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Contents

Medical Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Problem-Oriented Daily Progress Note . . . . . . . . . . . . . . . . . . . . . . . . . .
Procedure Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discharge Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discharge Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Cardiovascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chest Pain and Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Palpitations and Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Pulmonary Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wheezing and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . .
Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fever and Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cough and Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pneumocystis Carinii Pneumonia and AIDS . . . . . . . . . . . . . . . . . . . . .
Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urinary Tract Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abdominal Pain and the Acute Abdomen . . . . . . . . . . . . . . . . . . . . . . .
Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anorexia and Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematemesis and Upper Gastrointestinal Bleeding . . . . . . . . . . . . . . .
Melena and Lower Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . .
Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jaundice and Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gastritis and Peptic Ulcer Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mesenteric Ischemia and Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Gynecologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abnormal Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pelvic Pain and Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Neurologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dizziness and Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Delirium, Coma and Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weakness and Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Renal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oliguria and Acute Renal Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic Renal Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nephrolithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Endocrinologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diabetic Ketoacidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypothyroidism and Myxedema Coma . . . . . . . . . . . . . . . . . . . . . . . . . .
Hyperthyroidism and Thyrotoxicosis . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Hematologic and Rheumatologic Disorders . . . . . . . . . . . . . . . . . . . . . . 81

Deep Venous Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Connective Tissue Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Psychiatric Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical Evaluation of the Psychiatric Patient . . . . . . . . . . . . . . . . . . . . .
Mini-mental Status Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attempted Suicide and Drug Overdose . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Commonly Used Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Commonly Used Drug Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Commonly Used Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

History and Physical Examination 5

Medical Documentation
History and Physical Examination
History
Identifying Data: Patient's name; age, race, sex. List the patient’s significant
medical problems. Name of informant (patient, relative).
Chief Compliant: Reason given by patient for seeking medical care and the
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when it began, character of the symptoms, location where the
symptoms began; aggravating or alleviating factors; pertinent positives and
negatives. Describe past illnesses or surgeries, and past diagnostic testing.
Past Medical History (PMH): Past diseases, surgeries, hospitalizations;
medical problems; history of diabetes, hypertension, peptic ulcer disease,
asthma, myocardial infarction, cancer. In children include birth history,
prenatal history, immunizations, and type of feedings.
Developmental history (in pediatrics)

Medications:

Allergies: Penicillin, codeine?

Family History: Medical problems in family, including problems similar to

patient's disorder. Asthma, coronary artery disease, heart failure, cancer,
tuberculosis.
Social History: Alcohol, smoking, drug usage. Marital status, employment
situation. Level of education.
Review of Systems (ROS):
General: Weight gain or loss, loss of appetite, fever, chills, fatigue, night
sweats.
Skin: Rashes, skin discolorations.
Head: Headaches, dizziness, masses, seizures.
Eyes: Visual changes, visual field deficits.
Ears: Tinnitus, vertigo, hearing loss.
Nose: Nose bleeds, discharge, sinus diseases.
Mouth and Throat: Dental disease, hoarseness, throat pain.
Respiratory: Cough, shortness of breath, sputum (color).
Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dyspnea;
dyspnea on exertion, claudication, edema, valvular disease.
Gastrointestinal: Dysphagia, abdominal pain, nausea, vomiting,
hematemesis, diarrhea, constipation, melena (black tarry stools),
hematochezia (bright red blood per rectum).
Genitourinary: Dysuria, frequency, hesitancy, hematuria, discharge.

arthritis. Ears: Acuity. blood pressure. myalgias. uterine size. splenomegaly. breath sounds. ptosis. hernias. breast masses. contraception. tonsils. Musculoskeletal: Joint pain or swelling. distended). respirations. pulses (radial. rebound. pulses (graded 0-2+). scaphoid. Chest: Equal expansion. cyanosis. tympanic membranes (dull. arteriovenous nicking. Head: Bruising. Skin and Lymphatics: Easy bruising. Heart: Point of maximal impulse (PMI). murmurs (grade 1-6). Abdomen: Contour (flat. ovaries. capillary refill (in seconds). tenderness. edema (CCE). hepatomegaly. costovertebral angle tenderness (CVAT). axillary masses. heat intolerance. intact. adnexal masses. abdominojugular reflux. axillary. clubbing. femoral. extra ocular movements intact (EOMI). Skin: Rashes. exudates). Extremities: Joint swelling. liver span by percussion. inguinal nodes. Eyes: Pupils equal round and react to light and accommodation (PERRLA). last menstrual period (frequency. auscultation. Funduscopy (papilledema. cervical discharge.” well. shiny. injected. ulnar. Neck: Jugular venous distention (JVD) at a 45 degree incline. regular rate and rhythm (RRR). and visual fields. Endocrine: Polyuria. percussion note (tympanic). Vital Signs: Temperature. or malnour­ ished. moles. obese. abortions. Lymph Nodes: Cervical. heart rate. tenderness. tenderness. Genitourinary: Inguinal masses. seizures. Mouth and Throat: Mucus membrane color and moisture. dysmenorrhea. Check fontanels in pediatric patients. Breast: Dimpling. duration). vaginal bleeding. scars. . masses. thrills (palpable turbulence). rhonchi. percussion. crackles. fissures. scars. lymphadenopathy. rubs. test for occult blood. guarding. supraclavicular. edema (grade 1-4+). posterior tibial. prostate (nodules. menopause. tenderness. popliteal. range of motion. Physical Examination General appearance: Note whether the patient looks “ill. dorsalis pedis. masses. gallops (S3. bruits. memory changes.6 History and Physical Examination Gynecological: Gravida/para. polydipsia. bulging). S2). whispered pectoriloquy. masses. size. skin or hair changes. lymphadenopathy. lumps. depression. size). testicles. tactile fremitus. masses. pharynx. dentition. oral lesions. scrotum. bowel sounds. Rectal Examination: Sphincter tone. suprapubic tenderness. masses. hemorrhages. simultaneous palpation of radial and femoral pulses). egophony. first and second heart sounds (S1. Neuropsychiatric: Weakness. bruits. scleral icterus. Pelvic Examination: Vaginal mucosa. S4). nipple discharge. thyromegaly. age of menarche. varicoceles.

liver function tests (LFTs). ECG. extraocular eye movements. VII: Close eyes tightly.” speech XI: Shoulder shrug and turns head against resistance XII: Stick out tongue in midline Labs: Electrolytes (sodium. urine analysis (UA). x-rays. medications. deep tendon reflexes (biceps. Plan: Describe therapeutic plan for each numbered problem. ankle. pressure. chloride. post-operative day number. ability to open jaw against resistance. ptosis V: Facial sensation. give reasons for excluding other diagnoses. VI: Pupil responses to light. hypokalemia). discuss any additional orders. platelets. . pain. position and vibration. Discuss differential diagnosis and give reasons that support the working diagnosis. differential). and give observations about the patient. and discuss the progress of each problem. Assessment (Impression): Assign a number to each problem and discuss separately. strength (graded 0-5). patellar. gait. Problem-Oriented Daily Progress Note Problem List: List each problem separately (heart failure. Plan: For each problem. changes in drug regimen or plans for discharge or transfer. laboratory data. show teeth VIII: Hears watch tic. Rinne test (air conduction last longer than bone conduction when tuning fork is placed on mastoid process) IX. including testing. and antibiotic day number. physical exam for each system. and antibiotics. pneumonia. Cranial Nerve Examination: I: Smell II: Vision and visual fields III. graded 0-4+). smile. X: Palette moves in midline when patient says “ah. Objective: Vital signs. Weber test (lateralization of sound when tuning fork is placed on top of head). touch sensation. bicarbonate. Subjective: Describe how the patient feels in the patient's own words. CBC (hemoglobin. IV. creatinine). Assessment: Evaluate each numbered problem. triceps. laboratory studies.Problem-Oriented Daily Progress Note 7 Neurological: Mental status and affect. potassium. WBC count. hematocrit. BUN. Romberg test (ability to stand erect with arms outstretched and eyes closed). State hospital day number. corneal reflex.

risks and alternatives to the procedure were explained to the patient. Studies Performed: Electrocardiograms. surgery. Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure.8 Procedure Note Procedure Note A procedure note should be written in the chart when a procedure is performed. Lab tests: Relevant labs. including antibiotic therapy. Discharge Note Date/time: Diagnoses: Treatment: Briefly describe therapy provided during hospitalization. devices used. Note that the patient was given the opportunity to ask questions and that the patient consented to the procedure in writing. and outcome. ana­ tomic location of procedure. anesthesia method. and cardiovascular drugs. CT scan. Procedure notes are brief operative notes. such as the INR and CBC Anesthesia: Local with 2% lidocaine Description of Procedure: Briefly describe the procedure. Procedure Note Date and time: Procedure: Indications: Patient Consent: Document that the indications. Discharge Note The discharge note should be written in the patient’s chart prior to discharge. Specimens: Describe any specimens obtained and labs tests which were ordered. Discharge medications: Follow-up Arrangements: . patient position. including sterile prep.

including physical exam and laboratory data. tablets size): Lasix 40 mg Quantity to dispense: #40 Frequency of administration: Sig: 1 po qAM Refills: None Signature Discharge Summary Patient's Name and Medical Record Number: Date of Admission: Date of Discharge: Admitting Diagnosis: Discharge Diagnosis: Attending or Ward Team Responsible for Patient: Surgical Procedures. Disposition: Describe the situation to which the patient will be discharged (home. Copies: Send copies to attending. Discharged Medications: List medications and instructions for patient on taking the medications. . medications. and describe present status of the patient. including evaluation. and indicate who will take care of patient. consultants.Prescription Writing 9 Prescription Writing • • • • • • • Patient’s name: Date: Drug name and preparation (eg. Discharged Condition: Describe improvement or deterioration in the patient's condition. and Laboratory Data: Describe the course of the patient's disease up until the time that the patient came to the hospital. nursing home). Hospital Course: Describe the course of the patient's illness while in the hospital. Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic. clinic. diet. and outcome of treatment. exercise. Diagnostic Tests. Invasive Procedures: Brief History. Pertinent Physical Examination. treatment. Problem List: List all active and past problems.

10 Discharge Summary .

radiation (to arm. ECGs. nicotine replace­ ment therapy. sharp. rate of onset (gradual or sudden). third heart sound (S3) (heart failure. sputum. “silver wire” arteries. . during sleep. HEENT: Fundi. angiograms. Extremities: Edema. femoral bruits. unequal or diminished pulses (aortic dissection). orthopnea. pallor. swelling (thrombosis). Chest: Crackles. effect of eating. stress. A-V nicking. BP. coronary bypass grafting or angioplasty. Physical Examination General: Visible pain. carotid bruits. back). syncope. dysphagia. ascites. Prior history of myocardial infarction. pulsatile mass (aortic aneurysm). Cardiac Testing: Past stress testing. diabetes. cardiac rub (pericarditis). relationship of pain to activity (at rest. claudication. edema. Medications: Aspirin. Location. stroke. paresthesias. Note whether the patient looks “ill. alcohol. Improvement or worsening of pain. dull). hypercholesterol­ emia. arteriolar narrowing. Social History: Cocaine usage. beta-blockers. Vital Signs: Pulse (tachycardia). or malnourished. xanthomas (hypercholes­ terolemia). Skin: Cold extremities (peripheral vascular disease). hypertension. S4 gallop (more audible in the left lateral position. respirations (tachypnea). during exercise). relief by nitroglycerine. estrogen replacement. dilation). temperature.Chest Pain and Myocardial Infarction 11 Cardiovascular Disorders Chest Pain and Myocardial Infarction History of the Present Illness: Duration of chest pain. history of peptic ulcer disease. Exercise tolerance. smoking. jaw. palpitations. calf pain.” well. Heart: Decreased intensity of first heart sound (S1) (LV dysfunction). apprehension. hypertensive retinopathy. mitral insufficiency murmur (papillary muscle dysfunction). PMH: History of diabetes. vomiting. hepatomegaly. decreased LV compliance due to ischemia). distress. jugular venous distention. Rectal: Occult blood. dyspnea. Associated Symptoms: Diaphoresis. elicit drugs. smoking. Aggravating and Relieving Factors: Effect of inspiration on pain. intensity. alcohol. cough. Abdomen: Epigastric tenderness (peptic ulcer). increase in frequency or severity of baseline anginal pattern. nuclear scans. NSAIDS. percussion note. Risk Factors for Coronary Heart Disease: Family history of coronary artery disease before age 55. character (squeezing. nausea.

Aortic Dissection. occupational exposures. . cardiac medications (noncompliance). Differential Diagnosis of Chest Pain A. ECG's. Physical Examination General Appearance: Respiratory distress. troponin I or troponin T. Medications: Bronchodilators. hypertension. cough. weight gain. and anemia. HIV risk factors. aggravating or relieving factors (noncompliance with medications. Chest x-ray: Cardiomegaly. Esophageal Rupture. coronary artery disease. palpitations. “Tearing” chest pain with uncontrolled hyperten­ sion. pallor. Epigastric pain with melena or hematemesis. x-rays. Past Medical History: Emphysema. Dyspnea History of the Present Illness: Rate of onset of shortness of breath (gradual. asthma. Acute Pericarditis. C. Affect of physical exertion. CPK with isoenzymes. diaphoresis. Fluid input and output balance. Characterized by pleuritic-type chest pain and diffuse ST segment elevation. CBC. hyperacute T waves. syncope. fever. Vital Signs: BP (supine and upright). temperature. magnesium. respiratory rate (tachypnea). and fever. paroxysmal nocturnal dyspnea (PND). electrolytes.” well. sudden). Acute Cholecystitis. x-ray may reveal air in mediastinum or a left side hydrothorax. anxiety. nausea. D. lightheadedness. drug allergies. Past Treatment or Testing: Cardiac testing. and LDH. history of myocardial infarction. dyspnea. or malnourished.12 Dyspnea Labs: Electrocardiographic Findings in Acute Myocardial Infarction: ST segment elevations in two contiguous leads with ST depressions in reciprocal leads. leg pain (DVT). Echocardiography. Past episodes. HEENT: Jugular venous distention at 45 degrees. Edema. chest pain. pulse (tachycardia). pulmonary edema (CHF). B. Occurs after vomiting. vomiting. spirometry. Characterized by right subcostal abdominal pain with anorexia. widened mediastinum and increased aortic prominence on chest x-ray. sputum. tracheal deviation (pneumothorax). heart failure. salt overindulgence). Note whether the patient looks “ill. orthopnea (dyspnea when supine). LDH. Acute Peptic Ulcer Disease. myoglobin. E.

History of heart failure. hyperinflation with flattened diaphragms. anemia. barrel chest (COPD). respiratory rate. dullness to percussion. unilateral hyperresonance (pneumothorax). malignancy. Edema History of the Present Illness: Duration of edema.” well. carotid pulse amplitude. dullness to percussion (pleural effusion). Medications: Cardiac drugs. ventila­ tion/perfusion scan. shortness of breath. irregular rhythm (atrial fibrillation). Vitals: BP (orthostatic). liver. Physical Examination General Appearance: Respiratory distress. or renal disease. pulse. associated pain. Extremities: Edema. irregular. clubbing. S3 gallop (LV dilation). irregular). temperature. or malnourished. cardiac enzymes. dyspnea. HEENT: Jugular venous distention at 45E. Electrocardiogram A. friction rubs. upper airway obstruction. breath sounds. thyroid disease. atrial fibrillation (irregular. Heart: Lateral displacement of point of maximal impulse. pallor. prolonged immobility. crackles (rales). wheezing. myocardial infarction. Recent fluid input and output balance. infiltrates. cyanosis. pulmonary edema). holosystolic apex murmur (mitral regurgitation). History of deep vein thrombosis. venous insufficiency. . Past Treating and Testing: Cardiac testing. Calf tenderness or swelling (DVT). new left bundle-branch block.Edema 13 Chest: Stridor (foreign body). pulses. B. S4 (myocardial infarction). chest x-rays. pneumonia. Chest: Breath sounds. Abdomen: Abdominojugular reflux (pressing on abdomen increases jugular vein distention). redness. ST elevations in two contiguous leads. calcium channel blockers. Differential Diagnosis: Heart failure. foreign body aspiration. chronic diarrhea (protein losing enteropathy). chronic obstructive pulmonary disease. with ST depressions in recipro­ cal leads (MI). wheeze. Exacerbation by upright position. pneumothorax. crackles. alcoholism. asthma. rhonchi. hepatomegaly. effusions. diuretics. liver tenderness. faint heart sounds (pericardial effusion). Note whether the patient looks “ill. pulmonary embolism. diaphoresis. S3 gallop (LV dilation). malnutrition. Heart: Displacement of point of maximal impulse. chest x-ray (cardiomegaly. Labs: ABG. allergies. hyperventilation. retractions. ST segment depression or elevation. localized or generalized. weight changes.

antiarrhythmics). edema of lower extremities. nonsteroidal antiinflammatory drugs. lymphoma). clubbing. nephrotic syndrome. noncompliance with diuretics. Thyroid disease. nausea. malnutrition). ascites. lymphatic obstruction (neoplasm . sudden). distention. anemia. noncompliance with low salt diet. redness. pulmonary disease. viral illness. splenomegaly. obstruction of hepatic venous outflow. hypertension. volume diuresed. dyspnea on exertion (DOE). ECG. anemia. cough. thrombo­ sis). Differential Diagnosis of Edema Unilateral Edema: Deep venous thrombosis. Treatment in Emergency Room: IV Lasix given. paroxysmal nocturnal dyspnea (PND). warmth. Homan's sign (dorsiflexion elicits pain. cirrhosis. chills. Cardiac Risk Factors: Smoking. Endocrine: Mineralocorticoid excess. sputum. Doppler studies of lower extremities. Labs: Electrolytes. Past Medical History: Past episodes of heart failure. myocardial infarction. angio­ grams. weight gain.14 Congestive Heart Failure Abdomen: Abdominojugular reflux. Exercise tolerance (past and present). mottled brown discoloration of ankle skin (venous insufficiency). ECGs. fluid wave. chest x-ray. drug use. orthopnea. cardiac testing. antihypertensives. alcoholism. Associated Symptoms: Fatigue. Miscellaneous: Chronic anemia. heart murmur. diabetes. cardiac enzymes. adverse drug reactions (beta blockers. pleuritic pain. pulmonary embolism. diaphoresis. family history of coronary artery disease or heart failure. leg circumference. hypoalbuminemia (protein losing enteropathy. . arrhythmias. hepatomegaly. CBC. palpitations. Past Testing: Echocardiograms for ejection fraction. Congestive Heart Failure History of the Present Illness: Duration of dyspnea. Precipitating Factors: Infections. digoxin. fever. note of onset (gradual. pulses. iatrogenic edema. Recent fluid input and output balance. excessive fluid intake. angioedema. shifting dullness. hypertension. syncope. hypercholesterolemia. Severity of dyspnea compared with past episodes. nocturia. coronary artery disease. obstruction of inferior or superior vena cava. heart failure. Generalized Edema: Renal disease (acute glomerulonephritis. Extremities: Pitting or non-pitting edema (graded 1 to 4+). excess salt or fluid intake. renal insufficiency. chest pain. tenderness.pelvic. liver function tests. diabetes. number of pillows needed under back when supine to prevent dyspnea. calcium blockers. hyperthyroidism. renal failure). cyanosis.

toxic. Renal failure. hypertension. rhonchi.Congestive Heart Failure 15 Physical Examination General Appearance: Respiratory distress.” well. beta-blockers. liver failure. genetic. Heart: Lateral displacement of point of maximal impulse. alcohol abuse. Coronary artery disease and myocardial infarction B. High output states: Anemia. carotid pulse. hepatojugular reflux (pressing on abdomen causes jugular venous distention). CBC. Paget's disease. fever. Increase Demand: Anemia. Tachyarrhythmias or bradyarrhythmias H. or malnourished. hepatomegaly. BUN. tempera­ ture. Conditions That Mimic or Provoke Heart Failure: A. Hypertension C. LDH. Abdomen: Ascites. Electrolytes. pallor. Kerley B lines (horizontal streaks in lower lobes). toxic. ectopic beats. Note whether the patient looks “ill. Dyspnea. infection. noncompliance with diuretics. thyrotoxicosis. CPK. anxiety. fibrous dysplasia. metabolic E. vascular cephalization (increased density of upper lobe vasculature). Vital Signs: BP (hypotension or hypertension). duration. Echocardiogram. Medications: Antiarrhythmics (disopyramide). postpartum. sodium. Cardiomyopathies: Hypertrophic. atrial fibrillation. idiopathic dilated. pulses. B. pulse (tachycardia). ECG: Left ventricular hypertrophy. irregular. calcium blockers. NSAID's. nutritional. Pulmonary disease J. creatinine. HEENT: Jugular venous distention at 45 degree incline (measure vertical distance from the sternal angle to top of column of blood). multiple myeloma K. Aortic or mitral valve disease D. Pulmonary embolism I. MB. pulmonary emboli. muscle wasting. excessive intravenous fluids . jaundice. A-V fistulas. excess dietary salt. irregular rhythm (atrial fibrillation). nephrotic syndrome Factors Associated with Heart Failure A. dullness to percussion (pleural effusion). amplitude. Labs: Chest x-ray: Cardiomegaly. serial cardiac enzymes. liver tenderness. cardiac ischemia/infarction. AV fistula. respiratory rate (tachypnea). crackles. diaphoresis. troponins. immune F. S3 gallop (LV dilation). perihilar congestion. hyperthyroidism. Myocarditis: Infectious. Pericardial constriction G. renal failure. bruits. pleural effusions. Arrhythmias. Chest: Breath sounds. Extremities: Edema (graded 1 to 4+).

S4. duration. but asymptomatic at rest. irregular tachycardia). pleuritic pain. tremor (hyperthyroidism). rheumatic heart disease. Class III: Symptomatic with minimal activity. pericardial rub (pericarditis). or malnourished. TSH. nausea. Dyspnea. sensory. potassium. dyskinetic apical pulse. electrolyte abnormalities. CN 2-12. anxiety). diabetes. dysphasia.” well. noncompliance with cardiac medications. coronary disease. ECG: Irregular R-R intervals with no P waves. Class IV: Symptomatic at rest. Heart: Irregular. COPD. weakness. thyromegaly (hyperthyroidism). Results of previous ECGs. Palpitations and Atrial Fibrillation History of the Present Illness: Palpitations (rapid or irregular heart beat). Chest x-ray. pallor. Echocardiogram for atrial chamber size. LDH. creatinine. Note whether the patient looks “ill. alcohol. mitral valve stenosis. irregular rhythm (atrial fibrillation). cocaine. Irregular baseline with rapid fibrillary waves (320 per minute). BUN. free T4. caffeine.16 Palpitations and Atrial Fibrillation New York Heart Association Classification of Heart Failure Class I: Symptomatic only with strenuous activity. CBC. carotid bruits. decongestants. (emboli) jugular venous distention. symptoms of hyperthyroidism (tremor. dizziness. pericarditis. Extremities: Peripheral pulses with irregular timing and amplitude. CPK. diet pills. Femoral artery bruits (atherosclerosis). The ventricular response rate is 130-180 per minute. pulse (irregular. Vital Signs: BP (hypotension). syncope. Cardiac History: Hypertension. fatigue. Chest: Crackles (rales). Class II: Symptomatic with usual level of activity. cyanosis. petechia (emboli). hypokalemia. displaced point of maximal impulse (cardiomegaly). arrhythmias. serial cardiac enzymes. mitral regurgitation murmur (rheumatic fever). . Edema. anxiety. edema. Rectal: Occult blood. HEENT: Retinal hemorrhages. exercise intolerance. dysarthria (stroke). Associated Symptoms: Chest pain. diaphoresis. Labs: Sodium. Neuro: Motor weakness (embolic stroke). diaphoresis. drug levels. hyperthyroidism. fatigue. Underlying Conditions: Pneumonia. dyspnea. Physical Examination General Appearance: Respiratory distress. magnesium.

carotid bruits. A-V nicking. baseline BUN and creatinine. palpitations. Past Testing: Urinalysis. Noncardiac Causes: Hypoglycemia. Alcohol withdrawal. Cardiac Causes: Hypertensive heart disease with left ventricular hypertro­ phy. myocardial infarction. dysuria. chronic obstructive pulmonary disease. Age of onset of hypertension. pericarditis. lethargy. pneumonia. diet pills. heavy alcohol intake or alcohol withdrawal. exudates. dyspnea. agitation (hypertensive encephalopathy). angina. Physical Examination General Appearance: Delirium. Vital Signs: Supine and upright blood pressure. pulse. hemorrhages. flank pain. “cotton wool” spots. temperature. Jugular venous distention. Chest: Crackles (rales. over-thecounter cold remedies. hypertrophic cardiomyopathy. bronchodilators. asthma. blurred vision (hypertensive retinopathy). heart failure. beta agonists. Stimulant abuse. amphetamines. patient’s baseline BP from records. theophylline intoxication. edema. cortico steroids. hypertension. orthopnea. ECG. amyloidosis. intercostal bruits (aortic . pulmonary embolus. BP in all extremities. Paroxysms of tremor. vomiting. HEENT: Hypertensive retinopathy. ocular medications (sympathomimetics). Risk Factors for Coronary Artery Disease: Family history of coronary artery disease before age 55. cocaine. alcohol. electrolyte abnormalities. coronary artery disease.Hypertension 17 Differential Diagnosis of Atrial Fibrillation Lone Atrial Fibrillation: No underlying disease state. pulmonary edema). wheeze. confusion (encephalopathy). smoking. Hypertension History of the Present Illness: Degree of blood pressure elevation. hyperthyroidism. diaphoresis. mitral valve stenosis or regurgitation. diabetes. thyromegaly (hyperthyroidism). oral contraceptives. excessive salt. excessive caffeine. hypercholesterol­ emia. noncompliance with antihypertensives (clonidine or beta-blocker withdrawal). nonsteroidal anti-inflammatory agents. creatinine. pyelonephritis. dizziness. illicit drugs. respirations. confusion. papilledema. systemic illness. headache (pheochromocytoma). thyroid disease. aortic stenosis. Associated Symptoms: Chest or back pain (aortic dissection). Medications: Over-the-counter cold remedies. nausea.

Renovascular Stenosis. tremor. 24 hour urine for metanephrines. or left ventricular hypertrophy. laterally displaced. posterior systolic bruits below ribs. apical impulse with patient in left lateral position (ventricular hypertrophy). E. G. visual acuity. UA with micro­ scopic analysis (RBC casts. rhythm and conduction disturbances. Primary Aldosteronism. proteinuria). rib notching. renal artery stenosis). systolic ejection murmurs. 12 lead electrocardiography: Evidence of ischemic heart disease. rapid return phase of deep tendon reflexes (hyperthyroidism). Extremities: Asymmetric femoral to radial pulses (coarctation of aortic). indentation of aorta (coarctation). hirsutism (adrenal hyperplasia). Neuro: Mental status. edema (peripheral vascular disease). CBC. Labs: Potassium. Tachycardia. C. F. uric acid. Femoral pulse delayed later than radial pulse. abdominal aortic enlargement (aortic aneurysm). creatinine. Heart: Rhythm. B. localized weakness (stroke). D. plasma renin activity. hyperthyroidism). hematuria. Pheochromocytoma. plasma catecholamines (pheochromocytoma). Aortic Coarctation.18 Hypertension coarctation).5 mg/dL. Flank or abdominal mass. Truncal obesity (Cushing's syndrome). costovertebral angle tender­ ness. plethora (pheochromocytoma). proteinuria. tremor (pheochromocytoma. Renal Parenchymal Disease. Pyelonephritis. Increased serum creatinine $1. . Chest x-ray: Cardiomegaly. Paraumbilical abdominal bruits. Findings Suggesting Secondary Hypertension: A. costovertebral angle tenderness. Initial serum potassium <3. narrowly split S2 with increased aortic component. forceful. Urinary tract infections. pallor. Skin: Striae (Cushing's syndrome). Abdomen: Renal bruits (bruit just below costal margin.5 mEq/L while not taking medication. glucose. uremic frost (chronic renal failure). enlarged kidney (polycystic kidney disease). sustained. Polycystic Kidneys. femoral bruits. renal masses. BUN.

myalgias. anorexia. tuberculosis exposure. onset. fatigue. Exacerbated by supine position. Primary (essential) Hypertension (90%) B. weight loss. coughing or deep inspiration. noncompliance with antihypertensive medications. Pericarditis History of the Present Illness: Sharp pleuritic chest pain. kidney disease.Pericarditis 19 Screening Tests for Secondary Hypertension Renovascular Hyperten­ sion Captopril Test: Plasma renin level before and 1 hr after captopril 25 mg PO. intensity. or alcohol. radiation. prior episodes of pain. rashes. procainamide. cocaine use. duration. A greater than 150% increase in renin is positive Captopril Renography: Renal scan before and after captopril 25 mg PO Intravenous pyelography MRI angiography Arteriography (DSA) Hyperaldosteronism Serum Potassium 24 hr urine potassium Plasma renin activity CT scan of adrenals Pheochromocytoma 24 hr urine metanephrine Plasma catecholamine level CT scan Nuclear MIBG scan Cushing's Syndrome Plasma ACTH Dexamethasone suppression test Hyperparathyroidism Serum calcium Serum parathyroid hormone Differential Diagnosis of Hypertension A. Associated Findings: History of recent upper respiratory infection. isoniazid. arthralgias. Medications: Hydralazine. fever. pheochromocytoma. dyspnea. withdrawal from alpha2 stimulants. . clonidine or beta blockers. S e c o n d a r y H y p e r t e n s i o n : R e n o v a s c u l a r h y p e r t e n s i o n . relieved by leaning forward. autoimmune disease. referred to trapezius ridge. penicillin. chills. palpitations.

weakness.” pericardial calcifications. Rectal: Occult blood. Labs: ECG: diffuse. procainamide. Vital Signs: BP. CPK. HEENT: Cornea. micturition. pain. rate of onset.” well. cough. Syncope History of the Present Illness: Time of occurrence and description of the episode.20 Syncope Physical Examination General Appearance: Respiratory distress. pallor. mental status before and after event. increased ESR. MB. myxedema. rhonchi. defecation. neck position (turning to side). tension. Valsalva. exertion. Prodromal Symptoms: Nausea. infectious pericarditis (viral. pulsus paradoxus (drop in systolic BP >10 mmHg with inspiration). tongue biting. pallor. jugular venous distention (cardiac tamponade). confusion. Skin: Malar rash (butterfly rash). cardiac rub with 1-3 components at lower left sternal border. Extremities: Arthralgias. urine protein. LDH. pulse (tachycardia). Duration of unconsciousness. Chest pain. Increased WBC. upright T waves. tight shirt collar). Precipitants (fear. PR segment depression. mycobacterial). activity before and after event. sclera. low QRS voltage. Note whether the patient looks “septic. sarcoidosis. Heart: Rhythm. hydralazine). vertigo. uremia. connective tissue disease. Seizure activity (tonic/clonic). anxiety. Chest x-ray: large cardiac silhouette. post myocardial infarction pericarditis (Dressler's syndrome). polymyositis. Post-syncopal disorientation. diaphoresis. Differential Diagnosis: Idiopathic pericarditis. bacterial. Lyme disease. or malnourished. urinary of fecal incontinence. arm position (reaching). hunger. lightheadedness. drugs (penicillin. dyspnea. downwardly. UA. palpitations. ST segment elevation in all 3 standard limb leads and several precordial leads. flushing. distant heart sounds (pericardial effusion). friction rub on end-expiration while sitting forward. Body position. concave. lupus. iris lesions. urine RBCs. joint tenderness. mycoplasmal. Echocardiogram. Dyspnea. diaphoresis. neoplasm. blood culture. rheumatic fever. “water bottle sign. discoid rash (lupus). Rate of return to alertness (delayed or spontane­ ous). isoniazid. . hyperventilation. dimming vision (vasovagal syncope). oral ulcers (lupus). Chest: Crackles (rales).

Neuro: Cranial nerves 2-12. diabetes. diaphoresis. up and down. Turn patient’s head side to side. Chest x-ray. Medications Associated with Syncope Antihypertensives or anti-angina agents Adrenergic antagonists Calcium channel blockers Diuretics Nitrates Vasodilators Antidepressants Tricyclic antidepressants Phenothiazines Antiarrhythmics Digoxin Quinidine Insulin Drugs of abuse Alcohol Cocaine Marijuana Physical Examination General Appearance: Level of alertness. Heart: Irregular rhythm (atrial fibrillation). tongue or buccal lacerations (seizure). tenderness pulsatile mass. gait. flat jugular veins (volume depletion). pallor. HEENT: Cranial bruising (trauma). extraocular movements. 24-hour Holter monitor. cardiac testing. respiratory distress. glucose. Chest: Crackles. Pupil size and reactivity. exercise testing. cardiac disease. ECG. EEG. seizures. capillary refill. CBC. Past Testing: 24 hour Holter. Extremities: Extremity palpation for trauma. mental status. rhonchi (aspiration). .Syncope 21 Past Medical History: History of past episodes of syncope. Labs: ECG: Arrhythmias. Blood pressure in all extremities.” well. carotid or vertebral bruits. Mg. Vital Signs: Temperature. blocks. pulse. Note whether the patient looks “ill. pallor. BUN. Genitourinary/Rectal: Occult blood. strength. urinary or fecal incontinence (seizure). cardiac friction rub. electrolytes. nystagmus. respiratory rate. anxiety. sensory. stroke. Skin: Turgor. bend down and pick up object. systolic murmurs (aortic stenosis). postural vitals (supine and after standing 2-5 minutes). Abdomen: Bruits. creatinine. arrhythmias. or malnourished. transient ischemic attacks. anxiety attacks. asymmetric radial to femoral artery pulsations (aortic dissection). Dyspnea. have patient reach above head.

22 Syncope Differential Diagnosis of Syncope Non-cardiovascular Cardiovascular Metabolic Hyperventilation Hypoglycemia Hypoxia Neurologic Cerebrovascular insufficiency Normal pressure hydrocephalus Seizure Subclavian steal syndrome Increased intracranial pressure Psychiatric Hysteria Major depression Reflex (heart structurally normal) Vasovagal Situational Cough Defecation Micturition Postprandial Sneeze Swallow Carotid sinus syncope Orthostatic hypotension Drug-induced Cardiac Obstructive Aortic dissection Aortic stenosis Cardiac tamponade Hypertrophic cardiomyopathy Left ventricular dysfunction Myocardial infarction Myxoma Pulmonary embolism Pulmonary hypertension Pulmonary stenosis Arrhythmias Bradyarrhythmias Sick sinus syndrome Pacemaker failure Supraventricular and ventricular tachyarrhythmias .

Note whether the patient looks “ill. second heart sound (pulmonary embolism). pH of expectorated blood (alkaline=pulmonary. . anticoagulants.Hemoptysis 23 Pulmonary Disorders Hemoptysis History of the Present Illness: Quantify the amount of blood. Heart: Mitral stenosis murmur (diastolic rumble). Lymph Nodes: Cervical. Smoking. liver nodules (metastases). anti­ glomerular basement membrane antibody. bronchitis. NSAIDs. HIV risk factors (pulmonary Kaposi’s sarcoma). clubbing (pulmonary disease). aspiration of food or foreign body. creatinine. edema. Labs: Sputum Gram stain. weight loss. BP (hypotension). jugular venous distention. Anxiety. tongue lacerations. ulcerations of nasal septum (Wegener's granulomatosis). Abdomen: Masses. character (coffee grounds. dyspnea. COPD. chills. past bronchoscopies. anorexia. hoarseness. bleeding time. rhonchi. dark). cryptococcus antigen. sputum fungal culture. malaise. chest pain (left or right). right ventricular gallop. assess hemodynamic status. immigration from a foreign country. Vital Signs: Temperature. apical crackles (tuberculosis). accentuated. residence in a nursing home. antinuclear antibody. cytology. Extremities: Petechiae. tenderness of chest wall. tenderness. Chest: Stridor. calf swelling (pulmonary embolism). acuteness of onset. cyanosis. gingival disease (aspiration). Farm exposure. respiratory distress.” well. color (bright red. clots). diaphoresis. PPD. breast masses (metastasis). HEENT: Nasal or oropharyngeal lesions. ABG. UA (hematuria). Skin: Purple plaques (Kaposi's sarcoma). hematuria. bone pain (metastasis). basilar crackles (pulmonary edema). telangiectasias on buccal mucosa (Rendu-Osler-Weber disease). exposure to tuberculosis. intrathoracic malignancy). pulse (tachycardia). or malnourished. platelets. Rectal: Occult blood. tenderness. rashes (paraneoplastic syndromes). CBC. leg pain or swelling (pulmonary embolism). aspirin. ecchymoses (coagulopathy). heart failure. Physical Examination General Appearance: Dyspnea. tuberculin testing (PPD). INR/PTT. localized wheezing (foreign body. pallor. pleural friction rub. fever. homelessness. malignancy). CT scans. Prior chest X-rays. Family history of bleeding disorders. acid fast bacteria stain. acidic=GI). respiratory rate (tachypnea). scalene or supraclavicular adenopathy (Virchow's nodes.

hay-fever. HEENT: Nasal flaring. drugs). lung abscess. dyspnea. Vital Signs: Temperature. Family History: Family history of asthma. mitral stenosis. Neoplasms: Bronchogenic carcinoma. past pulmonary function testing. atopic dermatitis. diaphoresis. purulent sputum. decreased intensity of breath sounds (emphysema). fungal infection. duration. home oxygen or nebulizer use. history of steroid dependency. third heart sound gallop (S3. CT scan. fever. aspiration. metastatic cancer. Past Pulmonary History: Previous episodes of asthma. recent upper respiratory infection. Goodpasture's syndrome. diaphoresis. bronchiectasis. intubation. seasons that provoke symptoms.blockers. hemosiderosis. Heart: Decreased cardiac dullness to percussion (hyperinflation). rhonchi. jugular venous distention. pharyngeal erythema. pulse (tachycardia). pulsus paradoxus (inspiratory drop in systolic blood pressure >10 mmHg = severe attack). distant heart sounds. increased anteroposterior diameter (hyperinflation). chest x-ray. pulmonary edema. barrel chest. new medica­ tions. animals. Vascular: Pulmonary embolism. Kaposi’s sarcoma. . smoking. baseline peak flow rate. tenderness. Wheezing and Asthma History of the Present Illness: Onset. exacerbation by exercise. pollen. somnolence. coagulopathy. grunting. increased intensity of pulmonic component of second heart sound (pulmonary hypertension). tuberculosis. hypotension). beta. chills. BP (widened pulse pressure. Abdomen: Retractions. pulmonary aneurysm rupture. chest pain. Physical Examination General Appearance: Dyspnea. ventilation/perfusion scan. COPD. pneumonia. respiratory distress. cyanosis. well. Note whether the patient looks cachectic. broncholithiasis. sternocleidomastoid muscle contractions. allergies. epistaxis. Treatment given in emergency room and response. or malnourished. Differential Diagnosis Infection: Bronchitis. cough. intracostal and supraclavicular retractions. Wegener's granulomatosis. severity of attack compared to previous episodes. cor pulmonale). respiratory rate (tachypnea >28/min). Baseline arterial blood gas results. pallor. Anxiety. vasculitis. and progression of wheezing. pneumonia. aspirin. oropharyngeal bleeding. frequency of exacerbations and hospitalizations. Exposure to allergens (foods. Chest: Prolonged expiratory wheeze. foreign body aspiration. lupus. Miscellaneous: Trauma. foreign body. bronchoscopy.24 Wheezing and Asthma EKG.

Treatment given in emergency room. clubbing. chills. Heart: Right ventricular heave. allergic reaction. Sputum gram stain. supraclavicular retractions. Physical Examination General Appearance: Diaphoresis. Anxiety. bullae. endobronchial tumors. history of intubations. nebulizer use. Diabetes. or malnourished. edema. COPD. respiratory rate (tachypnea). heart failure. somnolence. distant heart sounds. consistency. bullae. perioral cyanosis. elongated heart. clubbing. CBC. bronchitis. Vital Signs: Temperature. right ventricular hypertrophy. Chest: Barrel chest. small. Labs: Chest x-ray: Diaphragmatic flattening. S3 gallop (cor pulmonale). Associated Symptoms: Chest pain. Pulmonary function tests. peak flow rate. dyspnea. prolonged expiratory wheezing. Past History: Frequency of exacerbations.” well. BP. fever. Sputum gram stain. pallor. hypoxia. Skin: Rash. . anaphylaxis. Labs: Chest x-ray: hyperinflation. urticaria. edema. rhonchi. Note whether the patient looks “cachectic. Extremities: Cyanosis. electrolytes. ABG: Respiratory alkalosis. chest trauma. cough. increased sputum production. pneumonia. acidosis (late). ABG: Respiratory alkalosis (early). speech interrupted by breaths. dyspnea. Severity of attack compared to prior episodes. respiratory distress. pulse (tachycardia). steroid depend­ ency. hyperinflation. right axis deviation. Decreased air movement. past pulmonary function tests. alcohol abuse.Chronic Obstructive Pulmonary Disease 25 Extremities: Cyanosis. pleurisy. pneumonia. Neuro: Decreased mental status. Adverse drug reactions (beta blockers. hyperaeration. carcinoid. family history of emphysema. intercostal retractions. sternocleidomastoid muscle contractions. HEENT: Pursed-lip breathing. congestive heart failure. Mucous membrane cyanosis. flattening of diaphragms. theophylline level. Neuro: Decreased mental status. ECG: Sinus tachycardia. home oxygen use. color. upper airway obstruction. confusion. confusion. Baseline blood gases. sedatives). hypoxia. Chronic Obstructive Pulmonary Disease History of the Present Illness: Duration of wheezing. noncompliance with medications. jugular venous distention. Differential Diagnosis: Asthma. smoking (pack-years). retractions. sputum quantity.

increased calf circumference (>2 cm difference). Vitals: Temperature (fever). Neuro: Altered mental status. calf redness or tenderness. genitourinary. Unilateral leg pain. Extremities: Cyanosis. or malnourished. heart failure. respiratory rate (tachypnea. Note whether the patient looks “cachectic. right ventricular hypertrophy. calf swelling. loud.26 Pulmonary Embolism culture. pneumonia. ECG: Sinus tachycardia. Heart: Right ventricular gallop. Homan's Sign (pain with dorsiflexion of foot). HEENT: Jugular venous distention. Differential Diagnosis: COPD. syncope. prominent jugular A-waves. >16/min). Pulmonary Embolism History of the Present Illness: Sudden onset of pleuritic chest pain and dyspnea. CBC. apprehension. diaphoresis. right axis deviation. lung. bone). dilated superficial veins. pulmonic component of second heart sound (S2). history of heart failure. pregnancy. Rectal: Occult blood. breast mass (malignancy). trauma. fever. electrolytes. Virchow's Triad: Immobility. malignancy (pancreas. cystic fibrosis. pulse (tachycardia >100/min). stomach. breast. PVCs. pelvic.” well. . murmur. estrogens (oral contracep­ tives). chronic bronchitis. BP (hypotension). accentuated. S3 or S4 gallop. tenderness or splinting of chest wall. hypercoagulability. Physical Examination General Appearance: Dyspnea. diaphoresis. asthma. swelling. cough. Genitourinary: Testicular or pelvic masses. edema. hemoptysis. alpha-1-antitrypsin deficiency. History of deep vein thrombosis. Chest: Crackles. surgery. pleural friction rub.

wedge shaped infiltrate. asthma. S1Q3 pattern).8EC) Diaphoresis S3 or S4 gallop Thrombophlebitis 92 58 53 44 43 36 34 32 Labs: ABG: Hypoxemia. nonspecific ST-T wave changes. right axis deviation). hypocapnia. effusion. right bundle branch block. Pulmonary angiogram: Arterial filling defects. right heart strain pattern (P-pulmonale. localized oligemia. Lung Scan: Ventilation/perfusion mismatch. chronic obstructive pulmonary disease. Duplex imaging and impedance plethysmography of lower extremities.Pulmonary Embolism 27 Frequency of Symptoms and Signs in Pulmonary Embolism Symptoms % Signs % Dyspnea Pleuritic chest pain Apprehension Cough Hemoptysis Sweating Non-pleuritic chest pain Syncope 84 74 59 53 30 27 14 13 Tachypnea (>16/min) Rales Accentuated S2 Tachycardia Fever (>37. . segmental atelectasis. Differential Diagnosis: Heart failure. Chest x-ray: Elevated hemidiaphragm. pneumonia. respiratory alkalosis. aspiration of foreign body or gastric contents. QRS changes (acute right shift. ECG: Sinus tachycardia. pulmonary edema. myocardial infarction. hyperventilation.

28 Pulmonary Embolism

Fever and Sepsis 29

Infectious Diseases
Fever and Sepsis
History of the Present Illness: Degree of fever; time of onset, pattern of fever;
shaking chills (rigors), cough, sputum, sore throat, headache, neck stiffness,
dysuria, frequency, back pain; night sweats; vaginal discharge, myalgias,
nausea, vomiting, diarrhea, malaise, anorexia.
Chest or abdominal pain; ear, bone or joint pain; recent antipyretic use.
Cirrhosis, diabetes, heart murmur, recent surgery; AIDS risk factors.
Exposure to tuberculosis or hepatitis; travel history, animal exposure; recent
dental GI procedures. Ill contacts; IV or Foley catheter; antibiotic use, alcohol
use, allergies.
Physical Examination
General Appearance: Lethargy, toxic appearance, altered level of conscious­
ness. Dyspnea, apprehension, diaphoresis. Note whether the patient looks
“ill,” well, or malnourished.
Vital Signs: Temperature (fever curve), respiratory rate (tachypnea or
hypoventilation), pulse (tachycardia), BP (hypotension).
HEENT: Papilledema; periodontitis, tympanic membrane inflammation, sinus
tenderness; pharyngeal erythema, lymphadenopathy, neck rigidity.
Breast: Tenderness, masses.
Chest: Rhonchi, crackles, dullness to percussion (pneumonia).
Heart: Murmurs (endocarditis).
Abdomen: Masses, liver tenderness, hepatomegaly, splenomegaly; Murphy's
sign (right upper quadrant tenderness and arrest of respiration secondary to
pain, cholecystitis); shifting dullness, ascites. Costovertebral angle or
suprapubic tenderness.
Extremities: Cellulitis, infected decubitus ulcers or wounds; IV catheter
tenderness (phlebitis), calf tenderness, Homan's sign; joint or bone tender­
ness (septic arthritis). Osler's nodes, Janeway's lesions (peripheral lesions
of endocarditis).
Rectal: Prostate tenderness; rectal flocculence, fissures, and anal ulcers.
Pelvic/Genitourinary: Cervical discharge, cervical motion tenderness; adnexal
or uterine tenderness, adnexal masses; genital herpes lesions.
Skin: Pallor, cool extremities, delayed capillary refill; rash, purpura, petechia
(septic emboli, meningococcemia), ecthyma gangrenosum (purpuric necrotic
plaque of Pseudomonas infection). Pustules, cellulitis, furuncles, abscesses,
cysts.
Labs: CBC, blood C&S x 2, glucose, BUN, creatinine, UA, urine Gram stain,
C&S; lumbar puncture; urine, skin lesion cultures, bilirubin, transaminases;

30 Cough and Pneumonia
tuberculin skin test, Gram Strain of buffy coat
Chest x-ray; abdomen X-ray; gallium, indium scans.

Laboratory Tests for Serious Infections
Complete blood count, including leu­
kocyte differential and platelet
count
Electrolytes
Arterial blood gases
Blood urea nitrogen and creatinine
Urinalysis
INR, partial thromboplastin time,
fibrinogen
Serum lactate

Cultures with antibiotic sensitivities
Blood
Urine
Wound
Sputum, drains
Chest X-ray
Adjunctive imaging studies (eg, computed
tomography, magnetic resonance im­
aging, abdominal X-ray)

Differential Diagnosis
Infectious Causes: Abscesses, mycobacterial infections (tuberculosis),
cystitis, pyelonephritis, endocarditis, wound infection, diverticulitis,
cholangitis, osteomyelitis, IV catheter phlebitis, sinusitis, otitis media, upper
respiratory infection, pharyngitis, pelvic infection, cellulitis, hepatitis, infected
decubitus ulcer, furuncle, peritonitis, abdominal abscess, perirectal abscess,
mastitis; viral, parasite infections.
Malignancies: Lymphomas, leukemia, solid tumors, carcinomas.
Connective Tissue Diseases: Lupus, rheumatic fever, rheumatoid arthritis,
temporal arteritis, sarcoidosis, polymyalgia rheumatica.
Other Causes of Fever: Atelectasis, drug fever, pulmonary emboli, pericarditis,
pancreatitis, factitious fever, alcohol withdrawal. Deep vein thrombosis,
myocardial infarction, gout, porphyria, thyroid storm.
Medications Associated with Fever: Barbiturates, isoniazid, nitrofurantoin,
penicillins, phenytoin, procainamide, sulfonamides.

Cough and Pneumonia
History of the Present Illness: Duration of cough, chills, rigors, fever; rate of
onset of symptoms. Sputum color, quantity, consistency, blood; living situation
(nursing home, homelessness). Recent antibiotic use.
Associated Symptoms: Pleuritic chest pain, dyspnea, sore throat, rhinorrhea,
headache, stiff neck, ear pain; nausea, vomiting, diarrhea, myalgias,
arthralgias.
Past Medical History: Previous pneumonia, intravenous drug abuse, AIDS risk
factors. Diabetes, heart failure, COPD, asthma, immunosuppression,

mycoplasma pneumoniae. Legionella. travel history. bronchial breath sounds with decreased intensity. Aspiration Pneumonia: Streptococcus pneumoniae. . Prophylactic trimethoprim/sulfamethoxazole treatment. exposure to tuberculosis. ill contacts. whispered pectoriloquy (increased transmission of sound). ABG.” well. Neuro: Gag reflex. chills. air bronchograms. glucose. heart failure. stiff neck. CD4 lymphocyte count and HIV-RNA titer (viral load). bronchitis. Vital Signs: Temperature (fever). Physical Examination General Appearance: Respiratory distress. Chest x-ray: segmental consolidation. prior episodes of PCP or opportunistic infection. creatinine. antiviral therapy. insidious onset. BP. egophony (E to A changes). or malnourished. legionella. tuberculin testing. weakness. Enterobacteriaceae. Chest: Dullness to percussion. lymphadenopathy. Klebsiella. UA. Dry nonproductive cough (or productive of white. Etiologic Agents of Community Acquired Pneumonia Age 5-40 (without underlying lung disease): Viral. smoking. atelectasis. HEENT: Tympanic membranes. influenza. BUN. Bacteroides sp. ECG. clubbing. Staphylococcus aureus. end-inspiratory crackles. Pneumocystis Carinii Pneumonia and AIDS History of the Present Illness: Progressive exertional dyspnea and inability to perform usual activities (climbing stairs). steroids. asthma.. respiratory rate (tachypnea). pharyngeal erythema. duration of HIV positivity. Chlamydia pneumoniae. Streptococcus pneumoniae.Pneumocystis Carinii Pneumonia and AIDS 31 alcoholism. Sputum Gram stain: >25 WBC per low-power field. >40 (no underlying lung disease): Streptococcus pneumonia. tactile fremitus (increased sound conduction). Associated Symptoms: Headache. dehydration. pulse (tachycar­ dia). fatigue. group A streptococcus. malignancy. Note whether the patient looks “ill. pulmonary embolism. Chlamydia pneumoniae. neck rigidity. rhonchi. night sweats. Enterobacter. lethargy. H. effusion. Pneumococcal vaccination. Labs: CBC. frothy sputum). Baseline and admission arterial blood gas. electrolytes. bacteria. aspiration. mental status. Differential Diagnosis: Pneumonia. viral infection. Extremities: Cyanosis. >40 (with underlying disease): Klebsiella pneumonia. Fever. anaerobes.

cyanosis. sexual. Dermatologic Stigmata of AIDS: Rashes. sinusitis. Abdomen: Right upper quadrant tenderness. oropharyngeal thrush. cotton wool spots (CMV retinitis). nausea. sputum. respiratory rate (tachypnea). rigors. disorientation (AIDS dementia complex. Mode of acquisition of HIV infection. blood transfusion. headache. hepatitis. sensory. vomiting. retinitis. oral Kaposi's sarcoma (purple-brown macules). Note whether the patient looks “ill. Physical Examination General Appearance: Cachexia. Pelvic/Rectal: Candidiasis. motor. sputum gram stain. Kaposi's sarcoma (multiple purple nodules or plaques). HIV RNA titer. hepatosplenomegaly. or malnourished. . high resolution CT scan. chills. Heart: Murmurs (IV drug users). electrolytes. Differential Diagnosis: Pneumocystis carinii pneumonia. toxoplasmosis. prescribed and alternative medications. hepatitis surface antigen and antibody. Labs: Chest x-ray: Diffuse. diarrhea. ulcers. pulse (tachycar­ dia). substance use history (intravenous drugs). tuberculosis. Diabetes. CD4 count. bacterial pneumonia. perivascular white spots. HEENT: Herpetic lesions. herpes. Prior pneumococcal immunization. mycobacterium avium complex. History of pneumonia. Kaposi's sarcoma. skin lesions. hairy leukoplakia. zoster. increased Aa gradient. respiratory distress. odynophagia (painful swallowing). anal herpetic lesions. BP (hypotension). bronchitis. interstitial infiltrates. Lymph Node Examination: Enlarged nodes. Skin rashes. oral thrush. endocarditis. sickle cell disease. Past Infectious Disease History: History of herpes simplex. meningitis). syphilis. decreased breath sounds at bases.” well. cranial nerves. altered consciousness. Bronchoalveolar lavage. tuberculosis. Chest: Dullness. ABG: hypoxia. lethargy. seborrheic dermatitis. visual changes. Oral lesions. dysuria.) Neck rigidity. Vital Signs: Temperature (fever). otitis media. hemorrhages. visual field deficits (toxoplasmosis. cough. neck stiffness.32 Meningitis malaise. Medications: Antivirals. molluscum contagiosum. weight loss. crackles. Meningitis History of the Present Illness: Duration and degree of fever. ill contacts. Pneumocystis immunofluorescent stain. lymphadenopathy. splenectomy malignancy. CBC. condyloma. Neuro: Confusion. travel history. alcoholism. irritability (high pitched cry in children).

petechia. cranial nerve palsies. protein (1-2 mL). respiratory rate (tachypnea). electrolytes. Vital Signs: Temperature (fever). Heart: Murmurs. recent upper respiratory infections. labored respira­ tions. or malnourished. obtundation. CT Scan: Increased intracranial pressure should be excluded. Skin: Capillary refill. HEENT: Pupil reactivity. intravenous drug use. CSF Tube 2 . coccidioides. Janeway's lesions (Endocarditis). tuberculosis. nail bed splinter hemorrhages. Full fontanelle in infants. Listeria. antibiotic use. rashes.Gram stain. Labs CSF Tube 1 .Meningitis 33 immunosuppression. creatinine. AIDS: Cryptococcus neoformans. papilledema. sensory deficits. Note whether the patient looks “ill. bacterial antigen screen (12 mL). crackles. osteomyelitis.Cell count and differential (1-2 mL). Physical Examination General Appearance: Level of consciousness.Glucose. CBC. purpura (meningococcemia). streptococci. culture and sensitivity. Brudzinski's sign (neck flexion causes hip flexion). Babinski's sign. brain abscess. encephalitis. . extraocular movements. subarachnoid hemorrhage.Hemophilus influenza. Etiology of Bacterial Meningitis 15-50 years: Streptococcus pneumoniae. BP (hypotension). BUN. >50 years or debilitated: Same as above plus .” well. weakness. herpes encephalitis. Kernig's sign (flexing hip and extending knee elicits resistance). CSF Tube 3 . pulse (tachycardia). AIDS. Differential Diagnosis: Meningitis. Toxoplasma gondii. Chest: Rhonchi. Pseudomonas. Neisseria meningitis. tuberculosis. Neuro: Altered mental status. viral infection.

toxoplasmosis Clear opales­ cent Slightly elevated or normal 10-500 WBC with predominant lymphs Normal to low . par­ tially treated bacterial. syphilitic meningitis. fungal. ½-2/3 of blood glu­ cose level drawn at same time Bacterial meningitis or tuberculous meningitis Yellow opal­ escent Elevated 501500 25-10000 WBC with predominate polys low Tuberculous. low Viral meningitis. meningeal metastases Clear opales­ cent Elevated usually <500 10-500 WBC with predominant lymphs 20-40.Cerebral Spinal Fluid Analysis Disease Color Protein Cells Glucose Normal CSF Fluid Clear <50 mg/100 mL <5 lymphs/mm3 >40 mg/100 mL. encephalitis. partially treated bacterial men­ ingitis.

renal calculus. cervicitis. Physical Examination General Appearance: Signs of dehydration. Endocarditis History of the Present Illness: Fever. weight loss. urgency. suprapubic discomfort or pain. costovertebral angle tenderness. chills. BP. vulvovaginitis. night sweats. appendicitis. Recent antibiotic use. pulse. skin lesions. fatigue. malaise. urine C&S. prostate enlargement. Pathogens: E coli. intravenous drug use. Proteus. Recent dental or gastrointestinal procedure. wound infection. Klebsiella. Pseudomonas. pain in fingers or toes (emboli). Vital Signs: Temperature (fever). prosthetic valve. Chlamydia trachomatis. colonic disease. History of urinary infections. enterococcus. nausea. decubitus ulcers. Urine Gram stain. respiratory rate. pleuritic chest pain. Enterobacter. or malnourished. Staphylo­ coccus saprophyticus. Pelvic/Genitourinary: Urethral or vaginal discharge. chills. masses.Pyelonephritis and Urinary Tract Infection 35 Pyelonephritis and Urinary Tract Infection History of the Present Illness: Dysuria. CBC with differential. Note whether the patient looks “ill. Rectal: Prostatic hypertrophy or tenderness (prostatitis). malaise (pyelonephritis). SMA7. sexual intercourse. catheterization. group B streptococcus. recent intravenous catheterization. History of stroke. Urinary tract obstruction. urinary tract infection. pelvic inflammatory disease. Diaphragm use. herpes. Risk factors: Diaphragm or spermicide use. rheumatic heart disease. calculi. fever. Differential Diagnosis: Acute cystitis.” well. septic appearance. anatomic abnormality. papillary necrosis. Labs: UA with micro. pyelonephritis. renal stones or colicky pain. urinary tract instrumenta­ tion. gonococcal or chlamydia urethritis. elderly. . back pain. Abdomen: Suprapubic tenderness. frequency (voiding repeatedly of small amounts). history of heart murmur. heart failure. hematuria. cholecystitis. prostatic obstruction. cystocele. vomiting.

Abdomen: Liver tenderness (abscess).36 Endocarditis Physical Examination General Appearance: Septic appearance.” well. Enterobacter sp. enterococci. Note whether the patient looks “ill. spinal tenderness (vertebral abscess). valvular insufficiency. Roth's spots (retinal hemorrhages with pale center. Heart: New or worsening cardiac murmur. streptococcus bovis. streptococcus pneumonia. Extremities: Splinter hemorrhages under nails. Echocardiogram: Vegetations. HEENT: Oral mucosal and conjunctival petechiae. pseudomo­ nas. nontender lesions on palms and soles. septic emboli). urine culture. Native Valve Pathogens: Streptococcus viridans. Chest x-ray: Cardiomegaly. staphylococcus aureus. UA (hematuria).. pulse (tachycardia). blood cultures x 3. multiple focal infiltrates. emboli). Labs: WBC. Janeway lesions (erythematous. Neuro: Focal neurological deficits (septic emboli). BP (hypotension). valvular calcifications. Vitals: Temperature (fever). staphylococcus epidermidis. Prosthetic Valve Pathogens: Staphylococcus aureus. joint pain (septic arthritis). or malnourished. splenomegaly. group D streptococcus. Osler's nodes (erythematous or purple tender nodules on pads of toes or fingers). .

Associated Symptoms: Fever. inspiration. tarry stools). nausea. chills. dysuria. aspirin. weight loss. alcoholism. visible peristalsis (small bowel obstruction). flat neck veins (hypovolemia). flat. nutritional status. Past Treatment or Testing: Endoscopies. hernias. Rebound tenderness. vomiting (bilious. Effect of eating. constipation. blood. peptic ulcer. early satiety. ecchymosis. Scaphoid. back. Similar episodes in past. atherosclerotic retinopathy. laxatives. septic appearance. exact location at onset and at present. dull). trauma. hepatomegaly. Aggravating or Relieving Factors: Fatty food intolerance. melena (black. diarrhea. coffee grounds). coronary disease. Timing and characteristics of last bowel movement. Bimanual palpation of flank (renal disease or retrocecal appendix). aortic graft). anorexia. cirrhosis. gallstones. hematochezia (rectal bleeding). Virchow node (supraclavicular mass). pulse (tachycardia). body positioning to relieve pain. crampy. vomiting before or after onset of pain. pattern of progression. “silver wire” arteries (ischemic colitis). undigested food. radiation (to shoulder. . inguinal. relation to last menstrual period. constant or intermittent (“colicky”). Lymphadenopathy. Signs of dehydration. location and character at onset and at present (burning. splenomegaly. respiratory rate (tachypnea). Abdomen Inspection: Scars. antacids. Note whether the patient looks “ill. sudden or gradual onset. x-rays. kidney stones. change in bowel habits or stool caliber. BP (hypotension). chest pain. odynophagia (painful swallowing). Physical Examination General Appearance: Degree of distress. or malnourished.” well. upper GI series. flatus. scleral icterus.Abdominal Pain and the Acute Abdomen 37 Gastrointestinal Disorders Abdominal Pain and the Acute Abdomen History of the Present Illness: Duration of pain. sharp. dyspepsia. medications. cholecystectomy. Vitals: Temperature (fever). defecation. anticholinergics. position. History of abdominal surgery (appendectomy. hernias (incisional. feculent. jaundice. HEENT: Pale conjunctiva. dysphagia. obstipation (inability to pass gas). NSAID's. hematuria. Palpation: Begin palpation in quadrant diagonally opposite to point of maximal pain with patient's legs flexed and relaxed. narcotics. movement. vomiting. Auscultation: Absent bowel sounds (paralytic ileus or late obstruction). masses. diffuse or localized. urination. distension. high-pitched rushes (obstruction). groin). bruits (ischemic colitis).

sentinel loop. cholangitis. jaundice. peritoneal hemorrhage. periumbilical collateral veins (Caput medusae). dependent purpura (mesenteric infarction). Charcot's sign: Right upper quadrant pain. testicular atrophy. costovertebral angle tenderness. petechia (gonococcemia). McBurney's point tenderness: Located two thirds of the way between umbilicus and anterior superior iliac spine. infiltrates. diabetic ketoacidosis. cervical motion tenderness. nontender gallbladder with jaundice. Specific Signs on Palpation Murphy's sign: Inspiratory arrest with right upper quadrant palpation. masses. subdiaphragmatic free air. Obturator sign: Flexion of right thigh and external rotation of thigh causes pain in pelvic appendicitis. lipase. distended loops of bowel. Stigmata of Liver Disease: Spider angiomata. calcifications. Percussion: Loss of liver dullness (perforated viscus. Rectal Examination: Masses. fluid wave (ascites). adnexal tenderness. retrocecal appendicitis. appendicitis. Bulging flanks. amylase. Extremities: Femoral pulses. ascites. gallstones. Iliopsoas sign: Elevation of legs against examiner's hand causes pain. Cullen's sign: Bluish periumbilical discoloration. Pulsating masses. pregnancy test. hepatitis. Rovsing's sign: Manual pressure and release at left lower quadrant colon causes referred pain at McBurney's point. gynecomastia. X-rays of abdomen (acute abdomen series): Flank stripe. psychogenic pain. gastritis. Genital/Pelvic Examination: Cervical discharge. effusion (pancreatitis). obstruction. peritonitis. hepatosplenomegaly. Right Upper Quadrant: Cholecystitis. Courvoisier's sign: Palpable. retroperitoneal hemorrhage. uterine size. portal vein gas. gonococcal perihepatitis (Fitz-Hugh-Curtis syn- . Skin: Jaundice. Grey Turner's sign: Flank ecchymoses. Differential Diagnosis Generalized Pain: Intestinal infarction. impacted stool. mass effects. shifting dullness. fecaliths. appendicitis. Labs: CBC. pneumatobilia. free air in peritoneum). gross or occult blood.38 Acute Abdomen and Abdominal Pain femoral). UA. liver function tests. edema. thumb printing. hepatic metastases. tenderness. penetrating posterior duodenal ulcer. acute porphyria. sickle crisis. pancreati­ tis. electrolytes. fever. Chest x-ray: Free air under diaphragm. air fluid levels. popliteal pulses (absent pulses indicate ischemic colitis). ECG. cholecystitis. liver and spleen span by percussion. pancreatic malignancy.

peptic ulcer. pancreatitis. Ingestion of spoiled food . perforated viscus. myocardial infarction. mesenteric thrombosis. cardiac disease. ileus. ectopic pregnancy. progesterone. gastroenteritis. pulmonary embolus. peptic ulcer. dark urine. salpingitis. ectopic pregnancy. . ovarian cyst torsion. intussusception. projectile). anticholinergics. intestinal obstruction. prostatitis. Epigastrium: Gastritis. gastritis. contraception. aortic aneurysm. ectopic pregnancy. antiarrhythmics. endometritis. ergotamines. endoscopy. pancreatitis. odynophagia. peptic ulcer. bilious. nephrolithiasis. vertigo. gastroenteritis. retrocecal appendicitis. bladder distension. Drugs Associated with Nausea: Digoxin. psychogenic pain. oral contraceptives. endometriosis. diverticulitis. hematemesis. Past Testing: X-rays. recent change in medications. pneumonia. splenic infarction. exposure to Ill contacts. CNS disease. meperidine (Demerol). pneumonia. liver disease. sickle crisis. erythromycin. pyelonephritis. Left Upper Quadrant: Peptic ulcer. salpingitis. coffee ground material.Nausea and Vomiting 39 drome). inflammatory bowel disease. aortic aneurysm. early satiety. esophagitis. Hypogastric/Pelvic: Cystitis. strangulated hernia. food. endometriosis. Clay colored stools. antibiotics. Diabetes. renal calculus. strangulated hernia. mesenteric lymphadenitis. abdominal pain. dysphagia. Possibility of pregnancy (last menstrual period. endometriosis. intussusception. gastroesophageal reflux. colitis. feculent. headache. gastroesophageal reflux disease. morphine. volvulus. Left Lower Quadrant: Diverticulitis. jaundice (biliary obstruction). effect of vomiting on pain. hemorrhage or rupture of ovarian cyst. myocardial ischemia. Nausea and Vomiting History of the Present Illness: Character of emesis (color. ovarian cyst. diverticulitis (redundant sigmoid) salpingitis. theophylline. colchicine. sexual history). nephrolithiasis. Right Lower Quadrant: Appendicitis. fever. chemother­ apy. esophagitis. melena. appendicitis. tinnitus (labyrinthitis). testicular torsion. antidepressants. intestinal obstruction. upper GI series. malignancy.

Labs: CBC. Differential Diagnosis: Gastroenteritis. renal disease. distention. psychiatric disease. drug abuse (cocaine. occult blood. pancreatitis. abdominal pain. gastroesophageal reflux. UA. amphetamines). or malnourished. cough. pregnancy test. Vital Signs: BP (orthostatic hypotension). papilledema. gastric) increased intracranial pressure. Signs of dehydration. systemic infections. Dietary restrictions (low salt. low fat). or malnourished. sleep abnormalities. temperature (hypother­ mia). Polyuria. pulse (tachycardia). loss of interest in usual activities.” well. bowel sounds. change in appetite. chemotherapy. four views of the abdomen series. hepatitis. chills. AIDS risks factors. respiratory rate. polydipsia. respiratory rate. BP. Anorexia and Weight Loss History of the Present Illness: Time of onset. Physical Examination General Appearance: Muscle wasting. pregnancy. spider angiomas. fever. gastroparesis. change in bowel habits. septic appearance. tenderness. amount and rate of weight loss (sudden. rigidity. night sweats.40 Anorexia and Weight Loss Physical Examination General Appearance: Signs of dehydration. diabetic ketoacidosis. ketone odor on breath (apple odor. Note whether the patient looks “ill. electrolytes. Abdomen: Scars. decreased libido. antibiotics). Rectal: Masses. jaundice. labyrinthitis. jugular venous distention or flat neck veins. Vital Signs: Pulse (bradycardia). . peptic ulcer. dysuria. skin or hair changes. LFTs. bulimia. Extremities: Edema. antiarrhythmics. ascites. vomiting. dyspepsia. Skin: Pallor. Note whether the patient looks “ill. diarrhea. HEENT: Nystagmus. 24-hour diet recall. rebound. diminished taste. jaundice. intestinal obstruction. cholecystitis. malignancy. cachexia. toxins. lipase. myocardial ischemia. renal failure. nausea. amylase. chronic medical illness. exacerbation of pain with eating (intestinal angina). ileus. diabetic ketoacidosis). dysphagia. gradual). temperature (fever). medications (contraceptives. tumors (esophageal. bruits. appendicitis. dental problems. restricted access to food. psychogenic vomiting.” well. hepatomegaly. alcoholism. Signs of depression: Weight change. change in appetite.

transferrin. coronary artery disease. tenesmus (painful urge to defecate). bloating. hepatomegaly splenomegaly. Diarrhea History of the Present Illness: Rate of onset. Abdomen: Scars. milk. alcohol abuse. AIDS risk factors. diminished olfaction. Cramping. protein. temporal wasting. fever. cholinergic agents. duration. narcotics.Diarrhea 41 Skin: Pallor. Chest: Rhonchi. depression. Differential Diagnosis: Inadequate caloric intake. peptic ulcer. arthralgias. poor proprioception. masses. electrolytes. glossitis (Pellagra). foul odor. abdominal cramps. toxicology screen. shellfish. skin laxity. flatulence. cholelithiasis. Recent ingestion of spoiled poultry (salmonella). palpable masses. Heart: Murmurs. hyper/hypothyroidism. clindamycin). HEENT: Dental erosions from vomiting. oropharyngeal lesions. magnesiumcontaining antacids. immunosuppressive agents. antibiotics (erythromycin. Stool Appearance: Buoyancy. colchicine. lymphadenopathy. . hair changes. barrel shaped chest. oily. LFTs. diminished taste. Exacerbation by stress. travel history. gum (sorbitol). blood or mucus. vomiting. glossitis. Neuropathy: Decreased sensation. inflammatory bowel disease. milk (lactase deficiency). Labs: CBC. Volume of stool output (number of stools per day). peripheral vascular disease (ischemic colitis). common sources (restaurant). Ill contacts with diarrhea. nausea. family history of coeliac disease. timing of the diarrheal episodes. systemic infection. decreased bowel sounds. supraclavicular adenopathy (Virchow's node). AIDS. thyroid studies. cardiopulmonary disease. laxative abuse. muscle wasting. hepatic or renal failure. dementia. thyromegaly. lightheadedness. Drugs and Substances Associated with Diarrhea: Laxatives. displaced PMI. gastritis. myalgias. tenderness. Vibrio parahaemolyticus). weight loss. poor dental hygiene (loose dentures). jaundice. dermatitis. mesenteric ischemia. Periumbilical adenopathy. skin abrasions on fingers. Sexual exposures. Rectal: Occult blood. frequency. pre-albumin. anorexia nervosa. seafood (shrimp. anorexia. sulfa drugs. Extremities: Edema. bloating. hyperthyroidism. albumin. cheilosis. malignancy (gastric carcinoma). watery stools.

lactase deficiency (gastroenteritis. occult blood. Neuro: Mental status changes. riboflavin deficiency). diverticulitis. carcinoid tumors. Abdominal X-ray: Air fluid levels. rebound. Secretory Diarrhea: Bacterial enterotoxins. dilation. or malnourished. Peripheral neuropathy (B6. vasoactive intestinal peptide tumor. Bacillus cereus). Labs: Electrolytes. medullary thyroid carcinoma. Zollinger-Ellison syndrome. Extremities: Arthritis. Campylobacter. Vital Signs: BP (orthostatic hypotension). Exudative Diarrhea: Bacterial infection. ova and parasites x 3. constipation-related diarrhea. temperature (fever). masses. CBC with differential. Diarrhea Secondary to Altered Intestinal Motility: Diabetic gastroparesis. Differential Diagnosis Acute Infectious Diarrhea: Infectious diarrhea (salmonella. folate deficiency). Septic appearance.42 Diarrhea Physical Examination General Appearance: Signs of dehydration or malnutrition.” bacterial overgrowth. tenderness. Wright's stain for fecal leucocytes. decreased perianal sensation. Rectal: Perianal or rectal ulcers. lactulose. B12 deficiency). antibiotic-related diarrhea Chronic Diarrhea: Osmotic Diarrhea: Laxatives. glossitis (B12. “dumping syndrome. tenderness. ulcerative colitis. laxatives. HEENT: Oral ulcers (inflammatory bowel or coeliac disease).” well. distention. cheilosis (cracked lips. hepatomegaly guarding. dry mucous membranes. parasites. sorbitol. Oropharyngeal candidiasis (AIDS). Absent peripheral pulses or bruits (ischemic colitis). albumen. enteric viruses (rotavirus. respiratory rate. bruits (ischemic colitis). calcium. irritable bowel syndrome. viral infection. E coli. cultures for enteric pathogens. pulse (tachycardia). delayed capillary refill. pancreatic calcifications. cholinergics. enteral feeding. sprue). traveler's diarrhea. rigidity (peritoneal signs). AIDS associated disorders (mycobacterial. . clostridium difficile toxin. shigella. HIV). Abdomen: Hyperactive bowel sounds. Skin: Skin turgor. Norwalk virus). Note whether the patient looks “ill. flexible sigmoidoscopy. colonic villus adenoma. intestinal ischemia. jaundice. hyperthyroidism. joint swelling (ulcerative colitis). diverticulitis. Clostridium difficile. ingestion of mannitol. other disaccharidase deficiencies. Crohn's disease. sphincter tone. Sphincter reflex.

poor memory. fatigue. Family history of liver disease or bleeding disorders. transfusions given previously. diaphoresis. melena. masses.” well. glucose. HEENT: Scleral pallor. Past Testing: X-ray studies. tenderness. nuclear scan. Past Treatment: Endoscopic sclerotherapy. confusion. syncope. Vital Signs: Supine and upright pulse and blood pressure (orthostatic hypotension). coffee ground material). flat neck veins. pallor. malaise. angiography. ECG. Abdominal pain. nausea. Hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome). Chest: Gynecomastia (cirrhosis). INR/PTT. Endoscopy. oral telangiectasia. splenomegaly. Ascites. jaundice. hematocrit. steroids. BUN (elevation suggests upper GI bleed). esophageal varices. Extremities: Dupuytren's contracture (palmar contractures. Labs: CBC. history of peptic ulcer. petechiae. Weight loss. Nasogastric aspirate quantity and character. cirrhosis). Genitourinary/Rectal: Gross or occult blood. nonsteroidal anti-inflammatory drugs. Neuro: Decreased mental status. hepatic encephalopathy. esophagitis. temperature. postural hypotension indicates a 20-30% blood loss). aortic surgery. purple brown nodules (Kaposi's sarcoma). asterixis (flapping with wrists when hyperextended. shunt surgery. Forceful retching prior to hematemesis (Mallory-Weiss tear). masses. History of liver or renal disease. early satiety. anorexia. hepatic atrophy (cirrhosis). dilated abdominal veins. lightheadedness. umbilical venous collaterals (caput medusae). aspirin. anticoagulants. Heart: Systolic ejection murmur. Stigmata of liver disease [jaundice. prior bleeding episodes. esophageal varices. hematochezia (bright red blood per rectum). Differential Diagnosis of Upper GI Bleeding: Gastric or duodenal ulcer. Signs of dehydration. hepatic encephalopathy).Hematemesis and Upper Gastrointestinal Bleeding 43 Hematemesis and Upper Gastrointestinal Bleed­ ing History of the Present Illness: Duration and frequency of hematemesis (bright red blood. confusion. rebound. parotid gland hypertrophy]. nose bleeds. platelets. edema. cold extremities. volume of blood. Abdomen: Scars. liver nodules. testicular atrophy. or malnourished. Mallory Weiss tear (gastroesophageal junction tear due . Ingestion of alcohol. oliguria (<20 mL of urine per hour). (resting tachycardia indicates a 10% blood volume loss. breast masses (metastatic disease). abnormal pigmentation (Peutz-Jeghers syndrome). Skin: Delayed capillary refill. endoscopy. spider angiomas. electrolytes. Physical Examination General Appearance: Pallor. Note whether the patient looks “ill.

fever. malaise. splenomegaly. Physical Examination General Appearance: Signs of dehydration. Past Testing: Barium enema. Genitourinary: Testicular atrophy. coronary or renal disease. fissures. color of bleeding (gross blood. asterixis (flapping hand tremor. easy bruising. hematemesis. ulcers. anorectal pain. cirrhosis. vascular ectasias. Constipation. clammy skin. hemorrhoids. NSAIDS. Heart: Systolic ejection murmurs. liver function tests. Note whether the patient looks ill. hypertrophic gastropathy (Menetrier's disease). liver atrophy (cirrhosis). weight loss. bleeding polyps. masses. oliguria. streaks on stool. infectious or ischemic colitis. spider angiomata. buccal mucosa discolorations or pigmentation (Henoch-Schönlein purpura or Peutz-Jeghers polyposis syndrome). tenesmus (straining during defecation). jaundice. Change in bowel habits or stool caliber. parotid gland hypertrophy. lightheadedness. colitis. vomiting. Skin: Cold. . Anticoagulants. Rectal: Gross or occult blood. jaundice. Rashes. well. confusion. upper GI series. Abdominal x-ray series (thumbprinting. Differential Diagnosis of Lower Gastrointestinal Bleeding: Hemorrhoids. upper GI bleeding. pulsatile masses (aortic aneurysm). carcinoma. aspirin. HEENT: Atherosclerotic retinal disease. diverticulosis. pallor. bruits. Epistaxis. bleeding disease. alcoholism. delayed capillary refill. recent hematocrit. pallor. gynecomastia. Melena and Lower Gastrointestinal Bleeding History of the Present Illness: Duration. aorto-enteric fistula. hepatic encephalopathy). rebound. history of diverticulosis. coagulopathy. quantity. hemorrhoids.44 Melena and Lower Gastrointestinal Bleeding to vomiting or retching). Stigmata of liver disease: Umbilical venous collaterals (Caput medusae). anorexia. gastritis. pulse (orthostatic hypotension). Vital Signs: BP. Extremities: Cold. atrial fibrillation (mesenteric emboli). Abdomen: Scars. rectal trauma. swallowed blood (nose bleed. duodenitis. Fecal mucus. respiratory rate. tenderness. fissures. hernias. melena). sigmoidoscopy. esophagitis. purpura. colonoscopy. Neuro: Decreased mental status. Ascites. abdominal pain. diarrhea. oral lesion). air fluid levels). gastric cancer. “silver wire” arteries (ischemic colitis). masses. peptic ulcer. or malnourished. Labs: CBC (anemia). temperature (tachycardia). inflammatory bowel disease. distention. pale extremities. Color of nasogastric aspirate. polyps.

pyelonephritis. early satiety. Signs of dehydration. endometriosis. sausage-like mass in RUQ (enlarged gallbladder). vomiting.Cholecystitis 45 angiodysplasias. nausea. hyperalimentation.” well. pregnancy. lasting several hours). Differential Diagnosis: Calculus cholecystitis. Skin: Jaundice HEENT: Scleral icterus. angina. AST. epistaxis. alcohol. rebound (peritoneal signs). hereditary spherocytosis. peptic ulcer. Charcot's sign (intermittent right upper quadrant abdominal pain. Causes of Cholesterol Stones: Hereditary. pneumonia. Causes of Pigment Stones: Asians with biliary parasites. nephrolithiasis. hereditary spherocytosis. small bowel obstruction (gallstone ileus). gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome). pancreatitis. rapid weight loss. sickle cell anemia. obesity. bloating. alkaline phosphatase. Note whether the patient looks “ill. diabetes. . or malnourished. 30-90 minutes after meals. sickle cell anemia. firm tender. low grade fever. flatulence. rapid weight loss. jaundice. respiratory rate (shallow respirations). cholangitis. Prior Testing: Ultrasounds. biliary stasis. Physical Examination General Appearance: Obese. jaundice. guarding. rigidity. Murphy's sign (tenderness and inspiratory arrest during palpation of RUQ). Previous epigastric pain. restless patient unable to find a comfortable position. Plain Abdominal X-ray: Increased gallbladder shadow. coagulopathies. gallstones. gastroesophageal reflux disease. hepatitis. fatty food intolerance. Vital Signs: Pulse (mild tachycardia). HIDA (radionuclide) scan. appendicitis. gallbladder calcifications. clay colored stools. WBC. scapula or back. intussusception. HIDA scans. estrogen. aortoenteric fistula. anorexia. endoscopies. air in gallbladder wall (emphysematous cholecystitis). Meckel's diverticulitis. exogenous steroids. cirrhosis. Abdomen: Epigastric or right upper quadrant tenderness. Cholecystitis History of the Present Illness: Duration of biliary colic (constant right upper quadrant pain. dark urine. septic appearance. hyperalimentation. temperature (low-grade fever). pleurisy. Crohn's disease. herpes zoster. hyperbilirubinemia. Radiation to epigastrium. diabetes. pregnancy. amylase. sublingual jaundice. Labs: Ultrasound. terminal ileal resection. hepatic metastases. fever). BP. History of fasting.

Hepatotoxins: Acetaminophen. alpha-1-antitrypsin deficiency. bowel sounds. liver biopsy. hepatomegaly. hepatitis B surface antigen. antimitochondrial antibody (primary biliary cirrhosis). .” well. Weight loss. somnolence (hepatic encephalopathy). vomiting. sclerotic veins (from intravenous injections). BP. ANA. sepsis. Umbilical venous collaterals (Caput medusae). phenytoin. methotrexate. Family history of jaundice/liver disease. Murphy's sign (cessation of inspiration with palpation of the right upper quadrant). serum iron. asterixis (flapping tremor when wrists are hyperextended. sulfonamides. blood transfusion. septic appearance. NSAIDS. ascites. hepatitis A IgM. arthralgias. dark urine. alcoholism. urticarial rash. ceruloplasmin. Wilson's disease). confusion. bronze discoloration (hemochromatosis). isoniazid. pancreatic or biliary malignancy). hematochezia. hepatitis C antibody). increased abdominal girth (ascites). right upper quadrant tenderness. day care centers. IV drug abuse. Heart failure. liver span. jaundice. respiratory rate. urine copper (Wilson's disease). Courvoisier's sign (palpable nontender gallbladder with jaundice. urticaria. Neuro: Disorientation. TIBC. firm). needle tracks. HEENT: Scleral icterus. hepatitis serologies (hepatitis B surface antibody. nausea. ferritin (hemochromatosis). Genitourinary: Testicular atrophy. or malnourished. drug screen. irregular. Physical Examination General Appearance: Signs of dehydration. Extremities: Joint tenderness. Rectal: Occult blood. encephalopathy). KayserFleischer rings (bronze corneal pigmentation. Skin: Jaundice. prior hepatitis immunization. exposure to hepatitis or jaundiced persons. spider angiomas. sublingual jaundice. nitrofurantoin.46 Jaundice and Hepatitis Jaundice and Hepatitis History of the Present Illness: Dull right upper quadrant pain. LFTs. Abdomen: Scars. amylase. Chest: Gynecomastia. Prior Testing: Hepatitis serologies. melena. liver function tests. splenomegaly (hepatitis) or hepatic atrophy (cirrhosis). hemorrhoids. hematemesis. liver biopsy. liver margin texture (blunt. anorexia. residential institutions. fever. lipase. Vital Signs: Pulse. Dupuytren's contracture (fibrotic palmar ridge). pruritus. palmar erythema. temperature (fever). lymphadenopathy. Labs: CBC with differential. foreign travel history. Note whether the patient looks “ill.

Cirrhosis 47
Differential Diagnosis of Jaundice
Extrahepatic: Biliary tract disease (gallstone, stricture, cancer), infections
(parasites, HIV, CMV, microsporidia); pancreatitis, pancreatic cancer.
Intrahepatic: Viral hepatitis, medication-related, acute fatty liver of pregnancy,
alcoholic hepatitis, cirrhosis, primary biliary cirrhosis, autoimmune hepatitis,
Wilson's disease, right heart failure, total parenteral nutrition; Dubin Johnson
syndrome, Rotor’s syndrome (direct hyperbilirubinemia); Gilbert's syndrome,
Crigler-Niger syndrome (indirect); sclerosing cholangitis, sarcoidosis,
amyloidosis, tumor.

Cirrhosis
History of the Present Illness: Jaundice, anorexia, nausea, fever; abdominal
distension, abdominal pain, increased abdominal girth (ascites); vomiting,
diarrhea, fatigue. Somnolence, confusion (encephalopathy); alcohol use. Viral
hepatitis, blood transfusion, IV drug use.
Precipitating Factors of Encephalopathy: Gastrointestinal bleeding, high
protein intake, constipation, azotemia, CNS depressants.
Physical Examination
General Appearance: Muscle wasting, fetor hepaticas (malodorous breath).
Signs of dehydration. Note whether the patient looks “ill,” well, or malnour­
ished.
Vital Signs: Pulse, BP, temperature, respiratory rate.
Skin: Jaundice, spider angiomas (stellate, erythematous arterioles), palmar
erythema; bronze skin discoloration (hemochromatosis), purpura, loss of body
hair.
HEENT: Kayser-Fleischer rings (bronze corneal pigmentation, Wilson's
disease), jugular venous distention (fluid overload). Parotid enlargement,
sclera icterus, gingival hemorrhage (thrombocytopenia).
Chest: Bibasilar crackles, gynecomastia.
Abdomen: Bulging flanks, tenderness, rebound (peritonitis); fluid wave, shifting
dullness, “puddle sign” (examiner flicks over lower abdomen while
auscultating for dullness). Courvoisier's sign (palpable nontender gallbladder
with jaundice; pancreatic malignancy); atrophic liver; liver margin texture
(blunt, irregular, firm), splenomegaly. Umbilical or groin hernias (ascites).
Genitourinary: Scrotal edema, testicular atrophy.
Extremities: Lower extremity edema.
Neuro: Confusion, asterixis (jerking movement of hand with wrist
hyperextended; hepatic encephalopathy).
Rectal: Occult blood, hemorrhoids.
Stigmata of Liver Disease: Spider angiomas (stellate red arterioles), jaundice,

48 Cirrhosis
bronze discoloration (hemochromatosis), dilated periumbilical collateral veins
(Caput medusae), ecchymoses, umbilical eversion, venous hum and thrill at
umbilicus (Cruveilhier-Baumgarten syndrome); palmar erythema, Dupuytren's
contracture (fibrotic palmar ridge to ring finger). Lacrimal and parotid gland
enlargement, testicular atrophy, gynecomastia, ascites, encephalopathy,
edema.
Labs: CBC, electrolytes, LFTs, albumin, INR/PTT, liver function tests, bilirubin,
UA. Hepatitis serologies, antimitochondrial, antibody (primary, biliary
cirrhosis), ANA, anti-Smith antibody, ceruloplasmin, urine copper (Wilson's
disease), alpha-1-antitrypsin, serum iron, TIBC, ferritin (hemochromatosis).
Abdominal x-ray: Hepatic angle sign (loss of lower margin of right lateral liver
angle), separation or centralization of bowel loops, generalized abdominal
haziness (ascites). Ultrasound, paracentesis.
Differential Diagnosis of Cirrhosis: Alcoholic liver disease, viral hepatitis (B,
C, D), hemochromatosis, primary biliary cirrhosis, autoimmune hepatitis,
inborn error of metabolism (Crigler Najjar syndrome; Wilson's disease, alpha1-antitrypsin deficiency), heart failure, venous outflow obstruction (BuddChiari, portal vein thrombus).

Evaluation of Ascites Fluid
Etiology

Appearance

Protein

Serum/fluid
albumen
ratio

RBC

WBC

Other

Cirrhosis

Straw

<3 g/dL

>1.1

low

<250
cells/mm3

Spontane­
ous
Bacterial
Peritoni­
tis

Cloudy

<3

>1.1

low

>250 polys

Bacteria on gram stain and cul­
ture

Secondary
Bacterial
Peritoni­
tis

Purulent

>3

<1.1

low

>10000

Bacteria on gram stain and cul­
ture

Neoplasm

Straw/bloody

>3

varies

high

>1000 lymphs

Malignant cells on cytology; tri­
glycerides

Tuberculo­
sis

Clear

>3

<1.1

low-high

>1000 lymphs

Acid fast bacilli

Heart Fail­
ure

Straw

>3

>1.1

low

<1000

Pancreatitis

Turbid

>3

<1.1

varies

varies

Elevated amylase, lipase

Precipitating Factors: Alcohol. . vomiting. rebound. palpable purpura (polyarteritis nodosum). glucose. jaundice. diffuse ground-glass appearance (ascites). elevated amylase. left lower lobe dullness (pleural effusion). Note whether the patient looks “ill. boring. Labs: Amylase. scorpion stings. Medications Associated with Pancreatitis: Sulfonamides. LDL. Chvostek's sign (taping cheek results in facial spasm. Grey-Turner's sign (bluish flank discoloration. calcium. During initial 48 hours: Hematocrit decrease >10%. respirations (tachypnea). subcutaneous fat necrosis (erythematous skin nodules on legs and ankles). Chest x-ray: Left plural effusion. tumor. trauma. tetracycline. abscess. triglycerides. relieved by sitting with knees drawn up. pulse (tachycardia). calcium <8. pancreatic calcifications. rigors. Vital Signs: Temperature (low-grade fever). peptic ulcer. hypertriglyceridemia. LDH >350 IU/L. nausea. AST >250. estimated fluid sequestration >6 L. AST. Differential Diagnosis of Midepigastric Pain: Pancreatitis. retroperitoneal hemorrhage). anasarca. pancreatic edema or enlargement. estrogens. pentamidine. mid-epigastric or left upper quadrant pain. furosemide. gallstones. anorexia. retrograde cholangiopancreatography. Lupus. trauma.50 Pancreatitis Pancreatitis History of the Present Illness: Constant. hypocalcemia). Coxsackie virus or mumps infection. distension. exacerbated by supine position. guarding. Chest: Crackles. Septic appear­ ance. arterial pO2 <60 mmHg. BP (hypotension). WBC. mycoplasma infection. Colon cutoff sign (spasm of splenic flexure with no distal colonic gas). Early criteria: Age >55. displaced or atonic stomach. Abdomen X-Rays: Ileus. postoperative. low-grade fever. obscure psoas margins. pseudocyst. valproate. WBC >16. Physical Examination General Appearance: Signs of volume depletion. HEENT: Scleral icterus. renal failure. Skin: Jaundice. glucose >200. base deficit >4 mEq/L.” well. radiation to the mid-back. Extremities: Peripheral edema. Cullen's sign (periumbilical bluish discoloration from hemoperitoneum). tachypnea. Ranson's Criteria of Pancreatitis Severity. dyspnea. BUN increase >5. or malnourished. thiazides. dideoxyinosine (DDI). penetration of peptic ulcer. azathioprine. Abdomen: Epigastric tenderness. dull. Ultrasound: Gallstones. rigidity.000. upper abdominal mass. vasculitis. CT scan with oral contrast: Pancreatic phlegmon. lipase. hypoactive bowel sounds. hypercalcemia. UA.

burning. nonsteroidal anti-inflammatory drugs. temperature. rigidity. Differential Diagnosis: Pancreatitis. gastroenteritis. guarding (perforated ulcer). BP (orthostatic hypotension). dull. Skin: Pallor. salicylates. weight loss. familial pancreatitis. awakens patient at night or in early morning. vasculitis. myocardial ischemia. delayed capillary refill. rebound. Signs of dehydration. May radiate to back. relieved by or worsen by food.” well. medications. hyperlipidemia. history of previous ulcer disease and Helicobacter pylori (HP) therapy. vomiting. lipase. methyl alcohol. hypercalcemia. septic appearance. respiratory rate. Rectal: Occult blood. amylase. pancreatic malignancy. gallstone pancreatitis. History of previous examinations: Endoscopy upper GI series. gastroesophageal reflux disease. Abdominal x-ray series. Vital Signs: Pulse (tachycardia). mesenteric adenitis. scorpion stings. pancreatic divisum. nausea. renal colic. Physical Examination General Appearance: Mild distress. perforating ulcer. pneumonia. 1-3 hours after meals.Gastritis and Peptic Ulcer Disease 51 cholecystitis. bowel obstruction. non-ulcer dyspepsia. penetrating peptic ulcer. mesenteric thrombosis. surgery. relieved by antacids. viral infections. endoscopy. or malnourished. melena. BUN. Labs: CBC. Note whether the patient looks “ill. aortic dissection. Factors Associated with Pancreatitis: Alcoholic pancreatitis. coffee ground hematemesis. . Abdomen: Mild to moderate epigastric tenderness. aortic aneurysm. gastritis. intestinal obstruction. mesenteric ischemia. endoscopic retrograde cholangiopancreatography. epigastric pain. worse when supine or reclining. Alcohol. trauma. bowel sounds. Gastritis and Peptic Ulcer Disease History of the Present Illness: Recurrent. electrolytes. hepatitis.

nausea. poorly localized. or malnourished. periumbilical pain. pulse (tachycardia). pulsatile masses (aortic aneurysm). Abdomen: Initially hyperactive. Vitals: Pulse. portal vein gas. carcinoma. myocardial infarction. Peripheral vascular disease. frequent episodes of bloody diarrhea.52 Mesenteric Ischemia and Infarction Mesenteric Ischemia and Infarction History of the Present Illness: Sudden onset of severe. electrolytes. gastroenteritis. Labs: CBC. bowel obstruc­ tion. chest pain. angiogram. heart failure. Signs of dehydra­ tion. rigidity (peritoneal signs). well. . Hemoconcentration. respiratory rate. femoral bruits. temperature. asymmetric pulses (atherosclerotic disease). distention. mild to moderate distress. peptic ulcer. atrial fibrillation. guarding. metabolic acidosis. clammy skin. angina. abdominal bruit. carotid bruits (mesenteric ischemia). food aversion. Rectal: Occult or gross blood. perforated viscus. peritoneal signs rebound. Bowel wall gas (colonic ischemia. Pain is usually out of proportion to the physical findings may be the only presenting symptom. Note whether the patient looks “cachectic. BP (orthostatic hypotension). hypertension. Skin: Cold. Abdominal x-ray: “thumb-printing” (edema of intestinal wall). claudication. pancreatitis. pain is postprandial and may be relieved by nitroglycerine. HEENT: Atherosclerotic retinopathy. delayed capillary refill. Chest x-ray: Free air under diaphragm (perforated viscus). diabetes. vomiting. then absent bowel sounds. Extremities: Weak peripheral pulses. prerenal azotemia. hyperamylasemia. Physical Examination General Appearance: Lethargy.. tenderness. “silver wire” arteries. acute appendicitis. leukocytosis. weight loss. ruptured aortic aneurysm. Peritonitis. acute cholecystitis. nonocclusive). hypercholesterolemia. Differential Diagnosis. septic appearance. pallor.” ill.

sickle crisis. colon cancer. Tenderness. bloody). Inflammatory bowel disease with stricture. air-fluid levels. Ischemia. hyperamylasemia. nausea. Ogilvie's syndrome (chronic pseudoobstruction). Causes of Small Bowel Obstruction: Adhesions (previous surgery). strictures from inflammatory processes. Abdomen: Hernias (incisional. pancreatitis. or malnourished. Initially crampy or colicky pain with exacerbations every 5-10 minutes. temperature (fever). Rectal: Gross blood. cancer. peritonitis. ladder pattern of dilated loops of bowel in the mid-abdomen. gallstone ileus. rebound. Bowel Sounds: High pitch rushes and tinkles coinciding with cramping (early) or absent bowel sounds (late). hernias. history of constipation. distention. obstipation. anticholinergics. renal colic.” well. respiratory rate. recent weight loss. pallor. narcotic ileus. masses. metastatic cancer. femoral. crampy abdominal pain. septic appear­ ance. Colonic distention with haustral markings. . electrolytes. gastroenteritis. use of opiates. antipsychotics. mesenteric ischemia. diverticulitis. tender mass. peptic ulcer.Intestinal Obstruction 53 Intestinal Obstruction History of the Present Illness: Vomiting (bilious. Physical Examination General Appearance: Severe distress. previous abdominal surgery. recent weight loss. hypokalemic metabolic alkalosis due to vomiting. Vital Signs: BP (hypotension). Hernias. superior mesenteric artery syndrome. Pain localizes to periumbilical region in small bowel obstruction and localizes to lower abdomen in large bowel obstruction. Abdominal x-rays: Dilated loops of small or large bowel. volvulus. Pain becomes diffuse with fever. rigidity. inguinal. gastritis. Differential Diagnosis: Myocardial infarction. Skin: Cold. Causes of Large Bowel Obstruction: Colon cancer. feculent. elevated BUN and creatinine. distention. cholecystitis. clammy skin. scars (intraabdominal adhesions). adynamic ileus. gallstones. bruits. Note whether the patient looks “ill. signs of dehydration. small bowel tumors. pulse (tachycardia). umbilical). Labs: Leucocytosis.

temporal balding. thyroid symptoms. Previous radiation therapy.54 Amenorrhea Gynecologic Disorders Amenorrhea History of the Present Illness: Primary amenorrhea (absence of menses by age 16) or secondary amenorrhea (cessation of menses in a female with previously normal menstruation). Progesterone-estrogen challenge testing. vaginal atrophy. Chest: Galactorrhea. hirsutism. or malnourished. Note whether the patient looks “ill. bradycardia. Menstrual pattern. clitoromegaly. possibility of pregnancy. Prior pregnancies. visual field defects. signs of hyperthyroidism (tremor) or hypothyroidism (non-pitting edema. prolactin. free T4. Hot flushes and night sweats (hypoestrogenism). postpartum infection (Asherman’s syndrome) or hemorrhage (Sheehan's syndrome). Physical Examination General Appearance: Secondary sexual characteristics. medications (contraceptives) or drugs (marijuana). weight gain or loss. vaginal septum. brittle hair). History of dilation and curettage. pregnancy testing. cool dry skin. last menstrual period. HEENT: Acne. Neuro: Focal motor deficits. ovarian cysts or tumors. breast tenderness). dieting and excessive exercise. deepening of the voice (hyperandrogenism). TSH. breast atrophy. antidepressants. sexual activity. Gyn: Pubic hair distribution. chemotherapy. Abdomen: Abdominal striae (Cushing’s syndrome). thyroid enlargement or nodules. hypothermia. headaches. breast development. symptoms of pregnancy (nausea. Age of menarche. obesity. phenothiazines. body habitus. uterine enlargement. . Labs: Pregnancy test. medications or drugs. imperfo­ rate hymen. timing of breast and pubic hair development. Inguinal or labial masses. obesity. psychologic stress.” well. galactorrhea (prolactinoma). visual disturbances. Life style changes. Assess diet.

tachycardia. passing of clots. weight changes.” well. endocrine disorders. obesity. abdominal pain. orthostatic vitals.Abnormal Uterine Bleeding 55 Differential Diagnosis of Amenorrhea Pregnancy Hormonal contraception Hypothalamic-related Chronic or systemic illness Stress Athletics Eating disorder Obesity Drugs Tumor Pituitary-related Hypopituitarism Tumor Infiltration Infarction Ovarian-related Dysgenesis Agenesis Ovarian failure Outflow tract-related Imperforate hymen Transverse vaginal septum Agenesis of the vagina. Obstetrical history. sexual activity. thyroid enlargement. uterus Uterine synechiae Androgen excess Polycystic ovarian syndrome Adrenal tumor Adrenal hyperplasia (classic and nonclassic) Ovarian tumor Other endocrine causes Thyroid disease Cushing syndrome Abnormal Uterine Bleeding History of the Present Illness: Last menstrual period. Pallor. endometriosis. bloating. fine thinning hair (hypothyroidism). cervix. fibroids. birth control method. signs of shock. dysmenorrhea). number of pads per day. possibility of pregnancy. Physical Examination General Appearance: Assess rate of bleeding. hormonal contraception. lightheadedness. fever. or malnourished. renal. Family history of coagulopathies. postcoital or intermenstrual bleeding. or hepatic diseases. galactorrhea. Note whether the patient looks “ill. age of menarche. Vital Signs: Assess hemodynamic stability. exercise. Adenomyosis. coagulopathies. regularity. hypotension. endometrial biopsies. amount of bleeding. Thyroid. . hirsutism. petechiae. skin and hair changes. Psychologic stress. Changes in hair or skin texture or distribution Molimina symptoms (premenstrual breast tenderness. Dental bleeding. duration and frequency of menses.

Thyroid disease. age of menarche. Risk Factors for Ectopic Pregnancy: Prior pelvic infection. cervical lesions. pelvic or abdominal pain (bilateral or unilateral). uterine size. infertility. Trauma. uterine carcinoma.56 Pelvic Pain and Ectopic Pregnancy Gyn: Cervical motion tenderness. pelvic tumor. prior ectopic pregnancy. diethylstilbestrol exposure in utero. bleeding time. onset. gynecologic history. Urinary or gastrointestinal symptoms. abnormalities of platelet function. Associated Symptoms: Fever. adrenal disease Hematologic-related. intrauterine device (IUD). Menstrual interval. fever. palliative or aggravating factors. cervicitis Pelvic Pain and Ectopic Pregnancy History of the Present Illness: Positive pregnancy test. serum pregnancy test. Chronic or systemic illness. platelets. gonococcal culture. vaginal tumor. endometriosis. adrenal hyperplasia (classic and nonclassic) Other endocrine causes. Polycystic ovarian syndrome. Prolactinoma Outflow tract-related. Cervical lesions should be biopsied. type and screen. obstetrical history. adnexal tenderness. anticoagulant medications Infectious causes. drugs Pituitary-related. INR/PTT. Chlamydia. Rupture of ectopic pregnancy usually occurs 6-12 weeks after last menstrual period. or vaginal discharge. Labs: CBC. shoulder pain. endometrial sampling. excessive exercise. Differential Diagnosis Pregnancy-related. Characteristics of pelvic pain. Ectopic pregnancy. eating disorders. gonorrhea. adrenal tumor. abnormalities of clotting factors. ovarian tumor. missed menstrual period. endometrial polyp. pelvic/tubal surgery. uterine myoma. intrauterine device Androgen excess. Past Medical History: Surgical history. duration. vaginal discharge. abnormal vaginal bleeding (quantify). duration. sexually transmit­ ted diseases. Chlamydia test. stress. cervical carcinoma. intrauterine device. Pelvic inflammatory disease. infertility. symptoms of pregnancy. foreign body. Thrombocytopenia. . abortion Hormonal contraception Hypothalamic-related. Method of Contraception: Oral contraceptives or barrier method. abnormal bleeding. Current sexual activity and practices. obesity.

abortion (spontaneous.” well. or incomplete). Urinary Tract. Rh. primary dysmenorrhea. transvaginal ultrasound. intraabdominal bleeding). pallor. tender adnexal mass or cul-de-sac fullness. Type and hold. Urinary tract infection. Differential Diagnosis of Pelvic Pain Pregnancy-Related Causes. irritable bowel syndrome. adnexal torsion. pregnancy). chlamydia culture. or distressed. Pelvic inflammatory disease. Laparoscopy. delayed capillary refill. GC.Pelvic Pain and Ectopic Pregnancy 57 Physical Examination General Appearance: Moderate to severe distress. tumor. renal calculus. UA with micro. Appendicitis. endometriosis. enlarged uterus. Gynecologic Disorders. septic appearance. threatened. Ectopic pregnancy. ovarian cyst hemorrhage or rupture. CBC. pulse (tachycardia). respiratory rate. mesenteric adenitis. inflammatory bowel disease. Vital Signs: BP (orthostatic hypotension). Non-reproductive Tract Causes Gastrointestinal. uterine leiomyoma torsion. tenderness. intrauterine pregnancy with corpus luteum bleeding. diverticulitis. pregnancy). rebound (peritoneal signs). Labs: Quantitative beta-HCG. Hegar's sign (softening of uterine isthmus. cervical motion tenderness. Signs of dehydration. temperature (low fever). Abdomen: Cullen's sign (periumbilical darkening. Mittelschmerz. Chadwick's sign (cervical cyanosis. local then generalized tenderness. Skin: Cold clammy skin. Pelvic: Cervical discharge. . Note whether the patient looks “ill.

58 Pelvic Pain and Ectopic Pregnancy .

nausea. hypertension. theophylline. Symptoms of Depression: Sleep disturbance. monosodium glutamate. Aura or Prodrome: Visual scotomata. flushing. exacerbating or relieving factors. depressed mood. HEENT: Cranial or temporal tenderness (temporal arteritis). decreased energy. eye pain or redness (glaucoma). Physical Examination General Appearance: Note whether the patient looks “ill” or well. sinus tenderness (sinusitis). paraspinal muscle tenderness. cocaine. Aggravating or Relieving Factors: Relief by analgesics or sleep. Skin: Café au lait spots (neurofibromatosis). photophobia. Associated Symptoms: Numbness. eye drops. estrogen. “The worst headache ever” (subarachnoid hemorrhage). transient blindness. effect of supine posture. emotional upset. lacrimation. rhinorrhea (cluster headache). sympathomimetics. menses. asymmetric pupil reactivity. . cold remedies. nasal discharge (sinusitis). fever. blurred vision. decreased appetite. frequency. Conjunctival injection. pulse. nitrates. weakness. tooth tenderness to percussion (abscess). Drugs: Nitrates. trauma. temporal or ocular bruits (arteriovenous malformation). loss of interest in usually pleasurable activities. time of day. cheese). neck stiffness (meningitis). Weight loss. temporal. phenothiazines. corticosteroids. location (retro-orbital. extraocular movements.Headache 59 Neurologic Disorders Headache History of the Present Illness: Quality of pain (dull. excessive ergotamine. Temporomandibular joint tenderness (TMJ syndrome). sensory disturbances. suboccipital. Vital Signs: BP (hypertension). lack of or excess sleep. temperature (fever). sedatives. facial angiofibromas (adenoma sebaceum). diplopia. Dental infection. bilateral or unilateral). exacerbation by fatigue. vomiting. wine. time course of typical headache episode. intermittent periodicity of headaches (cluster headaches). family history of migraine. diet pills. Exacerbation by foods (chocolate. Lacrimation. Neck: Neck rigidity. ataxia. awakening from sleep. dysarthria. band-like. visual field deficits. alcohol. analgesic or codeine use. papilledema. sharp. throbbing). respiratory rate. poor concentration. Age at onset of headaches. exertion. onset (gradual or sudden). change in severity.

Characteristics of Cluster Headache: Unilateral. anemia. excruciating or paroxysmal headache. venous sinus thrombosis. Onset in adolescence or young adult. Lacrimation. bitemporal or suboccipital. encephalitis. focal weakness (intracranial tumor). relief with sleep. hearing loss. arteriovenous malformation. coughing. persistent vomiting. CBC with differential. analgesic overuse. awakening from sleep. Lasts hours and is usually relieved by simple analgesics. followed by pain-free periods. Characteristics of Tension Headache: Bilateral. Indications for MRI scan: Focal neurologic signs. Hyperventilation. sedatives. Band-like pressure. light headedness. trigeminal neuralgia. paresthesias. post concussion syndrome. diplopia. sinusitis. sensory deficits. tension headache. furosemide. deep tendon reflexes. lumbar puncture. Drugs Associated with Vertigo: Antihypertensives. subdural hematoma. hyperten­ sive encephalopathy. generalized. Labs: Electrolytes. Lasts 2-6 hours. phenytoin. Occurs several times each day over several weeks. gentamicin. aspirin. usually a family history. head trauma. nasal and conjunctival congestion. diuretics. nausea. ataxia. vomiting. ESR. decreased visual acuity. diabetes. Young males. unilateral pulsating or throbbing pain. Characteristics of Migraine: Childhood to early adult onset. hypertension. postural unsteadiness. Dizziness and Vertigo History of the Present Illness: Sensation of spinning or movement of surroundings. Headache. Rate of onset and intensity of vertigo. Associated Symptoms: Recent upper respiratory infection. changing from supine to standing. occurs late in day. intracranial tumor. benign intracranial hypertension (pseudotumor cerebri). cardiovascular disease. meningitis. . throbbing pain. glaucoma. related to stress. Differential Diagnosis: Migraine. nausea. retro-orbital searing pain. syncope. MRI scan. head trauma with focal neurologic signs or lethargy. turning of head. post-herpetic neuralgia.60 Dizziness and Vertigo Neuro: Cranial nerve palsies (intracranial tumor). lasts 20-60 min. temporal arteritis. Recent change in eyeglasses. auditory acuity. transient ischemic attack. Aggravation by change in position. systemic infection. tinnitus. history of stroke. alcohol. vomiting. increased frequency or severity of headache. papilledema. subarachnoid hemorrhage. aura of scotomas or scintillations. psychogenic headache. INR/PTT.

suicide attempts or depression. Central Causes of Vertigo: Vertebrobasilar insufficiency. Coma and Confusion History of the Present Illness: Level of consciousness. deafness). tumors. Vital Signs: Pulse. respiratory rate. poor concentration. Differential Diagnosis Drugs Associated with Vertigo: Aminoglycosides. Labs: CBC. meningitis. Other Disorders Associated with Vertigo: Motion sickness. electrolytes.Delirium. hallucination. cholesteatoma (chronic middle ear effusion). agitation. caffeine. tandem gait. postural hypotension). sensory deficits. Use of insulin. drugs. tremor. psychotropics (lithium. HEENT: Nystagmus. . Coma and Confusion 61 Physical Examination General Appearance: Effect of hyperventilation on symptoms. antipsychotics. Parkinson’s disease. benign positional vertigo. anticoagulants. cerebellopontine angle tumor. Heart: Rhythm. Effect of head turning or of placing the patient recumbent with head extended over edge of bed. altered visual input (new eyeglasses). presyncope. papilledema. history of trauma. stupor (unconscious but awakable with vigorous stimulation). aspirin. alcohol. coordination (finger to nose test). weakness. orthostatic hypotension. benzodiazepines. brain stem or cerebellar infarctions. Confusion. oral hypoglycemics. encephalitis. murmurs. Weber test (lateralization of sound). Rectal: Occult blood. impacted cerumen. visual impairment. Tympanic membrane inflammation (otitis media). epilepsy (post-ictal state). brain stem or cerebellar contusion. acoustic neuroma. tinnitus. coma (cannot be awakened). multiple sclerosis. otitis media. Delirium. BP (supine and upright. Rinne's test (air/bone conduction). Peripheral Causes of Vertigo: Acute labyrinthitis/neuronitis. visual field deficits. MRI scan. orthopedic problems). Neuro: Cranial nerves 2-12. loop diuretics. haloperidol). Effect of Valsalva maneuver on symptoms. Meniere's disease (vertigo. obtundation (awake but not alert). delirium. Romberg test. temperature. syndrome of multiple sensory deficits (peripheral neuropathies. alcohol. cerumen. anticholinergics. Activity and symptoms prior to onset. Note whether the patient looks “ill” or well. ataxia. formification (sensation that insects are crawling under skin). facial weakness. phenytoin. visual acuity. narcotics.

pulse. cranial nerves 2-12.2. Coma and Confusion Fever. coordination. Best Eye Opening Response: No eye opening .4. Total Score: 3-15 Special Neurologic Signs Decortication: Painful stimuli causes flexion of arms.1. Battle's sign (ecchymosis over mastoid process). wrist and fingers with leg extension. headache. Babinski's sign. delirium tremens).1.2.6. abnormal extension to pain . tatoos. place. Tremor (Parkinson's disease. stroke. recent events. masses. indicates damage to contralateral hemisphere above midbrain. Skin: Cyanosis. raccoon sign (periorbital ecchymosis. Chest: Breathing pattern (Cheyne-Stokes hyperventilation). septic appearance. hypertension. weakness. Extremities: Needle track marks (drug overdose). Best Motor Response: None . spider angiomata. wheezes.4. primitive reflexes (snout. transient ischemic attacks. Heart: Rhythm. obeys commands .4. ascites. Pupil size and reactivity.3. jaundice. withdraws to pain . Tongue or cheek lacerations (post-ictal state). corneal reflexes.3. Neck: Neck rigidity. hemotympanum (basal skull fracture). ptosis. incoherent speech. time. eyes open spontaneously .” well. petechia. murmurs. abnormal flexion to pain . lethargy. liver or cardiac disease.3. lacerations. tenderness.62 Delirium. hemorrhages. incomprehensible sounds or cries . splinter hemorrhages. dilated superficial veins (liver failure). orientation to person. capillary refill. skull fracture). somnolence. palmar erythema (hepatic encephalopathy). carotid bruits. Papilledema. localizes to pain . strength.5.5. or malnourished. palmomental grasp). eyes open to pain . renal. Note whether the patient looks “ill. flame lesions. HEENT: Skull palpation for tenderness. wrists and . appropriate words or vocal sounds . crackles. distention. facial asymmetry.2. Decerebration: Painful stimuli causes extension of legs and arms. Injection site fat atrophy (diabetes). splenomegaly. delirium). eyes open to speech . confused speech or words . history of dementia. suck. oriented speech . temperature (fever). Vital Signs: BP (hypertensive encephalopathy). Neuro: Concentration (subtraction of serial 7s. mini-mental status exam. Atrophic tongue (B12 deficiency).1. Abdomen: Hepatomegaly. extraocular movements. respiratory rate. glabella. Glasgow Coma Scale Best Verbal Response: None . Physical Examination General Appearance: Signs of dehydration.

alcohol. Labs: Glucose. meningitis. head trauma. visual aura. factitious coma. prior transient ischemic attacks (neurologic deficit lasting less than 24 hours) or strokes. alcohol or drug withdraw or intoxication. hypertensive encephalopathy. electrolytes. neck movement. hepatic encephalopathy. hyperlipidemia. urine toxicology screen. subdural hematoma. dysphagia. claudication. sudden). CT/MRI. LP if no signs of elevated intracranial pressure and suspicion of meningitis. improvement or progression of symptoms. Past testing: CT scans. indicates midbrain and pons functioning. cigarette smoking. incontinence of stool or urine. liver function tests. anatomic location of deficit. dysarthria. seizure. dehydration. encephalitis. head trauma. sleeping). endocarditis. ABG. exacerbation of dementia. narcotic or anticholinergic overdose. alcohol. carotid Doppler studies. causes tonic deviation of eyes to irrigated ear if intact brain stem. Confusion. intracranial hemorrhage. folate levels. coronary disease. nystagmus and vertigo will occur. arrhythmias (atrial fibrillation). anticoagulants. Weakness and Ischemic Stroke History of the Present Illness: Rate and pattern of onset of weakness (gradual. palpitations. loss of consciousness. hypoxia. Oculocephalic Reflex (Doll's eyes maneuver): Eye movements in response to lateral rotation of head. if the patient is conscious. stroke. Oculovestibular Reflex (Cold caloric maneuver): Raise head 60 degrees and irrigate ear with cold water. Family history: Stroke. past transient monocular blindness (Amaurosis fugax). psychotic states. Differential Diagnosis of Delirium: Electrolyte imbalance. Past Medical History: Hypertension. tongue biting. heart failure. exertion. time of onset and time course to maximum deficit. postictal state. creatinine. uremia. antihypertensives. hypothyroidism. IV drug abuse. activity prior to onset (Valsalva. echocardiograms. vitamin B12 or folate deficiency. systemic infection. cardiac disease. diabetes. BUN. . nausea. vomiting. steroid withdrawal. cocaine use. headache prior to event. B-12. calcium. valvular disease. hyperglycemia. no eye movements or loose movements occur with bihemispheric (diencephalon) lesions.Weakness and Ischemic Stroke 63 fingers flex. hypoglycemia (insulin overdose). hyperlipidemia. ammonia. vertigo. tonic-clonic movements. ketoacidosis.

HEENT: Signs of head trauma. behavioral change. basilar artery stenosis. ecchymoses. Signs of Increased Intracranial Pressure: Lethargy. Differential Diagnosis of Stroke: Infection (abscess. mass effect. metabolic imbalance (hypoglycemia. Signs of Cerebral Herniation: Obtundation. palmomental. ascending weakness. migraine headaches. hypocalcemia). ECG. conversion reaction. gaze. pallor. murmurs (mitral stenosis. infarction. Neuro: Focal motor deficits. Babinski's sign (stroke sole of foot. respiratory rate. cardiogenic emboli). papilledema. endocarditis). hypertension. . cranial nerves 2-12.64 Seizure Physical Examination General Appearance: Level of consciousness. midline shift. Tongue lacerations. Vital Signs: BP. duration of seizure. vomiting. encephalitis). facial asymmetry or weakness. Past seizures. delirium. Cushing’s response (bradycardia. Prodrome (visual changes. Neck: Neck rigidity. noncompliance with anticonvulsant medication (recent blood level). ptosis. post-ictal weakness or paralysis. transient ischemic attack. Cheyne Stokes respiration (periodic breathing with periods of apnea. papilledema. pupil size and reactivity. subdural hematoma. Aura (irritability. Fundi: hypertensive retinopathy. meningitis. dilation of ipsilateral pupil. abnormal respirations. Skin: Petechia. memory concentration. Cushing's response . trauma. temperature. retinal hemorrhages (subarachnoid hemorrhage). grasp). elevated intracranial pressure). splinter hemorrhages. Clonus. Pulse (bradycardia). decerebrate posturing (extension of arms and legs in response to painful stimuli). carotid bruits. stroke. lethargy. and toes dorsiflex if pyramidal tract lesion). Extremities: Unequal peripheral pulses. abnormal respirations). Mini-mental status exam. Note whether the patient looks “ill” or well. tonic-clonic movements. lethargy). vomiting. hyperten­ sion. extraocular movements. glabella. Seizure History of the Present Illness: Time of onset of seizure. fever. paresthesias). CBC. postictal paralysis (Todd's paralysis). headache. Labs: CT scan: Bleeding. S3 (heart failure). Abdomen: Aortic pulsations. Chest: Breathing pattern. atypical migraine. renal bruits (atherosclerotic disease). Heart: Irregular. irregular rhythm (atrial fibrillation). focal neurologic deficits. meningismus.bradycardia. Roth spots (flame shaped lesions. incontinence of urine or feces. primitive reflexes (snout. description of seizure. brain tumor.

Extremities: Cyanosis. Factors that May Precipitate Seizures: Fatigue. . RPR/VDRL. Spider angiomas (hepatic encephalopathy). Differential Diagnosis: Epilepsy (complex partial seizure. lumbar puncture. sleep deprivation. respiratory rate. noncompliance with anticonvulsant medications. anticonvulsant levels. encephalitis. Genitourinary/Rectal: Incontinence of urine or feces. papilledema. wheeze (aspiration). urine toxicology. facial angiofibromas (adenoma sebaceum). trauma. neck rigidity. temperature (hyperpyrexia). generalized seizure). Physical Examination General Appearance: Post-ictal lethargy. pupil reactivity and equality. stroke. stroke. extraocular movements. HEENT: Head trauma. uremia. Past testing: EEG's. Chest: Rhonchi. pseudo-seizure. Labs: Glucose. neurofibromas (Von Recklinghausen's disease). high fever. CT scans. Neuro: Dysarthria. MRI. splinter hemorrhages (endocarditis). murmurs. focal weakness (Todd's paralysis). fractures. sensory deficits. liver function tests. infection. hypopigmented ash leaf spots (tuberous sclerosis). meningitis. pulse. tongue or buccal lacerations. gum hyperplasia (phenytoin). alcohol withdrawal. hypoglycemia. electrolytes. hypocalcemia. Babinski's sign. Unilateral port-wine facial nevus (SturgeWeber syndrome). CBC. head trauma. meningitis. family history of epilepsy. brain tumor. hyponatremia. hypoglycemia. Heart: Rhythm. vasculitis. theophylline toxicity. hyperventilation. visual field deficits.Seizure 65 chills. Note whether the patient looks “ill” or well. carotid bruits. alcohol or drug withdrawal. Diabetes (hypoglycemia). Skin: Café-au-lait spots. hypomagnesemia. hypertensive encephalopathy. cranial nerves. Vital Signs: BP (hypertension). cocaine intoxica­ tion. calcium. EEG.

66 Seizure .

prostate enlargement. anticholinergics. uric acid. flat neck veins (volume depletion). potassium. temperature (fever). Administration of renally excreted medications. pulse (tachycardia). Urine and serum osmolality. abdominojugular reflex (heart failure). sepsis. amphotericin. heart failure. diarrhea.Oliguria and Acute Renal Failure 67 Renal Disorders Oliguria and Acute Renal Failure History of the Present Illness: Oliguria (<20 mL/h. flank pain. chills. Pelvic: Pelvic masses. Physical Examination General Appearance: Signs of dehydration. fever. costovertebral angle tenderness. Abdominal pain. Heart: S3 (volume overload). UA. passing of tissue fragments. HEENT: Oral mucous membrane moisture. jaundice (hepatorenal syndrome). ocular moisture. respiratory rate (tachypnea). distended bladder. absent sphincter reflex. Extremities: Peripheral edema (heart failure). hematuria. nasogastric suction. an increase in heart rate by >15 mmHg and a fall in systolic pressure >15 mmHg. indicates significant volume depletion). urethrocele. kidney stones. creatinine. vomiting. venous distention (heart failure). recent chemotherapy (tumor lysis syndrome). NSAID's). decreased sensation (atonic bladder due to vertebral disk herniation). cystocele. Nephrotoxic drugs (aminoglycosides. septic appearance. 400-500 mL urine/day). Abdomen: Hepatomegaly. measured fluid input and output by Foley catheter. Chest: Crackles (heart failure). Note whether the patient looks “ill” or well. Skin: Decreased skin turgor over sternum (hypovolemia). skin temperature and color. BUN. nephromegaly (obstruction). Vital Signs: BP (orthostatic vitals. delayed capillary refill. Recent upper respiratory infection (post streptococcal glomerulonephritis). urine creatinine. infection. dysuria. Fractional excretion of sodium (FE Na) = Renal Failure Index = UNa x 100 U/PCr UNa(mMol/L) x SCr(mmol/L) x 100 SNa(mMol/L) UCr(mMol/L) . Ultrasound of bladder and kidneys. Rectal: Prostate hypertrophy. foamy urine (proteinuria). anuria (<100 mL urine/day). Labs: Sodium. hemorrhage.

renal vasoconstriction (sepsis. bacteria Differential Diagnosis of Acute Renal Failure Prerenal Insult A. . Prerenal insult is the most common cause of acute renal failure. or secondary to extracellular fluid sequestration (pancreatitis. accounting for 70%. thiazides. Insult to the renal parenchyma (tubular necrosis) causes 20% of acute renal failure. Nephrotoxins (radiographic contrast. allopurinol. WBCs. sepsis). liver disease). It is usually caused by reduced renal perfusion pressure secondary to extracellular fluid volume loss (diarrhea. Post-renal Failure Prerenal ARF Postrenal BUN/Creatinine ratio >15:1 <15:1 varies Urine sodium <20 mMol/L >20 varies Urine osmolality >500 mOsm/kg <350 varies Renal failure Index <1 >1 varies FE Na <1% >1% varies Urine/plasma creatinine >40 >20 varies Urine analyses normal cellular casts RBCs. sulfonamides. D. phenytoin. B. diuresis. Renal. rifampin. Intrarenal Insult A. NSAIDs. GI hemorrhage). E. aminoglycosides) are the second most common cause of tubular necrosis. C. cimetidine. analgesics) are occasional causes of intrarenal kidney failure. furosemide. Prolonged hypoperfusion is the most common cause of tubular necrosis. B. inadequate cardiac output. Acute glomerulonephritis or acute inflammation of renal interstitium (acute interstitial nephritis) (usually from allergic reactions to beta-lactam antibiotics. or inadequate fluid intake or replacement.68 Oliguria and Acute Renal Failure Clinical Findings in Pre-renal. Pigmenturia induced renal injury can be caused by intravascular hemolysis or rhabdomyolysis.

rashes or purpura. fatigue. Abdomen: Distended bladder. muffled heart sounds (effusion). benign prostatic hypertrophy. malaise. urethral obstruction. Past ultrasounds. creatinine. potassium (hyperkalemia). over-diuresis. multiple myeloma. hemorrhage. history of pyelonephritis. or malnourished. pelvic masses.” well. fine white powder (uremic frost). liver disease. HEENT: Neck vein distention (volume overload). renal calculi obstruction) or by intrarenal obstruction (amyloidosis. current and baseline creatinine. ascites. prostate disease. myoclonus. phospho­ rus. sepsis. flank pain. hereditary glomerulonephritis. heart failure. accounting for 10%. diabetic nephrosclerosis. Note whether the patient looks “ill. hypertension.Chronic Renal Failure 69 Postrenal Insult A. insomnia. Chest: Crackles (rales). weight loss. and it is the least common cause of acute renal failure. contrast dyes). sallow yellow skin (urochromes). interstitial nephritis. sensory deficits. Physical Examination General Appearance: Evaluate intravascular volume status. uric acid crystals. glomerulonephritis. glomerulonephritis. Family history of polycystic kidney disease. prostate enlargement. B. paresthesias. Heart: S3 gallop (volume overload). peripheral edema. displace­ ment of heart border. Diabetes. respiratory rate. spider angiomas (hepatorenal syndrome). temperature (fever). Neuro: Asterixis. Anorexia. Postrenal insult may be caused by extrarenal obstructive uropathy (prostate cancer. Hypovolemia secondary to diarrhea. Chronic Renal Failure History of the Present Illness: Oliguria. and BUN. Jaundice. arrhythmias (electrolyte imbalances). dark colored urine. aminoglycosides. costovertebral angle or suprapubic tenderness. Vital Signs: Postural blood pressure and pulse (tachycardia. polycystic . petechiae (coagulopathy). Skin: Skin turgor. calcium. Rectal: Occult blood. anemia. Labs: BUN. cardiac friction rub (pericarditis). purpura. medications (nonsteroidal anti-inflammatory drugs. history of kidney stones. albumin. Postrenal damage results from obstruction of urine flow. bleeding diathesis. proteinuria. Signs of fluid overload. or acyclovir). hypertension). Differential Diagnosis of Chronic Renal Failure: Hypertensive nephrosclerosis.

myoglobinuria. (3) gross hematuria The patient should abstain from exercise for 48 hours prior to urine collection. terminal hematuria (bladder neck or prostate lesion). or malnourished. flava beans. Prior pyelonephritis. unequal peripheral pulses (aortic dissection). fever. irregular. reflux nephropathy. Extremities: Peripheral edema (nephrotic syndrome). streptococcal skin infection (glomerulonephritis). quinine. Hematuria History of the Present Illness: Frequency. dysuria. prostate cancer). discharge. abdominal bruits. nodules. analgesic nephropathy. Abdomen: Tenderness. ibuprofen. condyloma. beets. Genitourinary: Urethral lesions. Physical Examination General Appearance: Signs of dehydration. deafness (Alport's syndrome). cervical malignancy. intravenous pyelogram. pattern of hematuria: Initial hematuria (anterior urethral lesion). Note whether the patient looks “ill. or enlargement (prostatitis. hypertension. Causes of Red Urine: Pyridium.” well. arthritis. Recent sore throat. suprapubic tenderness. irregular (atrial fibrillation. phenobarbital. prostate tenderness. INR/PTT. Indicators of Significant Hematuria: (1) >3 RBC's per high-power field on 2 of 3 specimens. sickle cell. prior stone passage. levodopa. suprapubic pain. nephromegaly. costovertebral angle tenderness (renal calculus or pyelonephritis). tissue passage in urine. ibuprofen. food coloring. Labs: UA with microscopic exam of urinary sediment. cyclophosphamide. Streptozyme panel. cascara laxatives. Color. menstrua­ tion. bleeding diathesis. Medications Associated with Hematuria: Warfarin. bleeding between voidings. aspirin. phenytoin. renal emboli). Family History: Hematuria. foreign body. masses. abdominal or perineal pain. chronic obstructive uropathy. Heart: Heart murmur. HEENT: Pharyngitis.70 Hematuria kidney disease. tubulointerstitial renal disease. petechiae. Foley catheterization. naproxen. renal disease. hematuria throughout voiding (bladder or upper urinary tract). flank pain (renal colic). (2) >100 RBC's per HPF in 1 specimen. . joint pain. occupational exposure to toxins. berries. carotid bruits. rifampin. Recent exercise. CBC. KUB. ultrasound. Skin: Rashes. timing. methyldopa. Vital Signs: BP (hypertension). Lupus nephropathy. phenytoin. hemoglobinuria. ecchymoses. ANA. joint pain. amyloidosis. rhubarb. allopurinol.

plasma proteins filter into urine out of proportion to the amount of hematuria. salpingitis. fever. History of low fluid intake. Abdomen: Costovertebral angle tenderness. immobilization. Differential Diagnosis: Nephrolithiasis. Proteus mirabilis urinary tract infection with . cystitis. testicles or labia. diverticulitis. Note whether the patient looks “ill. UA microscopic (hematuria). Nephrolithiasis History of the Present Illness: Severe. hyperoxaluria. It is characterized by glomerular RBCs that are distorted with crenated membranes and an uneven hemoglobin distribution and casts.” well. Labs: Serum calcium. migrating. carcinoma (colon. rhubarb. Medical Hematuria is caused by a glomerular lesion. Diet high in oxalate: Spinach. Urine cystine. or malnourished. indinavir. unusual dietary habits. Micro­ scopic hematuria and a urine dipstick test of 2+ protein is more likely to have a medical cause. furosemide. Pelvic examination for cervical motion tenderness. urine culture. uric acid. prostatitis. ileal resection. RBCs are disk shaped with an even hemoglobin distribution. suprapubic tenderness. nuts. lower abdominal pain. bladder obstruction. intravenous pyelogram. Urologic Hematuria is caused by a urologic lesion such as a urinary stone or carcinoma. Differential Diagnosis A. neurogenic bladder. renal tubular acidosis. enlarged kidney. ectopic pregnancy. hyperuricosuria. parenteral nutrition. colicky. dysuria. flank pain. hematuria. bladder). prostrate. and there is an absence of casts. ovarian cyst rupture or hemorrhage. it is characterized by minimal proteinuria. abdominal pain may radiate laterally around abdomen to groin. phosphorus. creatinine. tea. torsion of hernia. Causes of Nephrolithiasis: Hypercalcemia. urinary tract infection. and protein appears in urine proportional to the amount of whole blood present. appendicitis. adnexal tender­ ness. family history of kidney stones. Inflammatory bowel disease. septic appearance. Physical Examination General Appearance: Signs of dehydration. chemotherapy. Excess vitamin C intake. cervix. B. intermittent. cocoa.Nephrolithiasis 71 and it should not be collected during menses. ovarian torsion. Pain is not associated with position. cystinuria. prostate cancer. colonic obstruction. prior history of renal stones. endometriosis. Excessive calcium administration. hydrochlorothiazide. bicarbonate.

plasma renin activity. heparin. Pseudo-hyperkalemia: Hemolysis after collection of blood.72 Hyperkalemia staghorn calculi. internal hemorrhage. sine wave. succinylcholine. Skin: Hyperpigmentation (Addison's disease). ventricular arrhythmias. angiotensin converting enzyme inhibitors. Increased Potassium Production: Hemolysis. prolonged tourniquet use. hyperkalemic periodic paralysis. potassium sparing diuretics (spironolactone). chemotherapy (tumor lysis syndrome). platelets. acidosis. Neuro: Muscle weakness. nonsteroidal anti-inflammatory drugs. use of excessively small needle. precordial T waves. abnormal deep tendon reflexes. ACE inhibitors. syncope. Hyperkalemia History of the Present Illness: Serum potassium >5. rhabdomyolysis. excess intake of oral or intravenous potassium. Excess Intake of Potassium: Oral or IV potassium supplements. asystole. ECG: Tall peaked. drugs (succinylcholine. diminished QT interval. thrombocytosis. beta blockers). LDH. heparin. muscle weakness. beta blockers. Serum aldosterone. urinary tract obstruction. adrenal insufficiency (Addison’s syndrome). palpitations. Differential Diagnosis Inadequate Excretion: Renal failure. Note whether the patient looks “ill. bicarbonate. Labs: Potassium. History of renal disease. Physical Examination General Appearance: Dehydration. salt substitutes. digoxin toxicity cyclosporine. anion gap. hypoaldosteronism. chloride. cranial nerves 2-12. AV block. hyperosmolality. NSAIDs. muscle trauma. digoxin overdose. . salt substitutes. pH. oliguria. lupus. prolonged PR interval. lightheadedness. P wave flattening. urine K. hematomas.5 mMol/L (repeat test to exclude lab error). Abdomen: Suprapubic tenderness. diabetes. muscle crush injury. excessive shaking of sample. potassium sparing diuretics. adrenal insufficiency (Addison’s syndrome). or malnourished.” well. leukocytosis. delayed transport of blood to lab. History of episodic paralysis precipitated by exercise (familial hyperkalemic periodic paralysis). widened QRS complex.

Hypertensive Low Renin. cramping pain. hypothermia. paresthesias. High Aldosterone States. vomiting. supraventricular tachycardia. potassium binding resin ingestion Non-gastrointestinal Loss. Neuro: Weakness. first or second degree block. ECG: Flattening and inversion of T-waves (II. If <20 mEq/d. Conn’s syndrome (hyperaldosteronism). V3). nephrotoxins. V1. 24 hour urine potassium >20 mEq/day indicates excessive urinary K loss. chewing tobacco. Congenital adrenal . excessive licorice ingestion. Hypertensive Low Renin. Labs: Serum potassium. BUN. magnesium. creatinine. vomiting. Urine specific gravity. Abdomen: Hypoactive bowel sounds (ileus). Diarrhea. Electrolytes. laxative abuse. low potassium ingestion. Differential Diagnosis of Hypokalemia Cellular Redistribution of Potassium: Intracellular shift of potassium by insulin (exogenous or glucose load). beta2 agonist. Precipitating Factors: Renal disease.Hypokalemia 73 Hypokalemia History of the Present Illness: Potassium <3. enteric fistula. Note whether the patient looks “ill. Malignant hypertension. familial periodic paralysis. Sweating. renin-producing tumor. thyrotoxic periodic paralysis. diarrhea. CBC. Heart: Rate and rhythm. temperature. dialysis Renal Potassium Loss: Hypertensive High Renin States. dialysis. vitamin B12 treatment. glucose. diuretics. beta agonists. U waves (II. acute myeloid leukemia.5 mMol/L (repeat test to exclude lab error). palpitations. constipation. nausea. poor intake of potassium containing foods. Low Aldosterone States. biliary drainage. Vital Signs: BP. hypoactive tendon reflexes. V3). low K intake or nonurinary K loss is the cause. vitamin B12 treatment. renal artery stenosis.” well. enteric fistula. laxative abuse. pulse. Physical Examination General Appearance: Signs of dehydration. alkalosis-induced shift (metabolic or respiratory). V2. biliary drainage. bicarbonate. Nonrenal Potassium Loss: Gastrointestinal Loss. corticosteroids. polyuria. stress (catecholamine release). aldosterone. ST segment depression. or malnourished. villous adenoma. Primary hyperaldosteronism (adenoma or hyperplasia). QT interval prolongation. Associated Symptoms: Muscle weakness. respiratory rate. Kayexalate ingestion. premature atrial or ventricular contractions. hyperglycemia. plasma renin activity. ventricular tachycardia or fibrillation.

Low Urine Osmolality (50-180 mOsm/L). Differential Diagnosis of Hyponatremia Based on Urine Osmolality A. crackles. diuretics. metabolic alkalosis with a urine chloride <10 mEq/day is caused by vomiting. cramps. BUN. normotensive hyperaldosteronism Hyponatremia History of the Present Illness: Serum sodium <135 mMol/L (repeat test to exclude lab error). CNS. Heart: Rhythm and rate. Extremities: Edema. licorice. hyperlipidemia (pseudohyponatremia). Addi- . psychotropic medica­ tions. agitation. moon-face. Renal. Physical Examination General Appearance: Signs of dehydration. chest x-ray. ataxia. High Urine Sodium (>40 mEq/L) and Volume Contracted. Premature ventricular contractions. confusion. or malnourished. triglycerides. tenderness. nausea. urine sodium. B. polydipsia (water intoxication). hyperpigmentation (Addison's disease).” well. irritability. creatinine. osmolality.74 Hyponatremia hyperplasia. Chest: Cheyne-Stokes respirations. chemotherapeutic agents. Liddle's syndrome Normotensive. magnesium depletion. urine osmolality. or pulmonary disease (syndrome of inappropriate antidiuretic hormone). diarrhea. cirrhosis. cranial nerve palsies. anorexia. hypotonic IV fluids. diuretics. Renal tubular acidosis (type I or II). delayed capillary refill. motor weakness. Abdomen: Ascites. positive Babinski's sign. exogenous mineralocorticoids (Florinef. High Urine Osmolality (urine osmolality >serum osmolality) 1. seizures. metabolic alkalosis with a urine chloride >10 mEq/day is caused by Bartter's syndrome. irritability. decreased mental status. glucose. hypothyroidism. protein. heart failure. lethargy. Vital Signs: BP. Cushing's syndrome. muscle weakness or tremor. HEENT: Decreased ocular and oral moisture. muscle twitches. Neuro: Confusion. hypoactive deep tendon reflexes. cholesterol. respiratory rate. ECG. steroid withdrawal. Renal fluid loss (excessive diuretic use. temperature. albumin. Skin: Decreased skin turgor. vomiting. truncal obesity (hypocortisolism with steroid withdrawal). Primary excessive water intake (psychogenic water drinking). Labs: Electrolytes. Note whether the patient looks “ill. salt-wasting nephropathy. chewing tobacco). headache. decreased output of dark urine (dehydration). pulse (orthostatic vitals).

Labs: Increased hematocrit. adipsia (lack of thirst). obtundation. Heart failure. respiratory rate. or malnourished.” well. Altered mental status. Extrarenal source of fluid loss (vomiting. sodium chloride). 4. pulse (tachycardia). urine and serum. hyperglycemia. salt ingestion. stupor. agitation. moon-face. sweating. diarrhea. hypothyroidism. decreased urine output. phenytoin. renal disease. syndrome of inappropriate antidiuretic hormone secretion. Differential Diagnosis: Hypernatremia with Hypovolemia A. 2. impaired access to water (elderly). Vital Signs: BP (orthostatic hypotension). Renal loss of water (urine sodium <10 mMol/L). truncal obesity. ataxia. sodium. creatinine. osmotic diuresis). decreased eye turgor. hyperpigmentation (Conn’s syndrome). . Water retention caused by a drug (carbamazepine. HEENT: Dry mucous membranes. heat exposure. respiratory water loss. Hypernatremia History of the Present Illness: Serum sodium >145 mEq/L (repeat test to exclude lab error). anorexia. Spot urine sodium. administration of hypertonic fluids (sodium bicarbonate. Drugs causing hypernatremia: Amphotericin. head injury. stria (hypoadrenal crisis. steroid withdrawal). temperature. spasticity. Low Urine Sodium (<20 mEq/L) and Volume-expanded. Edema­ tous. Skin: Decreased skin turgor (“doughy” consistency). burns).Hypernatremia 75 son's disease. osmolality. Diuretics. cyclophosphamide). creatinine. renal failure. burns. extensor plantar reflexes (Babinski’s sign). Low Urine Sodium (<20 mEq/L) and Volume Contraction. B. muscle twitching. Extrarenal Loss of Water (urine sodium >20 mMol/L). High Urine Sodium (>40 mEq/L) and Normal Volume. Neuro: Decreased muscle tone. tremor. aminoglycosides. lithium. lethargy. diarrhea. pancreatitis. Note whether the patient looks “ill. vomiting. Vomiting. nephrotic syndrome. 3. Physical Examination General Appearance: Lethargy. BUN. sweating. delayed capillary refill. polyuria. cirrhosis with ascites. flat neck veins. elevated glucose. hyperreflexia. History of dehydration due to fever. Recent fluid intake.

hyperaldosteronism. Diabetes insipidus (central or nephrogenic secretion of excessive antidiuretic hormone). syndrome.76 Hypernatremia Euvolemic Hypernatremia with Renal Water Losses. congenital adrenal hyperplasia. Hypernatremia with Hypervolemia (urine sodium >20 mMol/L): Hypertonic solutions of sodium chloride or sodium bicarbonate. . Cushing's.

foot ulcers. costovertebral angle tenderness (pyelonephritis). decreased visual acuity. exudates). Chest x-ray. ketones. serum ketones. BUN. dyspnea. pulse (tachycardia). stroke. frequency (urinary tract infection). myocardial infarction. retinopathy. toxic appearance. noncompliance with insulin. Extremities: Decreased pulses (atherosclerotic disease). chest pain. Neuro: Delirium.” well. polydipsia. confusion. creatinine. fatigue. physical stress. infection. sensory deficits in extremities (diabetic neuropathy). suprapubic tenderness (urinary tract infection). Renal disease. erythrasma. or malnourished. apple odor). acetone breath odor (musty. back pain (pyelonephritis). hypoglycemic agents. low oral moisture (dehydration). respiratory rate (tachypnea). dysuria. Kussmaul respirations (deep sighing breathing). potassium. hyporeflexia. neck rigidity. infection. Abdomen: Hypoactive bowel sounds (ileus). localized fat atrophy (insulin injections). ketones). hyperpigmented atrophic macules on legs (shin spots). hypotonia. frequent Candida albicans or bacterial infections. dehydration. Labs: Glucose. abdominal pain (appendicitis). lethargy. tympanic membrane inflammation (otitis media). peripheral neuropathy (decreased proprioception and sensory deficits in feet). nausea. polyphagia. Note whether the patient looks “ill. Cough. hypertension. Skin: Decreased skin turgor. . Polyuria. abdominal tenderness. fever. or diet. cellulitis. HEENT: Diabetic retinopathy (neovascularization. chloride. ear pain (otitis media). chills. sodium. pregnancy. Factors that May Precipitate Diabetic Ketoacidosis. stress. bicarbonate. Chest: Rales. noncompliance with insulin. phosphate. delayed capillary refill. Signs of dehydration. hemorrhages. temperature (fever or hypothermia). Vital Signs: BP (orthostatic hypotension). New onset of diabetes. ECG. anion gap. UA (proteinuria. CBC. anion gap. prior ketoacidosis. rhonchi. triglycerides.Diabetic Ketoacidosis 77 Endocrinologic Disorders Diabetic Ketoacidosis History of the Present Illness: Initial glucose level. blurred vision. flat neck veins. pancreatitis. trauma. vomiting. Physical Examination General Appearance: Somnolence. weight loss. intertriginous candidiasis.

Physical Examination General Appearance: Hypoactivity. HEENT: Thin. uremia. DKA. Hyperglycemia-Causing Conditions. doughy skin. rough. phenytoin. hallucinations. Non-Anion Gap Acidoses. alopecia. amenorrhea. lactic acidosis. deep voice. Hyperkeratosis of elbows and knees. Vital Signs: Bradycardia. Signs of dehydration. brittle dry nails with longitudinal ridges. constipation. myxedematous ascites. dry.3. macroglossia (enlarged tongue). yellowish skin without scleral icterus (carotenemia). thyroid surgery scar. hypothermia. confusion. deepening of voice. thyroid surgery or radioactive iodine treatment. Somnolence. trauma. apathy. Hypothyroidism and Myxedema Coma History of the Present Illness: Fatigue. pale. delusions. hypotension. Skin: Cool. Alcoholic ketoacidosis or starvation. Cold exposure. Diagnostic Criteria for DKA. displacement of lateral heart border.78 Hypothyroidism and Myxedema Coma Differential Diagnosis Ketosis-Causing Conditions. Myxedema: transient local swelling after tapping a muscle. propranolol. loss of lateral third of eyebrows. brittle hair. lethargy. weight gain or inability to lose weight. phenothiazines. Hyperosmolar nonketotic coma. infection. restlessness. papilledema. Acidosis-Causing Conditions Increased Anion Gap Acidoses. . Heart: Muffled heart sounds (pericardial effusion). thyroid testing. thyroid swelling or mass. Factors Predisposing to Myxedema Coma. anesthesia. dull. Jugular venous distention (pericardial effusion). coarse. dry hair and skin. depression. pH <7. alcohol. thin. bicarbonate <15. cold intolerance. muscle weakness. sedatives. dry. Extremities: Diminished muscle strength and power. Past history of hyperthyroidism. lithium. mental slowing. somnolence. disorientation. dyspnea on exertion. ketone positive >1:2 dilutions. expressionless face. antithyroid medication. and salicylate or methanol poisoning. carpal tunnel syndrome. paranoia. surgery. Chest: Dullness to percussion (pleural effusion). bradycardia. Renal or gastrointestinal bicarbonate losses due to diarrhea or renal tubular acidosis. puffy face and eyelids. Glucose $250. narcotics. Myxedema madness: Agitation. Abdomen: Hypoactive bowel sounds (ileus).

lacrimation. Factors Precipitating Thyroid Storm: Infection. iodine-131 or iodine therapy. cerebral vascular accident. labor and delivery. family history of thyroid disease. diaphoresis. insomnia. hypertriglyceridemia. LDH. proximal muscle weakness (especially thighs when climbing stairs). medication. . eye discomfort or pain. paresthesias. Decreased mental status. Labs: Thyroid stimulating hormone. palpitations. surgery. recent upper respiratory infection. Weight loss with increased appetite. ataxia.Hyperthyroidism and Thyrotoxicosis 79 Neuro: Visual field deficits. irradia­ tion with iodine 131. ECG: Bradycardia. hypercholesterolemia. dyspnea and fatigue after slight exertion. creatinine phosphokinase. diabetic ketoacidosis. fine. nervousness. heat intolerance. sensory impairment. prolonged Q-T interval. myocardial infarction. electrolytes. hypoactive tendon reflexes with delayed return phase. masses. stupor. thyroid pain. flattened or inverted T waves. thyroid enlargement. Differential Diagnosis of Hypothyroidism Cause Clues to Diagnosis Autoimmune thyroiditis (Hashimoto's disease) Family or personal history of autoimmune thyroiditis or goiter Iatrogenic: Ablation. Previous thyroid function testing. pulmonary embolus. cranial nerve palsies (pituitary tumor). diplopia. amenorrhea. irritability. hyperdefecation. or thio­ amide drug therapy Diet (high levels of iodine) Kelp consumption Subacute thyroiditis (viral) History of painful thyroid gland or neck pain Postpartum thyroiditis Symptoms of hyperthyroidism fol­ lowed by hypothyroidism 6 months postpartum Hyperthyroidism and Thyrotoxicosis History of the Present Illness: Tremor. low voltage QRS complexes. softening of the skin. CBC. hyperkinesis (restless­ ness). silky hair texture. fever. excess hormone medication. Atrial fibrillation. reduced visual acuity. weakness. surgery History of thyroidectomy.

rapid. Loss of subcutaneous fat and muscle mass. Neuro: Proximal muscle weakness. systolic murmur (mitral or tricuspid regurgitation. hyperactive. thyroid thrill and bruit. acute thyroiditis. palmar erythema. Differential Diagnosis: Grave's disease. Skin: Moist. flow murmur). beta-HCG pregnancy test. displacement of apical impulse. difficulty with convergence. fine silky hair. TSH. Plummer's nails (distal onycholysis. hyperpyrexia (>104EF). Accentuated first heart sound. corneal ulcers. atrial fibrillation. hypertension. thyroid adenoma or carcinoma. ECG: Sinus tachycardia. velvety skin. clubbing of fingers and toes (acropachy). toxic multinodular goiter. hyperreflexia (rapid return phase of deep tendon reflexes). anxiety. widened palpebral fissures. diffusely enlarged. irregular rhythm (atrial fibrillation). anxious. trophoblastic tumor (molar pregnancy). postpartum thyroiditis. HEENT: Exophthalmos (forward displacement of the eyeballs). diaphoresis. functional follicular carci­ noma). optic nerve atrophy. chemosis (edema of conjunctiva). Heart: Irregular.80 Hyperthyroidism and Thyrotoxicosis Physical Examination General Appearance: Restless. TSH producing pituitary adenoma. . Ophthalmoplegia (restricted extraocular movements). Vital Signs: Widened pulse pressure (difference between systolic and diastolic pressure). thyrotoxicosis factitia (ingestion of thyroid hormone). non-pitting pre-tibial edema (Grave’s disease). Painless. impaired visual acuity. ectopic thyroid tissue (struma ovarii. thyroid without masses. separation of fingernail from nail bed). conjunctival injection. lid lag. periorbital edema or ecchymoses. tachycardia. infrequent blinking. proptosis. Extremities: Fine tremor. Labs: Free T4. pressured speech. delirium. warm. Signs of dehydration.

high estrogen level (pregnancy. Past Medical History: Peptic ulcer. exacerbation of pain by walking and flexing of foot. creatinine. central venous access catheters. Abdomen: Distention. CBC. INR/PTT. and redness. Risk Factors for Deep Venous Thrombosis A. protein S deficiency. D. Note whether the patient looks “ill. Homan's sign (tenderness with dorsiflexion of foot).” well. surgery. masses. cellulitis. antithrombin III deficiency. hematoma. prostate masses. C. previous thromboembolic event. protein C deficiency. Chest: Breast masses. Vital Signs: BP.Deep Venous Thrombosis 81 Hematologic and Rheumatologic Disorders Deep Venous Thrombosis History of the Present Illness: Sudden onset of unilateral calf pain. respiratory distress. ruptured Baker's cyst. melena. leukocytosis. pacemaker wires. Extremities: >2 cm difference in calf circumference. BUN. age >65 years old. Genitourinary/Rectal: Occult fecal blood. respiratory rate (tachypnea if pulmonary embolus). Endothelial injury risk factors include surgery. B. mottling. muscle injury. UA. tenderness. heart failure. cyanosis. pulse. obesity. Polycythemia. swelling. Hematologic Disorders. dilated varicose veins. plantaris tendon rupture. myocardial infarction. inguinal lymphadenopathy. Hypercoagulable state risk factors include malignant disease. electrolytes. lymphatic obstruction. trauma. chest x-ray. thrombocytosis. redness. Labs: Doppler studies. oral contraceptives). testicular or pelvic masses. Differential Diagnosis: Thrombophlebitis. stroke. antiphospholipid syndrome. or malnourished. temperature (low-grade fever). Physical Examination General Appearance: Dyspnea. . Venous stasis risk factors include prolonged immobilization. anesthesia. ECG. dyspnea. warmth. tenderness. venogram.

casts). Extremities: Joint tenderness. UA (proteinuria. ESR. methyldopa (Aldomet). pleurisy. Malar rash 2. Arthritis in 3 or more joints (>6 weeks) 3. UA. anemia. muscle aches. malar rash (erythematous rash in “butterfly” pattern on the face). morning joint stiffness. stroke. antineutrophilic cytoplasmic antibody. fine rales (interstitial fibrosis). 1. fever. HEENT: Keratoconjunctivitis sicca (dry inflammation of conjunctiva). fatigue. purpura. Raynaud's syndrome (cyanosis of hands when exposed to cold). CBC. Diagnostic Criteria for Rheumatoid Arthritis: Four or more of the following. X-ray abnormalities: Erosions. hypertension. bony decalcification (especially in hands/wrist). Hip and back pain. Diagnostic Criteria for Systemic Lupus Erythematosus: Four or more of the following. Abdomen: Hepatosplenomegaly. scleroderma). oral ulcers. complement. psychiatric illness. Arthritis of hand joints (>6 weeks) 4. Symmetric arthritis (>6 weeks) 5. skin ulcers. creatinine. xerophthalmia (dry eyes). telangiectasias. Heart: Cardiac friction rubs (pericarditis). renal disease. oral ulcers.82 Connective Tissue Diseases Connective Tissue Diseases History of the Present Illness: Joint pain. Positive rheumatoid factor 7. rheumatoid nodules. discoid lesions (erythematous plaques). skin rashes. Morning stiffness (>6 weeks) 2. photosensitivity. Drugs Associated with Lupus: Procainamide. malaise. RPR. LE cell prep. abdominal tenderness. positional chest pain (pericarditis). Chest: Pleural friction rub (pleuritis). Rheumatoid nodules 6. livedo reticularis. hydralazine. weakness. depression. anti-DNA antibody. migraine headaches. dysphagia. ANA. swelling of upper and lower extremities. weight loss. isoniazid. ECG. or malnour­ ished. Physical Examination General Appearance: Note whether the patient looks “ill. lymphadenopathy sclerodactyly (thickening of digital subcutaneous tissue). Episcleritis or scleritis. parotid enlargement.” well. muscle weakness. 1. anti-Smith antibody. Vital Signs: Hypertension Skin: Skin fibrosis (thickening. Labs: Electrolytes. Discoid rash .

5. 9. Photosensitivity Oral or nasopharyngeal ulcers Nonerosive arthritis Pleuritis or pericarditis Persistent proteinuria Seizures or psychosis Hemolytic anemia Positive lupus erythematosus cell. false positive VDRL. 7. 6.Connective Tissue Diseases 83 3. 11. 4. positive anti-DNA antibody. Smith antibody. Positive ANA . 8. 10.

84 Connective Tissue Diseases .

number of children. Support network 4. developmental milestones. History of suicide attempts E. school performance . over the counter medications. Past Psychiatric History 1. Suicidal Ideation. relationships with parental figures and siblings. Current and previous medical problems 2. marital status. Current Symptoms: Date of onset. Previous and current psychiatric diagnoses 2. alcohol or substance abuse. C. Family History: Relatives with history of psychiatric disorders. Reason the patient is presenting now 5. Source of income 2. Previous psychiatric symptoms and treatment 3. Level of education. Psychiatric History A. sex. race. Treatments. History of Present Illness (HPI) 1. duration and course 2. including marriages and sexual orientation. including prescription. Recent Psychosocial Stressors: Stressful life events that may have contributed to the patient's current presentation 4. Social History 1. D.Clinical Evaluation of the Psychiatric Patient 85 Psychiatric Disorders Clinical Evaluation of the Psychiatric Patient I. Intent and planning. Occupational history H. Developmental History: Family structure during childhood. Identifying Information: Age. History of psychiatric treatment. relationship history. often a direct quote from the patient. suicide or suicide attempts. home or folk remedies. individuals that currently live with patient. F. Past Medical History 1. 6. This section should provide evidence that supports or rules out the diagnosis. including outpatient and inpatient treatment 3. History of psychotropic medication use 4. B. Chief Complaint (CC): Reason for consultation. 3. peer relationships. Current alcohol or illicit drug usage 5. G.

Definition: External range of expression observed by interviewer. b. Degree of eye contact B. gustatory or olfactory in nature.86 Clinical Evaluation of the Psychiatric Patient II. Psychomotor activity: Agitation or psychomotor retardation 5. delusions and other perceptual distur­ bances 2. level of hygiene. c. Thought Content 1. Mood: Internal emotional tone of the patient (ie. visual. place and date 3. Orientation: Person. Cognitive Evaluation 1. anxious). Types of Affect a. Abstraction: Proverb interpretation and similarities G. Attitude: Ability to interact with the interviewer 4. Labile: Intense changes in affect d. tactile. Full or wide range of affect: Appropriate affect C. Delusions: Fixed. euthymic. Unusual physical characteristics or movements 3. angry. General Appearance and Behavior 1. Derealization: Feelings of unrealness involving the outer environ­ ment F. range. Flat: Absence of all or most affect b. Affect 1. Fund of Knowledge: Ability to name past five presidents or historical dates 6. Level of consciousness 2. Blunted or restricted: Moderately reduced range of affect c. Calculations: Subtraction of serial 7s. Illusions: Misinterpretations of reality d. and appropriateness 2. firmly held in spite of contradictory evidence. may be auditory. Definition: Hallucinations. Thought Processes 1. described in terms of quality. Mental Status Examination A. Use of Language: Quality and quantity of speech 2. false beliefs. Thought Content Disorders a. Grooming. characteristics of clothing 2. tone. Short-Term Memory: Ability to recall 3 objects after 5 minutes 5. Hallucinations: False sensory perceptions. simple math problems 7. Insight: Does the patient display an understanding of his current problems? Does the patient understand the implication of these prob- . euphoric. dysphoric. associations and fluency of speech E. Rate. Attention and Concentration: Repeat 5 digits forwards and back- wards or spell a five letter word (“world”) forwards and backwards 4. D.

city. .3 points Written command: “Close your eyes. fold it in half.3 points Language: Name a pencil and a watch . visual changes. floor ? . DSM-IV Multiaxial Assessment Diagnosis Axis I: Clinical Disorders Other conditions that may be a focus of clinical attention Axis II: Personality Disorders Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems Axis V: Global Assessment of Functioning Mini-mental Status Examination Orientation: What is the year.1 point Three stage command: “Take this paper in your right hand. date. county. Best evaluated by assessing a patient's history of decision making. Ability to make sound decisions regarding everyday activities 2.2 points Repeat. coat. other medications. . place where medication was obtained. and put it on the floor. “No ifs.5 points What is the state.5 points Registration: Repeat: 3 objects: apple.” .” .3 points Attention/Calculation: Spell “WORLD” backwards .1 point Visual Spacial: Copy two overlapping pentagons . book. Judgment 1. hospital. month? . and's or buts” . last menstrual period. seizures.5 points Memory: Recall the names of the previous 3 objects: . Alcohol intake. agitation.1 point Total Score Normal: 25-30 Mild intellectual impairment: 20-25 Moderate intellectual impairment: 10-20 Severe intellectual impairment: 0-10 Attempted Suicide and Drug Overdose History of the Present Illness: Time suicide was attempted and method.1 point Write a sentence. . III. hallucinations. Quantity of pills. day of week. season. motive for attempt. Symptoms of Tricyclic Antidepressant Overdose: Dry mouth.Mini-mental Status Examination 87 lems? H.

guilt. Family history of depression. sources of emotional stress. hyperactive reflexes. agitation. Alcohol Withdrawal History of the Present Illness: Determine the amount and frequency of alcohol use and other drug use in the past month. affect of alcohol use on family . further desire to commit suicide. humiliating event. nystagmus. delirium. hematemesis. rhonchi (aspiration). AV block. family support. vomiting. Alcohol. Availability of other dangerous medications or weapons. BUN. or sexual abuse. Heart: Rhythm (arrhythmias). ABG. abdominal pain. tremors. suicide. Previous abuse of alcohol or other drugs. helplessness. nausea. ECG Signs of Antidepressant Overdose: QRS widening. History of blackouts or motor vehicle crashes. unemployment. diaphoresis. Neuro: Mental status exam. hallucinations. urine toxicology screen. respiratory rate. HEENT: Signs of trauma. glucose. clonus. Time of last alcohol consumption. pupil size and reactivity. family. Effects of the alcohol or drug use on the patient's life may include problems with health. and day. mydriasis. headaches. pulse (bradycardia). psychiatric disease. Abdomen: Decreased bowel sounds.88 Alcohol Withdrawal Psychiatric History: Previous suicide attempts or threats. Determine whether the patient ever consumes five or more drinks at a time (binge drinking). job or financial status or with the legal system. Reasons that a patient has to wish to go on living. physical. ecchymoses. is there a definite plan? Was action impulsive or planned? Detailed account of events 48-hours prior to suicide attempt and events after. Feelings of sadness. Precipitating factor for suicide attempt (death. anxiety. fever. medical illness). Did the patient believe that he would succeed in suicide? Is the patient upset that he is still alive? Personal or family history of emotional. past withdrawal reactions. Torsades de pointes vertricular arrhythmia. wounds. alcohol or drug abuse. tremor. Labs: Electrolytes. ventricular tachycardia. marital conflict. PR or QT interval prolongation. hopelessness. presence of potentially dangerous objects or substances (belts. Chest: Abnormal respiratory patterns. Extremities: Needle marks. shoe laces). chest x-ray. melena. Vital Signs: BP (hypotension). divorce. week. creatinine. confusion. history of delirium tremens. chest pain. acetaminophen levels. temperature (hyperpyrexia). Physical Examination General Appearance: Level of consciousness.

head trauma. Past Medical History: Gastritis. muscle atrophy (stigmata of liver disease). Rectal: Occult blood. anticholinergic poisoning. respiratory rate. Physical Examination General Appearance: Poor nutritional status. drug abuse. reflexes. tempera­ ture (hyper/hypothermia). spider angiomas (stellate arterioles with branching capillaries). HEENT: Signs of head trauma. ulcers. UA. diaphoresis. liver span. ataxia. chest X-ray. crackles (aspiration). pulse (tachycardia). pupil reactivity. cirrhosis. Labs: Electrolytes. extraocular movements. splenomegaly. icterus. meningitis. disorientation. Family history of alcoholism. Neuro: Cranial nerves 2-12. liver function tests. Genitourinary: Testicular atrophy. CBC. Wernicke's Encephalopathy: Ophthalmoplegia. pancreatitis. Asterixis. sedative-hypnotic with­ drawal. alcoholic ketoacidosis.Alcohol Withdrawal 89 members. hepatitis. ascites. Heart: Rate and rhythm. . Korsakoff's Syndrome: Retrograde or antegrade amnesia. Vital Signs: BP (hypertension). nystagmus. hypoglycemia. Differential Diagnosis of Altered Mental Status: Alcohol intoxication. ECG. glucose. hepatomegaly or liver atrophy. Abdomen: Liver tenderness. narcotic overdose. confabulation. Chest: Rhonchi. Skin: Jaundice. GI bleeding. Age of onset of heavy drinking. slurred speech. intracranial hemorrhage. palmar erythema. ataxia. hernias. magnesium. Conjunctival injection. decreased vibratory sense (peripheral neuropathy). confusion (thiamine deficiency). gynecomastia (cirrhosis). drug overdose. needle tracks. murmurs. ecchymoses.

Commonly Used Formulas A-a gradient = [(PB-PH2O) FiO2 . PH2O = 47 mmHg .8 x (4 .003(PaO2)= NL 20 vol% O2 delivery = CO x arterial O2 content = NL 640-1000 mL O2/min Cardiac output = HR x stroke volume CO L/min = 125 mL O2/min/M2 8.8 ) -pO2 arterial PB = 760 mmHg.PCO2/R] .36(Hgb)(SaO2)+0.5 {(1. Corrected = measured Ca mg/dL + 0.(Cl + HCO3) For each 100 mg/dL increase in glucose.albumin g/dL) serum Ca+ (mg/dL) .pCO2/0. R .8 glucose = NL 270-290 mOsm 18 kg Fractional excreted Na = U Na/ Serum Na x 100 = NL<1% U Cr/ Serum Cr Anion Gap = Na .PCWP x 80 = NL 45-120 dyne/sec/cm2 CO L/min GFR mL/min = (140 .(1. 85-105(females) Body water deficit (L) = 0.36)(Hgb)(SvO2)} x 100 Normal CO = 4-6 L/min SVR = MAP .age) x wt in Kg 72 (males) x serum Cr (mg/dL) 85 (females) x serum Cr (mg/dL) Creatinine clearance = U Cr (mg/100 mL) x U vol (mL) P Cr (mg/100 mL) x time (1440 min for 24h) Normal creatinine clearance = 100-125 mL/min(males).PO2 arterial = (713 x FiO2 . 0.36 mL O2/gm Hgb Arterial O2 content = 1.6(weight kg)([measured serum Na]-140) 140 Osmolality mOsm/kg = 2[Na+ K] + BUN + 2.36)(Hgb)(SaO2) . Na+ decrease by 1.8 normal Aa gradient <10-15 mmHg (room air) Arterial oxygen capacity =(Hgb(gm)/100 mL) x 1.6 mEq/L.CVP x 80 = NL 800-1200 dyne/sec/cm2 COL/min PVR = PA .

7 x height cm)-(4.25 .7 x actual weight Kg) + (5 x height cm)-(6.35 100 .29-0.41 70 0.08 Heart rate/min Q-T 60 0.27-0.5 kg for first 5 feet + 2.Ideal body weight males = 50 kg for first 5 feet of height + 2.38 80 0.8 x age) Females= 655+(9.(3-4 gm/d insensible loss) Predicted Maximal Heart Rate = 220 .33-0.31-0.06-0.12-0.3 kg for each addi­ tional inch.36 90 0.3 kg for each additional inch.urine urea nitrogen . Ideal body weight females = 45.43 0.age Normal ECG Intervals (sec) PR 0.7 x age) Nitrogen Balance = Gm protein intake/6. Basal energy expenditure (BEE): Males=66 + (13.20 QRS 0.6 x actual weight Kg)+(1.28-0.

Commonly Used Drug Levels Drug Therapeutic Range Amikacin Amitriptyline Carbamazepine Desipramine Digoxin Disopyramide Doxepin Flecainide Gentamicin Imipramine Lidocaine Lithium Nortriptyline Phenobarbital Phenytoin Procainamide Quinidine Salicylate Streptomycin Theophylline Tocainide Valproic acid Vancomycin Peak 25-30.0.0 mcg/mL 150-300 ng/mL 2-5 mcg/mL 0.0 mcg/mL Peak 6.0 ng/mL 2-5 mcg/mL 75-200 ng/mL 0.0-8. trough <5 mcg/mL 8-20 mcg/mL 4-10 mcg/mL 50-100 mcg/mL Peak 30-40.0 mcg/mL 2.5-1.5-5. trough <10 mcg/mL 100-250 ng/mL 4-10 mcg/mL 150-300 ng/mL 0. trough <10 mcg/mL .0-8.0 mcg/mL 15-25 mg/dL Peak 10-20.8-2. trough <2.4 mEq/L 50-150 ng/mL 10-30 mEq/mL 8-20 mcg/mL 4.2-1.

also D10W. gonococcus glomerular filtration rate gastrointestinal gram drop drops hour water hepatitis B surface antigen bicarbonate hematocrit high-density lipoprotein mercury hemoglobin concentration human immunodeficiency virus hour hora somni (bedtime. assist mode ventilation antinuclear antibody before anteroposterior adult respiratory distress syndrome acetylsalicylic acid a s p a r t a t e aminotransferase bis in die (twice a day) vitamin B-12 (cyanocobalamin) bowel movement blood pressure blood urea nitrogen complaint of cum (with) culture and sensitivity centigrade calcium capsule complete blood count. hematocrit. D50W disseminated intravascular coagulation differential count diabetic ketoacidosis deciliter docusate sodium sulfosuccinate delirium tremens electrocardiogram emergency room endoscopic retrograde cholangiopancreatography erythrocyte sedimentation rate endotracheal tube alcohol iron/total iron-binding capacity iron forced expiratory volume (in one second) fractional inspired oxygen gram(s) gonococcal. hour of sleep) intramuscular . discontinue 5% dextrose water solution. and platelets cubic centimeter coronary care unit centimeter cyclophosphamide.45% saline solution ante cibum (before meals) arterial blood gas before meals adrenocorticotropic hormone ad libitum (as needed or desired) antidiuretic hormone acid-fast bacillus a l k a l i n e phosphatase a l a n i n e aminotransferase morning against medical adampule assisted mandatory ventilation. fluorouracil CNS CO2 COPD CPK-MB CPR CSF CT CVP CXR d/c D5W DIC diff DKA dL DOSS DT’s ECG ER ERCP ESR ET ETOH Fe/TIBC Fe FEV1 FiO2 g GC GFR GI gm gt gtt h H20 HBsAG HCO3 Hct HDL Hg Hgb HIV hr hs IM central nervous system carbon dioxide chronic obstructive pulmonary disease myocardial-specific CPK isoenzyme cardiopulmonary resuscitation cerebrospinal fluid computerized tomography central venous pressure chest x-ray discharge. includes hem o g l o b i n . white blood cell count. methotrexate. red blood cell indices.Commonly Used Abbreviations 1/2 NS ac ABG ac ACTH ad lib ADH AFB alk phos ALT am AMA vice amp AMV ANA ante AP ARDS ASA AST bid B-12 BM BP BUN c/o c C and S C Ca cap CBC cc CCU cm CMF 0.

including urine. pulmonary artery arterial oxygen pressure partial pressure of oxygen in alveolar gas phenobarbital after meals partial pressure of carbon dioxide positive end-expiratory pres­ sure by hydrogen ion concentration (H+) pelvic inflammatory disease afternoon orally. vomit. ureters. low potency lactated Ringer's (solution) myocardial band minimal bacterial concentration microgram milliequivalent milligram magnesium Magnesium Sulfate myocardial infarc­ tion minimum inhibitory concentration milliliter millimeter Milk of Magnesia magnetic resonance imaging sodium sodium bicarbonate neurologic nasogastric NKA NPH NPO NS NSAID O2 OD oint OS Osm OT OTC OU oz p. and drainage international units intensive care unit immunoglobulin M intermittent manda­ tory ventilation isoniazid International normal­ ized ratio intermittent positivepressure breathing intravenous or intra­ venously intravenous pyelogram. post pc PA PaO2 pAO2 PB pc pCO2 PEEP per pH PID pm PO pO2 polys PPD PR prn PT PTCA PTT PVC q qid qAM qd qh qhs qid qOD qs no known allergies neutral protamine Hagedorn (insulin) nulla per os (nothing by mouth) normal saline solution (0. q2h every 6 hours. per os partial pressure of oxygen polymorphonuclear leuko­ cytes purified protein derivative per rectum pro re nata (as needed) physical therapy. prothrombin time percutaneous transluminal coronary angioplasty partial thromboplastin time premature ventricular contraction quaque (every) q6h. diar­ rhea.I and O IU ICU IgM IMV INH INR IPPB IV IVP K+ kcal KCL KPO4 KUB L LDH LDL liq LLQ LP LR MB MBC mcg mEq mg Mg MgSO4 MI MIC mL mm MOM MRI Na NaHCO3 Neuro NG intake and output-­ measurement of the patient's intake and output. every 2 hours quarter in die (four times a day) every morning quaque die (every day) every hour every night before bedtime 4 times a day every other day quantity sufficient .9%) nonsteroidal anti-inflamma­ tory drug oxygen right eye ointment left eye osmolality occupational therapy over the counter each eye ounce after post cibum (after meals) posteroanterior. bowels) liter l a c t a t e dehydrogenase low-density lipopro­ tein liquid left lower quadrant lumbar puncture. intrave­ nous piggyback potassium kilocalorie potassium chloride potassium phos­ phate x-ray of abdomen (kidneys.

room air. albumin.R/O RA Resp RL ROM rt s s/p sat SBP SC SIADH SL SLE SMA-12 SMX sob sol SQ ss STAT susp tid T4 T3RU tab TB Tbsp Temp TIA tid TKO TMP rule out rheumatoid arthritis. glucose. HCO3 . and a l k a l i n e phosphatase. a panel of 12 chemistry tests. adriamycin. Other chemistry panels include SMA-6 and SMA-20 sulfamethoxazole shortness of breath solution under the skin one-half statim (immediately) suspension ter in die (three times a day) Thyroxine level (T4) Triiodothyronine resin uptake tablet tuberculosis tablespoon temperature transient ischemic attack three times a day to keep open. total pro­ tein. Tests include Na+ . an infusion rate (500 mL/24h) just enough to keep the IV from clotting trimethoprim TMP-SMX trimethoprim-sulfameth­ oxazole combination tissue plasminogen activator thyroid-stimulating hormone teaspoon units urinalysis ointment upper respiratory infection as directed urinary tract infection vincristine. Chloride . K+. and cyclophosphamide vag vaginal VC vital capacity VDRL Venereal Disease Research Laboratory VF ventricular function V fib ventricular fibrillation VLDL very low-density lipoprotein Vol volume VS vital signs VT ventricular tachycardia W water WBC white blood count x times TPA TSH tsp U UA ung URI Ut Dict UTI VAC . calcium. right atrial respiratory rate Ringer's lactated solution (also LR) range of motion right sine (without) status post (the con­ dition of being after) saturated systolic blood pres­ sure subcutaneously syndrome of inap­ propriate antidiuretic hormone sublingually under tongue systemic lupus erythematosus sequential multiple analysis. creatinine. BUN. bilirubin.

81 Hyperaldosteronism 19 Hyperdefecation 79 Hyperinflation 24 Hyperkalemia 72 Hyperkeratosis 78 Hypernatremia 75 Hyperparathyroidism 19 Hypertension 17 Hypertensive retinopathy 17 Hyperthyroidism 79 Hypertrophic gastropathy 44 Hypokalemia 73 Hyponatremia 74 Hypothyroidism 78 Iliopsoas sign 38 Illusions 86 Increased intracranial pressure 64 Infectious diseases 29 Intestinal obstruction 53 Ischemic stroke 63 Janeway lesions 36 Jaundice 46 Jugular venous distention 15 JVD 6 Kaposi's sarcoma 32 . 12 Cheyne Stokes respira­ Egophony 31 Electrolytes 7 tion 64 Endocarditis 35 Chief Compliant 5 Endocrinology 77 Cholecystitis 12. 69 History 5 History of Present Illness 5 Homan's Sign 26. 46. 47 Deep tendon reflexes 7 Asthma 24 Deep vein thrombosis Atrial fibrillation 16 81 Axis I 87 Delirium 61 Axis II 87 Delusions 86 Axis III 87 Depression 59 Axis IV 87 Derealization 86 Axis V 87 Diabetic ketoacidosis 77 B12 deficiency 62 Diabetic retinopathy 77 Babinski's sign 64 Diarrhea 41 Body water deficit 90 Discharge Note 8 Brudzinski's sign 33 Discharge summary 9 Bruit Discoid rash 82 renal 18 Caput medusae 38.14 Connective tissue dis­ ease 82 Cor pulmonale 24 Abdominal pain 37 Cough 30 Acropachy 80 Courvoisier's sign 38 Acute abdomen 37 Adenoma sebaceum 59 Cr/BUN ratio 68 Cranial Nerve Examina­ Alcohol withdrawal 88 tion 7 Alveolar/arterial O2 gradi­ Cruveilhier-Baumgarten ent 90 syndrome 48 Amaurosis fugax 63 CSF fluid 34 Amenorrhea 54 Cullen's sign 38 Anorexia 40 Cushing's Syndrome 19 Aortic Coarctation 18 Cushing's triad 64 Aortic Dissection 12 Arteriovenous nicking 17 CVAT 6 Decerebration 62 Ascites 49 Decortication 62 Asterixis 46. 45 Chronic obstructive pul­ EOMI 6 monary disease 25 Epistaxis 44 Chronic Renal Failure 69 Esophageal Rupture 12 Fever 29 Chvostek's sign 50 Fitz-Hugh-Curtis syn­ Cirrhosis 47 drome 45 Cold caloric maneuver 63 Fluid wave 47 Colon cutoff sign 50 Formulas 90 Coma 61 Fractional excretion of Confusion 61 sodium 67 Congestive heart failure Index Friction rub 20 Gastritis 51 Gastrointestinal bleeding lower 44 upper 43 Glasgow coma scale 62 Grey Turner's sign 38 Gum hyperplasia 65 Hallucinations 86 Hashimoto's disease 79 Headache 59 Heart failure 14 Hegar's sign 57 Hematemesis 43 Hematochezia 37 Hematology 81 Hematuria 70 Hemoptysis 23 Hepatic angle sign 48 Hepatitis 46 Hepatorenal syndrome 67. Dizziness 60 Doll's eyes maneuver 63 48 Dupuytren's contracture Carotenemia 78 48 CBC 7 Dysdiodokinesis 61 CCE 6 Dyspnea 12 Cephalization 15 Ecthyma gangrenosum Cerebral Herniation 64 29 Charcot's sign 38 Ectopic 56 Charcot's triad 45 Edema 13 Chest pain 11.

67 Onycholysis 80 Ophthalmoplegia 80 Orthostatic hypotension 43 Osler's nodes 36 Osmolality. 61 Renal failure Weight loss 40 Wheezing 24 table 68 Renal failure index 67 Whispered pectoriloquy Rendu-Osler-Weber 31 disease 23 Wilson's disease 46 Renovascular Hyperten­ sion 19 Renovascular Stenosis 18 Review of Systems 5 Rheumatology 81 Rinne's test 61 Romberg's test 7 Roth's spots 36 Rovsing's sign 38 RRR 6 Seizure 64 Sepsis 29 Spider angiomas 47 Stigmata of Liver Dis­ . Sturge-Weber syndrome 19 65 Physical Examination 6 Subcutaneous fat necro­ Pigmenturia 68 sis 50 Pleuritic pain 19 Subhyloid retinal hemor­ Plummer's nails 80 rhages 64 PMI 6 Syncope 20 Pneumocystis pneumo­ Tactile fremitus 31 Tenesmus 44 nia 31 Thyroid Storm 79 Pneumonia 30 Thyroiditis 79 Port-wine nevus 65 Thyrotoxicosis 79 Postrenal failure 68 Postural hypotension 43 Todd's paralysis 65 Transient ischemic attack Prerenal failure 68 Prescription Writing 9 62 Presyncope 61 Tuberculous 34 Primitive reflexes 64 Tumor lysis syndrome 72 Problem-oriented prog­ UA 7 Upper Gastrointestinal ress note 7 Procedure Note 8 Bleeding 43 Progress note 7 Uremic frost 69 Pseudo-hyperkalemia Urinary tract infection 35 Urine analysis 7 72 Urochromes 69 Psychiatry 85 Uterine bleeding 55 Puddle sign 47 Pulmonary embolism 26 Vertigo 60 Vomiting 39 Pulmonology 23 Von Recklinghausen's Pulses 6 Pulsus paradoxicus 24 disease 65 Pyelonephritis 35 Water bottle sign 20 Raynaud's syndrome 82 Weakness 63 Renal bruit 18 Weber test 7. 38. 64 PERRLA 6 Stupor 61 Pheochromocytoma 18. 45 Muscle Contraction Headache 60 Myocardial infarction 11. 47 Kerley B lines 15 Kernig's sign 33 LFT's 7 Lower Gastrointestinal Bleeding 44 Lupus 82 Macroglossia 78 Malar rash 82 Mallory Weiss tear 44 McBurney's point 38 Melena 37. estimate of 90 Palmar erythema 47. 40 Nephrolithiasis 71 Nephrology 67 Nephromegaly 70 Nephrotoxic drugs 67 Neurology 59 New York Heart Assoc 16 Obstipation 37 Obtundation 61 Obturator sign 38 Oculocephalic reflex 63 Oculovestibular reflex 63 Odynophagia 37 Oliguria 43. 12 Myxedema coma 78 Myxedema madness 78 Nausea 39. 44 Menetrier's disease 44 Meningitis 32-34 pathogens 33 Mesenteric ischemia 52 Migraine 60 Mini-mental status exam 87 Murmurs 6 Murphy's Sign 29.Kayser-Fleischer rings 46. 19 ease 38 Peritonitis 49 Stroke 63. 48 Palpitations 16 Pancreatitis 50 Paracentesis table 49 Past Medical History 5 Peptic ulcer disease 51 Pericarditis 12.