the fatigue?
What makes the fatigue better or worse?
Have you had a fever?

Heavy metals & pesticides may cause

fatigue & neurological sx
Lyme disease (malaise, chronic fatigue
before skin manifestations)
Psychological - Often related to stressful
event & may have sudden onset.
Matabolic - slow, progressive onset
May limit social fxning, rec. activities
Psych - usually < am, > w/ phys. Activity
Organic - not relieved w/ sleep or rest
Seen w/ infectious dz
Prolonged fever - chronic infxn,
inflammatory dz, malignancy

How you had any bleeding?

Heavy menses may lead to anemia, also

GI ulcers, polyps, bowel CA
If I suspect a psychological cause, what else do I Stressful events inc risk of depression
need to know?
Muscle atrophy w/ inactivity can lead to
fatigue
Describe your stress level and how you cope with
stress in your life.
Have you recently had a stressful event in your life? Family Hx of depression increases risk of
Do you or anyone in your family have a problem with depression
m/c women b/w 20-30
anxiety or depression?
How are you doing in school?

Dec academic performance & dec.

productivity may be early sx of dpression
Overachievers may be compensating &
hiding depression
Page 37 of 52

Ferritin - stored iron (low

in iron def. anemia)
Total Iron Binding
Capacity- indirect
measure of transferretin
UA- infxn or systemic dz,
hematuria, pyuria,
leukocytes,
ESR - rate at which
blood settlesin
anticoagulated blood; inc
in inflammation (infxn,
RA)
Fasting Blood glucose>126mg/dl suggests
diabetes
Hepatic fxn - AST/ALT
for general inflammation
of liver (hepatitis)

MSK exam- joints for

TSH - level identifies
inflammation & swelling,
hypoT
test stamina (fatigue level) HIV infxn - enzyme
Neuro exam - Cognitive & linked immunosorbet
assay to R/O infxn
physical fxn (attn span,
judgement, memory), CN, TB skin test - mantoux
relflexes, cerebellar, motor for Tb antibodies
Monospot- detects
heterophil Ab not specific
to EBV
Chest Radiographpneumonia, heart size,
fluid (CHF)

DELERIUM

CONFUSION

DEMENTIA

DEPRESSION

reduced attn span; disorganized thoughts; decreased

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

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

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

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

abrupt onset confusion; some diurnal variation; more

consistent over time than delirium; Hx of phsychiatric
problems; fluctuating cognitive losses; no
hallucinations; suicidl thoughts; anxious mood

DDX: FATIGUE
Physiological causes

Adolescent and younger adult, history of overwork,

psychological stress, disturbed sleep, poor diet

Normal examination

None

Psychological causes:
Depression: Children

Feeling sad, angry, irritable; Decreased academic

performance; Somatic complaints

None

DSM-PC, DSM-IV

Depression: Adults

Loss of interest in usual activities; Feelings of

worthlessness; Sleep problems
Numerous somatic complaints, breathlessness

Depressed affect; normal examination

Depression screening instrument

Tachycardia, palpitations, diaphoresis

None

Sudden onset; history of exposure; recent viral illness

Fever; lymphadenopathy, localized signs of

CBC, ESR, monospot
erythema, edema
Bilaterally enhanced or depressed DTRs; pupilary CAGE alcohol screening
changes; reduced attn span, judgement
Increased pulse; pale mucosa; smooth red tongue CBC w/ indices, serum iron, ferretin,
transferretin
Decreased pulse; dry skin, coarse dry hair,
T4 low, T3 low, TSH elevated
thyroid possibly enlarged, hoarseness
Lid lag, fine thinning hair, tachycardia
T4 increased, T3 increased, TSH
depressed
Hypertension, obesity, narrowed upper airway
sleep studies

Anxiety

Organic causes:
Infection
Drugs and Alcohol

Hypothyroidism (myxedema)

History of smoking, alcohol use; antihistamines,

analgesic, antihypertensive meds
Breathlessness w/ exertion; menstruating female;
recent surgery, delivery
Poor appetite, fatigue, weight gain, cold intolerance

Hyperthyroidism (Graves)

Hyperactivity, heat intolerance, sleep problems

Organic causes:
Sleep apnea

Male, middle aged or older, partner reports periods of

no breathing during sleep, fatigue

Medications

Hx of allergies treated with antihistamines; meds for

hypertension, heart disease, chronic pain
Dyspnea, wt gain, fatigue, cough
Fatigue, unexplained wt loss

Anemia

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

Nasal congestion, cough, injected conjunctiva

Anxiety, JVP, displaced PMI, rales

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

Page 38 of 52

Evaluate medication choices

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

Limb Pain

Is the pain related to an urgent problem that

needs immediate treatment to avoid disability or
death?
Have you had a recent injury?

Do you have any other symptoms, such as fatigue,

fever or swollen joints?
What is the severity of the pain?
Does the pain occur with exercise or rest?

Muscguloskeletal injury can rainge from

simple muscular strain to a significant
fractureof
associated
with nerve
or vascular
Priority
recent trauma
is to assess
injury.
vascular and neurological integrety of the

Symptoms of coldness,
severe pain or paresthesia
warrant physical exam
immediately to assess
need for emergency
limb
treatment. Ask specifically
Suggests systemic disorder such as
about the mechanism of
infection or rheumatic disease.
injury and also wether or
Unrelenting diffuse pain, often occurring at not the patient heard any
night, is an indication of bone involvement noise to assess if there is a
Claudication and neurogenic pain increase broken bone
with activity and decrease with rest, more
immediately for vascular causes and more
slowly for neurogenic causes

What does the location of the pain tell me?

Where does it hurt?
Is the pain localized or generalized?
Could this be caused by a sprain or strain?

Describe how the injury occurred?

Did you hear a noise with the injury, such as a

ripping or cracking sound?

Were you able to use the limb after the injury?

If there is no history or trauma or a precipitating

event, what else is causing the pain?
Describe your usual daily activities at home, work
and with hobbies
How does the pain afect your activities?

Do you have other illnesses?

In joint pain with injury, what do I need to know

about the specific joints involved?
Upper extremities: Shoulder, wrist, elbow key
questions
Is the pain in your dominant limb?
Did you fall on an outstretched hand or arm?
Did you overuse a joint?

Lower extremities: Knee, ankle

Location of pain provides a clue for

identifying the site where the pain
originates
Local pain receptors signal the site of
irritation and an increase in sensitivity
(hyperesthesia) results. Referred pain
generally involves the muscle chains, nerve
pathways, and vessels. Unilateral,
circumscribed limb or quadrant pain
involves autonomic nerve fibers. Bilaterla
pain is more likely to originate from
systemic involvement. Diffuse pain with
inconsistent distribution may be the result
of psychosomatic conditions such as
depression and anxiety
Strain involves injury to muscles and
tendons, whereas sprains involve injury to
ligamentous structures. Both produce
ripping or tearing sounds.

Always observe for

symmetry and then
functionally assess limbs
and joint bilaterally
beginning with unaffected
side. Order the exam so
painful tests are done last.

Complete Blood Cell

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

Observe patient walking,

removing coat, getting into
sitting position. Look for a
limp. Have the patient
locate the pain. Note any
A fracture produces diffuse swelling around
deformities
the injured vone soon after injury. Deformity
will be present if the fracture is displaced.

Radiography Obtain at
least two radiographic
views, anteroposterior
and latera becausae
injuries are not always
apparent on a single
view. MRI and CT usually
ordered by specialists.
MRI good for spone, joint
and soft tissue imaging.
Barotrauma --> acute serous otitis. Failure Assess vital signs.
of eustachian tube to open and equilibrate Elevated temperatures are CT good for bone
visualization
--> fluid collection in middle ear.
seen in neoplastic,
systemic and infectious
processes such as
osteomyelitis, septic
arthritis and septic hip in
Overuse: repetitive microtrauma results
children and rheumatic
from cumulative injury or overuse.
disease.
Activities: a person may adapt to chronic
musculoskeletal problems by using an
assistive device such as a cane or by
limiting activities.

Inspect skin and nails.

Lyme disease has a target
lesion and rash on the
trunk. Look for puncture or
abcess which may be
Presence of coronary artery disease
source of infection. Look
increases the risk of arterial insufficiency
for ecchymosis and
and associated caludication pain.
bruising indicating trauma.
Peripheral neuropathy associated with
Look for swelling and
diabetes can produce a burning pain or
redness of joints.
'pins and needles' sensation, esp. lower
Measure limb
extremities.
circumference and length.
Pain in the dominant hand may indicate
Palpate extremties and
repetitive microtrauma or overuse.
joints
Breaking a fall with an outstretched arm is Perform passive and active
a common mecahnism of injury for a
ROM of all limbs. Test for
fracture or dislocation of the hand or wrist muscle strength with
RROM. Neurological exam
of dermatomes and
myotomes.

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

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

How is the pain affected by weight bearing or

activity?

Continuing with activity means the injury

did not totally disrupt any ligamentous
structures.

Did you feel a sense of 'giving way?'

An inability to straighten or ben the knee

suggests a mechanical blockage

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

A loud pop is virtually diagnostic of an ACL

tear. A ripping sound suggests a meniscus
injury. A cracking sound may signify a bony
injury or dislocation of the patella

What position was your leg in when you hurt your

knee?
Could this be musculoskeletal joint disease?

A sudden change in direction or sudden

stop may put more force on the ligaments
than they can dissipate, resulting in acute
rupture

What does the pain feel like?

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

What does the history of swelling tell me?

is there any swelling?

Swelling is always abnormal.

Page 39 of 52

Musculoskeletal
Inflammation

Tenosynovitis

Repetitive trauma activities; pain with movement

History of overuse; aching pain over affected bursae
that radiates along the limb

Swelling over tendon, crepitus

Local tenderness, swelling, limited joint motion,
muscle weakness

none

Fibrositis

Pain in trigger sites throughout body, joint stiffness,

disturbed sleep

Fatty, fibrous nodules in muscles, palpation of

trigger points elicits pain

none

Osteomyelitis

Presentation depends on age, location of infection,

trauma, penetration, invasive procedure; refusal to
bear weight (hip); constant pain

Fever, chills, vomiting, pain localized over

affected area but progressively worsens; soft
tissue injury or abcess

Increased WBC, ESR, C-reactive

protein, radiographs

Joint Inflammation
Osteoarthritis

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

ESR; radiograph may reveal

osteophytes, loss of joint space

Rheumatoid arthritis

Morning stiffness of small joints, symmetrical

involvement, anorexia, weight loss

Fever, rehumatoid nodules, ulnar deviation of

wrists

Increased ESR, positive rheumatoid

factor, anemia on CBC, radiograph
shows bony erosion

Juvenile rheumatoid arthritis

Fatigue, weight loss, failure to thrive, refusal to walk,

joint pain and stiffness

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

Septic arthritis

History of systemic infection, malaise, diaphoresis,

refusal to bear weight (hip), acute joint pain

Fever, red, swollen joint, limited ROM

Gout

Acute pain of large joint, asymmetrical, males over 30 Inflamed swollen joint, tophi, sodium urate crystals Increased serum uric acid level,
years, history of gout
ESR, WBC

Bursitis

none

WBC, culture of joint aspirate, ESR,

C-reactive protein, ultrasound of joint

Musculoskeletal Pain
Related to Trauma and
Overuse
Shoulder dislocation

History of trauma, pain

History of trauma, pain

Limited rotation, arm abduction and hand

supination
Limited shoulder movemnt; obvious deformity

Radiograph of shoulder

Acromioclavicular joint injury

Bicipital tendonitis

History of overuse of biceps; pain worse with

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

Positive Yergason's test; pain localized over the

intertubercular groove
Acute: inability to raise arm side-ways, shrug
shoulders; chronic: tenderness over AC joint,
crepitus, weakness in external shoulder rotation

radiograph (Fisk view)

Lateral humeral epicondylitis

repetitive motion of or pressure to the elbow, localized

pain
History fo repetitive contraction of extensor and
supinator muscles, pain over lateral epicondyle that
progresses

warmth, redness and swelling over joint, full ROM radiograph to rule out fracture of the
olecranon process
Tenderness over later epicondyle; palaption
none
roduces pain, motion does not; supination against
resistance worsens pain

Subluxation of radial head

Occurs in children, pain in the elbow or arm

The afected arm is flexed and the hcild cries

when attempts are made to move the joint

Wrist fracture

History of fall on an outstretched hand, pain and

swelling of forearm and wrist

Palpation of snuffbox increases pain; observe for Three-view radiographs to determine

joint deformity
scaphoid or Colle's fracture

Finger fracture

History of trauma or fall, joint tenderness

Joint swelling, instability

Three-view radiographs (PA. lateral

and oblique)

Ganglion

Noticeable lump on dorsal surface of wrist

Gelatinous filled, nodule, soft, transilluminates

none

Slipped capital femoral

epiphysis
Transient synovitis of the hip

Children during rapid growth spurts, knee pain worse

with activity
Children less than 10 yrs, history of upper respiratory
infection, limp, pain in the anteromedial thigh and
knee

Limitation of medial hip rotation, limp

Radiograph of epiphyseal plate

Tenderness on palpation over anterior hip; hip

movement increases pain and is limited; lowgrade fever.

Ultrasound, ESR

Legg-Calve-Perthes disease

Boys 3-11 yrs, groin or medial thigh pain, limp

Decreased ROM of hip

AP and frog lateral radiograph of the

hip; LCPD may show increased
density of the femoral head

Iliopspas tendinitis

History of repetitive flexion of hip; pain worse with

movement

With patient sitting, place the heel of affected leg none

on the knee of the other; test is positive if pain is
elicited

Chondromalacia patellae

Adolescent females; history of knee trauma or

misalignment, knee pain worse with activity

Tenderness to palpation over knee

Rotator cuff tear

Olecrenon bursitis

Page 40 of 52

Radiograph of shoulder

radiograph may reveal humeral

displacement or spurs

radiograph of elbow

Four-view radiographs of knees to

rule out arthritis

Limb Pain
Continued

When did the swelling begin?

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

Is this an acute or chronic problem?

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

When did the pain first occur?

When did you first notice a problem?

Problems with activities of daily living are

noticed

How is activity affected? What will this tell me?

What are your usual activities?

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

What activity makes the pain worse?

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

What movements make the pain worse?

In children with septic hip pain increases with movement

What does joint stiffness or locking tell me?

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

Have you had any joint stiffness?

Does activity make the stiffness worse or better?

common feature of inflammatory arthropathy eg RA or SLE

Do you have any locking of the knee?

Sign of chronic unstable meniscus tear

What does a history of a limp tell me?

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

Is there pain with the limp?

Did the limp come on suddenly?

Limp after strenuous running may indicate stress fracture

is the limp constant or intermittent?

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

what is the effect of running or climbing stairs?

quadraceps weakness causes difficulty climbing stairs

Could this be caused by systemic disease?

Have you been treated with any antibiotics lately?

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

have you had any recent immunizations?

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

has the fever been constant or intermittent?

does the pain awaken you at night?

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

is the pain worse ar night?

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

Lyme disease is an infection caused by tick-borne spirochete borrelia burgdorferi. Symptoms

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

Page 41 of 52

Patellar tendinitis

History fof overuse, especially running or jumping;

dull, achy knee pain; click

Q angle greater than 10 degress in males, 15

none
degrees in females, clicking or popping with knee
movement

Limb pain DDX cont'd:

Medial collateral ligament
sprain

History of valgus stress to knee; limp; pain

Effusion and point tenderness over knee; valgus

and varus pressure to assess instability

AP and lateral radiographs may

reveal a ligament avulsion of femoral
origin

medial meniscus tear

History of twisting injury to the knee, pain, diffculty

flexing; bearing weight, clicking or catching of knee
with movement

Positive McMurray's test, clicking or locking

during joint movement

Four-view radiographs to rule out

bony deformity

Anterior cruciate ligament tear History of twisting or extension knee injury; audible
Swelling; positive Lachman's test
'pop'
Adolescent males, knee pain and swelling aggravated Tenderness, warmth, swelling over anterior tibial
Osgood-Schlatter disease
by activity, limp
tubercle

radiograph to rule out fracture

Baker's cyst

Fullness or swelling of posterior knee, aggravated by

walking

none

Ankle Sprain

History of inversion stress with audible pop, immediate Swelling, soft tissue trauma, able to perform
swelling
active ROM with ligament sprain

Shin splints

Ache or pain over medial tibia that is worse with

exercise, history of running

Achilles tendinitis

Pain and tightness over Achilles tendon, especially

with walking or running

Negative Foucher's sign; normal joint

examination; positive Homan's sign in ruptured
cyst

Radiograph with knee rotated inward

may show soft tissue swelling

Radiograph needed only with

tendernes over lateral malleolus to
rule out fracture

tenderness over medial tibia

AP and lateral radiographs may

show a stress fracture; a bone scan
will be positive with increased
uptake along the medial tibia
Tenderness over Achilles tendon; pain worse with Lateral ankle radiograph reveals
dorsiflexion of ankle, calf weakness
enlarged posterosuperior tuberosity
of calcaneus

Plantar faciitis

History of chronic weight bearing, aching feet, muscle Misalignment of foot structures, sepecially talus,
spasms, obesity
calcanues, and plantar ligaments
Muscle Pain (Myalgia) Viral Hisotry of upper respiratory infection, malaise, chills, Fever, I;;-appearing adult or child
Infections
cold symptoms, general muscle aches

none

Psychogenic

Pain is diffuse, varies in pattern of activity, setting;

history of depressioin or anxiety

Normal examination orpatient response to

examination maneuvers disproportionate to
physical findings or subjective complaints

none

Fibromyalgia

Female 20-50 yrs, history of depression, sleep

Palpation of trigger points will produce pain;
disturbance, chronic fatigue, general muscle and joint normal physical examination
aches

none

Systemic Disorders
Leukemia
Sickel cell disease

Acute Hip pain in children, refusal to walk

Fever, hepatosplenomegaly, bruising

African-American, family history; appears after 6 mo of Normal examination

age; acute pain with swelling of hands and feet,
abdominal pain, decreased appetite, malaise

Viral serum titer

CBC
Hemoglobin S genotype

Systemic lupus erythematosus Female, transient arthritis of small joints, malar rash
Lyme arthritis

Normal examination may habe joint tenderness

Kidney function tests, antinuclear
on palpation
antibody, CBC
History of exposure to endemic areas of deer tick,
Asymmetrical swelling, warmth of joint, erythema Serum IgM and IgG antibodies, ESR
chills, diffuse joint pain and swelling, often the knee is migrans, may have myocardial involvement
affected

Neuroblastoma

Under 5 yrs, pain in bones

Osteogenic sarcoma

Persons 10-25 yr, intermittent pain of lower femur,

upper tibia, limp
History of sleeping with arm against head, morning
shoulder pain, pain worse with lifting, paresthesia;
rounded shoulder posture

Nerve Entrapment
Syndromes
Thoracic outlet syndrome

Urine for vannillylmandelic or

homovanillic acid; CT scan
Radiograph, serum alkaline
Tenderness over affected area
phosphatase
Bruit over supraclavicular fossa; pallor, decreased EMG
pulses of upper extremity, weakness, skin and
nail atrophy
Unexplained fever

Carpal tunnel syndrome

History of repetitive upper extremity motion;

paresthesia, weakness, or clumsiness of hand;
symptoms worse at nights

Peroneal nerve compression

History of pressure to the knee from a cast, sports

Unilateral foot drop
injury, or trauma; pain over head of fibula; clumsy gait

none

Tarsal tunnel syndrome

Pain in ankle and proximal foot, weakness of toe

flexors, ill-fitting shoes
Pain and sensory loss, usually of lower extremities;
history of alcohol ingestion, diabetes

Tapping posterior tibial nerve elicits pain

none

Decreased sensory and pain sensation

Liver function tets, hemoglobin A1C

to rule out diabetes

Neuritis

Positive Phalen's and Tinel;s sign, weakness of

hand, dry skin over distribution of median nerve

Page 42 of 52

none

What Clues Indicate This Is a Potentially Serious, Need to know if patient is fully oriented
Life-Threatening Headache?
before proceeding. Can screen with a MiniMental Staus Exam. If patient shows a
mental status deficit, immediate emergency
treatment is indicated

Headache

How did the headache begin?

What is your age? Have you had this type of

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

On a scale from 0 (no pain) to 10 (worst pain ever)

how severe is the pain?

Is there a history of recent trauma to the head?

Was there a loss of consciousness?

Do you notice any other symptoms associated with
headache pain?

Complete Blood Cell

Count
Detects
major blood dyscrasias.
Hypoxia secondary to
severe anemia can cause
headache.
Blood
Cultures Do if patient
Onset of sudden severe headache with
has fever, headache,
neurological signs is an emergency; the
nuchal rigidity and altered
patient needs immediate emergency
mental status
treatment
CT Scan
Detects
intracranial disease. DO
New onset headache in children or elderly
for new-onset headache
or persons over 50 years of age is a
or if headache is
warning sign of a serious cause
associated with
New, severe headache or headache
Take Vital Signs and
neurological signs.
different than prior occurences and
Obtain Growth
Lumbar Puncture Do if
headache that progressively worsens are Parameters
Fever infection is suspected but
warning signs of serious causes
may be the only sign of
contraindicated if
infection. Bradycardia and increased intracranial
Trauma may cause subdural or eppidural
narrowing of pulse
pressure Erythrocyte
bleeding. Anyone who experienced head
pressure are signs of
Sedimentation Rate
trauma must be carefully observed for at
increased intracranial
Non-specific for
least 24 hours for signs of neurological
pressure. In children,
temporal arteritis
damage
plotted height and weight inflammation
Skull
significantly below average Radiograph
Higher chance of neurological signs
Do for
considers hypothalamic
Headache associated with infection
post-traumatic
presents with fever and possibly stiff neck. neoplasm. Macrocephaly headache
may indicate
Intracranial hemorrhage associatedw ith
hydrocephalus or brain
confusion, vomiting, lethargy and focal
tumour
neurological signs. Brain tumours in
children associated with vomiting, recurrent
morning headaches, reflex asymmetry and
papiledema

Do you have any chronic health problems?

Persons with AIDS have increased risk of

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

After Determining the Headache Is Not Serious,

How Can I narrow Down the Causes?

A moderately intense, constant throbbing

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

What does it feel like?

Where does it hurt?

Observe the Patient

Any patient who complains
of headache and exhibits
an ataxic gait,
uncoordinated movements,
or reduced mental
alertness should be
immediately transported to
an emergency center for
neurological evaluation

Palpate and Percuss the

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

What makes it worse?

Triggers such as sound, odour and

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

How long have you had this headache?

Tension type headaches and migraines last

less than 24 hours. Cluster headaches are
less than 3 hours

Can you tell when it is coming on?

Auras can occur before, during or after

headaches and last no more than 30
minutes. Other prodromal symptoms
include fatigue, depressed or euphoric
mood, increased or decreased appetite,
constipation or diarrhea and yawning.

Inspect the Ears, Eyes,

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

How does the pain afect your activities?

What Does the Chronicity of Pain Suggest?
How frequently do you get a headache?

Activities: a person may adapt to chronic

musculoskeletal problems by using an
assistive
such asheadaches
a cane or by
A
patient device
with constant
for more
than 3 months may demonstrate
papilledema, bilateral or unilateral cranial
nerve VI palsies, gait or balance
disturbances or spasticity of the lower
extremities. Continuous headaches for four
weeks or more without these symptoms is
of psychogenic origin.

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

Can you describe any pattern to the headache?

headaches throughout the day indicate

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

Page 43 of 52

Assess Cranial Nerve

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

Primary Headache Without

Structural or Systemic
Pathology
Tension
(muscle) headache

Common in adults, bilateral pain, general or localized

in bandlike distribution; history of anxiety, stress or
depression

Normal physical examination; neck muscle

tightness or fasciculations may be palpated

None

Migrain without aura

(common)

More common in children; unilateral, throbbing pain;

nausea

photophobia and phonophobia

none

Migraine with aura (classic)

Pain precipitated by environmental stimuli; visual

disturbances (scintillating scotoma) precede pain

nausea and vomiting, photophobia and

phonophobia

None

Mixed headache

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

Cluster headache

Rare in children; abrupt, nighttime onset; unilateral

periorbital pain that is severe

Benign exertional headache

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

coitus

May need to distinguish from

subarachnoid hemorrhage with CT
scan

Infectious Origin
Sinusitis

Frontal, upper molar, or periorbital pain: cough,

rhinorrhea

Low or no fever, pain on palpation of frontal,

maxillary sinuses; purulent nasal or postnasal
discharge

Radiographs (Waters view)

Dental Disorders

Localized pain in jaw and top of head

Malocclusion, caries, abcesses of teeth present,

gum disease

dental referral

Pharyngitis
Otitis media
Meningitis

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

Fever; infection of the posterior pharynx

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

Throat culture
None
Lumbar puncture

Neurogenic Origin
Trigeminal neuralgia

Persons over 55 yrs; bursts of sharp pain over the

face innervated by the affected nerve; triggered by
stimulus to the affected nerve

Normal physical examination; stimulation of

triggers may provoke pain

None

None

Ipsilateral rhinorrhea, nasal stiffness, conjunctival None

injection, sweating, ptosis

Secondary Headaches With

Structural or Systemic
Pathology

Page 44 of 52

How long does the headache last?

Examine the Neck

Do
full ROM and assess
stiffness which may
Have you had this kind of headache before?
Acute-onset headaches must be evaluated indicate muscle tension or
for organic causes. Subacute and chronic meningitis
ones are usually caused by vascular
Do you use alcohol? Take any medications?
Test for Meningitis eg
inflammation or muscle tension. Migraines Kernig's sign. Assess
usually begin between 10 and 30 yrs. New Deep Tendon Reflexes
onset migraines in adults over 50 yrs is
for cerebral lesions.
unusual. Tension headaches usually begin
between 8-12 yrs. Cluster headaches
What Associated Symptoms Does the Patient
Associated with migraines. Vomiting can be Assess Motor Strength
Have?
a sign of increased intracranial pressure.
and Coordination of
Headaches from tumours produces early
Extremities
morning vomiting without nausea.
Asymmetrical increase in
Do you have any nausea or vomiting?
muscle tone on affected
side, contralateral to the
DO you notice any vision changes?
Auras procede migraines. Cluster
hemisphere lesion
headaches associated with ipsilateral
suggests a cerebral lesion.
conjunctival injection, lacrimation and
If person exhibits forearm
edema of eyelid.
drift with arms extended
and eyes closed may have
Does light bother you?
Often present with migraines but not
tension headaches. Present in meningitis a motor neuron or
cerebellar disturbance with
expanding intracranial
Are you dizzy?
1/3 people with migraines have vertigo
lesion.
What Do the Aggravating and Alleviating Factors Meningeal irritation headaches are better
Suggest?
with lying down. Tension headaches
respond to analgesics. Rest relieves
migraines but not tension headaches in
children. Sleep, rest in dark quiet room
Does anything make the headache better?
Have Children Draw a
relieves migraines in adults. Increased
Picture of Their
headache with sneezing or coughing may
Headache
Help
indicate benign headache or lesion at level
to diagnose type of
Does anything make the headache worse?
of foramen magnum that is not clinically
headache eg. Children will
present yet. Migraines are worse withe
draw flashes of light for
xertion. Cluster headaches are worse lying
What Does Family History Indicate?
migraine aura.
down. Headaches wrose in morning and
better on rising indicate tumour. Benign
exertional headaches can occur during
Tension type headaches have no family
Does anyone else in the family have headaches?
history. Migraine headaches have positive
family history
Is There Anything Else That Woud Help narrow
the Cause or Causes?
Have you been ill recently?
Have you taken any medications or vitamins?
Could you have been exposed to carbon monoxide?

Meningitis indicated. Lumbar punctures

can cause headache in 25% of people.
Chronic infection predisposes to brain
abcess. Penetratin skull fractures allow
bacteria to enter. Melanomas can
Exposure may cause severe, throbbing,
generalized headache. Occupation
exposure to toxins should be assessed.
Winter headaches may be due to faulty
kerosene or gas heater.

Page 45 of 52

Optic neuritis

Acute onset of pain with extraocular movement,

followed by blurred vision

Diminished visual acuity, decreased pupillary

reflec, hyperemia of the optic disk; pain with
extraocular movement

Cervical spine disorders

May have a history of trauma; occipital pain, muscle

stiffness
Age>50 yr; sharp localized temporal pain; malaise,
anorexia, history of polymyalgia rheumatica

Normal physical examination or pain associated Cervical spine radiograph

with neck motion
fever, weight loss; tender over a nodular temporal Elevated ESR (>50); immediate
artery
referral for treatment

Metabolic Origin
Carbon monoxide poisoning
Severe hypoglycemia

History of exposure, throbbing headache, mild

dyspnea
History of diabetes or medication, alcohol and food
ingestion; generalized headache, dizziness, sense of
not feeling well

nausea, vomitting, change in mental status,

lethargy, loss of consciousness
Normal physical examination or pallor, sweating,
and weakness

Drug withdrawal

Pattern of headache associated with stopping

normal physical exam
medication or substance use
Mild to moderately severe headache after ingestion of normal physical exam
foods or medication

blood chemistry

Cardiovascular Origin
Intracranial tumour

Sudden-onset headache that is progressive,

exacerbated by coughing or exercise; worse in
morning; history of trauma increases risk

CT scan

Hydrocephalus
Subdural hematoma

Progressive headache, vomiting, irritability

Rapid enlargement of head, bulging fontanels
History of head trauma, bleeding disorders, child
unequal pupils, photophobia, neurological
abuse; adult over 35 yrs; sudden onset of 'worst ever' chnges, seizures
headache, often over the eye, transient loss of
consciousness

CT scan and referral

CT scan and neurosurgical referral

Pseudotumour cerebri

Teens, menopausal women, history of vitamin A or

tetracycline ingestion; progressive headache

Papilledema may be present

CT scan, neurology referral to

assess risk related to lumbar
puncture

Brain abcess

teens, menopausal women, history of vitamin A or

tetracycline ingestion; progressive headache
Risk factors; persons over 50 yrs, with AIDS, on
anticoagulation therapy, or with hypertension

fever, seizures, focal neurological findings

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

CT scan

Temporal arteritis

Dietary ingestion

Intracerebral hemorrhage

Papilledema, vomiting, asymmetrical reflexes,

weakness, sensory deficit, or other neurological
deficit

Page 46 of 52

opthalmology, referral

Blood gases and

carboxyhemaglobin level
Blood glucose level; may need selfmonitoring of blood glucose to
establish pattern

blood chemistry

Emergency transport for immediate

evaluation (CT scan) and possible
surgical treatment

Lower Back
Pain

Do you have a fever?

The presence of a fever indicates an

inflammation; spondyloarthropathy or
systemic infection. Ask for chills, weight
loss, fever. Also, may inquire about
intravenous drug use or
immunosuppressed conditions.

Assess the overall

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

Have you experienced any trauma?

Acute trauma to the spinal cord can result

in a fracture, dislocation or misalignment or
the muscles, ligaments and IVD. Spinal
cord injury should be suspected with
anyone whose level of consciousness is
impaired after an accident.

Perform range of motion of

the spine. Straight Leg
Raising, Deep tendon
reflexes, muscle strength

Do you have any other health problems/been treated Assess for systemic diseases (metabolic,
for cancer?
inflammatory diseases and fibromyalgia).
Patients with a history of cancer are more
susceptible to spinal tumours.

What is your age?

In the absence of trauma a sudden and

severe onset of middle back pain can be a
sign of an aortic aneurysm in a patient
above the age of 30. Patients above 50 are
at risk of compression fractures and
cancer.

Have you had a loss of your bowels or bladder

control?

Assess for cauda equina or S1-S2 nerve

root compromise secondary to a herniated
disk, nerve entrapment, spinal stenosis,
infection or tumor. A Surgical emergency is
indicated if there is saddle anesthesia,
urinary retention and fecal incontinence.

Are you on any medications?

Long-term use of corticosteroids can lead

to compression fractures of te vertebrae.
Use of intravenous drugs may suggest
infection as a cause

Where does it hurt?

Sciatica is usually sharp, burning pain that

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

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

Pain that is mild and or short duration (1-2

weeks) is rarely serious. Back pain lasting
longer than 4 weeks needs to be reevaluated for further diagnostic studies. In
children back pain that is present for more
than 3 weeks is often due to organic and
serious causes.

Does the pain interfere with your sleep?

Night pain is often a worrisome symptom

that often signals a serious problem such
as tumor, infection or inflammation.
Genreally muscular issues are relieved at
night. Nighttime back pain is unusual and
indicates the need for a complete and
thorough work-up.

Does the pain travel?

2 types - (1) pain referred from the spine

into areas lying within the lumbar and
upper sacral dermatomes. (2) pain referred
from the pelvic and abdominal viscera to
the spine. Pain from the upper lumbar
spine usually radiates to the anterior
aspects of the thighs and legs, and that of
the lower lumbar spine radiates to the
gluteal regions, posterior thighs and calves.
Visceral disease usually stays with in the
abdomnial cavity (flanks). Gallbladder pain
radiates around the trunk to the right
scapula. Position does not affect the pain.

Page 47 of 52

CBC - detect anemia as

well as other conditions
that might manifest as
back pain, such as tumor
or infection.

Urinalysis - assess
kidney and metabolic
function, including
infectious process, rule
out pyelonephritis.

Spinal fracture

major trauma, impact or fall, strenous lifting, elderly

minor fall, treated as a medical emergency

palpable tenderness over site of fracture

considered an emergency;
radiographs

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

ESR; bone scan; plain film

Infection (osteomyelitis,
diskitis).

The spine is the most common site for osteomyelitis in acute onset presents with fever, diaphoresis;
adults. Staph aureus is the most common bacteria.
tenderness over affected disk; positive SLR
Stiffness and pain over the site of the infection. Tender
spinous process, positive SLR test, paravertebral
muscle spasm. Often secondary to pharyngitis or otitis
media, intravenous drug use, diabetes mellitus,
immunosuppression

ESR; blood culture; bone biopsy; CT

scan; MRI

Cauda Equina Syndrome

Compression of the S1 nerve. saddle anesthesia,

urinary retention and fecal incontinence. Unable to
heel or toe walk, asymmetrical knee and ankle deep
tendon reflexes.

surgical emergency

Sciatica

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

Aortic Aneurysm

severe acute-onset not related to activity or

movement, increased risk in persons over age 30;
anxiety, sweating confusion

intact aneurysm will be a visible pulsatile midline

upper quadrant abdominal mass; in a dissected
aneurysm upper extremity pulse and pulse
pressure are asymmetrical; posterior thoracic
pain may be felt

emergency surgical referral

Gallstones

Increased incidence with age; steady, intense pain in

RUQ with radiation to right scapula or shoulder;
belching, bloating, fatty food intolerance

normal physical; positive Murphy's sign on

palpation of abdomen

surgical referral

Pyelonephritis

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

fever; cloudy malodorous urine, CVA tenderness

Urinalysis, urine culture

positive SLR, motor weakness

Page 48 of 52

Is This Really A Fever?

Fever

How do you know you have a fever?

Has the temperature been measured? How?

An elevation of
Should Sepsis or Meningitis Be of Concern?
temperature above
normal daily variation and Has there been any recent head traumas?
is a symptom of an
underlying process
Have you had recurrent ear infections?
Have you had contact with anyone else who had
meningococcal disease?
Have you had any headache, lethargy, confusion or
stiff neck?
If an infant: How old is the baby?

Fever in a Child Less

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

Complete Blood Cell

Count
Leukocytosis
with a left shift suggests
bacterial infection.
Atypical lymphocytes are
characteristic if viral
infection. Immature
neutrophils suggest
leukemia.
Erythrocyte
Observe the Patient
Sedimentation Rate
Do they appear ill,
Elevation indicates
Entrance for infection especially at base of dehydrated or lethargic?
inflammatory condition,
Look for toxic signs and
skull
responsiveness in children non-specific
May have mastoiditis spreading to
meninges
Increased risk of contacting it
Take Vital Signs and Note
Temperature
Adults oral temp. Children and
Characteristic meningitis symptoms. Any infants - rectal temp. Temp
patient with minimal neurological signs and > 40 degrees celsius is a
symptoms should be evaluated for
marker for bacterial
meningitis
infection though people
Fever in infants less than 2 months is
uncommon but is serious. May be infection with these high temps do
not necessarily have major
or indicator of underlying anatomical
defect. UTI and bacteremia are indications diseases. Extreme fever of
of abnormal urinary tract structure. Infants > 41.5 degrees celsius is
rarely due to infection and
with galactosemia may present in first
weeks to 1 month of life with gram-negative is more likely seen in drug
fevers, CNS injury,
sepsis. Infants can get sepsis from
malignant hyperthermia,
delivery instruments. All infants younger
than 2 months with fever are considered to stroke and HIV
have sepsis or meningitis until proved
otherwise

What Does a Pattern of Fever Tell Me?

How long have you had the fever?

What has the highest temperature been? When did

this occur?

Is the Fever Caused by a Localized Infection?

Do you have frequency, burning or urgency with

urination?
Are you having any unusual vaginal/penile
discharge?
Do you have any face or sinus pain?

Do you have nasal discharge? What colour?

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

In adults, fevers in acute processes

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

Observe Skin and

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

Dehydration and febrile seizures are

related to height of fever. Temperatures
greater than 41.1 degress celsius seen in
heat illness, central nervous system
disease or these in combo with infection.
Higher the fever, greater likelihood of
bacteremia.

Examine the Head and

Neck Sinuses, ears,
tympanic membrane, eyes
and fontanels

Palpate Lymph Nodes

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

Fever can be present in otitis media

Viral and bacterial pharyngitis produces
fever. GI tract infection produces fever.
Connective tissue disorder, osteomyelitis
and septic arthritis produce fever. Apthous
ulcers with pharyngitis and cervical
lymphadenopathy seen in children with
periodic children.

Do you have any apthous ulcers?

Can The Diagnostic Possibilities Be Narrowed or Prodromal Rash can occur with varicella,
a Cause Be Eliminated?
rubella, erythema infectiosum (1 day),
scarlet fever (2 days), rocky mountain
Have you noticed a rash?
spotted fever (3 days), measles (4 days),
roseola infantum (5 days)
Do you ache all over?
Fever localized to a site without general
body manifestations are often bacterial in
nature. Fever accompanied by muscle
aches, malaise and respiratory symptoms
are often viral in nature.
Page 49 of 52

Examine the Lungs and

Chest
Check for respiratory
infection. Sputum colour:
yellow/green - bacterial.
Brown - check smoking
history. Blood streaked Uri or bronchitis.
Hemoptysis - tumour,
trauma, pulmonary
emoblism.
Palpate Breasts if
Indicated
Examine
Perform Gitonitourinary
System if Indicated
Neurological/Mental
Examine
Musculoskeletal
Status
Exam
system if indicated

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

DNA Probe for

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

URI

Any age group; systemic symptoms; often known

contact with ill others

fever < 38.7 degrees C; cough; nonpurulent

sputum; erythema of pharynx, viral exanthem

None

Gastroenteritits

nausea, vomiting, diarrhea; abdominal cramping

Mild fever; abdomen may be diffusely tender

None

UTI

Female>male; burning urgency, frequencyin adults;

systemic symptoms/bedwetting in children

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

PID

May have pelvic or lower abdominal pain

May have suprapubic tenderness; cervical

discharge; CMT, adnexal tenderness

CBC; culture, DNA probe

Prostatitis

Perineal discomfort, frequent urination, chills and

malaise

Prostate tender to palpation; fever

Segmental urine specimens; C and

S of urine; C and S of prostate
discharge

Pharyngitis

Sore throat; may or may not have other upper

respiratory symptoms

Erythematous pharynx; may have pharyngeal or

tonsillar exudate or ulcers; may have palatine
petechiae in mononucleosis; lymphadenopathy

CBC; culture; rapid strep test if

suspect strep; Monospot if suspect
mono

Sinusitis

facial or sinus pressure or pain; headache

Purulent nasal discharge; sinuses tender to

percussion; headache or pressure worsens on
bending forward

Radiographs or CT scan of limited

value

Ear infections

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

Pneumatic otoscopy

meningitis

nonspecific symptoms; nausea, vomiting, irritability

Petechiae, nuchal rigidity, positive Kernig's and

Brudzinski's signs, bulging fontanel in infant

Lumbar puncture

Osteomyelitis

Pain in affected bone or joint

Swelling or tenderness over affected joint

Kawasaki disease

Under 5 yrs; males>females; fall and spring

Factitious fever

Vague or no symptoms

Roseoloa infantum

Irritable child with fever for 4-5 days

Culture; CBC; radionuclide scan, CT,

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

Enterovirus

Mild nonspecific febrile illness lasting 2-5 days;

summer and early fall peaks

Normal physical examination; when fever breaks, None

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

Occult bacteremia

Fever in children older than 3 month

No localizing signs, child appears well

Blood culture, WBC

Periodic fever in children

Abrupt fever on periodic basis (about every 6 wks);

last about 4 days; child aged 2-5 yrs, malaise

Cervical adenopathy, apthous stomatitis

WBC and ESR elevated

Fevers without localizing signs No other specific symptoms

Page 50 of 52

Does the Patient Have a Increased Risk for

Complications?
Do you have any chronic health problems?
Have you had any recent surgery?
Have you been diagnosed with an infectious disease
recently?

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

Are you sexually active? How many partners?

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

Are immunizations up to date?

Does anyone in the family have TB or hepatitis?
Does the Parent Report a Behaviour Change in
the Child?
Is the child sleepier than normal?
Is the child more irritable?
How is the child acting?
Could the Fever Be Caused by Something
Acquired While Traveling?
Have you been out of the country recently?

More likely to contract illness if not immunized

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

Have you been in the woods or camping recently?

Could the Fever Be Medication Related or
Caused by Poisoning?
What medications have taken recently?

Risk of ticks, Q fever, tularemia, Rocky Mountain spotted fever, Giardia or Lyme disease

Describe the foods you have eaten in the past 3

days.
Could the child have eaten a poisonous plant?

Prone to relapse or reoccurrence

Risk of amoebiasis, malaria, schistosomiasis, typhoid fever or hepatitis

Medications may hide an occult infection or induce a fever. Immunosuppressent medications

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

Could Exposure to Animals Explain the Fever?

Has a cat scratched you recently?

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

Have you been around any other animals?

Dogs - brucellosis and leptospirosis. Rabbits - tularemia. Birds - ornithosis, histoplasmosis,

psittacosis. Hamsters and cats - lymphocytic choriomeningitis

Could This Be the Result of a Recent

Immunization?
What immunizations have you had recently?

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

Could The Fever Be Caused by Heat Exposure?

Were you overdressed? Is the infant overbundled?

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

Do you have air conditioning or windows that open?

During a heat wave a person may become overheated if they don't have air conditioning

How warm is the room you live/sleep in?

Windows may not open due to safety reasons and cause overheating

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Page 52 of 52