Current Clinical Strategies

History and Physical Examination
Tenth Edition

Paul D. Chan, M.D. Peter J. Winkle, M.D.

Current Clinical Strategies Publishing

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Copyright © 2005 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced or stored in an information retrieval network without the permission of the publisher. No warranty exists, expressed or implied, for errors or omissions in this text. Current Clinical Strategies Publishing 27071 Cabot Road Laguna Hills, California 92653-7012 Phone: 800-331-8227 Fax: 800-965-9420 E-mail: Internet: Printed in USA ISBN 1-929622-28-7

History and Physical Examination 5

Medical Documentation
History and Physical Examination
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. List all of the patients medical problems. 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. Medications: Allergies: Penicillin, codeine? Family History: Medical problems in family, including the 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, eye pain. 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. Gynecological: Gravida/para, abortions, last menstrual period (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding, breast masses. Endocrine: Polyuria, polydipsia, skin or hair changes, heat intolerance.

6 History and Physical Examination Musculoskeletal: Joint pain or swelling, arthritis, myalgias. Skin and Lymphatics: Easy bruising, lymphadenopathy. Neuropsychiatric: Weakness, seizures, memory changes, depression. Physical Examination General appearance: Note whether the patient appears ill, well, or malnourished. Vital Signs: Temperature, heart rate, respirations, blood pressure. Skin: Rashes, scars, moles, capillary refill (in seconds). Lymph Nodes: Cervical, supraclavicular, axillary, inguinal nodes; size, tenderness. Head: Bruising, masses. Check fontanels in pediatric patients. Eyes: Pupils equal round and react to light and accommodation (PERRLA); extra ocular movements intact (EOMI), and visual fields. Funduscopy (papilledema, arteriovenous nicking, hemorrhages, exudates); scleral icterus, ptosis. Ears: Acuity, tympanic membranes (dull, shiny, intact, injected, bulging). Mouth and Throat: Mucus membrane color and moisture; oral lesions, dentition, pharynx, tonsils. Neck: Jugulovenous distention (JVD) at a 45 degree incline, thyromegaly, lymphadenopathy, masses, bruits, abdominojugular reflux. Chest: Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy. Heart: Point of maximal impulse (PMI), thrills (palpable turbulence); regular rate and rhythm (RRR), first and second heart sounds (S1, S2); gallops (S3, S4), murmurs (grade 1-6), pulses (graded 0-2+). Breast: Dimpling, tenderness, masses, nipple discharge; axillary masses. Abdomen: Contour (flat, scaphoid, obese, distended); scars, bowel sounds, bruits, tenderness, masses, liver span by percussion; hepatomegaly, splenomegaly; guarding, rebound, percussion note (tympanic), costovertebral angle tenderness (CVAT), suprapubic tenderness. Genitourinary: Inguinal masses, hernias, scrotum, testicles, varicoceles. Pelvic Examination: Vaginal mucosa, cervical discharge, uterine size, masses, adnexal masses, ovaries. Extremities: Joint swelling, range of motion, edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses). Rectal Examination: Sphincter tone, masses, fissures; test for occult blood, prostate (nodules, tenderness, size). Neurological: Mental status and affect; gait, strength (graded 0-5); touch sensation, pressure, pain, position and vibration; deep tendon reflexes (biceps, triceps, patellar, ankle; graded 0-4+); Romberg test (ability to stand erect with arms outstretched and eyes closed).

History and Physical Examination 7 Cranial Nerve Examination: I: Smell II: Vision and visual fields III, IV, VI: Pupil responses to light, extraocular eye movements, ptosis V: Facial sensation, ability to open jaw against resistance, corneal reflex. VII: Close eyes tightly, smile, show teeth VIII: Hears watch tic; Weber test (lateralization of sound when tuning fork is placed on top of head); Rinne test (air conduction last longer than bone conduction when tuning fork is placed on mastoid process) IX, X: Palette moves in midline when patient says “ah,” speech XI: Shoulder shrug and turns head against resistance XII: Stick out tongue in midline Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC (hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, urine analysis (UA), liver function tests (LFTs). Assessment (Impression): Assign a number to each problem and discuss separately. Discuss differential diagnosis and give reasons that support the working diagnosis; give reasons for excluding other diagnoses. Plan: Describe therapeutic plan for each numbered problem, including testing, laboratory studies, medications, and antibiotics.

8 Progress Notes

Progress Notes
Daily progress notes should summarize developments in a patient's hospital course, problems that remain active, plans to treat those problems, and arrangements for discharge. Progress notes should address every element of the problem list.

Progress Note Date/time: Subjective: Any problems and symptoms of the patient should be charted. Appetite, pain, headaches or insomnia may be included. Objective: General appearance. Vitals, including highest temperature over past 24 hours. Fluid I/O (inputs and outputs), including oral, parenteral, urine, and stool volumes. Physical exam, including chest and abdomen, with particular attention to active problems. Emphasize changes from previous physical exams. Labs: Include new test results and circle abnormal values. Current medications: List all medications and dosages. Assessment and Plan: This section should be organized by problem. A separate assessment and plan should be written for each problem.

and outcome. Studies Performed: Electrocardiograms. devices used. including sterile prep. CT scans. anesthesia method. anatomic location of procedure. including surgical procedures and antibiotic therapy. Procedure notes are brief operative notes. INR. CBC Anesthesia: Local with 2% lidocaine Description of Procedure: Briefly describe the procedure. Note that the patient was given the opportunity to ask questions and that the patient consented to the procedure in writing. Procedure Note Date and time: Procedure: Indications: Patient Consent: Document that the indications. Discharge Note Date/time: Diagnoses: Treatment: Briefly describe treatment provided during hospitalization. Discharge Medications: Follow-up Arrangements: . risks and alternatives to the procedure were explained to the patient.Procedure Note 9 Procedure Note A procedure note should be written in the chart when a procedure is performed. patient position. Specimens: Describe any specimens obtained and laboratory tests which were ordered. Lab tests: Electrolytes. Discharge Note The discharge note should be written in the patient’s chart prior to discharge. Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure.

Disposition: Describe the situation to which the patient will be discharged (home. Pertinent Physical Examination. . and indicate who will take care of patient. exercise. Copies: Send copies to attending. dose. dosage form. diet. medications. treatment. Discharged Condition: Describe improvement or deterioration in the patient's condition. Invasive Procedures: Brief History. Problem List: List all active and past problems. Discharged Medications: List medications and instructions for patient on taking the medications. including evaluation. clinic. and outcome of treatment. route. consultants. Hospital Course: Describe the course of the patient's illness while in the hospital. # of oral solids • Refills: If appropriate • 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.10 Prescription Writing Prescription Writing • Patient’s name: • Date: • Drug name. frequency (include concentration for oral liquids or mg strength for oral solids): Amoxicillin 125mg/5mL 5 mL PO tid • Quantity to dispense: mL for oral liquids. and describe present status of the patient. Diagnostic Tests. and Laboratory Data: Describe the course of the patient's disease up until the time that the patient came to the hospital. nursing home). Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic. including physical exam and laboratory data.

coronary bypass grafting or angioplasty. dysphagia. well. or malnourished. relationship of pain to activity (at rest. alcohol. orthopnea. pallor. Cardiac Testing: Past stress testing. A-V nicking. Age of onset of angina. Improvement or worsening of pain. hyperlipidemia. hypertensive retinopathy.Chest Pain and Myocardial Infarction 11 Cardiovascular Disorders Chest Pain and Myocardial Infarction Chief Compliant: The patient is a 50 year old white male with hypertension who complains of chest pain for 4 hours. vomiting. carotid bruits. pulsatile . xanthomas (hypercholesterolemia). effect of eating. nausea. jaw. distress. Note whether the patient appears ill. cocaine usage. respirations (tachypnea). beta-blockers. relief by nitroglycerine. edema. sharp. sputum. stress echocardiogram. syncope. radiation (to arm. Abdomen: Hepatojugular reflux. Social History: Smoking. S4 gallop (more audible in the left lateral position. palpitations. paresthesias. during exercise). dilation). estrogen. Physical Examination General: Visible pain. cough. character (squeezing. third heart sound (S3 gallop) (heart failure. during sleep. decreased LV compliance due to ischemia). angiogram. Aggravating and Relieving Factors: Effect of inspiration on pain. dull). stress. alcohol. hepatomegaly. diabetes. back). ECGs. illicit drugs. systolic mitral insufficiency murmur (papillary muscle dysfunction). Location. nuclear scans. apprehension. increase in frequency or severity of baseline anginal pattern. History of the Present Illness: Duration of chest pain. BP (hypertension or hypotension). intensity. history of peptic ulcer disease. Past episodes of chest pain. and a strong family history (coronary artery disease in early or mid-adulthood in a first-degree relative). percussion note. stroke. jugulovenous distention. Cardiac Risk factors: Hypertension. Vital Signs: Pulse (tachycardia or bradycardia). Heart: Decreased intensity of first heart sound (S1) (LV dysfunction). PMH: History of diabetes. epigastric tenderness. temperature. “silver wire” arteries. NSAIDS. Associated Symptoms: Diaphoresis. HEENT: Fundi. smoking. claudication. Skin: Cold extremities (peripheral vascular disease). cardiac rub (pericarditis). Chest: Inspiratory crackles (heart failure). arteriolar narrowing. rate of onset (gradual or sudden). dyspnea. Medications: Aspirin. Prior history of myocardial infarction. Exercise tolerance.

E. Acute Pericarditis. Extremities: Edema (heart failure). LDH. femoral bruits. and fever. widened mediastinum and increased aortic prominence on chest X-ray. Rectal: Occult blood. nausea. Electrolytes. Characterized by pleuritic-type chest pain and diffuse ST segment elevation. Acute Cholecystitis. Acute Peptic Ulcer Disease. swelling (thrombosis). Characterized by right subcostal abdominal pain with anorexia. Common Markers for Acute Myocardial Infarction Marker Initial Elevation After MI Mean Time to Peak Elevations 6-7 h 10-24 h 12-48 h 10-24 h 12 h Time to Return to Baseline 18-24 h 3-10 d 5-14 d 48-72 h 38 h Myoglobin CTnl CTnT CKMB CKMBiso 1-4 h 3-12 h 3-12 h 4-12 h 2-6 h CTnI. Occurs after vomiting. myoglobin. “Tearing” chest pain with uncontrolled hypertension. calf pain. CBC. unequal or diminished pulses (aortic dissection). and LDH. hyperacute T waves. pulmonary edema (CHF). B. CPK with isoenzymes. Labs: Electrocardiographic Findings in Acute Myocardial Infarction: ST segment elevations in two contiguous leads with ST depressions in reciprocal leads. Echocardiography. MM = tissue Differential Diagnosis of Chest Pain A. C. Epigastric pain with melena or hematemesis. CPK-MB. vomiting. . CTnT = troponins of cardiac myofibrils. magnesium. Chest X-ray: Cardiomegaly.12 Chest Pain and Myocardial Infarction mass (aortic aneurysm). D. Esophageal Rupture. and anemia. troponin I or troponin T. Neurologic: Altered mental status. Aortic Dissection. X-ray may reveal air in mediastinum or a left side hydrothorax.

ST segment depression or elevation. well. liver tenderness. cardiac medications (noncompliance). Fluid input and output balance. occupational exposures. Differential Diagnosis: Heart failure. with ST depressions in reciprocal leads (MI). syncope. Neurologic: Altered mental status. retractions. rhonchi. coronary artery disease. upper airway . cough. fever. irregular rate. paroxysmal nocturnal dyspnea (PND). hyperinflation with flattened diaphragms. temperature. irregular rhythm (atrial fibrillation). HEENT: Jugulovenous distention at 45 degrees.Dyspnea 13 Dyspnea Chief Compliant: The patient is a 50 year old white male with hypertension who complains of shortness of breath for 4 hours. tracheal deviation (pneumothorax). new left bundle-branch block. Note whether the patient appears ill. heart failure. crackles (rales). or in distress. Calf tenderness or swelling (DVT). salt overindulgence). unilateral hyperresonance (pneumothorax). Abdomen: Abdominojugular reflux (pressing on abdomen increases jugular vein distention). drug allergies. S3 gallop (LV dilation). barrel chest (COPD). dullness to percussion (pleural effusion). orthopnea (dyspnea when supine). cyanosis. pulmonary edema). anxiety. Electrocardiogram A. B. effusions. sudden). Chest: Stridor (foreign body). ECG's. Past Medical History: Emphysema. pulse (tachycardia). dyspnea. hemoptysis. cardiac enzymes. asthma. ST elevations in two contiguous leads. wheezing. hypertension. ventilation/perfusion scan. History of the Present Illness: Rate of onset of shortness of breath (gradual. diaphoresis. Physical Examination General Appearance: Respiratory distress. leg pain (DVT). chest X-rays. chest X-ray (cardiomegaly. Labs: ABG. spirometry. pallor. faint heart sounds (pericardial effusion). Past episodes. Past Treatment or Testing: Cardiac testing. sputum. hepatomegaly. Vital Signs: BP (supine and upright). history of myocardial infarction. Extremities: Edema. Edema. breath sounds. respiratory rate (tachypnea). HIV risk factors. Medications: Bronchodilators. weight gain. pulses. S4 (myocardial infarction). chest pain. infiltrates. palpitations. Heart: Lateral displacement of point of maximal impulse. aggravating or relieving factors (noncompliance with medications. myocardial infarction. holosystolic apex murmur (mitral regurgitation). Dyspnea with physical exertion. clubbing.

malnutrition. localized or generalized. hepatomegaly. weight gain. or malnourished. Generalized Edema: Heart failure. Note whether the patient appears ill. pulse. malignancy. distention. cirrhosis. clubbing. hypoalbuminemia. angioedema. let pain. redness. anemia. well. Endocrine: Mineralocorticoid excess. mottled brown discoloration of ankle skin (venous insufficiency). Extremities: Pitting or non-pitting edema (graded 1 to 4+). Chest: Breath sounds. chronic obstructive pulmonary disease. thrombosis). Recent fluid input and output balance. HEENT: Jugulovenous distention at 45°. warmth. liver function tests. dullness to percussion. venous insufficiency. S3 gallop (LV dilation). Edema Chief Compliant: The patient is a 50 year old white male with hypertension who complains of ankle swelling for 1 day. pneumonia. liver. Labs: Electrolytes. Vitals: BP (hypotension). atrial fibrillation (irregular rhythm). Homan's sign (dorsiflexion elicits pain. wheeze. cyanosis. Heart: Displacement of point of maximal impulse. shortness of breath. shifting dullness. redness. obstruction of hepatic venous outflow. generalized tenderness. History of deep vein thrombosis. Past Medical History: Cardiac testing. iatrogenic edema. Doppler studies of lower extremities. chronic diarrhea (protein losing enteropathy). ascites. allergies. cardiac enzymes. Medications: Cardiac drugs. . History of heart failure. or renal disease. carotid pulse amplitude.14 Edema obstruction. foreign body aspiration. History of the Present Illness: Duration of edema. asthma. pulmonary embolism. ECG. leg circumference. alcoholism. fluid wave. friction rubs. diuretics. respiratory rate. pallor. diaphoresis. hyperventilation. Differential Diagnosis of Edema Unilateral Edema: Deep venous thrombosis. pulses. crackles. obstruction of inferior or superior vena cava. pneumothorax. dyspnea. chest X-ray. Physical Examination General Appearance: Respiratory distress. renal failure. Neurologic: Altered mental status. chest X-rays. splenomegaly. Miscellaneous: Anemia. Exacerbation by upright position. Abdomen: Abdominojugular reflux. nephrotic syndrome. temperature. acute glomerulonephritis. lymphatic obstruction by tumor. CBC. calcium channel blockers. calf tenderness.

number of pillows needed under back when supine to prevent dyspnea. edema of lower extremities. Note whether the patient appears ill. cough. or malnourished. syncope. excessive fluid intake. rhonchi. diaphoresis. fever. sudden). Severity of dyspnea compared with past episodes. hepatojugular reflux (pressing on abdomen causes jugulovenous distention). bruits. History of the Present Illness: Duration of dyspnea. arrhythmias. anxiety. Dyspnea. liver tenderness. vascular cephalization (increased density of upper lobe vasculature). pulmonary embolism. hypertension. sputum. beta blockers. Exercise tolerance (past and present). respiratory rate (tachypnea). heart murmur. myocardial infarction. temperature. digoxin. HEENT: Jugulovenous distention at a 45 degree incline (vertical distance from the sternal angle to top of column of blood). pleuritic pain. hepatomegaly. diaphoresis. well. carotid pulse. Associated Symptoms: Fatigue. S3 gallop (LV dilation). Precipitating Factors: Infections. Neurologic: Altered mental status. pulmonary disease. amplitude. viral illness. Cardiac Risk Factors: Smoking. Vital Signs: BP (hypotension or hypertension). cardiac testing. dullness to percussion (pleural effusion). pulse (tachycardia). antiarrhythmics. palpitations. irregular rhythm (atrial fibrillation). hypertension. perihilar congestion. ECGs. anemia. drug use. anemia. diabetes. angiograms. antihypertensives. Labs: Chest X-ray: cardiomegaly. hyperthyroidism.Congestive Heart Failure 15 Congestive Heart Failure Chief Compliant: The patient is a 50 year old white male with hypertension who complains of shortness of breath for 1 day. noncompliance with diuretics. orthopnea. Abdomen: Ascites. excess salt or fluid intake. Past Testing: Echocardiograms for ejection fraction. duration. diabetes. crackles. Thyroid disease. nonsteroidal antiinflammatory drugs. family history of coronary artery disease or heart failure. Physical Examination General Appearance: Respiratory distress. noncompliance with low salt diet. Treatment in Emergency Room: IV Lasix given. Recent fluid input and output balance. muscle wasting. volume diuresed. renal insufficiency. Chest: Breath sounds. chest pain. pallor. alcoholism. weight gain. jaundice. coronary artery disease. Kerley B lines (horizontal . dyspnea on exertion (DOE). rate of onset (gradual. pulses. Heart: Lateral displacement of point of maximal impulse. Extremities: Edema (graded 1 to 4+). calcium blockers. hypercholesterolemia. paroxysmal nocturnal dyspnea (PND). Past Medical History: Past episodes of heart failure.

ectopic beats. NSAID's. alcohol abuse. metabolic E. LDH. Electrolytes. serial cardiac enzymes. Coronary artery disease and myocardial infarction B. Pulmonary embolism I. Class III: Symptomatic with minimal activity. nutritional. Myocarditis: Infectious. B. hyperthyroidism. Arrhythmias. Renal failure. liver failure. Conditions That Mimic or Provoke Heart Failure: A. nephrotic syndrome Factors Associated with Heart Failure A. High output states: Anemia. postpartum. idiopathic dilated. Class II: Symptomatic with usual level of activity. Paget's disease. Medications: Antiarrhythmics (disopyramide). creatinine. ECG: Left ventricular hypertrophy. pleural effusions. cardiac ischemia/infarction. atrial fibrillation. troponins. excess dietary salt. Hypertension C. calcium blockers. toxic. renal failure. genetic. but asymptomatic at rest. hypertension. arteriovenous fistulas. fever. pulmonary emboli. sodium. multiple myeloma K. fibrous dysplasia. Increase Demand: Anemia. . CBC. Echocardiogram. Aortic or mitral valve disease D. Pulmonary disease J. beta-blockers. immune F. Class IV: Symptomatic at rest. toxic. MB. excessive intravenous fluids New York Heart Association Classification of Heart Failure Class I: Symptomatic only with strenuous activity. Tachyarrhythmias or bradyarrhythmias H. thyrotoxicosis. infection. BUN. arteriovenous fistula. Cardiomyopathies: Hypertrophic. Pericardial constriction G. noncompliance with diuretics. CPK.16 Congestive Heart Failure streaks in lower lobes).

diaphoresis. dyskinetic apical pulse. Rectal: Occult blood. Cardiac History: Hypertension. Extremities: Peripheral pulses with irregular timing and amplitude. mitral regurgitation murmur (rheumatic fever). pulse (irregular tachycardia). sensory. or malnourished. LDH. potassium. Neuro: Altered mental status. free T4. thyromegaly (hyperthyroidism). tremor (hyperthyroidism). The ventricular response rate is 130-180 per minute. alcohol. displaced point of maximal impulse (cardiomegaly). well. Past Medical History: Diabetes. magnesium. noncompliance with cardiac medications. carotid bruits. COPD. ECG: Irregular R-R intervals with no P waves (atrial fibrillation). TSH. diet pills. Echocardiogram for atrial chamber size. Associated Symptoms: Chest pain. anxiety). nausea. mitral valve stenosis. respiratory rate. cocaine. dysphasia. Femoral artery bruits (atherosclerosis). coronary artery disease. Chest: Crackles (rales). amyloidosis. pneumonia. heart failure. petechia (emboli). temperature. dysarthria (stroke). Physical Examination General Appearance: Respiratory distress. . History of the Present Illness: Palpitations (rapid or irregular heart beat). pericardial rub (pericarditis). dizziness. hypertrophic cardiomyopathy. coronary disease. Labs: Sodium. creatinine. dyspnea. Irregular baseline with rapid fibrillary waves (320 per minute). S4. Results of previous ECGs. pallor. Edema. exercise intolerance. Chest X-ray. Heart: Irregular rhythm (atrial fibrillation). CBC. Cardiac Causes: Hypertensive heart disease with left ventricular hypertrophy. HEENT: Retinal hemorrhages (emboli). anxiety. fatigue. drug levels. mitral valve stenosis or regurgitation. pleuritic pain. syncope. electrolyte abnormalities. decongestants. CPK. pericarditis. aortic stenosis. myocardial infarction. pericarditis. theophylline intoxication. cyanosis. symptoms of hyperthyroidism (tremor. Noncardiac Causes: Hypoglycemia. Dyspnea. rheumatic heart disease. Vital Signs: BP (hypotension).Palpitations and Atrial Fibrillation 17 Palpitations and Atrial Fibrillation Chief Compliant: The patient is a 50 year old white male with hypertension who complains of palpitations for 8 hours. arrhythmias. fatigue. serial cardiac enzymes. jugulovenous distention. edema. BUN. hyperthyroidism. diaphoresis. motor weakness (embolic stroke). Differential Diagnosis of Atrial Fibrillation Lone Atrial Fibrillation: No underlying disease state. caffeine. pneumonia. CN 2-12. Note whether the patient appears ill. duration of palpitations.

chronic obstructive pulmonary disease. costovertebral angle tenderness. Past Medical History: Cardiac Risk Factors: Family history of coronary artery disease before age 55. pulmonary embolism. nonsteroidal anti-inflammatory agents. History of the Present Illness: Degree of blood pressure elevation. angina. Paroxysms of tremor. oral contraceptives. Chest: Crackles (rales. narrowly split S2 with increased aortic component. intercostal bruits (aortic coarctation). beta agonists. amphetamines. renal masses. overthe-counter cold remedies. abdominal aortic enlargement (aortic aneurysm). eye medications (sympathomimetics). diaphoresis. baseline BUN and creatinine. electrolyte abnormalities. Truncal . hypertension. Alcohol withdrawal. renal artery stenosis). headache (pheochromocytoma). HEENT: Hypertensive retinopathy. hyperthyroidism. Vital Signs: Supine and upright blood pressure. palpitations. lethargy. dysuria. nausea. exudates. noncompliance with antihypertensives (clonidine or beta-blocker withdrawal). Stimulant abuse. enlarged kidney (polycystic kidney disease). hemorrhages. Past Testing: Urinalysis. papilledema. Associated Symptoms: Chest or back pain (aortic dissection). confusion (encephalopathy). systolic ejection murmurs. orthopnea. corticosteroids. wheeze. dizziness. Physical Examination General Appearance: Delirium. creatinine. vomiting. blurred vision (hypertensive retinopathy). Heart: Rhythm. Age of onset of hypertension. Hypertension Chief Compliant: The patient is a 50 year old white male with coronary heart disease who presents with a blood pressure of 190/120 mmHg for 1 day. excessive caffeine. “cotton wool” spots. thyromegaly (hyperthyroidism).18 Hypertension asthma. Medications: Over-the-counter cold remedies. systemic illness. A-V nicking. hypercholesterolemia. Abdomen: Renal bruits (bruit just below costal margin. Jugulovenous distention. patient’s baseline BP from records. flank pain. diabetes. laterally displaced apical impulse with patient in left lateral position (ventricular hypertrophy). smoking. alcohol. illicit drugs. carotid bruits. thyroid disease. respirations. excessive salt. pyelonephritis. edema. confusion (hypertensive encephalopathy). pulmonary edema). dyspnea. temperature. BP in all extremities. pulse. ECG. bronchodilators. diet pills. heavy alcohol intake or alcohol withdrawal. cocaine.

Renal Parenchymal Disease: Increased serum creatinine $1. 12 Lead Electrocardiography: Evidence of ischemic heart disease. plasma renin activity. or left ventricular hypertrophy. C.5 mg/dL. uric acid. rapid return phase of deep tendon reflexes (hyperthyroidism). Findings Suggesting Secondary Hypertension: A. hirsutism (adrenal hyperplasia). plasma catecholamines (pheochromocytoma). E. visual acuity. glucose. Chest X-ray: Cardiomegaly. proteinuria). Neuro: Altered mental status. Skin: Striae (Cushing's syndrome). UA with microscopic (RBC casts. tremor (pheochromocytoma. femoral bruits. Polycystic Kidneys: Flank or abdominal mass. rhythm and conduction disturbances. posterior systolic bruits below ribs. rib notching. indentation of aorta (coarctation). CBC. plethora (pheochromocytoma). Screening Tests for Secondary Hypertension Hypertensive Disorder Renovascular Hypertension Screening Test Captopril Test: Plasma renin level before and 1 hr after captopril 25 mg PO. edema. 24 hour urine for metanephrine. D. creatinine. costovertebral angle tenderness. Extremities: Asymmetric femoral to radial pulses (coarctation of aortic). Primary Aldosteronism: Serum potassium <3. hematuria. Pheochromocytoma: Tachycardia. hyperthyroidism).Hypertension 19 obesity (Cushing's syndrome). uremic frost (chronic renal failure). Aortic Coarctation: Femoral pulse delayed later than radial pulse. localized weakness (stroke). Labs: Potassium.5 mEq/L while not taking medication. BUN. B. pallor. F. Renovascular Stenosis: Paraumbilical abdominal bruits. proteinuria. tremor. G. Pyelonephritis: Urinary tract infections. A greater than 150% increase in renin is positive Captopril Renography: Renal scan before and after captopril 25 mg PO Intravenous pyelography MRI angiography Digital subtraction angiography Serum Potassium 24 hr urine potassium Plasma renin activity CT scan of adrenals Hyperaldosteronism .

pulse (tachycardia). History of the Present Illness: Sharp pleuritic chest pain. radiation. rhonchi. Chest: Crackles (rales). clonidine or beta blockers. pheochromocytoma. oral ulcers (lupus). jugulovenous distention (cardiac tamponade). chills. Medications: Hydralazine. distant heart sounds (pericardial effusion). Physical Examination General Appearance: Respiratory distress. Exacerbated by supine position. pulsus paradoxus (drop in systolic BP >10 mmHg with inspiration). Dyspnea. sclera. weight loss. discoid rash (lupus).20 Pericarditis Hypertensive Disorder Pheochromocytoma Screening Test 24 hr urine metanephrine Plasma catecholamine level CT scan Nuclear MIBG scan Plasma ACTH Dexamethasone suppression test Serum calcium Serum parathyroid hormone Cushing's Syndrome Hyperparathyroidism Differential Diagnosis of Hypertension A. . palpitations. diaphoresis. arthralgias. Heart: Rhythm. procainamide. Pericarditis Chief Compliant: The patient is a 50 year old white male with hypertension who complains of chest pain for 6 hours. Vital Signs: BP. coughing or deep inspiration. fever. onset. isoniazid. cocaine use. Associated Findings: History of recent upper respiratory infection. iris lesions. rashes. tuberculosis exposure. anxiety. duration. Secondary Hypertension: Renovascular hypertension. dyspnea. penicillin. friction rub on end-expiration while sitting forward. leaning forward position. HEENT: Cornea. prior episodes of pain. fatigue. Primary (essential) Hypertension (90%) B. alcohol withdrawal. pallor. noncompliance with antihypertensive medications. autoimmune disease. pain referred to the back. cardiac rub with 1-3 components at left lower sternal border. relieved by leaning forward. Skin: Malar rash (butterfly rash). kidney disease. withdrawal from alpha2 stimulants. intensity. myalgias. anorexia.

ST segment elevation in limb leads and precordial leads. tension. dimming vision (vasovagal syncope). ECG. downwardly. seizures. urinary of fecal incontinence. MB. mycoplasmal. Rate of return to alertness (delayed or spontaneous). procainamide. Duration of unconsciousness. lupus. transient ischemic attacks. urine protein. anxiety attacks.Syncope 21 Rectal: Occult blood. EEG. concave. activity before and after event. isoniazid.” pericardial calcifications. neoplasm. low QRS voltage. confusion. blood culture. PR segment depression. arm position (reaching). pain. Seizure activity (tonic/clonic). rheumatic fever. bacterial. vertigo. Labs: ECG: diffuse. Increased WBC. increased ESR. hyperventilation. drugs (penicillin. mental status before and after event. weakness. Precipitants (fear. “water bottle sign. Past Medical History: Past episodes of syncope. infectious pericarditis (viral. Syncope Chief Compliant: The patient is a 50 year old white male with hypertension who presents with loss of consciousness for 1 minute. tongue biting. cough. connective tissue disease. dyspnea. post myocardial infarction pericarditis (Dressler's syndrome). hunger. upright T waves. uremia. arrhythmias. LDH. Past Testing: 24 hour Holter. mycobacterial). Valsalva. diabetes. flushing. CPK. Prodromal Symptoms: Nausea. History of the Present Illness: Time of occurrence and description of the episode. Body position. defecation. pallor. Post-syncopal disorientation. Chest X-ray: large cardiac silhouette. palpitations. cardiac testing. neck position (turning to side). sarcoidosis. Lyme disease. Chest pain. Echocardiogram. tight shirt collar). polymyositis. joint tenderness. 1 hour before admission. urine RBCs. myxedema. lightheadedness. exertion. exercise testing. stroke. UA. micturition. hydralazine). diaphoresis. Differential Diagnosis: Idiopathic pericarditis. cardiac disease. Extremities: Arthralgias. rate of onset. .

BUN. urinary or fecal incontinence (seizure). conduction blocks. Mg. glucose. Labs: ECG: Arrhythmias. postural vitals (supine and after standing 2 minutes). pulse. Turn patient’s head side to side. Chest: Crackles. Abdomen: Bruits. electrolytes. altered mental status. injection site fat atrophy (diabetes). respiratory distress. Vital Signs: Temperature. anxiety. Note whether the patient appears ill or well. have patient reach above head. strength. tongue or buccal lacerations (seizure). Dyspnea. Genitourinary/Rectal: Occult blood. sensory. turgor. Skin: Pallor. up and down. extraocular movements. pallor. Heart: Irregular rhythm (atrial fibrillation). Neuro: Cranial nerves 2-12. friction rub. diaphoresis. HEENT: Cranial bruising (trauma). gait. rhonchi (aspiration). Pupil size and reactivity. Chest X-ray. extremity palpation for trauma. tenderness. systolic murmurs (aortic stenosis). flat jugular veins (volume depletion). Extremities: Needle marks. CBC. respiratory rate. Blood pressure in all extremities. Differential Diagnosis of Syncope Non-cardiovascular Metabolic Hyperventilation Hypoglycemia Hypoxia Neurologic Cerebrovascular insufficiency Cardiovascular Reflex (heart structurally normal) Vasovagal Situational Cough Defecation Micturition . asymmetric radial to femoral artery pulsations (aortic dissection). 24-hour Holter monitor. pulsatile mass. capillary refill. creatinine. nystagmus. and pick up object. carotid or vertebral bruits.22 Syncope 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.

Syncope 23 Non-cardiovascular Normal pressure hydrocephalus Seizure Subclavian steal syndrome Increased intracranial pressure Psychiatric Hysteria Major depression Cardiovascular 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 .

24 Syncope .

pallor. fever. tenderness. tongue lacerations. pleural friction rub. platelets. purple plaques (Kaposi's sarcoma). dyspnea. basilar crackles (pulmonary edema). CT scans. bone pain (metastasis). HEENT: Nasal or oropharyngeal lesions. residence in a nursing home. chest pain (left or right). hematuria. Family history: Bleeding disorders. rhonchi. breast masses (metastasis). apical crackles (tuberculosis). cytology. past bronchoscopies. Chest: Stridor. telangiectasias on buccal mucosa (Rendu-Osler-Weber disease). Labs: Sputum Gram stain. character (coffee grounds. anorexia. respiratory rate (tachypnea). BP (hypotension). gingival disease (aspiration). ulcerations of nasal septum (Wegener's granulomatosus). acid fast bacteria stain. ABG. Skin: Petechiae. acuteness of onset. edema. chills. Smoking. Farm exposure. accentuated second heart sound (pulmonary embolism). CBC. Vital Signs: Temperature. heart failure. assess hemodynamic status. Past Medical History: COPD. Extremities: Calf tenderness. intrathoracic malignancy). aspiration of food or foreign body. pH of expectorated blood (alkaline=pulmonary. calf swelling (pulmonary embolism). acidic=GI). Rectal: Occult blood. tuberculin testing (PPD). exposure to tuberculosis. Physical Examination General Appearance: Dyspnea. weight loss. Note whether the patient appears ill or well. bronchitis. dark). scalene or supraclavicular adenopathy (Virchow's nodes. cyanosis. liver nodules (metastases). pulse (tachycardia). tenderness of chest wall. clubbing (pulmonary disease).Hemoptysis 25 Pulmonary Disorders Hemoptysis Chief Compliant: The patient is a 50 year old white male with hypertension who has been coughing up blood for one day. NSAIDs. Anxiety. UA . leg pain or swelling (pulmonary embolism). right ventricular gallop. immigration from a foreign country. diaphoresis. malignancy). color (bright red. homelessness. Prior chest X-rays. respiratory distress. jugulovenous distention. aspirin. HIV risk factors (pulmonary Kaposi’s sarcoma). Medications: Anticoagulants. Lymph Nodes: Cervical. localized wheezing (foreign body. hoarseness. rashes (paraneoplastic syndromes). Heart: Mitral stenosis murmur (diastolic rumble). History of the Present Illness: Quantify the amount of blood. Abdomen: Masses. clots). ecchymoses (coagulopathy).

hemosiderosis. foreign body aspiration. fungal infection. pneumonia. relief of symptoms by bronchodilators. INR/PTT. Family History: Family history of asthma. chest X-ray. Past Medical History: Previous episodes of asthma. bronchoscopy. severity of attack compared to previous episodes. cyanosis. allergies. Wheezing and Asthma Chief Compliant: The patient is a 50 year old white male with hypertension who complains of wheezing for one day. epistaxis. Anxiety. sputum fungal culture. COPD. drugs). lung abscess. fever. History of the Present Illness: Onset. grunting. diaphoresis. Neoplasms: Bronchogenic carcinoma. lupus. respiratory distress. pulmonary edema. Miscellaneous: Trauma. foreign body. CT scan. metastatic cancer. recent upper respiratory infection. bleeding time. past pulmonary function testing. pulse (tachycardia). Precipitating factors. hay-fever. coagulopathy. ECG. . cryptococcus antigen. Differential Diagnosis Infection: Bronchitis. cough. purulent sputum. aspiration. jugulovenous distention. pulsus paradoxus (inspiratory drop in systolic blood pressure >10 mmHg = severe attack). and progression of wheezing. Physical Examination General Appearance: Dyspnea. alcohol. Vascular: Pulmonary embolism. Frequency of bronchodilator use. broncholithiasis. chest pain. Baseline arterial blood gas results. history of intubation. HEENT: Nasal flaring. current and baseline peak flow rate. animals. duration. respiratory rate (tachypnea >28 breaths/min). Frequency of exacerbations and hospitalizations or emergency department visits. aspirin. PPD. Treatment given in emergency room and response.26 Wheezing and Asthma (hematuria). oropharyngeal bleeding. pneumonia. home oxygen or nebulizer use. Note whether the patient appears cachectic. seasons that provoke symptoms. Worsening at night or with infection. pallor. creatinine. atopic dermatitis. antinuclear antibody. pharyngeal erythema. betablockers. Social History: Smoking. Wegener's granulomatosus. hypotension). pollen. antiglomerular basement membrane antibody. vasculitis. tuberculosis. chills. somnolence. bronchiectasis. duration of past exacerbations. or in distress. steroid dependency. well. BP (widened pulse pressure. diaphoresis. Goodpasture's syndrome. Kaposi’s sarcoma. exacerbation by exercise. ventilation/perfusion scan. exposure to allergens (foods. mitral stenosis. Vital Signs: Temperature.

Differential Diagnosis: Asthma. aspirin. animals. history of intubation. intracostal and supraclavicular retractions. duration of past exacerbations. Frequency of bronchodilator use. dyspnea. smoking (pack-years). hypoxia. fever. Pulmonary function tests. past pulmonary function tests. carcinoid. flattening of diaphragms. rhonchi. pleurisy. increased intensity of pulmonic component of second heart sound (pulmonary hypertension). steroid dependency. cough. Precipitating factors. sternocleidomastoid muscle contractions. small. . Frequency of exacerbations and hospitalizations or emergency department visits. anaphylaxis. distant heart sounds. pneumonia. Treatment given in emergency room and response. nebulizer use. recent upper respiratory infection. severity of attack compared to previous episodes. seasons that provoke symptoms. endobronchial tumors. COPD. pollen. drugs). Neuro: Decreased mental status. chills. Abdomen: Retractions. bullae. exposure to allergens (foods. upper airway obstruction. theophylline level. clubbing.Chronic Obstructive Pulmonary Disease 27 Chest: Expiratory wheeze. edema. urticaria. steroid dependency. home oxygen or nebulizer use. right ventricular hypertrophy. congestive heart failure. betablockers. third heart sound gallop (S3. History of the Present Illness: Duration of wheezing. Heart: Decreased cardiac dullness to percussion (hyperinflation). ABG: Respiratory alkalosis. tenderness. Chest trauma. increased anteroposterior diameter (hyperinflation). decreased intensity of breath sounds (emphysema). home oxygen use. right axis deviation. elongated heart. peak flow rate. Skin: Rash. sputum quantity. consistency. history of intubation. Baseline blood gases. cor pulmonale). Labs: Chest X-ray: hyperinflation. ECG: Sinus tachycardia. barrel chest. color. Sputum gram stain. confusion. Chronic Obstructive Pulmonary Disease Chief Compliant: The patient is a 50 year old white male with chronic obstructive pulmonary disease who complains of wheezing for one day. Current and baseline peak flow rate. Past Medical History: Frequency of exacerbations. noncompliance with medications. CBC. Diabetes. Worsening at night or with infection. exacerbation by exercise. pneumonia. electrolytes. bronchitis. Extremities: Cyanosis. relief of symptoms by bronchodilators. chest pain. heart failure. increased sputum production.

Vitals: Temperature (fever). hypercoagulability. fever. intercostal retractions. distant heart sounds.28 Pulmonary Embolism Medications: Bronchodilators. ipratropium. Extremities: Cyanosis. History of the Present Illness: Sudden onset of pleuritic chest pain and dyspnea. history of heart failure. HEENT: Jugulovenous distention. confusion. bone). . Decreased air movement. well. pulse (tachycardia). acidosis (late). respiratory distress. edema. supraclavicular retractions. Note whether the patient appears “cachectic. or well. syncope. genitourinary. cystic fibrosis. cough. electrolytes. ECG: Sinus tachycardia. retractions. pregnancy. Vital Signs: Temperature. Note whether the patient appears in respiratory distress. Social History: smoking. speech interrupted by breaths. culture. CBC. hypoxia. Chest: Barrel chest. heart failure. chronic bronchitis. somnolence. pulse (tachycardia >100/min). hyperaeration. right ventricular hypertrophy. Unilateral leg pain. alpha-1-antitrypsin deficiency. alcohol abuse. Anxiety. Neuro: Decreased mental status. Heart: Right ventricular heave. or malnourished. Pulmonary Embolism Chief Compliant: The patient is a 50 year old white male with hypertension who complains of shortness of breath for 4 hours. respiratory rate (tachypnea. BP. prednisone. malignancy (pancreas. S3 gallop (cor pulmonale). bullae. HEENT: Pursed-lip breathing. respiratory rate (tachypnea. ABG: Respiratory alkalosis (early). expiratory wheezing. >28 breaths/min). >28 breaths/min). dyspnea. diaphoresis. Mucous membrane cyanosis. estrogens (oral contraceptives). swelling. surgery. breast. asthma. hyperinflation. pneumonia. clubbing. Differential Diagnosis: COPD. sternocleidomastoid muscle contractions. stomach. pallor. diaphoresis. Physical Examination General Appearance: Dyspnea. History of deep venous thrombosis. trauma. apprehension. lung. prominent jugular A-waves.” in severe distress. perioral cyanosis. jugulovenous distention. pelvic. Virchow's Triad: Immobility. BP (hypotension). PVCs. right axis deviation. Labs: Chest X-ray: Diaphragmatic flattening. rhonchi. Family History: Emphysema. hemoptysis. Sputum gram stain. Physical Examination General Appearance: Diaphoresis.

QRS changes (acute right shift. Extremities: Cyanosis. pneumonia. tenderness or splinting of chest wall. loud. right axis deviation). myocardial infarction. dilated superficial veins. breast mass (malignancy). nonspecific ST-T wave changes.8°C) Diaphoresis S3 or S4 gallop Thrombophlebitis % 92 58 53 44 43 36 34 32 Labs: ABG: Hypoxemia. Chest X-ray: Elevated hemidiaphragm. Duplex ultrasound of lower extremities. localized oligemia. edema. Genitourinary: Testicular or pelvic masses. effusion. Heart: Right ventricular gallop. Neuro: Altered mental status. Frequency of Symptoms and Signs in Pulmonary Embolism Symptoms Dyspnea Pleuritic chest pain Apprehension Cough Hemoptysis Sweating Non-pleuritic chest pain Syncope % 84 74 59 53 30 27 14 13 Signs Tachypnea (>16/min) Rales Accentuated S2 Tachycardia Fever (>37. pulmonary edema. accentuated. pleuritis. Pulmonary Angiogram: Arterial filling defects. aspiration of foreign body or gastric contents. increased calf circumference (>2 cm difference). right heart strain pattern (P-pulmonale. calf swelling. Lung Scan: Ventilation/perfusion mismatch. Differential Diagnosis: Heart failure. asthma. ECG: Sinus tachycardia. wedge shaped infiltrate. pulmonic component of second heart sound (S2). calf redness or tenderness. respiratory alkalosis. hypocapnia. Homan's sign (pain with dorsiflexion of foot).Pulmonary Embolism 29 Chest: Crackles. segmental atelectasis. murmurs. S1Q3 pattern). chronic obstructive pulmonary disease. pleural friction rub. S3 or S4 gallop. . right bundle branch block. Rectal: Occult blood.

30 Pulmonary Embolism .

splenomegaly. rash. Rectal: Prostate tenderness. Heart: Murmurs (endocarditis). travel history. Homan's sign. meningococcemia). animal exposure. sore throat. acetaminophen. Skin: Pallor. pulse (tachycardia). vaginal discharge. dysuria. tenderness. Pustules. genital herpes lesions. pharyngeal erythema. adnexal masses. Janeway's lesions (peripheral lesions of endocarditis). dullness to percussion (pneumonia). Abdomen: Masses. septic. abscesses. diaphoresis. recent acetaminophen use. calf tenderness. Extremities: Cellulitis. allergies. alcohol. diabetes. cholecystitis). back pain. ill. urinary frequency. neck stiffness. time of onset. sputum. rectal flocculence. Foley catheter. altered level of consciousness. headache. ear. Physical Examination General Appearance: Toxic appearance. heart murmur. crackles. recent dental GI procedures. joint or bone tenderness (septic arthritis). delayed capillary refill. Murphy's sign (right upper quadrant tenderness and arrest of inspiration. Social History: Alcoholism. antibiotic use. Vital Signs: Temperature (fever curve). neck rigidity. friction rub (pericarditis). myalgias. cough. cervical motion tenderness. and anal ulcers. History of the Present Illness: Degree of fever. BP. night sweats. hepatomegaly. Osler's nodes. Chest or abdominal pain. AIDS risk factors. ascites. Neurologic: Altered mental status. vomiting. adnexal or uterine tenderness. Chest: Rhonchi. Costovertebral angle tenderness. HEENT: Papilledema. fissures. infected decubitus ulcers or wounds. bone or joint pain. suprapubic tenderness. Pelvic/Genitourinary: Cervical discharge.Fever 31 Infectious Diseases Fever Chief Compliant: The patient is a 50 year old white male with hypertension who complains of fever for one week. nausea. Note whether the patient appears. diarrhea. periodontitis. Ill contacts. Past Medical History: Cirrhosis. IV catheter tenderness (phlebitis). Dyspnea. sinus tenderness. recent surgery. masses. tympanic membrane inflammation. cellulitis. lymphadenopathy. or well. shifting dullness. Breast: Tenderness. Exposure to tuberculosis or hepatitis. petechia (septic emboli. pattern of fever. shaking chills (rigors). respiratory rate (tachypnea). Medications: Antibiotics. anorexia. . purpura.

pharyngitis. abdominal abscess. gallium. rheumatic fever. osteomyelitis. procainamide. Gram Strain of buffy coat Chest X-ray. sulfonamides. Malignancies: Lymphomas. ear. Foley catheter. indium scans. Differential Diagnosis Infectious Causes of Fever: Abscesses. AIDS risk factors. back pain. sputum. drug fever. or well. pelvic infection. thyroid storm. cholangitis. porphyria. upper respiratory infection. recent dental GI procedures. temporal arteritis. pericarditis. BUN. peritonitis. creatinine. altered level of consciousness. malaise. vaginal discharge. alcohol. respiratory rate (tachypnea or hypoventilation). pyelonephritis. acetaminophen. alcohol withdrawal. antibiotic use. blood C&S x 2. animal exposure. Deep vein thrombosis. Dyspnea. apprehension. History of the Present Illness: Degree of fever. lumbar puncture. BP (hypotension). vomiting. Physical Examination General Appearance: Toxic appearance. cellulitis. phenytoin. septic. pattern of fever. isoniazid. dysuria. diabetes. pulmonary emboli. polymyalgia rheumatica. myalgias. IV catheter. gout. endocarditis. Sepsis Chief Compliant: The patient is a 50 year old white male with hypertension who complains of high fever and chills for one day. wound infection. cystitis. tuberculin skin test. Note whether the patient appears. recent surgery. diverticulitis. urinary frequency. factitious fever. Other Causes of Fever: Atelectasis. Chest or abdominal pain. myocardial infarction. rheumatoid arthritis. Medications: Antibiotics. UA. headache. parasitic infections. transaminases. glucose. diaphoresis. diarrhea. hepatitis. infected decubitus ulcer. carcinomas. . bone or joint pain. Medications Associated with Fever: Barbiturates. solid tumors. anorexia. nausea. C&S. Vital Signs: Temperature (fever curve). pulse (tachycardia). allergies. sarcoidosis. bilirubin. otitis media. nitrofurantoin. Exposure to tuberculosis or hepatitis. pancreatitis. shaking chills (rigors). Social History: Alcoholism. perirectal abscess. leukemia. skin lesion cultures. mycobacterial infections (tuberculosis). IV catheter phlebitis. Connective Tissue Diseases: Lupus. Past Medical History: Cirrhosis.32 Sepsis Labs: CBC. urine Gram stain. heart murmur. sinusitis. neck stiffness. night sweats. ill. travel history. abdominal X-rays. viral infections. cough. mastitis. penicillins. sore throat. time of onset.

indium scans. diverticulitis. cholecystitis). rash. endocarditis. Abdomen: Masses. Laboratory Tests for Serious Infections Complete blood count. abdominal X-rays) Differential Diagnosis Infectious Causes of Sepsis: Abscesses. drains Chest X-ray Adjunctive imaging studies (eg. purpura. Heart: Murmurs (endocarditis). calf tenderness. cholangitis. UA. lymphadenopathy. IV catheter tenderness (phlebitis). perirectal abscess. C&S. partial thromboplastin time. cellulitis. Labs: CBC. Osler's nodes. friction rub (pericarditis). fissures. mycobacterial infections (tuberculosis). Gram Strain of buffy coat Chest X-ray. Pelvic/Genitourinary: Cervical discharge. neck rigidity. delayed capillary refill. Janeway's lesions (peripheral lesions of endocarditis). periodontitis. IV catheter phlebitis.Sepsis 33 Skin: Pallor. Chest: Rhonchi. infected decubitus ulcers or wounds. blood C&S x 2. tenderness. meningococcemia). leukocyte differential and platelet count Electrolytes Arterial blood gases Blood urea nitrogen and creatinine Urinalysis INR. transaminases. tympanic membrane inflammation. petechia (septic emboli. skin lesion cultures. wound. creatinine. Homan's sign. Murphy's sign (right upper quadrant tenderness and arrest of inspiration. urine Gram stain. Rectal: Prostate tenderness. fibrinogen Serum lactic acid Cultures with antibiotic sensitivities Blood. urine. cellulitis. osteomyelitis. dullness to percussion (pneumonia). adnexal masses. glucose. abdominal X-rays. shifting dullness. peritonitis. gallium. genital herpes lesions. hepatomegaly. adnexal or uterine tenderness. BUN. cool extremities. magnetic resonance imaging. bilirubin. Extremities: Cellulitis. Breast: Tenderness. pyelonephritis. rectal flocculence. sinus tenderness. ascites. joint or bone tenderness (septic arthritis). crackles. HEENT: Papilledema. wound infection. tuberculin skin test. pelvic infection. Pustules. mottling. sputum. Costovertebral angle tenderness. splenomegaly. pharyngeal erythema. abscesses. ecthyma gangrenosum (purpuric necrotic plaque of Pseudomonas infection). masses. . cervical motion tenderness. computed tomography. Neurologic: Altered mental status. lumbar puncture. suprapubic tenderness. abdominal abscess. and anal ulcers. parasitic infections. infected decubitus ulcer.

myalgias. rhinorrhea. immunosuppression. Recent antibiotic use.000 cells/mm3 . well. Pneumococcal vaccination. or an alteration in mental status. headache. ear pain. ill. <4000 cells/mm3 . aspiration. change in mental status) is present. intravenous drug abuse. fever. Sputum color. History of the Present Illness: Duration of cough. quantity. AIDS risk factors. ill contacts. Sepsis-induced hypotension despite adequate fluid resuscitation. COPD. tuberculin testing. Physical Examination General Appearance: Respiratory distress.34 Cough and Pneumonia Defining sepsis and related disorders Term Systemic inflammatory response syndrome (SIRS) Definition The systemic inflammatory response to a severe clinical insult manifested by $2 of the following conditions: Temperature >38°C or <36°C. living situation (nursing home. vomiting. lymphadenopathy. blood. nausea. respiratory rate (tachypnea). heart rate >90 beats/min. steroids. dehydration. Associated Symptoms: Pleuritic chest pain. HEENT: Tympanic membranes. smoking. stiff neck. along with the presence of perfusion abnormalities that may induce lactic acidosis. neck . respiratory rate >20 breaths/min or PaCO2 <32 mm Hg. heart failure. diarrhea. chills. BP (hypotension). Vital Signs: Temperature (fever). alcoholism. or malnourished. arthralgias. Note whether the patient appears septic. sore throat. Diabetes. or >10% band cells The presence of SIRS caused by an infectious process. oliguria. pharyngeal erythema. asthma. pulse (tachycardia). sepsis is considered severe if hypotension or systemic manifestations of hypoperfusion (lactic acidosis. consistency. Past Medical History: Previous pneumonia. travel history. rate of onset of symptoms. homelessness). oliguria. The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention Sepsis Septic shock Multiple organ dysfunction syndrome (MODS) Cough and Pneumonia Chief Compliant: The patient is a 50 year old white male with hypertension who complains of cough for 12 hours. white blood cell count >12. rigors. dyspnea. exposure to tuberculosis.

Streptococcus pneumoniae. prior episodes of PCP or opportunistic infection. Fever. Labs: CBC. fatigue. tuberculosis. sexual. insidious onset. legionella. Prior pneumococcal immunization. stiff neck. Dry nonproductive cough. Legionella. lethargy. atelectasis. Medications: Antivirals. History of the Present Illness: Progressive exertional dyspnea and fatigue with exertion (climbing stairs). . night sweats. group A streptococcus. visual changes. asthma. rhonchi. weight loss. mental status. Past Medical History: History of herpes simplex. syphilis. H. odynophagia (pain with swallowing). glucose. Chlamydia pneumoniae. Prophylactic trimethoprim/sulfamethoxazole treatment. Neuro: Gag reflex. Aspiration Pneumonia: Streptococcus pneumoniae. cranial nerves 2-12. UA. ABG. influenza. Bacteroides sp. >40 (no underlying lung disease): Streptococcus pneumonia. antibiotics. malignancy. Pneumocystis Carinii Pneumonia and AIDS Chief Compliant: The patient is a 32 year old white male with AIDS who complains of cough for 1 day. bacteria. creatinine. antiviral therapy. blood transfusion. Enterobacter.Pneumocystis Carinii Pneumonia and AIDS 35 rigidity. egophony (E to A changes). mycoplasma pneumoniae. air bronchograms. effusion. Differential Diagnosis: Pneumonia. pulmonary embolism. chills. ECG. malaise. bronchial breath sounds with decreased intensity. anaerobes. substance use history (intravenous drugs). toxoplasmosis. diarrhea. Klebsiella. heart failure. Staphylococcus aureus. >40 (with underlying disease): Klebsiella pneumonia. tactile fremitus (increased sound conduction). mycobacterium avium complex. BUN. Enterobacteriaceae. Oral lesions. electrolytes. whispered pectoriloquy (increased transmission of sound). end-inspiratory crackles. duration of HIV positivity. Associated Symptoms: Headache. clubbing. alternative medications. Chlamydia pneumoniae. Chest: Dullness to percussion. Extremities: Cyanosis. Mode of acquisition of HIV infection. CD4 lymphocyte count and HIV-RNA titer (viral load). Etiologic Agents of Community Acquired Pneumonia Age 5-40 (without underlying lung disease): Viral. weakness. viral infection. Baseline and admission arterial blood gas. Sputum Gram Stain: >25 WBC per low-power field. skin lesions. bronchitis. hepatitis. Chest X-ray: Segmental consolidation.

respiratory distress. Meningitis Chief Compliant: The patient is a 80 year old female with diabetes who complains of fever for 8 hours. high-resolution CT scan. Heart: Murmurs (IV drug users). Labs: Chest X-ray: Diffuse. History of the Present Illness: Duration and degree of fever. sinusitis. AIDS. well. hepatitis antibody. sputum. cotton wool spots (CMV retinitis). pulse (tachycardia). interstitial infiltrates. seborrheic dermatitis. irritability (high pitched cry). Pelvic/Rectal: Candidiasis. electrolytes. lethargy. Neuro: Confusion. hepatosplenomegaly. otitis media. Kaposi's sarcoma (multiple purple nodules or plaques). respiratory rate (tachypnea). meningitis). cough. oral Kaposi's sarcoma (purple-brown macules). ABG: hypoxia. Lymph Node Examination: Lymphadenopathy. increased Aa gradient. acetaminophen. CD4 count. Differential Diagnosis: Pneumocystis carinii pneumonia. rhonchi. sensory deficits. Neck rigidity. altered consciousness. travel history. sickle cell disease. Chest: Dullness. Medications: Antibiotics. CBC. retinitis. History of pneumonia. visual field deficits (toxoplasmosis). alcoholism. decreased breath sounds at bases. Note whether the patient appears septic. sputum gram stain. cranial nerves. lymphadenopathy. zoster. intravenous drug use. Bronchoalveolar lavage. ill contacts. hemorrhages. neck stiffness. condyloma. Dermatologic Signs of AIDS: Rashes. . nausea. disorientation (AIDS dementia complex. crackles. bacterial pneumonia. oropharyngeal thrush. molluscum contagiosum. recent upper respiratory infections. vomiting. chills. herpes. Kaposi's sarcoma. immunosuppression. oral thrush. perivascular white spots. headache. HEENT: Herpetic lesions. endocarditis. Vital Signs: Temperature (fever). Skin rashes. ulcers. Past Medical History: Diabetes. Abdomen: Right upper quadrant tenderness. splenectomy malignancy. Pneumocystis immunofluorescent stain. bronchitis. hepatitis surface antigen. hairy leukoplakia. perianal herpetic lesions.36 Meningitis Physical Examination General Appearance: Cachexia. motor deficits. BP (hypotension). or malnourished. HIV RNA PCR or bDNA. ill. tuberculosis. cyanosis. tuberculosis.

Labs: CSF Tube 1 . Heart: Murmurs. culture and sensitivity. Neisseria meningitis. respiratory rate (tachypnea). Pseudomonas. subarachnoid hemorrhage. BUN. Skin: Capillary refill. tuberculosis. BP (hypotension). herpes encephalitis. . labored respirations. Etiology of Bacterial Meningitis 15-50 years: Streptococcus pneumoniae. Neuro: Altered mental status. Janeway's lesions (endocarditis). extraocular movements. Toxoplasma gondii. Note whether the patient appears ill. Chest: Rhonchi. AIDS: Cryptococcus neoformans. S3. viral infection. Babinski's sign. weakness. splinter hemorrhages of nails.Gram stain. Full fontanelle in infants. Haemophilus influenza. papilledema.Cell count and differential (1-2 mL). Listeria. brain abscess. encephalitis.Meningitis 37 Physical Examination General Appearance: Level of consciousness. HEENT: Pupil reactivity. cranial nerve palsies. >50 years or debilitated: Streptococcus pneumoniae. friction rubs. coccidioides. CSF Tube 3 . Vital Signs: Temperature (fever). or septic. pulse (tachycardia). purpura (meningococcemia). S4. Neisseria meningitis. creatinine. streptococci. Brudzinski's sign (neck flexion causes hip flexion). rashes. Listeria. Differential Diagnosis: Meningitis. osteomyelitis. obtundation. CBC. petechia. well. bacterial antigen screen (12 mL). protein (1-2 mL). CT Scan: Increased intracranial pressure. crackles.Glucose. sensory deficits. CSF Tube 2 . electrolytes. Kernig's sign (flexing hip and extending knee elicits resistance).

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

Differential Diagnosis: Acute cystitis. Proteus. pleuritic chest pain. cystocele. Physical Examination General Appearance: Signs of dehydration. rheumatic heart disease. Abdomen: Suprapubic tenderness. hematuria. BP. septic appearance. or malnourished. creatinine. History of stroke.Pyelonephritis and Urinary Tract Infection 39 Pyelonephritis and Urinary Tract Infection Chief Compliant: The patient is a 50 year old female with diabetes who complains of flank pain for 8 hours. heart failure. papillary necrosis. urgency. herpes. respiratory rate. calculi. urinary tract obstruction. urinary tract instrumentation. recent intravenous catheterization. frequency (repeated voiding of small amounts). elderly. sexual intercourse. enterococcus. pain in fingers or toes (emboli). back pain. chills. urinary tract infection. Endocarditis Chief Compliant: The patient is a 50 year old white male with mitral valve prolapse who complains of fever for 4 hours. suprapubic discomfort or pain. nausea. costovertebral angle tenderness. vulvovaginitis. anatomic abnormality. gonococcal or chlamydia urethritis. malaise. weight loss. pulse. prostatic obstruction. vomiting. group B streptococcus. (pyelonephritis). History of the Present Illness: Fever. wound infection. Pathogens: E coli. . History of urinary infections. well. intravenous drug use. CBC with differential. pyelonephritis. appendicitis. History of heart murmur. urine C&S. fatigue. Note whether the patient appears ill. renal calculus. skin lesions. Pelvic/Genitourinary: Urethral or vaginal discharge. Chlamydia trachomatis. Rectal: Prostatic hypertrophy or tenderness (prostatitis). prostate enlargement. cholecystitis. catheterization. Enterobacter. Risk factors: Diaphragm or spermicide use. decubitus ulcers. Recent antibiotic use. Vital Signs: Temperature (fever). History of the Present Illness: Dysuria. Staphylococcus saprophyticus. colonic disease. Urine Gram stain. fever. masses. pelvic inflammatory disease. Pseudomonas. chills. electrolytes. Past Medical History: Recent dental or gastrointestinal procedure. Labs: UA with micro. Diaphragm use. cervicitis. Klebsiella. renal stones or colicky pain. night sweats. prosthetic valve.

. group D streptococcus. Labs: WBC. streptococcus bovis. Vitals: Temperature (fever). Roth's spots (retinal hemorrhages with pale center. urine culture. erythematous nodules on pads of toes or fingers). well. or malnourished. Janeway lesions (erythematous. staphylococcus epidermidis. blood cultures x 3. enterococci. Heart: New or worsening heart murmur. emboli). BP (hypotension). Prosthetic Valve Pathogens: Staphylococcus aureus. Chest X-ray: Cardiomegaly. HEENT: Oral mucosal and conjunctival petechiae. septic emboli). Note whether the patient appears ill.. pseudomonas. pulse (tachycardia). valvular calcifications. multiple focal infiltrates. splenomegaly. UA (hematuria). nontender lesions on palms and soles. Native Valve Pathogens: Streptococcus viridans. valvular insufficiency.40 Endocarditis Physical Examination General Appearance: Septic appearance. Neuro: Focal neurological deficits (septic emboli). joint pain (septic arthritis). Abdomen: Liver tenderness (abscess). Extremities: Splinter hemorrhages under nails. staphylococcus aureus. Enterobacter sp. Osler's nodes (tender. Echocardiogram: Vegetations. streptococcus pneumonia. spinal tenderness (vertebral abscess). cranial nerves.

Scaphoid. radiation of pain (to shoulder. septic appearance. exact location at onset and at present. visible peristalsis (small bowel obstruction). vomiting before or after onset of pain. Lymphadenopathy. constipation. obstipation (inability to pass gas). Similar episodes in past. hematochezia (rectal bleeding). feculent. Timing and characteristics of last bowel movement. kidney stones. well. anorexia. anticholinergics. flat neck veins (hypovolemia). blood. urination. jaundice. pattern of progression. hematuria. Abdomen Inspection: Scars. sharp. tarry stools). distension. Palpation: Begin palpation in quadrant diagonally opposite to point of maximal pain with patient's legs flexed and relaxed. constant or intermittent (“colicky”). Auscultation: Absent bowel sounds (paralytic ileus or late obstruction). high-pitched rushes (obstruction). relation to last menstrual period. respiratory rate (tachypnea). early satiety. inspiration. movement. laxatives. melena (black. antacids. Aggravating or Relieving Factors: Fatty food intolerance. nausea. dysuria. chest pain. scleral icterus. atherosclerotic retinopathy. coffee ground-colored material). medications. bruits (ischemic colitis). crampy. diarrhea. nutritional status. odynophagia (painful swallowing). flat. Associated Symptoms: Fever. flatus. sudden or gradual onset. defecation. dull). Note whether the patient appears ill. cirrhosis. back. groin). pulse (tachycardia). ecchymosis. change in bowel habits or stool caliber. vomiting (bilious. HEENT: Pale conjunctiva. Past Medical History: History of abdominal surgery (appendectomy. X-rays. alcoholism. chills. weight loss. NSAID's. Bimanual palpation . Effect of eating. Signs of dehydration. gallstones. upper GI series. narcotics. dysphagia. Physical Examination General Appearance: Degree of distress. trauma. vomiting. aspirin.Abdominal Pain and the Acute Abdomen 41 Gastrointestinal Disorders Abdominal Pain and the Acute Abdomen Chief Compliant: The patient is a 50 year old white male with diabetes who complains of right lower quadrant abdominal pain for 4 hours. hernias. coronary disease. cholecystectomy). Endoscopies. position on the pain. or malnourished. BP (hypotension). “silver wire” arteries (ischemic colitis). body positioning to relieve pain. dyspepsia. location and character at onset and at present (burning. Vitals: Temperature (fever). diffuse or localized. History of the Present Illness: Duration of pain. peptic ulcer. Virchow node (supraclavicular mass).

masses. mass effects. Grey Turner's sign: Flank ecchymoses. fluid wave (ascites). hepatomegaly. testicular atrophy. obstruction. Rovsing's sign: Manual pressure and release at left lower quadrant colon causes referred pain at McBurney's point. peritonitis. Right Upper Quadrant: Cholecystitis. appendicitis. jaundice. gallstones.42 Acute Abdomen and Abdominal Pain of flank (renal disease). nontender gallbladder with jaundice. fecaliths. Genital/Pelvic Examination: Cervical discharge. acute porphyria. UA. retroperitoneal hemorrhage. impacted stool. penetrating posterior duodenal ulcer. portal vein gas. psychogenic pain. retrocecal appendicitis. pneumatobilia. air fluid levels. lipase. Skin: Jaundice. shifting dullness. femoral). tenderness. sentinel loop. Iliopsoas sign: Elevation of legs against examiner's hand causes pain. Cullen's sign: Bluish periumbilical discoloration. uterine size. Differential Diagnosis Generalized Pain: Intestinal infarction. pancreatic malignancy. pancrea- . petechia (gonococcemia). ascites. cholecystitis. McBurney's point tenderness: Located two thirds of the way between umbilicus and anterior superior iliac spine. Obturator sign: Flexion of right thigh and external rotation of thigh causes pain in pelvic appendicitis. free air in peritoneum). costovertebral angle tenderness. dependent purpura (mesenteric infarction). calcifications. Bulging flanks. splenomegaly. edema. pregnancy test. hepatitis. cervical motion tenderness. cholangitis. appendicitis. hepatosplenomegaly. popliteal pulses (absent pulses indicate ischemic colitis). periumbilical collateral veins (Caput medusae). sickle crisis. hernias (incisional. liver function tests. ECG. effusion (pancreatitis). inguinal. Labs: CBC. gross or occult blood. gastritis. distended loops of bowel. adnexal tenderness. infiltrates. Chest X-ray: Free air under diaphragm. fever. electrolytes. gynecomastia. masses. Rectal Examination: Masses. subdiaphragmatic free air. Courvoisier's sign: Palpable. Specific Signs on Palpation Murphy's sign: Inspiratory arrest with right upper quadrant palpation. diabetic ketoacidosis. Extremities: Femoral pulses. Charcot's sign: Right upper quadrant pain. liver and spleen span by percussion. peritoneal hemorrhage. X-rays of abdomen (acute abdomen series): Flank stripe. Rebound tenderness. Stigmata of Liver Disease: Spider angiomata. amylase. Pulsating masses. Percussion: Loss of liver dullness (perforated viscus. thumbprinting.

gastroesophageal reflux. abdominal pain. myocardial ischemia. theophylline. salpingitis. intestinal obstruction. Physical Examination General Appearance: Signs of dehydration. X-rays. gastroesophageal reflux disease. History of the Present Illness: Character of emesis (color. ectopic pregnancy. pneumonia. endometritis. chemotherapy. well. esophagitis.Nausea and Vomiting 43 titis. upper GI series. antiarrhythmics. hemorrhage or rupture of ovarian cyst. psychogenic pain. respiratory rate. aortic aneurysm. pancreatitis. anticholinergics. sickle crisis. peptic ulcer. dark urine. jaundice (biliary obstruction). pneumonia. testicular torsion. Medications Associated with Nausea: Digoxin. Left Lower Quadrant: Diverticulitis. ileus. pyelonephritis. diverticulitis. food. ectopic pregnancy. antibiotics. esophagitis. strangulated hernia. aortic aneurysm. progesterone. myocardial infarction. Note whether the patient appears ill. CNS disease. Past Medical History: Diabetes. salpingitis. early satiety. cardiac disease. splenic infarction. peptic ulcer. pulse (tachycardia). volvulus. Possibility of pregnancy (last menstrual period. Nausea and Vomiting Chief Compliant: The patient is a 50 year old white male with diabetes who complains of vomiting for 4 hours. recent change in medications. liver disease. retrocecal appendicitis. morphine. gastritis. effect of vomiting on pain. meperidine (Demerol). nephrolithiasis. gastroenteritis. ectopic pregnancy. Epigastrium: Gastritis. gastroenteritis. tinnitus (labyrinthitis). nephrolithiasis. renal calculus. Clay colored stools. fever. endometriosis. Left Upper Quadrant: Peptic ulcer. projectile). hematemesis. contraception. intussusception. odynophagia. oral contraceptives. bladder distension. colchicine. peptic ulcer. endometriosis. diverticulitis (redundant sigmoid) salpingitis. ovarian cyst torsion. bilious. endometriosis. or malnourished. headache. erythromycin. exposure to ill contacts. intestinal obstruction. Vital Signs: BP (orthostatic hypotension). prostatitis. melena. sexual history). mesenteric thrombosis. malignancy. coffee ground material. . pulmonary embolus. Right Lower Quadrant: Appendicitis. feculent. antidepressants. ovarian cyst. perforated viscus. mesenteric lymphadenitis. strangulated hernia. gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome). hepatic metastases. colitis. Ingestion of spoiled food. dysphagia. Hypogastric/Pelvic: Cystitis. endoscopy. vertigo. appendicitis. septic appearance. pancreatitis. inflammatory bowel disease. intussusception.

diminished taste. medications (contraceptives. night sweats. temperature (hypothermia). Vital Signs: Pulse (bradycardia). Note whether the patient appears ill. displaced PMI. bruits. or malnourished. barrel shaped chest. tumors (esophageal. tenderness. systemic infections. Abdomen: Scars. spider angiomas. glossitis. nausea. gradual). dental problems. hepatomegaly. diabetic ketoacidosis. ileus. jaundice.44 Anorexia and Weight Loss temperature (fever). Extremities: Edema. rebound. fever. Heart: Murmurs. HEENT: Dental erosions from vomiting. Physical Examination General Appearance: Muscle wasting. BP. dermatitis (Pellagra). chills. papilledema. jaundice. dysphagia. bulimia. Labs: CBC. skin laxity. Abdomen: Scars. drug abuse (cocaine. Skin: Pallor. dyspepsia. supraclavicular adenopathy (Virchow's node). thyromegaly. increased intracranial pressure. diarrhea. chemotherapy. rigidity. Anorexia and Weight Loss Chief Compliant: The patient is a 50 year old white male with diabetes who complains of loss of appetite and weight loss for one week. respiratory rate. lipase. gastroesophageal reflux. amylase. amount and rate of weight loss (sudden. oropharyngeal lesions. change in bowel habits. psychogenic vomiting. labyrinthitis. vomiting. 24-hour diet recall. cough. occult blood. dysuria. four views of the abdomen series. exacerbation of pain with eating (intestinal angina). ketone odor on breath (apple odor. History of the Present Illness: Time of onset. electrolytes. alcoholism. polydipsia. Dietary restrictions (low salt. low fat). toxins. Skin: Pallor. tenderness. renal failure. jaundice. gastric). distention. restricted access to food. Chest: Rhonchi. cholecystitis. bowel sounds. Signs of dehydration. AIDS risks factors. well. decreased bowel sounds. hair changes. ascites. antibiotics). psychiatric disease. myocardial ischemia. Polyuria. skin or hair changes. pregnancy. gastroparesis. LFTs. malignancy. hepatitis. chronic illness. peptic ulcer. hepatomegaly . intestinal obstruction. antiarrhythmics. pregnancy test. UA. abdominal pain. cyanosis. cheilosis. pancreatitis. diabetic ketoacidosis). amphetamines). temporal wasting. change in appetite. Differential Diagnosis: Gastroenteritis. jugulovenous distention or flat neck veins. HEENT: Nystagmus. Rectal: Masses. appendicitis. cachexia. renal disease.

nausea. antibiotics (erythromycin. pre-albumin. inflammatory bowel disease. Skin: Decreased skin turgor. cardiopulmonary disease. Extremities: Edema. Septic appearance. anorexia. shellfish. protein. Rectal: Occult blood. Vibrio parahaemolyticus). Medications Associated with Diarrhea: Laxatives. alcohol abuse. albumin. tenesmus (painful urge to defecate). AIDS risk factors. family history of celiac disease. anorexia nervosa. milk. blood or mucus. lymphadenopathy. gum (sorbitol). skin abrasions on fingers. poor proprioception. AIDS. hepatic or renal failure. vomiting. skin mottling. Labs: CBC. History of the Present Illness: Rate of onset. weight loss. peripheral vascular disease (ischemic colitis). fever. muscle wasting. laxative abuse. glossitis (B12. Diarrhea Chief Compliant: The patient is a 50 year old white male with hypertension who complains of diarrhea for two days. pulse (tachycardia). Physical Examination General Appearance: Signs of dehydration or malnutrition. Ill contacts with diarrhea. myalgias. Volume of stool output (number of stools per day). Vital Signs: BP (orthostatic hypotension). cholinergic agents. magnesium-containing antacids. frequency. toxicology screen. flatulence. dementia. palpable masses. watery stools. temperature (fever). sulfa drugs. malignancy (gastric carcinoma). folate deficiency). clindamycin). bloating. cholelithiasis. infection.Diarrhea 45 splenomegaly. coronary artery disease. Note whether the patient appears ill or well. Recent ingestion of spoiled poultry (salmonella). Past Medical History: Sexual exposures. depression. poor dental hygiene (loose dentures). . duration. common sources (restaurants). Oropharyngeal candidiasis (AIDS). arthralgias. bloating. Neurologic: Decreased sensation. Exacerbation by stress. riboflavin deficiency). foul odor. electrolytes. Abdominal cramps. Stool Appearance: Buoyancy. dry mucous membranes. milk (lactase deficiency). respiratory rate. thyroid studies. cheilosis (cracked lips. immunosuppressive agents. delayed capillary refill. Differential Diagnosis: Inadequate caloric intake. transferrin. oily. gastritis. diminished taste. narcotics. HEENT: Oral ulcers (inflammatory bowel or celiac disease). peptic ulcer. jaundice. LFTs. Periumbilical adenopathy. hyper/hypothyroidism. travel history. seafood (shrimp. colchicine. diminished olfaction. masses.

parasites. Labs: Electrolytes. masses. lactulose. tenderness. hematocrit. . Nose bleeds. intestinal ischemia. prior bleeding episodes. Bacillus cereus). AIDS-associated disorders (mycobacterial. irritable bowel syndrome. clostridium difficile toxin. Abdominal X-ray: Air fluid levels. diverticulitis. history of peptic ulcer. sprue). ulcerative colitis. History of the Present Illness: Duration and frequency of hematemesis (bright red blood. distention. dilation. rebound. bacterial overgrowth. nausea. vasoactive intestinal peptide tumor. Exudative Diarrhea: Bacterial infection. Absent peripheral pulses. melena. enteral feeding. Extremities: Arthritis (ulcerative colitis). Abdominal pain. Hematemesis and Upper Gastrointestinal Bleeding Chief Compliant: The patient is a 50 year old white male with peptic ulcer disease who complains of emesis of blood for 4 hours.46 Hematemesis and Upper Gastrointestinal Bleeding Abdomen: Hyperactive bowel sounds. decreased perianal sensation. sorbitol. carcinoid tumors. hyperthyroidism. Clostridium difficile. bruits (ischemic colitis). guarding. Wright's stain for fecal leucocytes. Diarrhea Secondary to Altered Intestinal Motility: Diabetic gastroparesis. constipation-related diarrhea. cultures for enteric pathogens. albumin. Campylobacter. Neuro: Mental status changes. Norwalk virus). hematochezia (bright red blood per rectum). E coli. bruits (ischemic colitis). sphincter tone. ingestion of mannitol. CBC with differential. Secretory Diarrhea: Bacterial enterotoxins. esophagitis. colonic villus adenoma. laxatives. viral infection. pancreatic calcifications. tenderness. shigella. other disaccharidase deficiencies. occult blood. coffee ground material). HIV enteropathy). calcium. Peripheral neuropathy (B6. ova and parasites x 3. medullary thyroid cancer. Differential Diagnosis Acute Infectious Diarrhea: Infectious diarrhea (salmonella. Forceful retching prior to hematemesis (Mallory-Weiss tear). Crohn's disease. lactase deficiency (gastroenteritis. traveler's diarrhea. Zollinger-Ellison syndrome. cholinergics. sphincter reflex. diverticulitis. Rectal: Perianal ulcers. B12 deficiency). rigidity (peritoneal signs). flexible sigmoidoscopy. syncope. antibiotic-related diarrhea Chronic Diarrhea: Osmotic Diarrhea: Laxatives. enteric viruses (rotavirus. volume of blood. lightheadedness. hepatomegaly.

endoscopy. fatigue. temperature. Family History: Liver disease or bleeding disorders. hepatic atrophy (cirrhosis). Endoscopy. breast masses (metastatic disease). Genitourinary/Rectal: Gross or occult blood. platelets. BUN (elevation suggests upper GI bleed). Ascites. hepatic encephalopathy. parotid gland hypertrophy). Past Medical History: Liver or renal disease. confusion. masses. Vital Signs: Supine and upright pulse and blood pressure (orthostatic hypotension. Medications: Aspirin. pallor. postural hypotension indicates a 20-30% blood loss). Past Testing: X-ray studies. cold extremities. anorexia. Past Treatment: Endoscopic sclerotherapy. confusion. Skin: Delayed capillary refill. Mallory Weiss tear (gastroesophageal junction tear due to vomiting or retching). testicular atrophy. Hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome). dilated abdominal veins. swallowed blood (nose bleed. oliguria (<20 mL of urine per hour). flat neck veins. duodenitis. aorto-enteric fistula. angiography. splenomegaly. coagulopathy. steroids. rebound. umbilical venous collaterals [caput medusae]. Stigmata of liver disease (jaundice. malaise. oral telangiectasia. spider angiomas. edema. poor memory. resting tachycardia indicates a 10% blood volume loss.Hematemesis and Upper Gastrointestinal Bleeding 47 Ingestion of alcohol. . jaundice. Weight loss. HEENT: Scleral pallor. gastric cancer. purple-brown nodules (Kaposi's sarcoma). masses. esophageal varices. abnormal pigmentation (Peutz-Jeghers syndrome). or malnourished. tenderness. diaphoresis. Neuro: Decreased mental status. asterixis (flapping wrists. gastritis. Abdomen: Scars. Physical Examination General Appearance: Pallor. hepatic encephalopathy). Extremities: Dupuytren's contracture (palmar contractures. petechiae. shunt surgery. cirrhosis). INR/PTT. early satiety. Nasogastric aspirate quantity and character. hypertrophic gastropathy (Menetrier's disease). glucose. Differential Diagnosis of Upper GI Bleeding: Gastric or duodenal ulcer. nuclear scan. transfusions given previously. ECG. well. Note whether the patient appears ill. liver nodules. electrolytes. esophageal varices. Labs: CBC. aortic surgery. nonsteroidal anti-inflammatory drugs. oral lesion). anticoagulants. esophagitis. Heart: Systolic ejection murmur. vascular ectasias. Chest: Gynecomastia (cirrhosis).

Rashes. Ascites. pale extremities. diarrhea. Stigmata of liver disease: Umbilical venous collaterals (Caput medusae). hepatic encephalopathy). gynecomastia. weight loss. Change in bowel habits or stool caliber. colitis. quantity. well. fever. Physical Examination General Appearance: Signs of dehydration. aspirin. polyps. Vital Signs: BP. delayed capillary refill. angiodysplasias. masses. oliguria. hernias. . carcinoma. Color of nasogastric aspirate. asterixis (flapping hand tremor. rebound tenderness. coagulopathies. liver function tests. Note whether the patient appears ill. alcoholism. fissures. confusion. pallor. air fluid levels). Neuro: Decreased mental status. diverticulosis. Genitourinary: Testicular atrophy. Meckel's diverticulitis. pulsatile masses (aortic aneurysm). Past Testing: Barium enema. infectious colitis. anorectal pain. purpura. atrial fibrillation (mesenteric emboli). spider angiomata. splenomegaly. Rectal: Gross or occult blood. Differential Diagnosis of Lower Gastrointestinal Bleeding: Hemorrhoids. streaks on stool. colonoscopy. distention. masses. upper GI bleeding. hematemesis. Constipation. coronary or renal disease. ammonia level. easy bruising. parotid gland hypertrophy. anorexia. peptic ulcer. jaundice. hemorrhoids. jaundice. fissures. NSAIDS. Epistaxis. lightheadedness. aortoenteric fistula. ischemic colitis. abdominal pain. liver atrophy (cirrhosis). buccal mucosa discolorations or pigmentation (Henoch-Schönlein purpura or Peutz-Jeghers polyposis syndrome). bruits. Abdominal X-ray series (thumbprinting. sigmoidoscopy. inflammatory bowel disease. clammy skin. ulcers. tenesmus (straining during defecation). cirrhosis. respiratory rate. epistaxis. Extremities: Cold. Skin: Cold. Abdomen: Scars. or malnourished. vomiting. rectal trauma. upper GI series. “silver wire” arteries (ischemic colitis). Medications: Anticoagulants. Heart: Systolic ejection murmurs. Past Medical History: Diverticulosis. pallor. bleeding polyps. HEENT: Atherosclerotic retinal disease. bleeding disease. endometriosis.48 Melena and Lower Gastrointestinal Bleeding Melena and Lower Gastrointestinal Bleeding Chief Compliant: The patient is a 50 year old white male with diverticulosis who complains of rectal bleeding for 8 hours. malaise. color of bleeding (gross blood. Labs: CBC (anemia). Fecal mucus. melena). pulse (orthostatic hypotension). intussusception. History of the Present Illness: Duration. hemorrhoids. temperature (tachycardia). recent hematocrit.

vomiting. firm tender. pregnancy. estrogen. Skin: Jaundice. Previous epigastric pain. pyelonephritis. angina. small bowel obstruction (gallstone ileus). herpes zoster. endoscopies. Note whether the patient appears ill. amylase. HEENT: Scleral icterus. dark urine. Radiation to epigastrium. lasting several hours). History of the Present Illness: Biliary colic (constant right upper quadrant pain. obesity. BP. guarding. septic appearance. sausage-like mass in RUQ (enlarged gallbladder). Prior Testing: Ultrasounds. Labs: Ultrasound. sickle cell anemia. gallstones. rapid weight loss. diabetes. jaundice. air in gallbladder wall (emphysematous cholecystitis). or malnourished. sickle cell anemia. pneumonia. flatulence. alkaline phosphatase. AST. Crohn's disease. gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome). jaundice. fever). rigidity. gallbladder calcifications. nausea. early satiety. respiratory rate (shallow respirations). low-grade fever. Signs of dehydration. . HIDA scans. hereditary spherocytosis. WBC. 30-90 minutes after meals. Past Medical History: Fasting. Plain Abdominal X-ray: Increased gallbladder shadow. Murphy's sign (tenderness and inspiratory arrest during palpation of RUQ). hyperbilirubinemia. Differential Diagnosis: Calculus cholecystitis. Vital Signs: Pulse (mild tachycardia). appendicitis. Charcot's sign (intermittent right upper quadrant abdominal pain. well. fatty food intolerance. sublingual jaundice. hyperalimentation. nephrolithiasis. exogenous steroids. hepatic metastases. peptic ulcer. restless patient unable to find a comfortable position. temperature (low-grade fever). cirrhosis. diabetes. Abdomen: Epigastric or right upper quadrant tenderness. rebound (peritoneal signs). HIDA (radionuclide) scan. scapula or back. Causes of Pigment Stones: Asians with biliary parasites. weight loss. pleurisy. pregnancy. Physical Examination General Appearance: Obese. Causes of Cholesterol Stones: Hereditary.Cholecystitis 49 Cholecystitis Chief Compliant: The patient is a 50 year old white male with obesity who complains of right upper quadrant pain for 6 hours. capillary refill. hepatitis. clay colored stools. alcohol. hyperalimentation. bloating. cholangitis. anorexia. hereditary spherocytosis. pancreatitis. gastroesophageal reflux disease.

or malnourished. TIBC. Weight loss. Physical Examination General Appearance: Signs of dehydration. liver function tests. antimitochondrial antibody (primary biliary cirrhosis). BP. hepatomegaly. ferritin (hemochromatosis). asterixis (flapping tremor when wrists are hyperextended. Labs: CBC with differential. palmar erythema. LFTs. Rectal: Occult blood. Extremities: Joint tenderness. somnolence (hepatic encephalopathy). right upper quadrant tenderness. liver biopsy. phenytoin. Courvoisier's sign (palpable nontender gallbladder with jaundice. Vital Signs: Pulse. sclerotic veins from intravenous injections. day care centers. Family History: Jaundice. hematemesis. lipase. serum iron. respiratory rate. exposure to hepatitis or jaundiced persons. ascites. drug screen. arthralgias. blood transfusion. anorexia. bronze skin discoloration (hemochromatosis). isoniazid. jaundice. nausea. well. hepatitis A IgM. Past Medical History: Heart failure. Prior Testing: Hepatitis serologies. increased abdominal girth (ascites). dark urine. sepsis. spider angiomas. firm).50 Jaundice and Hepatitis Jaundice and Hepatitis Chief Compliant: The patient is a 50 year old white male with alcoholism who complains of jaundice for 3 days. methotrexate. Umbilical venous collaterals (Caput medusae). KayserFleischer rings (bronze corneal pigmentation. vomiting. bowel sounds. NSAIDS. urticaria. pancreatic or biliary malignancy). encephalopathy). liver margin texture (blunt. . liver disease. Neuro: Disorientation. septic appearance. irregular. alpha-1-antitrypsin deficiency. Abdomen: Scars. ceruloplasmin. melena. Wilson's disease). hepatitis serologies (hepatitis B surface antibody. sublingual jaundice. Medications: Hepatotoxins: Acetaminophen. alcoholism. Chest: Gynecomastia. HEENT: Scleral icterus. ANA. Dupuytren's contracture (fibrotic palmar ridge). liver biopsy. hemorrhoids. Note whether the patient appears ill. lymphadenopathy. amylase. urticarial rash. fever. nitrofurantoin. hematochezia. foreign travel. Skin: Jaundice. pruritus. sulfonamides. splenomegaly (hepatitis) or hepatic atrophy (cirrhosis). History of the Present Illness: Dull right upper quadrant pain. Murphy's sign (inspiratory arrest with palpation of the right upper quadrant). hepatitis B surface antigen. Genitourinary: Testicular atrophy. needle tracks. liver span. hepatitis C antibody). confusion. urine copper (Wilson's disease). temperature (fever). IV drug abuse. prior hepatitis immunization.

fetor hepaticas (malodorous breath). BP. cirrhosis. IV drug use. Skin: Jaundice. erythematous arterioles). History of the Present Illness: Jaundice. jugulovenous distention (fluid overload). Parotid enlargement. right heart failure. diarrhea. “puddle sign” (flick over lower abdomen while auscultating for dullness). total parenteral nutrition. Gilbert's syndrome. Cirrhosis Chief Compliant: The patient is a 50 year old white male with alcoholism who complains of jaundice for one week. amyloidosis. shifting dullness. nausea. medication-related hepatitis. gynecomastia. Extremities: Lower extremity edema. spider angiomas (stellate. gingival hemorrhage (thrombocytopenia). CMV. Chest: Bibasilar crackles. Precipitating Factors of Encephalopathy: Gastrointestinal bleeding. Crigler-Niger syndrome (indirect). liver texture (blunt. atrophic liver. well. methotrexate. Wilson's disease. pancreatic malignancy). temperature (fever). nitrofurantoin. asterixis (jerking movement of hand with wrist hyperexten- . Physical Examination General Appearance: Muscle wasting. Intrahepatic Causes of Jaundice: Viral hepatitis. Rotor’s syndrome (direct hyperbilirubinemia). phenytoin.Cirrhosis 51 Differential Diagnosis of Jaundice Extrahepatic Causes of Jaundice: Biliary tract disease (gallstone. stricture. autoimmune hepatitis. HIV. tenderness. splenomegaly. anorexia. Umbilical or groin hernias (ascites). alcoholic hepatitis. Medications Associated with Hepatotoxicity: Acetaminophen. Vital Signs: Pulse. loss of body hair. testicular atrophy. or malnourished. Courvoisier's sign (palpable nontender gallbladder with jaundice. tumor. vomiting. viral hepatitis. Wilson's disease). abdominal distension. fluid wave. constipation. sarcoidosis. pancreatic cancer. irregular. sclerosing cholangitis. sulfonamides. palmar erythema. rebound (peritonitis). Genitourinary: Scrotal edema. confusion (encephalopathy). microsporidia). azotemia. isoniazid. respiratory rate. high protein intake. Dubin Johnson syndrome. pancreatitis. Neuro: Confusion. fatigue. Alcohol use. cancer). acute fatty liver of pregnancy. NSAIDS. scleral icterus. primary biliary cirrhosis. abdominal pain. Somnolence. Abdomen: Bulging flanks. firm). purpura. blood transfusion. increased abdominal girth (ascites). CNS depressants. HEENT: Kayser-Fleischer rings (bronze corneal pigmentation. infections (parasites. Note whether the patient appears ill. bronze skin discoloration (hemochromatosis).

venous outflow obstruction (BuddChiari. alpha-1-antitrypsin. LFTs. hemochromatosis.52 Cirrhosis sion. paracentesis. portal vein thrombus). jaundice. palmar erythema. Hepatitis serologies. Labs: CBC. Ultrasound. Stigmata of Liver Disease: Spider angiomas (stellate. red arterioles). antimitochondrial. TIBC. encephalopathy. edema. inborn error of metabolism (Crigler Najjar syndrome. Dupuytren's contracture (fibrotic palmar ridge to ring finger). autoimmune hepatitis. liver function tests. ferritin (hemochromatosis). Lacrimal and parotid gland enlargement. serum iron. separation or centralization of bowel loops. bilirubin. hemorrhoids. INR/PTT. UA. urine copper (Wilson's disease). Wilson's disease. hepatic encephalopathy). ecchymoses. testicular atrophy. ANA. heart failure. albumin. umbilical eversion. Differential Diagnosis of Cirrhosis: Alcoholic liver disease. D). ceruloplasmin. dilated periumbilical collateral veins (Caput medusae). primary biliary cirrhosis. venous hum and thrill at umbilicus (Cruveilhier-Baumgarten syndrome). alpha1-antitrypsin deficiency). C. antibody (primary biliary cirrhosis). ascites. electrolytes. bronze discoloration (hemochromatosis). Rectal: Occult blood. viral hepatitis (B. Abdominal X-ray: Hepatic angle sign (loss of lower margin of right lateral liver angle). . anti-Smith antibody. generalized abdominal haziness (ascites). gynecomastia.

lipase .1 >1.Evaluation of Ascites Fluid Etiology Appearance Protein Serum/fluid albumen ratio >1.1 low >10000 Bacteria on gram stain and culture Straw/bloody Clear Straw Turbid >3 >3 >3 >3 varies <1. triglycerides Acid fast bacilli Elevated amylase.1 RBC WBC Other Cirrhosis Spontaneous Bacterial Peritonitis Secondary Bacterial Peritonitis Neoplasm Tuberculosis Heart Failure Pancreatitis Straw Cloudy <3 g/dL <3 low low <250 cells/mm3 >250 polys Bacteria on gram stain and culture Purulent >3 <1.1 >1.1 high low-high low varies >1000 lymphs >1000 lymphs <1000 varies Malignant cells on cytology.1 <1.

left lower lobe dullness (pleural effusion). base deficit >4 mEq/L. Septic appearance. diffuse ground-glass appearance (ascites). hypocalcemia). WBC. Coxsackie virus or mumps infection. . calcium. relieved by sitting with knees drawn up. estrogen. mycoplasma infection. LDL. During initial 48 hours: Hematocrit decrease >10%. Ranson's Criteria of Pancreatitis Severity: Early criteria: Age >55. dull. elevated amylase. pulse (tachycardia). tetracycline. Extremities: Peripheral edema. distension. Medications Associated with Pancreatitis: Sulfonamides. azathioprine. Chest X-ray: Left plural effusion. Chest: Crackles. Abdomen X-Rays: Ileus. respirations (tachypnea). calcium <8. scorpion stings. arterial pO2 <60 mmHg. CT Scan with Oral Contrast: Pancreatic phlegmon. well. Ultrasound: Gallstones. pancreatic calcifications. furosemide. tumor.000. or malnourished. vomiting. rigors. History of the Present Illness: Constant. rigidity. trauma. low-grade fever. tachypnea. rebound. guarding. lipase. hypertriglyceridemia. Colon cutoff sign (spasm of splenic flexure with no distal colonic gas). hypoactive bowel sounds. Lupus. palpable purpura (polyarteritis nodosum). pentamidine. dideoxyinosine (DDI). LDH >350 IU/L. pseudocyst. triglycerides. AST. vasculitis. penetration of peptic ulcer. glucose >200. displaced or atonic stomach. glucose. abscess. nausea. thiazides. hypercalcemia. Cullen's sign (periumbilical bluish discoloration from hemoperitoneum). Chvostek's sign (taping cheek results in facial spasm. Skin: Jaundice. UA. exacerbated by supine position. jaundice. anorexia. Abdomen: Epigastric tenderness. HEENT: Scleral icterus. Precipitating Factors: Alcohol. anasarca. AST >250. boring. postoperative pancreatitis. Grey-Turner's sign (bluish flank discoloration from retroperitoneal hemorrhage). radiation to the mid-back. retrograde cholangiopancreatography. obscure psoas margins. dyspnea. Vital Signs: Temperature (low-grade fever). mid-epigastric or left upper quadrant pain. Physical Examination General Appearance: Signs of volume depletion. BUN increase >5. pancreatic edema or enlargement. gallstones. renal failure. Note whether the patient appears ill. Labs: Amylase. WBC >16. valproate.54 Pancreatitis Pancreatitis Chief Compliant: The patient is a 50 year old white male with alcoholism who complains of abdominal pain for 4 hours. estimated fluid sequestration >6 L. BP (hypotension). subcutaneous fat necrosis (erythematous skin nodules on legs and ankles). upper abdominal mass.

mesenteric thrombosis. Disorders Associated with Pancreatitis: Alcoholic pancreatitis. pancreatic divisum. peptic ulcer. salicylates. delayed capillary refill. gastroenteritis. hyperlipidemia. electrolytes. renal colic. cholecystitis. hepatitis. pneumonia. scorpion stings. medications. History of the Present Illness: Recurrent. dull. Past Medical History: Endoscopy. BP (orthostatic hypotension). Pain may radiate to back. hypercalcemia. aortic aneurysm. . lipase. cholecystitis. intestinal obstruction. temperature. BUN. Abdomen: Scars. Differential Diagnosis: Pancreatitis. Physical Examination General Appearance: Mild distress. guarding (perforated ulcer). pancreatic malignancy. rebound. Skin: Pallor. coffee ground hematemesis. epigastric pain. Alcohol. worse when supine or reclining. 1-3 hours after meals. myocardial ischemia. hepatitis. mild to moderate epigastric tenderness. history of previous ulcer disease and Helicobacter pylori (HP) therapy. vomiting. familial pancreatitis. amylase. Signs of dehydration. surgery. rigidity. Abdominal X-ray series. bowel sounds. septic appearance. melena. endoscopic retrograde cholangiopancreatography. aortic dissection. awakens patient at night or in early morning. trauma. viral infections. non-ulcer dyspepsia. gastroesophageal reflux disease. Vital Signs: Pulse (tachycardia). gastritis. Note whether the patient appears ill. burning. relieved by or worsen by food. upper GI series. Gastritis and Peptic Ulcer Disease Chief Compliant: The patient is a 50 year old white male with arthritis who complains of abdominal pain for two days. well. respiratory rate. penetrating peptic ulcer. vasculitis. mesenteric ischemia. or malnourished. Labs: CBC. relieved by antacids. weight loss. nonsteroidal anti-inflammatory drugs. perforating ulcer. bowel obstruction. gallstone pancreatitis. methyl alcohol. endoscopy. nausea. Rectal: Occult blood.Gastritis and Peptic Ulcer Disease 55 Differential Diagnosis of Midepigastric Pain: Pancreatitis.

Hemoconcentration. Past Medical History: Peripheral arterial occlusive disease. Medications: Nitroglycerine. pain is postprandial and may be relieved by nitroglycerine. carotid bruits (mesenteric ischemia). perforated viscus. femoral bruits. mesenteric infarction. angiogram. myocardial infarction. peptic ulcer. septic appearance. vomiting. clammy skin. asymmetric pulses (atherosclerotic disease). Note whether the patient appears “cachectic. BP (orthostatic hypotension). portal vein gas. Chest X-ray: Free air under diaphragm (perforated viscus). delayed capillary refill. bowel obstruction. Rectal: Occult or gross blood. then absent bowel sounds. pulse (tachycardia). hypercholesterolemia. episodes of bloody diarrhea. Extremities: Weak peripheral pulses. Vitals: Pulse.56 Mesenteric Ischemia and Infarction Mesenteric Ischemia and Infarction Chief Compliant: The patient is a 50 year old white male with coronary heart disease who complains of abdominal pain for 6 hours. or malnourished. angina. Labs: CBC. History of the Present Illness: Sudden onset of severe. appendicitis. Abdominal X-ray: “thumb-printing” (edema of intestinal wall). Skin: Cold. Abdomen: Initially hyperactive bowel sounds. periumbilical pain. leukocytosis. mild to moderate distress. pancreatitis. Bowel wall gas (colonic ischemia. ruptured aortic aneurysm. hypertension. nonocclusive). well. electrolytes. poorly localized. claudication. pallor. metabolic acidosis. peritonitis. Signs of dehydration. pulsatile masses (aortic aneurysm). distention. nausea. food aversion.” ill. Physical Examination General Appearance: Lethargy. weight loss. carcinoma. gastroenteritis. prerenal azotemia. acute cholecystitis. atrial fibrillation. abdominal bruit. heart failure. Pain out of proportion to the physical findings may be the only presenting symptom. chest pain. diabetes. hyperamylasemia. aspirin. “silver wire” arteries. guarding. respiratory rate. temperature.. beta-blockers. . Differential Diagnosis: Mesenteric ischemia. HEENT: Atherosclerotic retinopathy. rebound tenderness. rigidity (peritoneal signs).

mesenteric ischemia. . Physical Examination General Appearance: Severe distress. Pain localizes to periumbilical region in small bowel obstruction and localizes to lower abdomen in large bowel obstruction. nausea. Skin: Cold. tender mass. peritonitis. distention. Tenderness. Causes of Large Bowel Obstruction: Colon cancer. History of the Present Illness: Vomiting (bilious. temperature (fever). bloody). small bowel tumors. cancer. air-fluid levels. use of opiates. distention. antipsychotics. hyperamylasemia. masses. Colonic distention with haustral markings. pallor. rebound. Abdominal X-rays: Dilated loops of small or large bowel. femoral. colon cancer. umbilical). feculent. diverticulitis. gastritis. rigidity. hernias. Ogilvie's syndrome (chronic pseudoobstruction). Bowel Sounds: High pitch rushes and tinkles coinciding with cramping (early) or absent bowel sounds (late). pulse (tachycardia). crampy abdominal pain. electrolytes. hypokalemic metabolic alkalosis due to vomiting. respiratory rate. gallstone ileus. strictures from inflammatory processes. narcotic ileus. Pain becomes diffuse with fever. gastroenteritis. ladder pattern of dilated loops of bowel in the mid-abdomen. history of constipation. Note whether the patient appears ill. previous abdominal surgery. Hernias. obstipation. myocardial infarction. adynamic ileus. bruits. inguinal. Ischemia. volvulus. Vital Signs: BP (hypotension). signs of dehydration. or malnourished. peptic ulcer. scars (intraabdominal adhesions). Initially crampy or colicky pain with exacerbations every 5-10 minutes. Differential Diagnosis: Cholecystitis. Labs: Leucocytosis. superior mesenteric artery syndrome. clammy skin. septic appearance. gallstones. Causes of Small Bowel Obstruction: Adhesions (previous surgery). pancreatitis. recent weight loss. Rectal: Gross blood. metastatic cancer. Abdomen: Hernias (incisional. renal colic. well.Intestinal Obstruction 57 Intestinal Obstruction Chief Compliant: The patient is a 50 year old white male with colon cancer who complains of abdominal pain for 6 hours. anticholinergics. sickle crisis. elevated BUN and creatinine.

58 Intestinal Obstruction .

FSH. medications (contraceptives) or drugs (marijuana). signs of hyperthyroidism (tremor) or hypothyroidism (bradycardia. thyroid symptoms. History of dilation and curettage. LH. radiation therapy. Age of menarche. psychologic stress. last menstrual period. Tanner stage of breast development. breast tenderness). timing of breast and pubic hair development. headaches. temporal balding. imperforate hymen. weight gain or loss. Chest: Galactorrhea. possibility of pregnancy. hypothermia. . focal motor deficits. deepening of the voice (hyperandrogenism). thyroid enlargement or nodules. sexual activity.Amenorrhea 59 Gynecologic Disorders Amenorrhea Chief Compliant: The patient is a 24 year old female with anorexia nervosa who complains of amenorrhea for 3 months. . vaginal atrophy. Labs: Pregnancy test. cool dry skin. Life style changes. obesity. body habitus. prolactin. inguinal or labial masses. Neuro: Visual field defects. HEENT: Acne. Menstrual pattern. Progesterone-estrogen challenge test. chemotherapy. Hot flushes and night sweats (hypoestrogenism). brittle hair). Note whether the patient appears ill. visual disturbances. well. Physical Examination General Appearance: Secondary sexual characteristics. antidepressants. vaginal septum. hirsutism. Abdomen: Abdominal striae (Cushing’s syndrome). pregnancy testing. cranial nerve palsies. history of severe hemorrhage (Sheehan's syndrome). breast atrophy. History of the Present Illness: Primary amenorrhea (absence of menses by age 16) or secondary amenorrhea (cessation of menses after previously normal menstruation). uterine enlargement. ovarian cysts or tumors. postpartum infection (Asherman’s syndrome). clitoromegaly. obesity. Past Medical History: Pregnancy complications. symptoms of pregnancy (nausea. Gyn: Pubic hair distribution. TSH. galactorrhea (prolactinoma). Medications: phenothiazines. dieting and excessive exercise. or malnourished.

. hormonal contraception. postcoital bleeding. Adenomyosis. fever. birth control method. fibroids. 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 Chief Compliant: The patient is a 24 year old female who complains of abnormal vaginal bleeding for two weeks. number of pads per day. possibility of pregnancy. or hepatic diseases. Thyroid. passage of clots. Psychologic stress. tachycardia. regularity. sexually active. amount of bleeding. coagulopathies. Note whether the patient appears ill or well. cervix. hypotension. renal. weight changes. endometriosis. Changes in hair or skin texture or distribution Molimina symptoms of pregnancy (premenstrual breast tenderness. bloating. Vital Signs: Assess hemodynamic stability. orthostatic vitals. Past Medical History: Obstetrical history. exercise. endometrial biopsies. lightheadedness. History of the Present Illness: Last menstrual period. abdominal pain. endocrine disorders. Dental bleeding. signs of shock. Physical Examination General Appearance: Assess rate of bleeding. dysmenorrhea). Family History: Coagulopathies. intermenstrual bleeding. obesity.60 Abnormal Uterine Bleeding 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. duration and frequency of menses. age of menarche.

obstetrical history. uterine size. breast tenderness). Cervical motion tenderness. cervical lesions. Thyroid disease. platelets. and intrauterine device (IUD) use Past Medical History: Surgical history. Polycystic ovarian syndrome. hirsutism. foreign body. intrauterine device Androgen excess. fine thinning hair (hypothyroidism). thrombocytopenia. adrenal disease Hematologic-related.Pelvic Pain and Ectopic Pregnancy 61 Skin: Pallor. History of the Present Illness: Positive pregnancy test. type and screen. gastrointestinal symptoms. Cervical lesions should be biopsied. Differential Diagnosis Pregnancy-related. bleeding time. INR/PTT. missed menstrual period. menstrual interval. adrenal tumor. gynecologic history. previous ectopic. endometrial polyp. Gyn: Pubic hair distribution. tubal surgery. excessive exercise. Associated Symptoms: Fever. cervicitis Pelvic Pain and Ectopic Pregnancy Chief Compliant: The patient is a 50 year old female with hypertension who complains of chest pain for 4 hours. uterine myoma. skin and hair changes. ovarian tumor. stress. symptoms of pregnancy (nausea. Characteristics of pelvic pain. endometrial sampling. cervical carcinoma. clotting factor deficiencies. onset. Prolactinoma Outflow tract-related. dysuria. Ectopic pregnancy. previous pelvic surgery. Oral contraceptive pills Hypothalamic-related. Rupture of ectopic pregnancy usually occurs 6-12 weeks after last menstrual period. Chlamydia test. eating disorders. vaginal discharge. HEENT: Thyroid enlargement Chest: Breast development by Tanner staging. age of menarche. duration. shoulder pain. duration. Pelvic inflammatory disease. petechiae. obesity. Dieting. Labs: CBC. Trauma. abnormal vaginal bleeding (quantify). sexually transmit- . adnexal tenderness. Current sexual activity and practices. Last menstrual period. chronic illness. fever. pelvic or abdominal pain (bilateral or unilateral). drugs Pituitary-related. abortion Hormonal contraception. gonococcal culture. serum pregnancy test. anticoagulant medications Infectious causes. vaginal tumor.. uterine carcinoma. adrenal hyperplasia Other endocrine causes. galactorrhea. Thrombocytopenia. pelvic inflammatory disease. Risk Factors for Ectopic Pregnancy: Multiparity.

ovarian cyst hemorrhage or rupture. CBC. irritable bowel syndrome. gonorrhea. Ectopic pregnancy. cervical motion tenderness. Pelvic inflammatory disease. enlarged uterus. Urinary tract infection. tumor. primary dysmenorrhea. pallor. well. pulse (tachycardia). Pelvic: Cervical discharge. Rh. uterine leiomyoma torsion. local then generalized tenderness. Type and hold. Differential Diagnosis of Pelvic Pain Pregnancy-Related Causes. pregnancy). Physical Examination General Appearance: Moderate to severe distress. Hegar's sign (softening of uterine isthmus. Chlamydia. Septic appearance. Medications: Method of Contraception: Oral contraceptives or barrier method. Vital Signs: BP (hypotension). respiratory rate. delayed capillary refill. transvaginal ultrasound. or incomplete). Mittelschmerz. abortion (spontaneous. Urinary Tract. rebound (peritoneal signs). intraabdominal bleeding). Appendicitis. threatened. temperature (low fever). pregnancy). Note whether the patient appears ill. Labs: Quantitative beta-HCG. Chadwick's sign (cervical cyanosis. chlamydia culture. Skin: Cold clammy skin. Gynecologic Disorders. diverticulitis. intrauterine device (IUD). intrauterine pregnancy with corpus luteum bleeding. UA with micro.62 Pelvic Pain and Ectopic Pregnancy ted diseases. Non-reproductive Tract Causes Gastrointestinal. tender adnexal mass or cul-de-sac fullness. inflammatory bowel disease. renal calculus. or distressed. Abdomen: Cullen's sign (periumbilical darkening. . endometriosis. mesenteric adenitis. adnexal torsion. infertility. GC.

calcium channel blockers. Lacrimation. Age at onset of headaches. Temporomandibular joint tenderness (TMJ syndrome). blurred vision. family history of migraine. sensory disturbances. Associated Symptoms: Weakness. Aggravating or Relieving Factors: Relief by analgesics or sleep. Dental infection. Conjunctival injection. “The worst headache ever” (subarachnoid hemorrhage).. asymmetric pupil reactivity. alcohol. H2 blockers. . nausea. metronidazole (Flagyl). effect of supine position.Headache 63 Neurologic Disorders Headache Chief Compliant: The patient is a 50 year old female with hypertension who complains of chest pain for 4 hours. neck stiffness (meningitis). alpha-adrenergic blockers. sinus tenderness (sinusitis). nasal discharge (sinusitis). Exacerbation by foods (chocolate. papilledema. oral contraceptives. fever. intermittent headaches (cluster headaches). exacerbating or relieving factors. History of the Present Illness: Quality of pain (dull. vomiting. onset (gradual or sudden). frequency. band-like. NSAIDs. lacrimation. facial angiofibromas (adenoma sebaceum). auditory acuity. e. Vital Signs: BP (hypertension). photophobia. exertion. temporal. wine. change in severity.g. rhinorrhea (cluster headache). extraocular movements. pulse. sensory deficits. exacerbation by fatigue. transient blindness. dysarthria. throbbing). Physical Examination General Appearance: Note whether the patient appears ill or well. hypertension. ataxia. visual field deficits. analgesic or codeine use. lack of sleep. menses. suboccipital. diplopia. awakening from sleep. time of day. Neuro: Cranial nerve palsies (intracranial tumor). bilateral or unilateral). nitrates. monosodium glutamate). depression. trauma. HEENT: Cranial or temporal tenderness (temporal arteritis). ataxia. eye pain or redness (glaucoma). tooth tenderness to percussion (abscess). time course of typical headache episode. location (retro-orbital. temperature (fever). cheese. Aura or Prodrome: Visual scotomata. deep tendon reflexes. sharp. respiratory rate. Drugs: ACE inhibitors and antagonists. temporal or ocular bruits (arteriovenous malformation). emotional upset. paraspinal muscle tenderness. selective-serotonin reuptake inhibitors. Skin: Café au lait spots (neurofibromatosis). Neck: Neck rigidity . nifedipine (Adalat). flushing. focal weakness (intracranial tumor).

occurs late in day. nausea. anemia. Rate of onset of vertigo. diplopia. excruciating or paroxysmal headache. ESR. Young males. awakening from sleep. aura of scotomas or scintillations. Physical Examination General Appearance: Effect of hyperventilation on symptoms. coughing. followed by pain-free periods. unilateral pulsating or throbbing pain. systemic infection. meningitis. subdural hematoma. MRI scan. BP (supine and upright. Dizziness and Vertigo Chief Compliant: The patient is a 50 year old female with hypertension who complains of chest pain for 4 hours. tension headache. diabetes. Headache. arteriovenous malformation. CBC with differential. Note whether the patient appears ill or well. Hyperventilation. changing from supine to standing. family history of headache. retro-orbital searing pain. Lasts hours and is usually relieved by simple analgesics. venous sinus thrombosis. Band-like pressure. throbbing pain.64 Dizziness and Vertigo Labs: Electrolytes. related to stress. postural hypotension). hypertension. Medications Associated with Vertigo: Antihypertensives. trigeminal neuralgia. Characteristics of Tension Headache: Bilateral. furosemide. Characteristics of Migraine: Childhood to early adult onset. cardiovascular disease. nausea. vomiting. vomiting. Lasts 2-6 hours. increased frequency or severity of headache. Differential Diagnosis: Migraine. transient ischemic attack. sinusitis. phenytoin. benign intracranial hypertension (pseudotumor cerebri). decreased visual acuity. recent change in eyeglasses. Occurs several times each day over several weeks. post concussion syndrome. aspirin. Vital Signs: Pulse. temporal arteritis. bitemporal or suboccipital. intracranial tumor. light headedness. tinnitus. encephalitis. Onset in adolescence or young adult. turning head. papilledema. alcohol. History of the Present Illness: Sensation of spinning or movement of surroundings. glaucoma. syncope. nasal and conjunctival congestion. respiratory . persistent vomiting. diuretics. hypertensive encephalopathy. subarachnoid hemorrhage. analgesic overuse. paresthesias. sedatives. gentamicin. history of stroke. Aggravation by change in position. Characteristics of Cluster Headache: Unilateral. Effect of Valsalva maneuver on symptoms. hearing loss. Past Medical History: Recent upper respiratory infection. lacrimation. generalized. Indications for MRI scan: Focal neurologic signs. head trauma with focal neurologic signs or lethargy. lasts 20-60 min. head trauma. relief with sleep. lumbar puncture.

formification (sensation that insects are crawling under skin). alcohol. drugs. Weber test (lateralization of sound). transient ischemic attacks. obtundation (awake but not alert). multiple sclerosis. anticoagulants. finger to nose test (coordination). renal. cerebellopontine angle tumor. Past Medical History: Trauma. meningitis. stupor (unconscious but awakable with vigorous stimulation). cholesteatoma (chronic middle ear effusion). Coma and Confusion 65 rate. History of the Present Illness: Level of consciousness. Effect of head turning or of placing the patient recumbent with head extended over edge of bed. tandem gait. temperature. brain stem or cerebellar infarctions. weakness. loop diuretics. Parkinson’s disease. murmurs. electrolytes. HEENT: Nystagmus. poor concentration. headache. sensory deficits. Neuro: Cranial nerves 2-12. hypertension. narcotics. Coma and Confusion Chief Compliant: The patient is a 50 year old male with coronary heart disease who presents with confusion for 6 hours. ataxia. presyncope. Romberg test. deafness). caffeine. aspirin. acoustic neuroma. suicide attempts or depression. . Confusion. benzodiazepines. impacted cerumen. agitation. Rinne's test (air/bone conduction). coma (cannot be awakened). Medications: Insulin. phenytoin. Labs: CBC. visual impairment. new eyeglasses. epilepsy (post-ictal state). antipsychotics. facial weakness. tinnitus. Central Causes of Vertigo: Vertebrobasilar insufficiency. Tympanic membrane inflammation (otitis media). Activity and symptoms prior to onset. haloperidol). brain stem or cerebellar contusion. visual field deficits. tumors. Other Disorders Associated with Vertigo: Motion sickness. Differential Diagnosis Drugs Associated with Vertigo: Aminoglycosides. Fever. psychotropics (lithium. orthopedic problems). liver or cardiac disease. papilledema. Peripheral Causes of Vertigo: Acute labyrinthitis/neuronitis. Heart: Rhythm. Meniere's disease (vertigo. dementia. oral hypoglycemics. benign positional vertigo. anticholinergics. Delirium.Delirium. Rectal: Occult blood. hallucination. otitis media. visual acuity. alcohol. stroke. encephalitis. MRI scan. orthostatic hypotension. cerumen. syndrome of multiple sensory deficits (peripheral neuropathies.

primitive reflexes (snout. or malnourished. respiratory rate. no eye movements or loose movements occur with bihemispheric lesions. delirium tremens). incoherent speech. jaundice.3. dilated superficial veins (liver failure). septic appearance. withdraws to pain . orientation to person. Oculovestibular Reflex (Cold caloric maneuver): Irrigation of ear with cold .6. flame lesions. ascites.3. somnolence. temperature (fever). facial asymmetry. eyes open spontaneously . indicates damage to contralateral hemisphere above midbrain. Glasgow Coma Scale Best Verbal Response: None . abnormal flexion to pain . wrist and fingers with leg extension. suck.2. obeys commands . petechia. extraocular movements. masses. Best Motor Response: None . confused speech or words . Neuro: Concentration (subtraction of serial 7s. place. splinter hemorrhages. eyes open to pain . Neck: Neck rigidity. Total Score: 3-15 Special Neurologic Signs Decortication: Painful stimuli causes flexion of arms. oriented speech . Tremor (Parkinson's disease. Pupil size and reactivity. raccoon sign (periorbital ecchymosis.1. strength. Papilledema. Chest: Breathing pattern (Cheyne-Stokes hyperventilation).4.4. HEENT: Skull palpation for tenderness.1. wrists and fingers flex.66 Delirium. incomprehensible sounds or cries . Note whether the patient appears ill. pulse. lethargy. Oculocephalic Reflex (Doll's eyes maneuver): Eye movements in response to lateral rotation of head.1. murmurs. glabella. hemotympanum (basal skull fracture). tenderness.2. hemorrhages. crackles. Extremities: Needle track marks (drug overdose). spider angiomata. splenomegaly. well. Skin: Cyanosis.2. abnormal extension to pain . appropriate words or vocal sounds . lacerations. weakness.5. palmomental grasp). Coma and Confusion Physical Examination General Appearance: Signs of dehydration. Abdomen: Hepatomegaly. recent events. delirium). skull fracture). Heart: Rhythm. Best Eye Opening Response: No eye opening . wheezes. palmar erythema (hepatic encephalopathy). mini-mental status exam. localizes to pain . Tongue or cheek lacerations (post-ictal state).5. distention. Atrophic tongue (B12 deficiency). indicates midbrain and pons functioning. eyes open to speech . Vital Signs: BP (hypertensive encephalopathy). Babinski's sign. Injection site fat atrophy (diabetes). carotid bruits.4. capillary refill. cranial nerves 2-12. ptosis. tattoos. Decerebration: Painful stimuli causes extension of legs and arms. Battle's sign (ecchymosis over mastoid process). time.3.

antihypertensives. heart failure. hyperlipidemia. abnormal respirations). factitious coma. cigarette smoking. uremia. cocaine use. arrhythmias (atrial fibrillation). nausea. hypoglycemia (insulin overdose). liver function tests. retinal hemorrhages (subarachnoid hemorrhage). pulse (bradycardia). hypertensive encephalopathy. alcohol. if the patient is conscious. loss of consciousness. systemic infection. exertion. echocardiograms. temperature. Past Medical History: Hypertension. dysphagia. headache prior to event. Physical Examination General Appearance: Level of consciousness. head trauma. palpitations. BUN. extraocular movements. IV drug abuse. History of the Present Illness: Rate and pattern of onset of weakness (gradual. encephalitis. visual aura. HEENT: Signs of head trauma. tongue biting. folate levels. tonic-clonic movements. vitamin B12 or folate deficiency. hypoxia. calcium. Vital Signs: BP. stroke. electrolytes. meningitis. hepatic encephalopathy. hypertension. prior strokes. sleeping). past transient monocular blindness (Amaurosis fugax). dysarthria. cardiac disease. endocarditis. B-12. activity prior to onset (Valsalva. . ABG. improvement or progression of weakness. Differential Diagnosis of Delirium: Electrolyte imbalance. vertigo. vomiting. exacerbation of dementia. Confusion. diabetes. nystagmus and vertigo will occur. hyperlipidemia. Medications: Anticoagulants. endocarditis). respiratory rate. ammonia. dehydration. anatomic location of deficit. sudden). head trauma . Note whether the patient appears ill or well. hypothyroidism. carotid Doppler studies. Family history: Stroke. Past testing: CT scans. Cushing’s response (bradycardia.Weakness and Ischemic Stroke 67 water causes tonic deviation of eyes to irrigated ear if intact brain stem. Weakness and Ischemic Stroke Chief Compliant: The patient is a 50 year old white male with claudication who presents with right arm weakness for 3 hours. intracranial hemorrhage. claudication. alcohol or drug withdraw or intoxication. subdural hematoma. alcohol. LP if no signs of elevated intracranial pressure and suspicion of meningitis. Labs: Glucose. narcotic or anticholinergic overdose. Roth spots (flame-shaped lesions. incontinence of stool or urine. coronary disease. ketoacidosis. neck movement. CT/MRI. lethargy. postictal state. hyperglycemia. creatinine. papilledema. pupil size and reactivity. urine toxicology screen. time of onset and time course to maximum deficit. prior transient ischemic attacks (neurologic deficit lasting less than 24 hours). Fundi: hypertensive retinopathy. psychotic states. valvular disease. steroid withdrawal. seizure.

carotid bruits. brain tumor. hypoglycemia. stroke. Mini-mental status exam. concentration. grasp). Chest: Breathing pattern. Biting of tongue. hypertension. high fever. theophylline toxicity. and toes dorsiflex if pyramidal tract lesion). atypical migraine. splinter hemorrhages. encephalitis. trauma. S3 (heart failure). abnormal respirations. Cushing's response . infection. dilation of ipsilateral pupil. Abdomen: Aortic pulsations. incontinence of urine or feces. headache. Past testing: EEG's. basilar artery stenosis. Neuro: Focal motor deficits. mass effect. tonic-clonic movements. hypocalcemia. past episodes of incontinence of urine during sleep. subdural hematoma. lethargy). . postictal paralysis (Todd's paralysis). cardiogenic emboli). Factors that May Precipitate Seizures: Fatigue. vomiting. cranial nerves 2-12. focal neurologic deficits. conversion reaction. head trauma. meningismus. MRI scans. description of seizure.68 Seizure facial asymmetry or weakness. papilledema. fever. Heart: Irregular rhythm (atrial fibrillation). Skin: Petechia. ptosis. duration of seizure. Tongue or buccal lacerations. infarction. ECG. Prodrome (visual changes.bradycardia. meningitis. hypoglycemia. primitive reflexes (snout. family history of epilepsy. migraine headaches. ecchymoses. glabella. vomiting. History of the Present Illness: Time of onset of seizure. chills. alcohol or drug withdrawal. post-ictal weakness or paralysis. elevated intracranial pressure). gaze. sleep deprivation. Signs of Increased Intracranial Pressure: Lethargy. Clonus. memory. Signs of Cerebral Herniation: Obtundation. transient ischemic attack. palmomental. Aura (irritability. CBC. Diabetes (hypoglycemia). behavioral change. paresthesias). renal bruits (atherosclerotic disease). uremia. Labs: CT scan: Bleeding. noncompliance with anticonvulsant medication (recent blood level). Past seizures. stroke. Babinski's sign (stroke sole of foot. Seizure Chief Compliant: The patient is a 50 year old white male with epilepsy who presents with a seizure 4 hours prior to admission. hyperventilation. decerebrate posturing (extension of arms and legs in response to painful stimuli). cocaine. delirium. Neck: Neck rigidity. Cheyne Stokes respiration (periodic breathing with periods of apnea. ascending weakness. murmurs (mitral stenosis. meningitis. Differential Diagnosis of Stroke: Abscess. midline shift. Extremities: Unequal peripheral pulses. pallor.

hirsutism (phenytoin). anticonvulsant levels. Babinski's sign. pupil reactivity and equality. papilledema. CBC. brain tumor. neck rigidity. Skin: Café-au-lait spots. hypoglycemia. EEG. fractures. pseudo-seizure. facial angiofibromas (adenoma sebaceum). extraocular movements. neurofibromas (Von Recklinghausen's disease). liver function tests. HEENT: Head trauma. gum hyperplasia (phenytoin). Labs: Glucose. Vital Signs: BP (hypertension). temperature (hyperpyrexia). hyponatremia. hypertensive encephalopathy. pulse. RPR/VDRL. murmurs. focal weakness (Todd's paralysis). generalized seizure). calcium. Extremities: Cyanosis. Neuro: Dysarthria. sensory deficits. alcohol withdrawal. Chest: Rhonchi. Spider angiomas (hepatic encephalopathy). stroke.Seizure 69 Physical Examination General Appearance: Post-ictal lethargy. Unilateral port-wine facial nevus (SturgeWeber syndrome). encephalitis. visual field deficits. hypocalcemia. meningitis. cranial nerves. noncompliance with anticonvulsant medications. vasculitis. wheeze (aspiration). urine toxicology. Genitourinary/Rectal: Incontinence of urine or feces. splinter hemorrhages (endocarditis). . hypopigmented ash leaf spots (tuberous sclerosis). electrolytes. Heart: Rhythm. Differential Diagnosis: Epilepsy (complex partial seizure. respiratory rate. trauma. MRI. tongue or buccal lacerations. Note whether the patient appears ill or well. lumbar puncture. carotid bruits. hypomagnesemia.

70 Seizure .

400-500 mL urine/day). respiratory rate (tachypnea). sepsis. creatinine. urethrocele. abdominojugular reflex (heart failure).Oliguria and Acute Renal Failure 71 Renal Disorders Oliguria and Acute Renal Failure Chief Compliant: The patient is a 50 year old white male with diabetes who presents with decreased urine output for 8 hours. NSAID's)renally excreted medications. BUN. skin temperature and color. passing of tissue fragments. diarrhea. fever. UA. indicates significant volume depletion). Pelvic: Pelvic masses. Urine and serum osmolality. venous distention (heart failure). pulse (tachycardia). Past Medical History: Recent upper respiratory infection (post streptococcal glomerulonephritis). hematuria. Skin: Decreased skin turgor over sternum (hypovolemia). S3 (volume overload). Rectal: Prostate hypertrophy. anuria (<100 mL urine/day). septic appearance. flat neck veins (volume depletion). costovertebral angle tenderness. Fractional excretion of sodium (FE Na) = UNa(mMol/L) x Scr(mmol/L) x 100 SNa(mMol/L) UCr(mMol/L) . kidney stones Dysuria. Physical Examination General Appearance: Signs of dehydration. an increase in heart rate by >15 mmHg and a fall in systolic pressure >15 mmHg. distended bladder. heart failure. flank pain. HEENT: Oral mucosa moisture. Ultrasound of bladder and kidneys. nasogastric suction. murmurs. Vital Signs: BP (orthostatic vitals. ocular moisture. recent chemotherapy (tumor lysis syndrome). uric acid. cystocele. measured fluid input and output by Foley catheter. Extremities: Peripheral edema (heart failure). Note whether the patient appears ill or well. History of the Present Illness: Oliguria (<20 mL/h. Labs: Sodium. Abdominal pain. urine creatinine. Chest: Crackles (heart failure). amphotericin. nephromegaly (obstruction). vomiting. absent sphincter reflex. decreased sensation (atonic bladder due to vertebral disk herniation). prostate enlargement. Abdomen: Hepatomegaly. Heart: Irregular rhythm. delayed capillary refill. potassium. chills. hemorrhage. jaundice (hepatorenal syndrome). temperature (fever). nephrotoxic drugs (aminoglycosides. foamy urine (proteinuria). Medications: Anticholinergics.

Prerenal insult is the most common cause of acute renal failure. Nephrotoxins (radiographic contrast. Post-renal Failure Prerenal BUN/Creatinine ratio Urine sodium Urine osmolality Renal failure Index FE Na Urine/plasma creatinine Urine analyses >15:1 ARF <15:1 Postrenal varies <20 mMol/L >500 mOsm/kg <1 >20 <350 >1 varies varies varies <1% >40 >1% >20 varies varies normal cellular casts RBCs. allopurinol. Acute glomerulonephritis or acute interstitial nephritis (usually from allergic reactions to beta-lactam antibiotics. furosemide. sepsis). . Renal. diuresis. rifampin. WBCs. D. Insult to the renal parenchyma (tubular necrosis) causes 20% of acute renal failure. It is usually caused by reduced renal perfusion pressure secondary to extracellular fluid volume loss (diarrhea. cimetidine. Prolonged hypoperfusion is the most common cause of tubular necrosis. Intrarenal Insult A. sulfonamides.72 Oliguria and Acute Renal Failure Renal Failure Index = UNa x 100 U/PCr Clinical Findings in Pre-renal. accounting for 70%. GI hemorrhage). or secondary to extracellular fluid sequestration (pancreatitis. phenytoin. or inadequate fluid intake or replacement. B. C. analgesics) are occasional causes of intrarenal kidney failure. thiazides. renal vasoconstriction (sepsis. inadequate cardiac output. liver disease). NSAIDs. bacteria Differential Diagnosis of Acute Renal Failure Prerenal Insult A. aminoglycosides) are the second most common cause of tubular necrosis. Pigmenturia induced renal injury can be caused by intravascular hemolysis or rhabdomyolysis.

or lethargic. and it is the least common cause of acute renal failure. muffled heart sounds (effusion). Labs: BUN. Chronic Renal Failure Chief Compliant: The patient is a 50 year old white male with diabetes who presents with an elevated creatinine for 2 weeks. hereditary glomerulonephritis. sallow yellow skin (urochromes). flank pain. prostate enlargement. Abdomen: Distended bladder. glomerulonephritis. hypertension). Signs of fluid overload. calcium. petechiae (coagulopathy). Neuro: Asterixis. sepsis. insomnia. paresthesias. Vital Signs: Postural blood pressure and pulse (tachycardia. Medications: Nonsteroidal anti-inflammatory drugs. hemorrhage. weight loss. proteinuria. Differential Diagnosis of Chronic Renal Failure: Hypertensive nephrosclero- . fatigue. respiratory rate. spider angiomas (hepatorenal syndrome). Diabetes. peripheral edema. multiple myeloma. cardiac friction rub (pericarditis). Note whether the patient appears ill. pelvic masses. benign prostatic hypertrophy. well. heart failure.Chronic Renal Failure 73 Postrenal Insult A. urethral obstruction. HEENT: Neck vein distention (volume overload). History of the Present Illness: Oliguria. anemia. Chest: Crackles (rales). purpura. aminoglycosides. sensory deficits. contrast dyes. myoclonus. kidney stones. uric acid crystals. Heart: S3 gallop (volume overload). costovertebral angle tenderness. rashes or purpura. over-diuresis. B. current and baseline creatinine and BUN. prostate disease. motor deficits. hypertension. Past Medical History: Past ultrasounds. ascites. Physical Examination General Appearance: Evaluate intravascular volume status. history of pyelonephritis. malaise. fine white powder (uremic frost). accounting for 10%. potassium (hyperkalemia). dark colored urine. phosphorus. Postrenal damage results from obstruction of urine flow. suprapubic tenderness. temperature (fever). liver disease. Skin: Skin turgor. Family History: Polycystic kidney disease. Jaundice. Rectal: Occult blood. Postrenal insult may be caused by prostate cancer. renal calculi obstruction or amyloidosis. albumin. interstitial nephritis. irregular rhythm (electrolyte imbalances). Excessive bleeding. creatinine. displacement of heart border. or acyclovir. Hypovolemia secondary to diarrhea. anorexia.

Frequency. Hematuria Chief Compliant: The patient is a 50 year old white male with hypertension who complains of bloody urine for 4 days. cyclophosphamide. deafness (Alport's syndrome). cervical malignancy. Medications Associated with Hematuria: Warfarin. Causes of Red Urine: Pyridium. Color. suprapubic tenderness. food coloring. fever. streptococcal skin infection (glomerulonephritis). temperature (fever). Recent exercise. pulse (tachycardia). renal disease. myoglobinuria. bleeding diathesis. Recent sore throat. hypertension. hemoglobinuria. chronic obstructive uropathy. hematuria throughout voiding (bladder or upper urinary tract). ANA. Labs: UA with microscopic exam of urine. Repeat testing. irregular rhythm (atrial fibrillation. phenobarbital. intravenous pyelogram. joint pain. arthritis. Skin: Rashes. Note whether the patient appears ill. quinine. glomerulonephritis. Past Medical History: Prior pyelonephritis. ibuprofen. phenytoin. methyldopa. joint pain. ibuprofen. unequal peripheral pulses (aortic dissection). Genitourinary: Urethral lesions. cascara laxatives. flava beans. Family History: Hematuria. analgesic nephropathy. suprapubic pain. nephromegaly. pattern of hematuria: Initial hematuria (anterior urethral lesion). carotid bruits. Abdomen: Tenderness. ecchymoses. levodopa. Streptozyme panel. reflux nephropathy. rifampin. bleeding between voidings. History of the Present Illness: Quantity of RBCs found on urinalysis. phenytoin. Extremities: Peripheral edema (nephrotic syndrome). perineal pain. condyloma. or lethargic. naproxen. tissue passage in urine. foreign body. menstruation. Heart: Heart murmur. nodules. terminal hematuria (bladder neck or prostate lesion). Lupus nephropathy. CBC. flank pain (renal colic). renal emboli). HEENT: Pharyngitis. polycystic kidney disease. berries. prostate tenderness. masses. Physical Examination General Appearance: Signs of dehydration. dysuria. amyloidosis. abdominal bruits. discharge. or enlargement (prostatitis. petechiae. Vital Signs: BP (hypertension).74 Hematuria sis. occupational exposure to toxins. prostate cancer). respiratory rate. . well. KUB. prior stone passage. timing. aspirin. allopurinol. rhubarb. Foley catheterization. INR/PTT. sickle cell. costovertebral angle tenderness (renal calculus or pyelonephritis). beets. ultrasound. tubulointerstitial renal disease. diabetic nephrosclerosis.

24-hour urine calcium. pyelonephritis. oxalate. colicky. History of low fluid intake. or lethargic. well. B. enlarged kidney. indinavir. inflammatory bowel disease. creatinine. citrate. cocoa. hematuria. intermittent. Medications: Excess vitamin C. ileal resection. it is characterized by minimal proteinuria. and cystine. Urologic Hematuria is caused by a urologic lesion. Labs: Serum electrolytes. and urine should not be collected during menses. plasma proteins filter into urine out of proportion to the amount of hematuria.. there is an absence of casts. hydrochlorothiazide. phosphate. urinary tract infection. urine culture. dysuria. septic appearance. Cr. such as a urinary stone or carcinoma. (2) >100 RBC's per HPF in 1 specimen. adnexal tenderness. flank pain. Differential Diagnosis: Nephrolithiasis. calcium. History of the Present Illness: Severe. immobilization. Excessive calcium administration. KUB. Family History: Kidney stones. urate. Abdominal pain may radiate laterally around abdomen to groin. Gyn: Cervical motion tenderness.Nephrolithiasis 75 Indicators of Significant Hematuria: (1) >3 RBC's per high-power field on 2 of 3 specimens. Nephrolithiasis Chief Compliant: The patient is a 40 year old white female who complains of flank pain for 8 hours. cystitis. Diet high in oxalate: Spinach. Medical Hematuria is caused by a glomerular lesion. intravenous pyelogram. . uric acid. Physical Examination General Appearance: Signs of dehydration. fever. appendicitis. parenteral nutrition. rhubarb. urea nitrogen. tea. Abdomen: Costovertebral angle tenderness. prior history of renal stones. Past Medical History: Chemotherapy. PTH levels (if hypercalcemia). Differential Diagnosis A. unusual dietary habits. UA microscopic (hematuria). suprapubic tenderness. phosphorus. Note whether the patient appears ill. It is characterized by glomerular RBCs that are distorted with crenated membranes and an uneven hemoglobin distribution and casts. furosemide. RBCs are disk shaped with an even hemoglobin distribution. sodium. lower abdominal pain. cysts. Microscopic hematuria and a urine dipstick test of 2+ protein is more likely to have a medical cause. testicles or labia. Urine cystine. nuts. and protein appears in urine proportional to the amount of whole blood present. (3) gross hematuria The patient should abstain from exercise for 48 hours prior to urine collection.

ACE inhibitors. sine wave. muscle weakness. torsion of hernia. cranial nerves 212. cyclosporine. History of episodic paralysis precipitated by exercise (familial hyperkalemic periodic paralysis). prostatitis. bladder). ovarian cyst rupture or hemorrhage. cystinuria. adrenal insufficiency (Addison’s syndrome). bladder obstruction. well. NSAIDs. bicarbonate. prostate cancer. Abdomen: Suprapubic tenderness. potassium sparing diuretics. salpingitis. urinary tract obstruction. Labs: Potassium. syncope.76 Hyperkalemia diverticulitis. palpitations. AV block. chemotherapy (tumor lysis syndrome). Plasma renin activity. Skin: Hyperpigmentation (Addison's disease). heparin. muscle trauma. oliguria. heparin. History of the Present Illness: Serum potassium >5. Past Medical History: Renal disease. prolonged PR interval. plasma renin activity. digoxin. nonsteroidal anti-inflammatory drugs. Causes of Nephrolithiasis: Hypercalcemia. Neuro: Muscle weakness. angiotensin converting enzyme inhibitors. Hyperkalemia Chief Compliant: The patient is a 50 year old white male with hypertension who presents with an elevated serum potassium on routine screening. oral or intravenous potassium. 24 hour urine K. potassium sparing diuretics (spironolactone). succinylcholine. precordial T waves. anion gap. HEENT: Extraocular movements. platelets. diminished QT interval. diabetes. widened QRS complex. P wave flattening. Note whether the patient appears ill. nonsteroidal antiinflammatory drugs. Proteus mirabilis urinary tract infection (staghorn calculi). hypoaldosteronism. renal tubular acidosis. beta-blockers. . lightheadedness. asystole. Serum aldosterone. Physical Examination General Appearance: Dehydration. pH.5 mMol/L (repeat test to exclude lab error). diminished deep tendon reflexes. Medications: Potassium sparing diuretics. endometriosis. hyperuricosuria. ECG: Tall peaked. urine potassium. salt substitutes. ovarian torsion. colonic obstruction. pupils equally reactive. lupus. hyperoxaluria. prostrate. ectopic pregnancy. cervix. ventricular arrhythmias. LDH. hematomas. adrenal insufficiency (Addison’s syndrome). carcinoma (colon. Differential Diagnosis Inadequate Excretion: Renal failure. chloride. angiotensin converting enzyme inhibitors. or malnourished.

ECG: Flattening and inversion of T-waves (II. meats). V3). vitamin B12. polyuria. biliary drainage. hyperglycemia. rhabdomyolysis. excessive licorice ingestion. respiratory rate. Differential Diagnosis of Hypokalemia Cellular Redistribution of Potassium: Intracellular shift of potassium by . temperature. . U waves (II. Conn’s syndrome (hyperaldosteronism). nephrotoxins. palpitations. Hypokalemia Chief Compliant: The patient is a 50 year old white male with hypertension who presents with a low serum potassium on routine screening. drugs (succinylcholine. dialysis. BUN. hyperkalemic periodic paralysis. premature atrial or ventricular contractions. Note whether the patient appears ill. Vital Signs: BP (hypotension). ventricular tachycardia or fibrillation.Hypokalemia 77 Increased Potassium Production: Hemolysis. 24 hour urine potassium >20 mEq/day indicates excessive urinary K loss. beta blockers). Excess Intake of Potassium: Oral or IV potassium supplements. Pseudo-hyperkalemia: Hemolysis after collection of blood. vomiting. QT interval prolongation. acidosis. internal hemorrhage. hypoactive deep tendon reflexes. diarrhea. nausea. Labs: Serum potassium. cramping pain. bicarbonate. V2. delayed transport of blood to lab. or malnourished. vegetables. V1. use of excessively small needle. Urine specific gravity. muscle crush injury. Heart: Irregular rhythm. Electrolytes. poor intake of potassium containing foods (fruits. digoxin overdose. thrombocytosis. stress (catecholamine release). glucose. diuretics. salt substitutes. CBC.5 mMol/L (repeat test to exclude lab error). creatinine. ST segment depression. constipation. excessive shaking of sample. prolonged tourniquet use. magnesium. V3). leukocytosis. laxative abuse. first or second degree block. If <20 mEq/d. clay ingestion. abdominal tenderness. enteric fistula. paresthesias. Urine potassium. Kayexalate ingestion. supraventricular tachycardia. chewing tobacco. Neuro: Weakness. History of the Present Illness: Potassium <3. well. Associated Symptoms: Muscle weakness. Abdomen: Hypoactive bowel sounds (ileus). Physical Examination General Appearance: Signs of dehydration. Past Medical History: Renal disease. low K intake or nonurinary K loss is the cause. aldosterone. Medications: Corticosteroids. hyperosmolality. plasma renin activity. pulse. beta-agonists. vomiting.

chewing tobacco). Vital Signs: BP (hypotension). alkalosis. CNS. pulse (tachycardia). Physical Examination General Appearance: Signs of dehydration. or malnourished. low potassium ingestion. chemotherapeutic agents. laxative abuse. Liddle's syndrome Normotensive. respiratory rate. seizures. Primary hyperaldosteronism (adenoma or hyperplasia). biliary drainage. normotensive hyperaldosteronism. hypothermia. Congenital adrenal hyperplasia. metabolic alkalosis with a urine chloride >10 mEq/day is caused by Bartter's syndrome. nausea. licorice. metabolic alkalosis with a urine chloride <10 mEq/day is caused by vomiting. familial periodic paralysis. irritability. heart failure. truncal obesity (hypocortisolism with steroid withdrawal). Hypertensive Low Renin. History of the Present Illness: Serum sodium <135 mMol/L (repeat test to exclude lab error). diarrhea. thyrotoxic periodic paralysis. hyperlipidemia (pseudo-hyponatremia). Medications: Steroid withdrawal hypotonic IV fluids. temperature. Skin: Decreased skin turgor. renin-producing tumor. villous adenoma. headache.78 Hyponatremia insulin (exogenous or glucose load). well. magnesium depletion. hypothyroidism. moon-face. Cushing's syndrome. Sweating. agitation. enteric fistula. Note whether the patient appears ill. Malignant hypertension. confusion. psychotropic medications. Renal tubular acidosis (type I or II). . anorexia. cirrhosis. cramps. beta2 agonist. potassium binding resin ingestion Non-gastrointestinal Loss. lethargy. Hypertensive Low Renin. dialysis Renal Potassium Loss: Hypertensive High Renin States. Hyponatremia Chief Compliant: The patient is a 50 year old white male with hypertension who presents with a low serum sodium on routine screening. polydipsia (water intoxication). renal artery stenosis. Nonrenal Potassium Loss: Gastrointestinal Loss. hyperpigmentation (Addison's disease). Past Medical History: Renal. exogenous mineralocorticoids (Florinef. Low Aldosterone States. vomiting. delayed capillary refill. High Aldosterone States. vitamin B12 treatment. Diarrhea. decreased output of dark urine (dehydration). or pulmonary disease (syndrome of inappropriate antidiuretic hormone). acute myeloid leukemia. diuretics. muscle weakness or tremor.

BUN. renal failure. Low Urine Sodium (<20 mEq/L) and Volume-expanded. . triglycerides. Primary excessive water intake (psychogenic water drinking). Premature ventricular contractions. impaired access to water (elderly). burns). diarrhea. aminoglycosides. Extrarenal source of fluid loss (vomiting. Extremities: Edema. hypothyroidism. Chest: Cheyne-Stokes respirations. urine osmolality. crackles. diabetes. nephrotic syndrome. serum osmolality. Edematous. Labs: Electrolytes. History of dehydration due to fever. lethargy. hypoactive deep tendon reflexes. head injury. Differential Diagnosis of Hyponatremia Based on Urine Osmolality A. chest X-ray. High Urine Sodium (>40 mEq/L) and Normal Volume. motor weakness. vomiting. Low Urine Sodium (<20 mEq/L) and Volume Contraction. Neuro: Confusion. salt ingestion. anorexia. 4. B. creatinine. lithium. ECG. cirrhosis with ascites. Hypernatremia Chief Compliant: The patient is a 50 year old white male with hypertension who presents with an elevated serum sodium on routine screening. urine sodium. renal disease. sweating. muscle twitching. Addison's disease. tenderness. administration of hypertonic fluids (sodium bicarbonate. glucose. High Urine Osmolality (urine osmolality >serum osmolality) 1.Hypernatremia 79 HEENT: Decreased ocular and oral moisture. syndrome of inappropriate antidiuretic hormone secretion. Abdomen: Ascites. High Urine Sodium (>40 mEq/L) and Volume Contracted. agitation. diarrhea. cholesterol. albumin. Renal fluid loss caused by excessive diuretic use. polyuria. Altered mental status. or osmotic diuresis. Water retention caused by carbamazepine or cyclophosphamide. salt-wasting nephropathy. Recent fluid intake. Heart: Irregular rhythm. Heart failure. heat exposure. phenytoin. ataxia. positive Babinski's sign. Past Medical History: Pancreatitis. muscle twitches. 3. irritability. sodium chloride). Low Urine Osmolality (50-180 mOsm/L). Medications Associated with Hypernatremia: Amphotericin. protein. burns. cranial nerve palsies. elevated glucose. 2. adipsia (lack of thirst). History of the Present Illness: Serum sodium >145 mEq/L (repeat test to exclude lab error).

syndrome. Spot urine sodium. Vital Signs: BP (orthostatic hypotension). Extrarenal Loss of Water (urine sodium >20 mMol/L). truncal obesity. creatinine. HEENT: Decreased eye moisture. hyperglycemia. dry oral mucosa. hyperaldosteronism. renal failure. . stupor. Note whether the patient appears ill. pancreatitis. Vomiting. or malnourished.. temperature (fever). creatinine. Labs: Increased hematocrit. BUN. hyperpigmentation (Conn’s syndrome). decreased urine output. Renal loss of water (urine sodium <10 mMol/L). tremor.80 Hypernatremia Physical Examination General Appearance: Lethargy. sodium. Skin: Decreased skin turgor (“doughy” consistency). ataxia. B. hyperreflexia. flat neck veins. Diuretics. sweating. diarrhea. Hypernatremia with Hypervolemia (urine sodium >20 mMol/L): Hypertonic solutions of sodium chloride or sodium bicarbonate. Diabetes insipidus (central or nephrogenic secretion of excessive antidiuretic hormone). Cushing's. well. steroid withdrawal). spasticity. moon-face. Euvolemic Hypernatremia with Renal Water Losses. obtundation. urine and serum. respiratory water loss. delayed capillary refill. stria (hypoadrenal crisis. osmolality. congenital adrenal hyperplasia. pulse (tachycardia). Neuro: Decreased muscle tone. decreased eye turgor. Differential Diagnosis: Hypernatremia with Hypovolemia A. extensor plantar reflex (Babinski’s sign). respiratory rate.

acetone breath odor (musty. well. infection. blurred vision. Abdomen: Hypoactive bowel sounds (ileus). abdominal tenderness. phosphate. triglycerides. hypotonia. hemorrhages. dyspnea. Cough. hyporeflexia. Vital Signs: BP (hypotension). polyphagia. ear pain (otitis media). CBC. myocardial infarction. chills. respiratory rate (tachypnea). Medications: Insulin. . hypertension. toxic appearance. Signs of dehydration. pancreatitis. suprapubic tenderness (urinary tract infection).Diabetic Ketoacidosis 81 Endocrinologic Disorders Diabetic Ketoacidosis Chief Compliant: The patient is a 12 year old male with diabetes who presents with an elevated serum glucose and ketoacidosis. Past Medical History: Renal disease. fatigue. costovertebral angle tenderness (pyelonephritis). BUN. flat neck veins. erythrasma. UA (proteinuria. HEENT: Diabetic retinopathy (neovascularization. chest pain. decreased visual acuity. vomiting. rhonchi. chloride. hyperpigmented atrophic macules on legs (shin spots). ketones). History of the Present Illness: Initial glucose level. localized fat atrophy (insulin injections). apple odor). ketones. pulse (tachycardia). Kussmaul respirations (deep sighing breathing). sodium. intertriginous candidiasis. bicarbonate. oral hypoglycemics. Extremities: Decreased pulses (atherosclerotic disease). weight loss. stroke. Physical Examination General Appearance: Somnolence. retinopathy. Polyuria. abdominal pain (appendicitis). Chest X-ray. trauma. neck rigidity. noncompliance with insulin. confusion. noncompliance with insulin. dysuria. dehydration. New onset of diabetes. hypoglycemic agents. Skin: Decreased skin turgor. ECG. frequent Candida or bacterial infections. foot ulcers. Neuro: Delirium. creatinine. lethargy. fever. tympanic membrane inflammation (otitis media). exudates). cellulitis. sensory deficits in extremities (diabetic neuropathy). temperature (fever or hypothermia). anion gap. Labs: Glucose. or malnourished. peripheral neuropathy (decreased proprioception and sensory deficits in feet). low oral moisture (dehydration). stress. anion gap. serum ketones. delayed capillary refill. Factors that May Precipitate Diabetic Ketoacidosis. frequency (urinary tract infection). back pain (pyelonephritis). prior ketoacidosis. Chest: Rales. infection. Note whether the patient appears ill. nausea. potassium. pregnancy. polydipsia.

HEENT: Thin. weight gain or inability to lose weight. thyroid surgery scar. thyroid testing. surgery. Chest: Dullness to percussion (pleural effusion). expressionless face. dry. Myxedema: transient local . delusions. Myxedema madness: Agitation. Factors Predisposing to Myxedema Coma. deepening of voice. alopecia. Somnolence. apathy. Jugulovenous distention (pericardial effusion). trauma. muscle weakness. narcotics. constipation. hypothermia. myxedematous ascites. Hypothyroidism and Myxedema Coma Chief Compliant: The patient is a 50 year old white female with hypothyroidism who presents with weakness for 5 days. Past Medical History: Hyperthyroidism. yellowish skin without scleral icterus (carotenemia). Diagnostic Criteria for DKA. and salicylate or methanol poisoning.82 Hypothyroidism and Myxedema Coma Differential Diagnosis Ketosis-Causing Conditions.3. infection. Extremities: Diminished muscle strength and power. Signs of dehydration. macroglossia (enlarged tongue). Vital Signs: Bradycardia. amenorrhea. hallucinations. Abdomen: Hypoactive bowel sounds (ileus). Physical Examination General Appearance: Hypoactivity. lithium. uremia. carpal tunnel syndrome. dyspnea on exertion. deep voice. somnolence. phenytoin. depression. Alcoholic ketoacidosis or starvation. phenothiazines. brittle dry nails with longitudinal ridges. confusion. bradycardia. hypotension. History of the Present Illness: Fatigue. doughy skin. cold intolerance. Glucose $250. propranolol. lethargy. Renal or gastrointestinal bicarbonate losses due to diarrhea or renal tubular acidosis. thin. Cold exposure. rough. antithyroid medication. Medications: Radioactive iodine treatment. anesthesia. Skin: Cool. DKA. sedatives. Non-Anion Gap Acidoses. disorientation. Hyperglycemia-Causing Conditions. Hyperkeratosis of elbows and knees. coarse. puffy face and eyelids. papilledema. Hyperosmolar nonketotic coma. thyroid swelling or mass. brittle hair. displacement of lateral heart border. pale. paresthesias. thyroid surgery. ketone positive >1:2 dilutions. dull. dry. loss of lateral third of eyebrows. mental slowing. bicarbonate <15. paranoia. restlessness. alcohol. Heart: Muffled heart sounds (pericardial effusion). pH <7. dry hair and skin. Acidosis-Causing Conditions Increased Anion Gap Acidoses.

hyperkinesis (restlessness). recent upper respiratory infection. hypoactive tendon reflexes with delayed return phase. iodine-131 or iodine therapy. silky hair texture. surgery. irritability. surgery Clues to Diagnosis Family or personal history of autoimmune thyroiditis or goiter History of thyroidectomy. ataxia. pulmonary embolus. diabetic ketoacidosis. diplopia. amenorrhea. masses. sensory impairment. dyspnea and fatigue after slight exertion. excess hormone medication. LDH. electrolytes. low voltage QRS complexes. Past Medical History: Factors Precipitating Thyroid Storm: Infection. History of the Present Illness: Tremor. Neuro: Visual field deficits. flattened or inverted T waves.Hyperthyroidism and Thyrotoxicosis 83 swelling after tapping a muscle. Labs: Thyroid stimulating hormone. myocardial infarction. fine. ECG: Bradycardia. softening of the skin. insomnia. labor and delivery. fever. hypercholesterolemia. weakness. irradiation with iodine 131. Weight loss with increased appetite. cranial nerve palsies (pituitary tumor). . medication. heat intolerance. Atrial fibrillation. stupor. hypertriglyceridemia. eye discomfort or pain. hyperdefecation. Differential Diagnosis of Hypothyroidism Cause Autoimmune thyroiditis (Hashimoto's disease) Iatrogenic: Ablation. nervousness. thyroid enlargement. diaphoresis. creatinine phosphokinase. lacrimation. Previous thyroid function testing. or thioamide drug therapy Kelp consumption History of painful thyroid gland or neck pain Symptoms of hyperthyroidism followed by hypothyroidism 6 months postpartum Diet (high levels of iodine) Subacute thyroiditis (viral) Postpartum thyroiditis Hyperthyroidism and Thyrotoxicosis Chief Compliant: The patient is a 50 year old white male who presents with tremor and restlessness for 4 days. Decreased mental status. CBC. prolonged Q-T interval. reduced visual acuity. cerebral vascular accident. thyroid pain. palpitations. proximal muscle weakness (especially thighs when climbing stairs).

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

Deep Venous Thrombosis 85

Hematologic and Rheumatologic Disorders
Deep Venous Thrombosis
Chief Compliant: The patient is a 50 year old white male with an paraplegia who complains of left calf pain for 6 hours. History of the Present Illness: Sudden onset of unilateral calf pain, swelling, and redness; exacerbation of pain by walking and flexing of foot, dyspnea. Risk Factors for Deep Venous Thrombosis A. Venous stasis risk factors include prolonged immobilization, stroke, myocardial infarction, heart failure, obesity, anesthesia, age >65 years old. B. Endothelial injury risk factors include surgery, trauma, central venous access catheters, pacemaker wires, previous thromboembolic event. C. Hypercoagulable state risk factors include malignant disease, high estrogen level (pregnancy, oral contraceptives). D. Hematologic Disorders. Polycythemia, leukocytosis, thrombocytosis, antithrombin III deficiency, protein C deficiency, protein S deficiency, antiphospholipid syndrome. Past Medical History: Peptic ulcer, melena, surgery. Physical Examination General Appearance: Dyspnea, respiratory distress. Note whether the patient appears ill, well, or malnourished. Vital Signs: BP, pulse, respiratory rate (tachypnea if pulmonary embolus), temperature (low-grade fever). Chest: Breast masses. Abdomen: Distention, tenderness, masses. Genitourinary: Testicular or pelvic masses, inguinal lymphadenopathy. Rectal: Occult fecal blood, prostate masses. Extremities: >2 cm difference in calf circumference, redness, cyanosis; mottling, tenderness; Homan's sign (tenderness with dorsiflexion of foot); warmth, dilated varicose veins. Labs: Doppler studies, venogram; INR/PTT, CBC, electrolytes, BUN, creatinine; ECG, UA, chest X-ray. Differential Diagnosis: Thrombophlebitis, ruptured Baker's cyst, lymphatic obstruction, cellulitis, muscle injury, hematoma, plantaris tendon rupture.

86 Low Back Pain and Sciatica

Low Back Pain and Sciatica
Chief Compliant: The patient is a 50 year old female who presents with low back pain for 1 week. History of the Present Illness: Onset of pain (eg, time of day, activity); location of pain (eg, site, radiation of pain to thigh or calf); type and character of pain (sharp, dull), duration of pain. Aggravating and relieving factors. Psychosocial stressors at home or work. "Red flags": Age greater than 50 years, fever, weight loss. Hip pain, joint pain, weakness, numbness, tingling; morning stiffness, night pain, bone pain, abdominal pain, leg pain. Difficult urination, incontinence of bladder or bowel, impotence, constipation. Past Medical History: Previous injuries, trauma, severe falls, occupational injuries, cancer. Previous therapy and efficacy. Social History: Drug or alcohol abuse; functional impact of the pain on the patient's work and activities. Medications: NSAIDs, acetaminophen, corticosteroids. Physical Examination General Appearance: Note whether the patient appears ill or well. Informal observation (eg, patient's posture, expressions, pain behavior). Painful grimacing with movements. Vital Signs: BP, pulse, respirations, temperature Skin: Discoid lesions (erythematous plaques), redness. HEENT: Malar rash (erythematous rash in “butterfly” pattern on the face). Chest: Pleural friction rub (pleuritis). Heart: Cardiac friction rubs. Abdomen: Abdominal tenderness. Back: Palpation of spinous processes and interspinous ligaments for tenderness. Range of motion, mobility (patient sits, lies down and stands up). Extremities: Joint tenderness, muscle weakness. Rectal: Decreased anal sphincter tone, anal reflex, perianal sensation Neuro: Posture, gait, deep tendon reflexes. Pinprick sensation in lower extremities. Muscle strength is graded from zero (no evidence of contractility) to 5 (complete range of motion against gravity, with full resistance). Straight leg raise test. Resistance to hip flexion, quadriceps strength, heel walking. Great toe dorsiflexion strength. Trendelenburg test: The patient to stands on one leg. A pelvis drop is a positive test. Labs: ESR, CBC, rheumatoid factor. X-Rays, MRI. Electromyography, nerve conduction studies. Differential Diagnosis: Back strain, acute disc herniation, osteoarthritis or

skin rashes. nodules. well. abdominal tenderness. hypertension. Medications Associated with Lupus: Procainamide. creatinine. telangiectasias. temperature. Skin: Skin fibrosis (thickening. spondylolisthesis. ANA. extraocular movements. renal disease. discoid lesions (erythematous plaques). Abdomen: Hepatosplenomegaly. malaise. sensory deficits. HEENT: Keratoconjunctivitis sicca (dry inflammation of conjunctiva). ECG. anti-DNA antibody. casts). Physical Examination General Appearance: Note whether the patient appears ill. rheumatoid factor. xerophthalmia (dry eyes). oral ulcers. Labs: Electrolytes. Extremities: Joint tenderness. weakness. Neuro: Mental status. CBC. antineutrophilic cytoplasmic antibody. Connective Tissue Diseases Chief Compliant: The patient is a 50 year old female who presents with joint pain and rash for 2 weeks. ESR. respiratory rate. Hip and back pain. weight loss. muscle weakness. rheumatoid nodules. methyldopa (Aldomet). UA (proteinuria. malignancy. anti-Smith antibody. or malnourished. LE cell prep. Arthritis in 3 or more joints (>6 weeks) 3. infection. psychiatric illness. stroke. hydralazine. 1. positional chest pain (pericarditis). livedo reticularis. Heart: Cardiac friction rubs (pericarditis). photosensitivity. complement. Raynaud's syndrome (cyanosis of hands when exposed to cold) Past Medical History: Migraine headaches. RPR. Vital Signs: Hypertension. lymphadenopathy sclerodactyly (thickening of digital subcutaneous tissue). Morning stiffness (>6 weeks) 2. skin ulcers. seizures. parotid enlargement. Arthritis of hand joints (>6 weeks) . Diagnostic Criteria for Rheumatoid Arthritis: Four or more of the following. swelling of upper and lower extremities. cranial nerves. Episcleritis or scleritis. ankylosing spondylitis. morning joint stiffness.Connective Tissue Diseases 87 spinal stenosis. Chest: Pleural friction rub (pleuritis). depression. UA. History of the Present Illness: Joint pain. malar rash (“butterfly” rash on the face). fever. purpura. fine rales (interstitial fibrosis). pleurisy. fatigue. pulse. scleroderma). isoniazid. muscle aches. oral ulcers. anemia. dysphagia.

7.88 Connective Tissue Diseases 4. 1. Positive ANA . Photosensitivity 4. Pleuritis or pericarditis 7. Nonerosive arthritis 6. Oral or nasopharyngeal ulcers 5. Discoid rash 3. 5. Positive lupus erythematosus cell. bony decalcification (especially in hands/wrist). Seizures or psychosis 9. 11. Malar rash 2. 6. Hemolytic anemia 10. Persistent proteinuria 8. false positive VDRL. Diagnostic Criteria for Systemic Lupus Erythematosus: Four or more of the following. Smith antibody. Symmetric arthritis (>6 weeks) Rheumatoid nodules Positive rheumatoid factor X-ray abnormalities: Erosions. positive anti-DNA antibody.

Source of income. 3. race. Age. 4. relationship history (including marriages.Clinical Evaluation of the Psychiatric Patient 89 Psychiatric Disorders Clinical Evaluation of the Psychiatric Patient I. History of psychiatric treatment. school performance. 5. 2. Occupational history. Identifying information. Current symptoms: date of onset. C. suicide or suicide attempts. including prescription. 2. 2. Social history 1. 3. E. Historical evidence in this section should be relevant to the current presentation. duration and course of symptoms. Reason the patient is presenting now. Past psychiatric history 1. History of psychotropic medication use. relationships with parental figures and siblings. the reason is often a direct quote from the patient. Therefore documenting the absence of pertinent symptoms is also important. individuals that currently live with patient. peer relationships. Developmental history. including outpatient and inpatient treatment. referral source. Previous psychiatric symptoms and treatment. Reason for consultation. History of present illness (HPI) 1. 5. Type of treatment. Relatives with history of psychiatric disorders. Family structure during childhood. H. Recent psychosocial stressors: stressful life events which may have contributed to the patient's current presentation. F. B. Previous and current psychiatric diagnoses. 3. marital status. 4. Support network. . sexual orientation. sex. This section provides evidence that supports or rules out relevant diagnoses. D. alcohol or substance abuse. 6. developmental milestones. G. 2. number of children). 4. over-the-counter medications. Current alcohol or illicit drug usage. Past medical history 1. home remedies. Current and/or previous medical problems. Chief complaint (CC). History of suicide attempts and potential lethality. Family history. Psychiatric history A. Level of education.

Ability to make sound decisions regarding everyday activities. Unusual physical characteristics or movements. Attention and concentration: Repeat 5 digits forwards and backwards or spell a five-letter word (“world”) forwards and backwards. Full or wide range of affect. Grooming. Affect 1. 6. dysphoric. Ability to interact with the interviewer. Psychomotor activity. 2. Use of language. The tone. place and date.90 Clinical Evaluation of the Psychiatric Patient II. 7. General appearance and behavior 1. Types of affect a. Generally appropriate. range and appropriateness. Abstraction. Hallucinations. level of hygiene. Absence of all or most affect. 3. Level of consciousness. B. Orientation: Person. Cognitive evaluation 1. rather than by asking hypothetical questions. Moderately reduced range of affect. H. Definition. Thought content 1. Agitation or retardation. 3. Internal emotional tone of the patient (ie. Fund of knowledge: Ability to name past five presidents. Calculations. euphoric. The mental status exam is an assessment of the patient at the present time. Degree of eye contact. . Judgement is best evaluated by assessing a patient's history of decision making. Ability of the patient to display an understanding of his current problems. Attitude. or historical dates. Insight. delusions and other perceptual disturbances. Proverb interpretation and similarities. angry. D. Blunted or restricted. Mental status exam. F. 2. b. associations and fluency of speech should be noted. Quality and quantity of speech. 4. External range of expression. E. Short-term memory: Ability to recall 3 objects after 5 minutes. simple math problems. A. anxious). G. 5. and the ability to understand the implication of these problems. five large cities. Mood. Judgment. Flat. characteristics of clothing. euthymic. Subtraction of serial 7s. c. Labile. Historical information should not be included in this section. 4. Thought processes 1. Definition. described in terms of quality. 5. 2. C. Multiple abrupt changes in affect. d.

This section should discuss pharmacologic treatment and other psychiatric therapy. floor ? . coat. Quantity of pills. county. Psychiatric History: Previous suicide attempts or threats. other medications.” .1 point Visual Spacial: Copy two overlapping pentagons . last menstrual period. Mini-mental Status Examination Orientation: What is the year. Alcohol intake. date. and's or buts” .5 points Registration: Repeat: 3 objects: apple.5 points Memory: Recall the names of the previous 3 objects: .1 point Write a sentence. city.1 point Three stage command: “Take this paper in your right hand.5 points What is the state. season. and put it on the floor. motive for attempt. seizures.3 points Attention/Calculation: Spell “WORLD” backwards . family support. “No ifs. including hospitalization. agitation. book. .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 Chief Compliant: The patient is a 50 year old white male with depression who presents after overdosing on antidepressants 3 hours prior to admission. fold it in half. Symptoms of Tricyclic Antidepressant Overdose: Dry mouth. History of the Present Illness: Time suicide was attempted and method. .Mini-mental Status Examination 91 III. DSM-IV multiaxial assessment diagnosis Axis I: Clinical disorders Other conditions that may be a focus of clinical attention.” . day of week. place where medication was obtained.2 points Repeat. visual changes.3 points Language: Name a pencil and a watch . month? .3 points Written command: “Close your eyes. Axis II: Personality disorders Mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning IV. hallucinations. hospital. . Treatment plan.

affect. Precipitating factor for suicide attempt (death. Torsades de pointes ventricular arrhythmia. delirium. pulse (bradycardia). chest pain. decreased bowel sounds. nausea. mydriasis. headaches. melena. helplessness. week. tremor. Physical Examination General Appearance: Demeanor. Labs: Electrolytes. wounds. Abdomen: Wounds. Heart: Irregular rhythm. further desire to commit suicide. or sexual abuse. tenderness. physical. is there a definite plan? Was action impulsive or planned? Detailed account of events 48-hours prior to suicide attempt and after. Reasons that a patient has to wish to go on living. tremors. hopelessness. Family History: Depression. PR or QT prolongation. hematemesis. HEENT: Signs of trauma. anxiety. emotional. hyperactive reflexes. abdominal pain. mood. Extremities: Needle marks. divorce. unemployment. History of the Present Illness: Determine the amount and frequency of alcohol use and other drug use in the past month. diaphoresis. alcohol or drug abuse. chest X-ray. ecchymoses. physical. glucose. guilt. and day. job stress. affect. temperature (hyperpyrexia). fever. Vital Signs: BP (hypotension). Alcohol. or sexual abuse. . pupil size and reactivity. level of consciousness. depressed mood. respiratory rate. shoe laces). hallucinations. urine toxicology screen. psychiatric disease. Chest: Abnormal respiratory patterns.92 Alcohol Withdrawal marital conflict. Age of onset . rhonchi (aspiration). ventricular tachycardia. past withdrawal reactions. BUN. presence of potentially dangerous objects or substances (belts. clonus. Neuro: Mental status exam. Feelings of sadness. acetaminophen levels. agitation. creatinine. nystagmus. family conflict. school stress. rapid-pressured speech. Time of last alcohol consumption. history of delirium tremens. AV block. emotional. Did the patient believe that he would succeed in suicide? Is the patient upset that he is still alive? Past Medical History: Prior suicide attempts. vomiting. confusion. Availability of other dangerous medications or weapons. medical illness). Alcohol Withdrawal Chief Compliant: The patient is a 50 year old white male with alcoholism who presents with tremor and agitation after discontinuing alcohol 12 hours prior to admission. ECG Signs of Antidepressant Overdose: QRS widening. humiliating event. suicide. ABG.

diaphoresis. Cranial nerves 2-12. pulse (tachycardia). pancreatitis. respiratory rate. meningitis. decreased vibratory sense (peripheral neuropathy). cirrhosis. Differential Diagnosis of Altered Mental Status: Alcohol intoxication. family. Family History: Alcoholism. aspartate aminotransferase (AST). disorientation. Conjunctival injection. sedative-hypnotic withdrawal. drug abuse. gynecomastia (cirrhosis). hypoglycemia. icterus. liver span. Heart: Irregular rhythm. depressed mood. mean corpuscular volume. Labs: Electrolytes. UA. Neuro: Mood. CBC. hernias. needle tracks. Korsakoff's Syndrome: Retrograde or antegrade amnesia. ataxia. confusion (thiamine deficiency). chest X-ray. drug overdose. Effects of the alcohol or drug use on the patient's life. confabulation. Skin: Jaundice. extraocular movements. nystagmus. HEENT: Signs of head trauma. ECG. History of blackouts or motor vehicle crashes. pupil reactivity. murmurs. magnesium. Rectal: Occult blood. anticholinergic poisoning. narcotic overdose. Asterixis. job or financial status or the legal system. affect. ataxia. Extremities: Dupuytren's contracture (fibrotic palmar ridge to ring finger). Wernicke's Encephalopathy: Ophthalmoplegia. liver function tests. carbohydrate-deficient transferrin (CDT). Physical Examination General Appearance: Poor nutritional status. alanine aminotransferase (ALT). ulcers. Chest: Rhonchi. ecchymoses. gamma-glutamyltransferase. Drug abuse. . Genitourinary: Testicular atrophy.Alcohol Withdrawal 93 of heavy drinking. Vital Signs: BP (hypertension). slurred speech. reflexes. Past Medical History: Gastritis. temperature (hyperthermia). splenomegaly. muscle atrophy (stigmata of liver disease). Abdomen: Liver tenderness. ascites. hepatitis. alcoholic ketoacidosis. GI bleeding. hepatomegaly or liver atrophy. including problems with health. spider angiomas (stellate arterioles with branching capillaries). Determine whether the patient ever consumes five or more drinks at a time (binge drinking). speech patterns. head trauma. glucose. palmar erythema. intracranial hemorrhage. crackles (aspiration).

(1.Commonly Used Formulas A-a gradient = [(PB-PH2O) FiO2 .PCWP x 80 = NL 45-120 dyne/sec/cm2 CO L/min GFR mL/min = (140 .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 .5 {(1.6 mEq/L.(Cl + HCO3) For each 100 mg/dL increase in glucose.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. Corrected serum Ca+ (mg/dL) = measured Ca mg/dL + 0.PCO2/R] .6(weight kg)([measured serum Na]-140) 140 Osmolality mOsm/kg = 2[Na+ K] + BUN + 2. 85-105(females) Body water deficit (L) = 0. Na+ decrease by 1.age) x wt in Kg 72 (males) x serum Cr (mg/dL) 85 (females) x serum Cr (mg/dL) U Cr (mg/100 mL) x U vol (mL) P Cr (mg/100 mL) x time (1440 min for 24h) Creatinine clearance = Normal creatinine clearance = 100-125 mL/min(males).36(Hgb)(SaO2)+0.36)(Hgb)(SvO2)} x 100 Normal CO = 4-6 L/min SVR = MAP . 0.8 normal Aa gradient <10-15 mmHg (room air) Arterial oxygen capacity =(Hgb(gm)/100 mL) x 1.36 mL O2/gm Hgb Arterial O2 content = 1. PH2O = 47 mmHg .8 x (4 .pCO2/0.PO2 arterial = (713 x FiO2 .CVP x 80 = NL 800-1200 dyne/sec/cm2 COL/min PVR = PA .36)(Hgb)(SaO2) . R .albumin g/dL) .8 ) -pO2 arterial PB = 760 mmHg.

27-0.8 x age) Females= 655+(9.3 kg for each additional inch.43 0.06-0.28-0.Ideal body weight males = 50 kg for first 5 feet of height + 2. Basal energy expenditure (BEE): Males=66 + (13.36 0. Ideal body weight females = 45.08 Q-T 0.age Normal ECG Intervals (sec) PR QRS Heart rate/min 60 70 80 90 100 0.38 0.3 kg for each additional inch.41 0.33-0.5 kg for first 5 feet + 2.29-0.12-0.7 x age) Nitrogen Balance = Gm protein intake/6.31-0.35 .25 .20 0.7 x actual weight Kg) + (5 x height cm)-(6.7 x height cm)-(4.(3-4 gm/d insensible loss) Predicted Maximal Heart Rate = 220 .urine urea nitrogen .6 x actual weight Kg)+(1.

0-8.0 mcg/mL Peak 6.0 mcg/mL 50-150 ng/mL 10-30 mEq/mL 8-20 mcg/mL 4.8-2. trough <5 mcg/mL 8-20 mcg/mL 4-10 mcg/mL 50-100 mcg/mL Peak 30-40.0 mcg/mL 150-300 ng/mL 2-5 mcg/mL 0.0 mcg/mL 2.Commonly Used Drug Levels Drug Amikacin Amiodarone Amitriptyline Carbamazepine Desipramine Digoxin Disopyramide Doxepin Flecainide Gentamicin Imipramine Lidocaine Lithium Mexiletine Nortriptyline Phenobarbital Phenytoin Procainamide Quinidine Salicylate Streptomycin Theophylline Tocainide Valproic acid Vancomycin Therapeutic Range Peak 25-30.0 ng/mL 2-5 mcg/mL 75-200 ng/mL 0.0 mcg/mL 100-250 ng/mL 4-10 mcg/mL 150-300 ng/mL 0.0-8. trough <10 mcg/mL .0 mcg/mL 15-25 mg/dL Peak 10-20.4 mEq/L 1.5-1.0.2-1. trough <10 mcg/mL 1.0-3. trough <2.0-2.5-5.

fluorouracil central nervous system carbon dioxide COPD chronic obstructive pulmonary disease CPK-MB myocardial-specific CPK isoenzyme CPR cardiopulmonary resuscitation CSF cerebrospinal fluid CT computerized tomography CVP central venous pressure CXR Chest X-ray d/c discharge. also D10W. gonococcus GFR glomerular filtration rate GI gastrointestinal gm gram gt drop gtt drops h hour H 20 water HBsAG hepatitis B surface antigen HCO3 bicarbonate Hct hematocrit HDL high-density lipoprotein Hg mercury Hgb hemoglobin concentration HIV human immunodeficiency virus hr hour hs hora somni (bedtime. white blood cell count. assist mode ventilation antinuclear antibody before anteroposterior adult respiratory distress syndrome acetylsalicylic acid aspartate 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. D50W DIC disseminated intravascular coagulation diff differential count DKA diabetic ketoacidosis dL deciliter DOSS docusate sodium sulfosuccinate DTs delirium tremens ECG electrocardiogram ER emergency room ERCP endoscopic retrograde cholangiopancreatography ESR erythrocyte sedimentation rate ET endotracheal tube ETOH alcohol FEV1 forced expiratory volume (in one second) FiO2 fractional inspired oxygen g gram(s) GC gonococcal.Commonly Used Abbreviations ½ NS ac ABG ac ACTH ad lib ADH AFB alk phos ALT am AMA amp AMV ANA ante AP ARDS ASA AST bid B-12 BM BP BUN c/o c C and S C Ca cap CBC 0. hematocrit. includes hemoglobin. and platelets cubic centimeter coronary care unit centimeter cyclophosphamide. discontinue D5W 5% dextrose water solution. red blood cell indices.45% saline solution ante cibum (before meals) arterial blood gas before meals adrenocorticotropic hormone ad libitum (desired) antidiuretic hormone acid-fast bacillus alkaline phosphatase alanine aminotransferase morning against medical advice ampule assisted mandatory ventilation. methotrexate. hour of sleep) cc CCU cm CMF CNS CO2 .

per os partial pressure of oxygen polymorphonuclear leukocytes purified protein derivative per rectum pro re nata (as needed) physical therapy. ureters. prothrombin time percutaneous transluminal coronary angioplasty partial thromboplastin time premature ventricular contraction quaque (every) q6h.IM 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 NKA NPH intramuscular intake and output--measurement of the patient's intake and output international units intensive care unit immunoglobulin M intermittent mandatory ventilation isoniazid International normalized ratio intermittent positivepressure breathing intravenous or intravenously intravenous pyelogram. low potency lactated Ringer's (solution) myocardial band minimal bacterial concentration microgram milliequivalent milligram magnesium Magnesium Sulfate myocardial infarction minimum inhibitory concentration milliliter millimeter Milk of Magnesia magnetic resonance imaging sodium sodium bicarbonate neurologic nasogastric no known allergies neutral protamine Hagedorn (insulin) NPO NS NSAID O2 OD oint OS Osm OT OTC OU oz p. pulmonary artery arterial oxygen pressure partial pressure of oxygen in alveolar gas phenobarbital after meals partial pressure of carbon dioxide positive end-expiratory pressure by hydrogen ion concentration (H+) pelvic inflammatory disease afternoon orally.9%) nonsteroidal anti-inflammatory drug oxygen right eye ointment left eye osmolality occupational therapy over the counter each eye ounce after post cibum (after meals) posteroanterior. q2h every 6 hours. intravenous piggyback potassium kilocalorie potassium chloride potassium phosphate X-ray of abdomen (kidneys. 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 . bowels) liter lactate dehydrogenase low-density lipoprotein liquid left lower quadrant lumbar puncture. 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 nulla per os (nothing by mouth) normal saline solution (0.

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


93 Dysdiodokinesis 65 Dyspnea 13 Ecthyma gangrenosum 33 Ectopic 61 Edema 14 Egophony 35 Electrolytes 7 Endocarditis 39 Endocrinology 81 EOMI 6 Epistaxis 48 Esophageal Rupture 12 Fever 31 Fitz-Hugh-Curtis syndrome 49 Fluid wave 51 Formulas 94 Fractional excretion of sodium 71 Friction rub 20 Fund of knowledge 90 Gastritis 55 Gastrointestinal bleeding lower 48 upper 46 Glasgow coma scale 66 Grey Turner's sign 42 Gum hyperplasia 69 Hashimoto's disease 83 Headache 63 Heart failure 15 Hegar's sign 62 Hematemesis 46 Hematochezia 41 Hematology 85 Hematuria 74 Hemoptysis 25 Hepatic angle sign 52 Hepatitis 50 Hepatorenal syndrome 71. 89 History of Present Illness 5 Homan's Sign 29. 82 Cholecystitis 12. 51 Asthma 26 Atrial fibrillation 17 Attention 90 Attitude 90 Axis 91 B12 deficiency 66 Babinski's sign 68 Body water deficit 94 Brudzinski's sign 37 Bruit renal 18 Calculations 90 Caput medusae 42. 49 Chronic obstructive pulmonary disease 27 Chronic Renal Failure 73 Chvostek's sign 54 Cirrhosis 51 CKMB 12 CKMBiso 12 Cognitive evaluation 90 Cold caloric maneuver 66 Colon cutoff sign 54 Coma 65 Confusion 65 Congestive heart failure 15 Connective tissue disease 87 Cor pulmonale 27 Cough 34 Courvoisier's sign 42 Cr/BUN ratio 72 Cranial Nerve Examination 7 Cruveilhier-Baumgarten syndrome 52 CSF fluid 38 CTnl 12 CTnT 12 Cullen's sign 42 Cushing's Syndrome 20 Cushing's triad 68 CVAT 6 Decerebration 66 Decortication 66 Deep tendon reflexes 6 Deep vein thrombosis 85 Delirium 65 Diabetic ketoacidosis 81 Diabetic retinopathy 81 Diarrhea 45 Discharge Note 9 Discharge summary 10 Discoid rash 86. 12 Cheyne Stokes respiration 68 Chief Compliant 5. 87 Dizziness 64 Doll's eyes maneuver 66 DSM-IV Multiaxial Assessment Diagnosis 91 Dupuytren's contracture 52. 85 Hyperaldosteronism 19 Hyperdefecation 83 Hyperinflation 27 Hyperkalemia 76 Hyperkeratosis 82 Hypernatremia 79 Hyperparathyroidism 20 Hypertension 18 Hypertensive retinopathy 18 Hyperthyroidism 83 Hypertrophic gastropathy 47 Hypokalemia 77 Hyponatremia 78 Hypothyroidism 82 Iliopsoas sign 42 Increased intracranial pressure 68 Infectious diseases 31 Insight 90 . 11. 73 History 5.Index Abdominal pain 41 Abstraction 90 Acropachy 84 Acute abdomen 41 Adenoma sebaceum 63 Affect 90 Alcohol withdrawal 92 Alveolar/arterial O2 gradient 94 Amaurosis fugax 67 Amenorrhea 59 Anorexia 44 Aortic Coarctation 19 Aortic Dissection 12 Arteriovenous nicking 18 Ascites 53 Asterixis 50. 50. 52 Carotenemia 82 CBC 7 CDT 93 Cephalization 15 Cerebral Herniation 68 Charcot's sign 42 Chest pain 11.

34 Septic shock 34 Spider angiomas 51. 52 Palpitations 17 Pancreatitis 54 Paracentesis table 53 Past Medical History 5 Peptic ulcer disease 55 Pericarditis 12. 48 Menetrier's disease 47 Meningitis 36. 38 pathogens 37 Mental status exam 90 Mesenteric ischemia 56 Migraine 64 Mini-mental status exam 91 Mood 90 Multiple organ dysfunction syndrome 34 Murmurs 6 Murphy's Sign 31. 33. 12 Myoglobin 12 Myxedema coma 82 Nausea 43. 42. 49 Muscle Contraction Headache 64 Myocardial infarction 11. 20 Peritonitis 53 PERRLA 6 Pheochromocytoma 19. 71 Onycholysis 84 Ophthalmoplegia 84 Orthostatic hypotension 47 Osler's nodes 40 Osmolality.Intestinal obstruction 57 Ischemic stroke 67 Janeway lesions 40 Jaundice 50 Judgment 90 JVD 6 Kaposi's sarcoma 36 Kayser-Fleischer rings 50. 20 Physical Examination 6 Pigmenturia 72 Pleuritic pain 20 Plummer's nails 84 PMI 6 Pneumocystis pneumonia 35 Pneumonia 34 Port-wine nevus 69 Postrenal failure 72 Postural hypotension 47 Prerenal failure 72 Prescription Writing 10 Presyncope 65 Primitive reflexes 68 Procedure Note 9 Progress Note 8 Pseudo-hyperkalemia 77 Psychiatric history 89 Psychiatry 89 Puddle sign 51 Pulmonary embolism 28 Pulmonology 25 Pulses 6 Pulsus paradoxicus 26 Pyelonephritis 39 Raynaud's syndrome 87 Renal bruit 18 Renal failure table 72 Renal failure index 72 R e n d u . 68 Stupor 65 Sturge-Weber syndrome 69 Subcutaneous fat necrosis 54 Syncope 21 Systemic inflammatory response syndrome 34 Tactile fremitus 35 Tenesmus 48 Thought content 90 Thyroid Storm 83 Thyroiditis 83 Thyrotoxicosis 83 Todd's paralysis 69 Transient ischemic attack 65 Tuberculous 38 Tumor lysis syndrome 76 UA 7 Upper Gastrointestinal Bleeding 46 Uremic frost 73 Urinary tract infection 39 Urine analysis 7 Urochromes 73 Uterine bleeding 60 Vertigo 64 Vomiting 43 Von Recklinghausen's disease 69 Water bottle sign 21 Weakness 67 Weber test 7. 52 Stigmata of Liver Disease 42 Stroke 67. 65 Weight loss 44 Wheezing 26 Whispered pectoriloquy 35 Wilson's disease 50 . 51 Kerley B lines 15 Kernig's sign 37 LFT's 7 Low back pain 86 Lower Gastrointestinal Bleeding 48 Lupus 87 Macroglossia 82 Malar rash 87 Mallory Weiss tear 47 McBurney's point 42 Melena 41. 44 Nephrolithiasis 75 Nephrology 71 Nephromegaly 74 Nephrotoxic drugs 71 Neurology 63 New York Heart Assoc 16 Obstipation 41 Obtundation 65 Obturator sign 42 Oculocephalic reflex 66 Oculovestibular reflex 66 Odynophagia 41 Oliguria 47. estimate of 94 Palmar erythema 51.O s l e r -W e b e r disease 25 Renovascular Hypertension 19 Renovascular Stenosis 19 Review of Systems 5 Rheumatology 85 Rinne's test 65 Romberg's test 6 Roth's spots 40 Rovsing's sign 42 RRR 6 Sciatica 86 Seizure 68 Sepsis 32.


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