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Symptom & Background Key Questions What these questions will tell you Physical Exam Lab Tests

Is this an acute infection? Need to view TM and Tympanometry. Insert a

How old are you? Acute otitis media (AOM) declines after 6 external ear canal. probe into the external
Earache Have you had a fever? Fever present in 60% of children with AOM Lavage indicated if ear while pressure in the
eardrum is continually
(infants <2mo uncommon, high fever is blockage. CI if history
systemic illness) suggests perforation. changed. Provides
indirect measure of
Generally an inflammatory Have you had an URTI? Organisms travel up eustatian tube --> Note behaviours in
pressure in the middle
process: in children its in obstruction --> mucus and bact growth children: irritability, poor
the middle ear. In adults it Have you had ear infections before? High risk of recurrens of AOM feeding, congestion, fever.
is referred from other Is there a family history of ear infections? Having a sibling or parent with chronic OM Older infants may pull on
head and neck structures makes you 2x as likely. May be environ'tal painful ear, bang head on
affected side.
What environmental conditions might suggest Audiometry. Tests
increased risk? frequency and intensity of
Does anyone around you smoke? Do you? 2-3x inc risk. Leads to functional Inspect External Ears sound that can be
eustachian tube obstruction, decreases perceived.
protective ciliary action in the tube
Child: does the child attend day care? Inc exposure to organisms Hemorrhage over matoid - Mastoid Process
Child: does the infant take a bottle lying down? Swallowing lying down may allow battle's sign - basal skull Radiography -
nasopharyngeal fluid to enter middle ear fracture radiographs of mastoid.
Have you been swimming recently? Swimming causes loss of protective Pain in opening of ear or
cerumen and excessive moisture and inflamed skin suggests
irritation to the canal bacteria
Have you recently been in an airplane or been scuba Barotrauma --> acute serous otitis. Failure Fungal and yeast infections CT of temporal bone for
diving? of eustachian tube to open and equilibrate are white or dark patches cholesteatoma and
--> fluid collection in middle ear. congenital syndromes

Could this be related to a systemic disease? Palpate External Ears.

Also pre and postaruicular
Do you have diabetes? Predisposition to malignant otitis externa (a lymph notes. Pre may be
cellulitis), OM, and mastoiditis enlarged in AOM and otitis
externa. Post in
Have you ever had dermatitis, eczema, or psoriasis? Overproduction of sebum can cause otitis
Child: does the child have a nonrepaired cleft palate? Can cause functional obstruction of the Inspect Ear Canals with
eustachian tubes Otoscope
What does the presence of pain tell me? Visualize any discharge,
Where specifically is the pain felt? Is it in one ear or Otitis externa - pinna. Mastoiditis - mastoid. noting color, consistency,
both? Bilateral - otitis externa. Referred pain or and odor. Disharge usually
AOM is unilateral. Children may tug at ears means infection, however,
CSF must be kept in mind
How severe is the pain? Does it interfere with AOM - deep pain or blockage of ear. with trauma.
Inspect Tympanic
sleeping, eating, or other activities? Serous otitis - bubbling, popping, or stuffy. Membrane noting light
Otitis externa - tender and may have reflex. Normal: transluscent
itching. Cerumen impaction - vague and pearly grey. Normally
discomfort concave.
How long have you had this pain? TMJ - lasts a few minutes and occurs 3- Bulging: increased
Is the pain constant or intermittent? If intermittent, 4x/day, sometimes with headache, worse hydrostatic pressure
how long does it last? in the morning (grinding). Chronic pain may
Does the pain travel (radiate) to other areas? be dental malocclusion or RA. Perform Pneumatic
What does the presence of discharge or itching Otoscopy (Insufflation)
tell me?
Do you have any discharge from the ear? Discharge seen after TM ruptures, can be Tests mobility of the TM by
secondary to mastoiditis. creating a seal - normal if
Do you have any itching in the ear? Itching indicates infection of the external there is slight motion when
canal. Can also be precursor to herpes air is insufflated
zoster of CN V.
What does a history of trauma or injury tell me? Test hearing acuity:
Weber and Rinne
Have you had any recent trauma to the ear? Trauma can perforate the eardrum.Fractur Examine Related Body
Have you had any head trauma? of the petrous temporal bone can destroy Systems: head and neck.
How do you clean your ears? Do you use cotton- the inner ear. Cotton-tipped swabs can Conjunctiva, mucosa and
tipped swabs? scratch the canal. patency of nose, sinuses,
larynx/tonsils, teeth and
Do you have a history of excessive earwax? Accumulation can cause hearing loss,
tinnitus, pressure sensation, vertigo,
infection. Self-cleaning can cause harm.
Child: does the child have a history of putting objects can cause ear pain and inflammation Perform an Intraotic
into ears? Manipulation. Face the
Have you had any recent insect bites around the Can lead to acute pain and tenderness of patient, insert a single
ear? the external canal and may develop fingertip in each ear and
secondary infection. pull the patient toward you
Have you been exposed to any loud noise? Loud prolonged noise can destroy cochlear as they are instructed to
hair cells. open and close their
mouth. Pain is elicited in
90% of patients with a TMJ

Is hearing loss a clue? Blockage, inflammation, neoplasm. Most Evaluate CN V, VII, and
Do you have any difficulty hearing? common cause of CHL is cerumen. IX. CN V: feel masseter as
Chronic OM can cause hearing loss. patient clenches teeth.
Do you have any dizziness? May indicate serious inner ear condition. Sharp/dull over CV V - 3
branches. Taste is CN VII
Do you have any ringing in the ear?
and IX and both apply
Child: do you think the child can hear normally? sensation to external ear.
Does he or she turn their head to listen?

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Condition History Physical Findings Diagnostic Studies
Earache DDX More common in adults, especially those with Discharge; inflamed, swollen external canal; pain None
External otitis diabetes, ear pickers, or swimmers. Bilaral itching; with movement of pinna; TM normal or not visible

Acute otitis media More comon in children <6 years; those with smoke Red, bulging TM; fever; decreased light reflex; None initially
exposure, recent URTI; severe or deep pain; opque TM; decreased TM mobility
unilateral; sensation of fullness
Serous otitis More common in children but occurs in adults with Fluid line or air observed behind TM; conductive Tympanogram
URTI; unilateral pain; senation of crackling or hearing loss; decreased TM mobility
decreased hearing

Cholesteatoma Hearing loss; recent perforated TM Pearly white leasion on or behind TM Immediate referral

Mastoiditis History of recent otitis media; chronic otitis pain Swelling over mastoid process; fever, palpable Radiograph of mastoid sinuses
behind ear tenderness, and erythema over mastoid reveals cloudiness, referral

Foreign body or cerumen Both children and adults have pain or vague Visualize foreign body or cerumen; may detect None
impaction sensation of discomfort; decreased hearing foul odor; conductive hearing loss

Barotrauma History of flying, diving; severe pain; hearing loss; Retraction of bulging of TM; perforation of TM; Tympanogram
sensation of fullness; history of recent nasal fluid in canal

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

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

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Sore Throat DDX: Sore throat, difficulty with secretions, odynophagia Respiratory distress, drooling, toxic appearance; Refer immediately
Pharyngitis without ulcers: (seen in pediatric patients >2), unable to lie flat, DO NOT EXAMINE PHARYNX
Epiglottitis cannot talk

Peritonsillar/ retropharyngeal History of recurrent tonsilitis; sore throat, difficulty Orthopnea, dyspnea, asymmetrical swelling, Rever immediately; CT scan; head
abscess swallowing, respiratory symptoms, fever, malaise abscess, trismus and neck radiographs; laryngoscopy

Viral pharyngitis Scratchy, sore throat, malaise, myalgias, headache, Erythema, edema of throat, tender posterior None
chills, cough, rhinitis cervical nodes
Group A B-hemolytic Most common in persons 5-15 years; known Temp >38.5C (101.5 F); exudate; anterior Positive rapid strep antibody screen,
streptococcal pharyngitis exposure; fall/winter season; sudden onset of fever, cervical lymphadenopathy strep culture
severe sore throat, and malaise; absence of cough
and upper respiratory symptoms
Mononucleosis (EBV) Young adults; slow onset of malaise, low-grade +/- pharyngeal exudate, palatine petechiae, Positive monospot; CBC with
temperature, mild sore throat posterior cerv LN, splenomegaly differential >50% leukocytes
Gonococcal pharyngitis History of orogenital sexual activity; may be Pharyngeal exudate; bilateral cervical Gram stain; gonorrhea culture
asymptomatic lymphadenopathy
Inflammation Exposure to irritants; postnasal drip; allergic symptoms Sinus tenderness, pale or swollen pharynx, Eosinophils in nasal secretions with
postnasal drainage visible, no fever or allergies

Pharyngitis with ulcers: More common in children; immunosupressed; painful Lymphadenopathy; small greyisk papulovesicular Serology
Herpangina (coxsackie virus) throat; fever, malaise lesions of the soft palate and pharynx,
progressing to shallow ulcres, <5mm
Fusospirochetal infection Poor oral hygiene; painful ulcers, foul breath, bleeding Gray necrotic ulcers without vesicles on the Gram stain reveals spirochetes
(Vincent's angina) gums ginigcal margins and interdental papillae

Apthout stomatitis Oral trauma, ill-fitting dentures; painful ulcers vary in Shallow ulcers, no vesicles; indurated papules None
size; absence of other symptoms that procress to 1cm ulcers; ulcer has yellow
membrane and red halo; no fever or nodes
Herpes simplex infection History of trauma to the mucosa; pain, fever, Perioral lesions; lymphadenitis; vesicles on Viral culture
headache palate, pharynx, gingiva
Candidiasis Immunosuppressed; persons on antibiotics or with Curdlike white plaques that bleed when scraped KOH smear shows hyphae; culture
diabetes; sore mouth/throat off

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What are the primary symptoms that will help me Perform a general Nasal smear -
Nasal narrow the possibilities? inspection eosinophils confirms
Symptoms How long have these symptoms been present? Acute symptoms with fever/chills: acute
infectious rhinitis
Take vital signs: acute
viral rhinitis or acute
allergic rhinitis

and Sinus Do you have a history of nasal or sinus problems? Chronic: rarely infectious, associated with sinusitis may be afebrile. Sinus radiographs for
anatomical abnormalities that impair the severe/chronic sx
Congestion sinus drainage system
Do the symptoms occur at any particular time of the Allergic rhinitis if with sneezing, wheezing, Inspect the face: children CT Scan
year or season? itchy/burning eyes that are seasonal. IgE with chronic allergic
Is there a family history of allergies or asthma? response. Early spring (tree pollens), early condition have an allergic MRI
Do you have other symptoms? summer (grass), early fall (weed pollens) "salute" (crease on nose Sinus aspiration - the
from wiping), allergic only way to confirm
If I suspect sinus problems, what do I need to Maxillary: toothache. Frontal: frontal
"shiners" are dark circles diagnosis of bacterial
know? headache worse on wakening. Ethmoid
under eyes from venous sinusitis
Do you have a history of sinus problems? can refer to the vertex, forehead, occipital
Do you have pain? Please point to the areas. or temporal regon. Sphenoid: top of head.
Do your symptoms change with position changes? Maxillary sinusitis: worse with bending or Periorbital cellulitis is the Allergy skin testing
leaning forward. Postnasal discharge most common serious
worse with lying down with sinusitis complication of severe
How long have you had these symptoms? Children: chronic sinusitis is >30 days bacterial sinusitis.
Do associated symptoms provide any clues? Acute bacterial infection: purulent nasal Perform a regional
discharge. Acute rhinitis: bacterial or viral examination of the head
and has fever, myalgia, chills. Sinus and neck: eyes (visual
complaints: pressure/pain of the cheeks, acuity), ears, LN.
forehead, behind eyes.
Do you have other acute symptoms such as cough, Acute sinusitis: <30 days, persistent cough, Examine the mouth and
fever, or muscle aches? fever >39C for 3 days, malodorous breath. teeth: look for abscesses,
MC maxillary and ethmoid sinuses, dental root infection.
occasionaly frontal and rarely sphenoid Erythema of tonsils in
acute viral rhinitis.
Do you have other chronic symptoms, such as eye Seen with chronic sinusitis, not bettwe with
pain, bad breath, or fatigue? meds.
Is it viral or bacterial? Test for smell severe
What color is your nasal discharge? Yellow or green purulent is viral or nasal congestion or
bacterial. Watery/clear is allergic. ethmoid sinusitis causes
How long have you had these symptoms? URTI is 5-10 days then subsides anosmia
Are the symptoms unilateral or bilateral? Is it on Infectious/allergic: bilatral. Unilateral are Inspect condition of
one side or both? MC anatomical cause: polyps, septal dev, nasal mucosa and
foreign body. turbinates
Are there risk factors that will narrow the Smoking has inc risk of sinusitis: more Inspect for masses: nasal
diagnosis? mucus and paralysis of the nasal cilia. Risk polyps look like skinned
Do you smoke? for upper and lower resp tract infections grapes. Septal deviation
Are you exposed to others who smoke? predisposes to infection.
Do you have any other health problems?
Have you had a recent history of head or facial Rare but serious post-trauma CSF
trauma? rhinorrhea may be present.
Have you been diving or swimming? Secondary to barotrauma, infection from Note the presence and
contaminated water, or allergic response to color of any discharge -
chlorine pus in middle turbinate
Have you been exposed to infections in day care, suggests bacterial sinusitis.
school, or work settings? CSF drainage will increase
Are you pregnant? Hormonal changes may lead to nasal in forward position
Is the patient using any drugs that would cause Transilluminate the
nasal congestion? sinuses - complete opacity
Are you using nasal sprays or drops? Use for more than 1 week can lead to suggests infection
rebound nasal congestion.
Do you use cocaine or other drugs? Also rebound nasal congestion Palpate and percuss
What medications are you taking? BCPs, ACE inhibitors, B-blockers may fornal and maxiallry
cause nasal congestion sinuses for tenderness
Is there a systemic disease present? Cystic fibrosis can cause dec mucociliary
Have you noticed any other general body symptoms? clearance. Also: diabetes, leukemia, AIDS, Test for facial fullness
hypothyroidism, acromegaly, horner's and pressure - bending
Do you have any chronic health problems? syndrom, neoplasm can cause nasal sx. forward from the waist or
valsalva will worsen
sumptoms of a partial or
complete sonus obstruction

Examine the lungs

Perform neurological
testing if indicated -
severe complications from
sinusitis - brain

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Nasal symptoms DDX: Perennial but more common in winter months; recent Red, swollen mucosa; purulent discharge Nasal smear for neutrophils,
Infectious rhinitis URI intracellular bacteria
Allergic rhinitis Family history of allergies; sneezing; recurrent pattern; Pale, boggy mucosa; rhinorrhea with clear, Nasal smear for eosinophils; allergy
more common in children and young adults watery mucus testing
Nonallergic rhinitis No allergenic cause identified Similar to allergic rhinitis Absence of eosinophilia on nasal

Rhinitis medicamentosus History of medication use: oral contraceptives, nasal Sollen mucosa; clear mucus or dry mucosa None
sprays, antihypertensives; nasal congestion
Acute sinusitis Smoker; recent URI; winter months; frontal Purulent discharge; maxillary toothache on None
headaches made worse with forward bending; percussion; postnasal drainage; decreased
sensation of fullness or pressure transillumination

Chronic sinusitis History of previous sinus infections; dull ache or no Same as above; decreased or no Sinus radiographs; CT scan; sinus
pain; persistent symptoms transillumination; obstruction such as deviated aspiration and culture
septum, polyps

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

Nasal polyposis History of asthma. Aspirin intolerance. Presence of polyps May require biopsy

Osteomyelitis of the frontal History of head trauma, diving Appear severely ill; periorbital and fronal edema Sinus and skull radiograph; blood
bone culture

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First, is this a life threatening condition? Observe general ECG - good to compare
Can you describe the pain? What does it feel like? Substernal heaviness, pressure or appearance. MI: previous ECG's. ST
Non E.g. dull, sore stabbing, burning, squeezing? squeezing provoked by exertion is anginal.
Tearing pain is aortic dissection. PE:
diaphoretic, pale, anxious.
PE: anxious, cyanotic. Rib
elevation means injured
myocardium. T wave
Emergent gripping, stabbing over lung. fx: shallow breaths. inversion: ischemia.

Chest Pain When did it start? Sudden onset and dyspnea is with PE.
Pneumonia is more gradual.
Measure vital signs and
respiratory patterns
What were you doing when it started? Determine if it is exercise related Aortic dissection: Treatmill exercise
If acute ischemic heart How long have you had the pain? Chronic pain is less likely to have a cause hypotension and unequal testing - tests risk of
disease is unlikely, other What other symptoms have you noticed? MI: n/d/v SOB, syncope. PE: SOB, pulses. severe CAD
causes could be from apprehension, hemoptysis. Fever, cough,
pulmonary, GI, think sputum in pneumonia.
musculoskeletal, or Does the patient have risk factors for CAD? Inspect the skin. Cool, Exercise myocardial
pericarditis How old are you? Major risk factors for CAD: smoking, HT, pale, moist skin in MI, PE, perfusion imaging
Do you smoke? low HDL, family history, age (men >45, or aortic dissection. Look
Do you have high BP, diabetes, or heart dz? women >55) for herpes zoster. Bruises.
Many causes of non- Cardiac Engymes: CK-
Look for central cyanosis.
cardiac chest pain relate Do you have a history of MI? MD rise within 4 hours of
to anatomy. Has anyone in your family had a heart attack or MI, peak at 24 hrs.
stroke before age 60? Troponins T and I are
predictive for future
In children, If this is not a life-threatening condition, what Palpate trachea and
events. Remain elevated
costochondritis is most does a description of pain tell me? chest - pneumothorax.
7-10 days.
common and respiratory Is the pain acute or chronic? Chronic pain is rarely emergent. May be Palpate for tenderness,
conditions associated with related to URTI or GERD. depressions, buldges.
cough Costochondritis is pain
What were you doing when the pain first occurred? Echocardiography
where bone meets
Emergent chest pain: Point to where the pain is located. Does it spread to Localized pain is more likely non-emergent. cartilage. Ventilation/ Perfusion
constricting, squeezing, any other part of your body? Lung Scan - for PE
burning, heavy. It What seems to trigger the pain? Percuss the chest
radiates. Does the pain awaken you from sleep? Awakening because of pain signals more Auscultate breath Pulmonary angiography
serious problems such as cardiac sounds
Non emergent chest pain: What do associated symptoms tell me? Auscultate for Arterial Blood gases -
dull or sharp. Do you have a cough or a change in your usual Usually infection. adventitious sounds detect resp alkalosis from
Submammary and cough? hyperventilation
hemothorax areas. Pain Do you bring up sputum? If so, how much and what Pneumonia sputum: green, rust color, or Auscultate heart sounds
provoked by body colour? red. - MI cannot be ID'd
movements or breaths
Do you have a fever? May indicate pneumonia, myocarditis,PE Observe spine for Radiography -
Are you lightheaded or dizzy? MC caused by structural heart disease, evidence of scoliosis pneumothorax and
arrhythmias, and cornary insufficiency. MC pneumonia
benign in children - breathing difficulties.

Do you feel like your heart is racing? Caffeine, stress, hormonal changes, mitral Examine abdomen - CT Scan
valve prolapse, and drugs can cause auscultate, palpate for
Is the pattern of pain related to activity and palpitations tenderness/masses. MRI
position change?
Describe your recent physical activities. Physical activities can cause muscle Examine extremities: aPTT and PT for
strains, rib fracturs, contusions. Decreased clubbing, cyanosis, pulses anticoagulant therapy
exercise tolerance: shunts, CAD, or (atherosclerosis,
arrhythmias. Investigate any episode aneurysm)
during exercise.
Have you had any injury to your chest? Recent muscle strain, Serum amylase and
hemo/pneumothorax, rib fracture. lipase - pancreas.
Does chest movement or position make the pain Pain of cardiac origin, except pericarditis, is
better or worse? not affected by respiration. Sharp, pleuritis
pain relieved by sitting up is pericarditis.
Pain worse with movement over sternum:
Is there a GI origin for the patient's chest pain? Bronchoscopy

Does the pain get better or worse from eating? Pain of esophagitis and cardiac origin are CBC - elevated WBC's
hard to ddx, both better with nitro. with infection
Esophagitis is associated with meals.
Do you have blood in your stools? Peptic ulceration. Esophageal pH - for
Have you vomited any blood? Pancreatitis has hypotension. GERD
Could this pain be from a systemic cause? Endoscopy
Do you have any skin problems? consider herpes zoster: persistent
unilateral pain thet is pruritis, burning, or
Do you have any chronic health problems? Local inflammation of muscles in
polymyositis, fibromyalgia, or SLE. Sickle
cell disease can cause chest pain. Marfan
syndrom: inc risk for aortic dissection
What does family history tell me?
Has anyone in your family had heart disease, chest Hypertension, hypertrophic
pain, or sudden death from cardiac arrest? cardiomyopathy, CAD have strong family
Has anyone in your family been born with heart
What is the emotional state of the patient?
In the past 6 months, have you had a spell or an Panic disorder, anxiety, depression. May
attack in which you felt frightened, anxious, or very have difficulty taking a deep breath.
uneasy? Or has your heart begun to race, felt faint,
or you could not catch your breath?

Page 7 of 52
Nonemergent Chest Pain Substernal chest pressure following exercise or stress Normal examination; possible transient S4 ECG during episode of chest pain
DDX: and relieved by rest or nitroglycerin; nausea, SOB,
Stable angina diaphoresis, sternal chest pressure

Myocarditis Chest pain; history of fever, dyspnea Heart murmur, friction rub, fever ECG, chest radiograph

Pericarditis Sharp, stabbing pain referred to left shoulder or Fever before onset of pain, tachycardia, WBC, ESR, ECG, chest radiograph
trapezius ridge, usually worse during coughing or pericardial friction rub
deep breathing; may be relieved by sitting forward;
history of viral or bacterial infection, autoimmune
Aortic stenosis Chest pain on exertion, subsernal and anginal in Radial pulse diminished; narrow pulse pressure; Echocardiogram, ECG, chest
quality; fatigue, palpitations, DOE, dizziness, syncope loud, hars, crescendo-decresc murmur heard at radiograph
2nd R ICS leaning forward; thrill

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

Pnemonia Productive cough of yellow or green or rust sputum; Fever; tachycardia, tachypnea; inspiratory Chest radiograph; sputum cultures;
dyspnea; pleuritic pain crackles; vocal fremitus; percussion dull or flat ABGs
over consolidation; bronchophony. Egophony
Mitral valve prolapse Chest pain, varies in location and intensity; Dysrhythmias, possible midsystolic click over ECG, echocardiogram
palpitations; anxiety; non-exertional pain of short apex, hear best sitting or squatting;
duration, history of Marfan's syndrome thoracoskeletal deformity common in children
Pleuritis Mild, localized chest pain, worse with deep breathing; Shallow respirations, local tenderness, pleural None initially
recent URI friction rub

Esophagitis Substernal pain worse after eating and lying down; Epigastric pain with palpation Esophageal pH
sour taste in mouth

Chest trauma (rib fracture) History of injury or trauma; pain with deep breaths; Shallow respirations; chest wall pain on palpation Chest radiograph
splinting of chest wall
Costochondritis Pain along sternal border, increases with deep Pain with palpation over costochondral joints; None
breaths, distory of exercise, URI or physical activity normal breath sounds

Herpes zoster Unilateral chest pain; painful rash Normal breath sounds; vesicular rash along None
Peptic ulcer disease Epigastric pain 1-2hrs after eating, > antacits; Tenderness to palpation in the epigastric area; Upper GI radiograph, upper
hematemesis and melena. Risks: smoking, alcohol signs of hypovolemia endoscopy, CBC
Cholecystitis Right upper quadrant abdominal pain radiating to the Positive Murphy's sign; palpable gallbladder Gallbladder ultrasound
right chest, often following high-fat meal; nausea and

Acute pancreatitis Severe left upper quadrant abdominal pain radiating Left upper abdominal pain with palpation; Serum amylase. Pancreas
into the left chest; pain worse supine; n/v, fever hypotension ultrasound or CT scan.
Lung tumors Chest pain, SOB, cough, hemoptysis, history of Normal exam or diminished breath sounds over Chest radiograph, CT scan of the
cigarette smoking; history of pneumonia tumor and dull percussion over tumor chest, bronchoscopy

Cocaine use Chest pain, SOB, diaphoresis, nausea; may relate to Tachycardia, hypertension ECG, serial cardiac enzymes, drug
substance use screen
Psychogenic origin Precordial chest pain, history of stressful situations Normal exam ECG, chest radiograph

Pleurodynia Severe, acute onset, stabbing, paroxysmal, pleuritis Pleural friction rub 25% of time; chest None
pain over lower ribcage and substernal edge; examination normal; fever usually present
headache, malaise, nonproductive cough
Precordial catch syndrome Sudden sharp not distressing pain near apex of heart; Normal examination None
seen in adolescence

Page 8 of 52
Is this a medical emergency? assess adequacy of the airway Note general appearance Transcutanous pulse
and observe posture: oximetry
Did this come on suddenly, or has it been New-onset acute may be an emergency respiratory distress? Chest radiography
developing gradually? Over what period of time did it such as: foreign body, anaphylaxis, PE,
Dyspnea develop? pneumoT
What were you doing before having difficulty Rule out epiglotitis in children: drooping, Electrocardiography
breathing? dysphonia, looks toxic.
Do you have other symptoms, such as itching or Anaphylaxis from insect bites or ingestion Assess level of Echocardiography
swelling? of potential allergins (meds, food) consciousness
Is the dyspnea caused by secondary obstruction Obstruction may be intraluminal (foreign Observe chest Hemoglobin and
in the lower respiratory tract? body, asthma), intramural (edema, movement: PE and Hematocrit anemia
Have you had a cough or cold symptoms recently? bronchiolitis), extramural (compression pneumothorax have Spirometry: in COPD,
from tumor, lymph nodes) unequal expansion FEV1 and the ratio are
Do you have a history of asthma?
dec. In restrictive lung
Is there a family history of asthma? Inspect shape and disease (pneumonia,
Is the dyspnea caused by trauma to the chest? symmetry of chest: pnumothorax, pleural
kyphosis & scoliosis can effusion) FVC is reduced
cause dyspnea. Inc AP and ratio is normal or
Have you experienced trauma to the chest? limitation of movement of thoracic cage diameter in COPD (air
Is the dyspnea caused by a pulmonary embolus? Risk for PE: >60, pulmonary HT, CHF, elevated
chronic lung disease, ischemic heart
Have you been confined to bed recently? Had recent disease, stroke, cancer. Also: 1) venous Look for retractions CT Scan
surgery? Had a recent fracture? stasis, 2) hypercoagulability, 3) endothelial contractions of intercostals
injury. MC after prolonged immobility,
Are you taking BCPs? Do you smoke? Pulmonary angiography
trauma to leg.
Do you take any other medications? Observe rate, rhythm and for PE
Are you feeling anxious or scared? People with PE feel a sense of impending depth of respiration for 1 CBC with diff for
doom. May be caused by O2 depletion full minute - expiration bacterial infection
Is the dyspnea related to a preexisting disease? CAD, valvular disease, CopD, or asthma longer in COPD. BUN and creatinine for
can cause dyspnea. Also MI. Also things Tachypnea: resp distress. renal function
Do you have a history of heart problems? Lung that dec oxygen capacity of blood (e.g. Listen for stridor ABGs
problems (asthma)? Anemia? anemia) inspiratory airway
Do you have any numbness or tingling in your body? Hyperventilation syndrome: nonemergent. Listen for audible wheeze Sputum culture
Where? Paresthesias around mouth and distal and voice changes
Have you noticed any other symptoms? > rest if lung/cardia orgin. < rest if from Take pulse, temperature,
anxiety and blood pressure.
What factors precipitate or aggravate dyspnea? Smoking most frequently causes chronic Palpate pulses.
dyspnea. COPD > rest.
What activities are associated with SOB? Inspect oral cavity -
Do you take any prescription medication? foreign body.
Do you have any known allergies? Trees? Dust? Associated with asthma. Inspect the nose -
Pollen? Animals? Have you been exposed recently? patency and flaring
Is there anything that makes your SOB better? Sit Palpate the neck -
up? Stay indoors? Lie down? Use meds? masses and trachea
Is the dyspnea caused by a neuromuscular May result in paresis/paralysis of resp Examine skin and
problem? muscles. extremities: cyanosis,
Are the patient's immunizations up to date? Can be caused by infections: poliomyelitis, pallor (anemia), clubbing,
tetanus. peripheral edema,
Child: has the infant had honey? Botulism --> respiratory distress. angioedema (allergy), cap
refill, diaphoresis
Do you live on a farm? Organophosphate chemicals can cause a
myasthenia-like syndrome
Child: are they at risk for lead poisoning? Palpate the chest
Do you have a headache, muscle weakness, or Could also be: meningitis, seizures, CNS Asses for vocal fremitus -
visual changes? lesion diminished in
Does the patient have any pertinent risk factors pneumothorax, asthma,
that will point me in the right direction? emphysema. Inc in
pneumonia, heart failure,
Do you or have you smoked? Are you exposed to tumor
cigarette smoke frequently?
What type of work do you do? Exposure to: asbestos, silicon, paint and Percuss the chest
chemical fumes, coal dust.
Have you had recent weight gain? Obese patients report SOB more Auscultate breath
frequently than their counterparts. sounds
Have you ever had eczema? Assoc with asthma Auscultate heart sounds

Page 9 of 52
Dyspnea DDX: Acute-onset dyspnea, cough, mild to severe chest Restlessness, fever, tachycardia, tachypnea, ABGs, chest radiograph, ECG,
Emergent Conditions pain, sense if impending doom; hemoptysis; history of diminshed breath sounds, crackles, wheezing, ventilation/ perfusion scan
Pulmonary Embolus DVT, recent surgery, oral contraceptive, smoker, pleural friction rub
hyperco-aguability states

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

Anaphylaxis Acute-onset dyspnea; history of insect sting, ingestion Angioedema, tachypnea, clammy skin, None; emergency measures
of drug, or allergen hypotension, bilateral wheezes, tachycardia necessary
Pneumothorax Acute-onset dyspnea; sharp, tearing chest pain; pain Tachycardia, diminished breath sounds, Chest radiograph, ABGs
may radiate to ipsilateral shoulder decreased tactile fremitus, hyper-resonance of
lung area affected; possible hypertension and
tracheal shift
Croup History of upper respiratory infection Hoarse, seal-bark cough, fever (variable) None initially; if respiratory distress
increases, pulse oximeter and
Acute epiglottitis Positional sitting forward; sore throat, anxious, toxic High fever, drooling, stridor, muffled voice Admit; life threatening

Bacterial tracheitis Recent viral infection Fever, stridor, purulent sputum Radiography of airway, WBC
increased, tracheal culture
Status asthmaticus Recent URI, exposure to allergins, breathlessness Wheezing, coughing, tachycardia, tachypnea Peak flows, chest radiograph, ABGs
Botulism Honey ingestion in infant, contaminated food ingestion Hypoventilation, drooling, weak cry, ptosis, Pulmonary function testing, chest
ophthalmoplegia, loss of head control radiograph, fluroscopy, stool culture

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

Hyperventilation syndrome Dyspnea, lightheadedness, palpitations, paresthesias Restlessness, anxiety, normal CV examination Chest radiograph
(perioral and extremities)

Laryngomalacia Neonate, infant: history of stridor, history of URI Inspiratory stridor; normal cough, cry Refer for visualization of larynx

Vascular ring Infant: dyspnea, brassy cough, difficulty swallowing Inspiratory stridor with expiratory wheeze Barium swallow, echocardiography

Heart failure Chronic progressive dyspnea, cough, frothy sputum, Altered level of consviousness, restlessness, ECG, chest radiograph, ABGs,
fatigue, lightheadedness, syncope, weight gain, ankle jugular venous distention, tachypnea, use of echocardiogram
swelling, palpitations, PND, orthopnea, hidsory of accessory muscles to breathe, rales, rhonchi,
heart disease; in children, chronic progressive wheezes, tachycardia, decreased peripheral
dyspnea, sweating above lip and forehead, expecially pulses, cool extremities, desplaced PMI, S3, S4,
while eating ascites, liver enlargement

Anemia Dyspnea on exertion, fatigue, palpitations, light- Pallor, tachypnea, cool dry skin on extremities, CBC, iron studies
headedness, history of chronic disease possible orthostatis hypotension
Poor physical conditioning Dyspnea on exertion, weight gain, palpitation on Overweight, tachycardia Cardiac stress test
exertion, sedentary lifestyle, cigarette smoker
Asthma Dyspnea, paroxysmal cough, audible wheeze, history Restlessness, tachypnea, use of accessory Spirometry, chest radiograph, ABGs
of asthma or allergies muscles to breathe, intercostal retractions,
decreased vocal fremitus, decreased breath
sounds, inspiratory and possible expiratory

COPD Chronic progressive dyspnea, dyspnea on exertion, Rapid shallow respirations, reddish complexion, Chest radiograph, pulmonary
persistent cough, minimal sputum, easy fatigue, increased AP diameter of thorax, use of function test, exercise tests, ABGs
history of smoking accessory muscles to breathe, pursed lip
breathing, decreased tactile fremitus, decreased
respiratory excursion bilaterally, lungs
hyperresonant, distant breath sounds, prolonged
expiration, occasional wheezes, possible
tachycardia, muffled heart sounds

Page 10 of 52
Is there a pregnancy? Important to rule out pregnancy! Note general Pregnancy Test: rule out
Amenorrhea appearance: short stature, pregnancy.
Are you sexually active? Ask questions about having
nonconsensual sex.
Lack of menstruation that Are you using any birth control methods? Contraceptive failures may account for Thyroid stimulating
may be a result of 1o or 2o unintended pregnancy. Amenorrhea may hormone: Identifies
causes. occur after discontinuation. hypothyroidism. Menses
resumes w/
Are you trying to become pregnant? Unintended or intended. Also may refer Assess nutritional status supplementation.
amenorrheic patient to infertility clinic. and plot measurements
on growth chart in
Is this primary or secondary? Age range for menarche is 9-17yrs. If adolescents: under/ Prolactin levels: fasting
Have you ever had a menstrual cycle? established menses (no outlet flow overnutrition. Height, levels.
problem and HPO axis & endometrium weight, arm span. If high or galactorrhea
functioning) at intervals of every 21-38 RO adenoma or illicit
days then classification of secondary. drugs.

Have you started pubertal development? Can you Begins w/ growth spurt 1 yr before breast Screen for eating
show me how your breast and pubic hair look buds at ~11yrs. Pubic hair at beginning of disorders: Anorexia or
compare with these pictures? (see pics in book menarche. Avg age for menarche 12 years bulimia. Refer to DSM for
pg.314 3rd ed.) 4months. Can look at peds growth chart to criteria.
see if normal dev.
At what age did you start you periods? Primary - lack of menses & 2o sex char. by Calculate BMI: 17% Serum Follicle
14 or lack of menses by 16 w/ 2o sex char. (19kg/m2) body fat needed Stimulating Hormone:
When was your last normal menstrual period? Ask about mother/sister's menses onset if for menses and 22% body Inc FSH = ovarian failure
What is the nature of your periods (amount of flow, delayed. fat for ovulation. w/ low E2
frequency, duration)? Secondary - Absence of menses for 6 BMI > 27% obesity = FSH & LH > 50, primary
months or cycle > 35days. imbalance in HPO axis ovarian failure.
Low FSH = hypothalamic-
pit. Dysfxn & 2o ovarian
Are there any constitutional delays causing the Severe stress of anorexia can produce failure.
amenorrhea? prolonged amenorrhea.
Has there been a change in weight, % body fat, or Low body fat causes menstrual irregularity. Examine skin and hair:
athletic training intensity? Obesity - sign of PCOS or cause of thyroid dysfxn, Cushing's,
amenorrhea. androgen excess.
Are you under unusual stress at school, home or Stress can disrupt normal cyclic menses. Perform head & neck
work? exam: visual changes,
Do you or anyone in your family have any congenital Turner's syndrome- abnormality of webbed neck, lowset ears. Serum LH: LH:FSH > 2:1
disorders or chronic diseases? components necessary for menses. suggestive of PCOS,
Structural anomalies - prevent outflow. >3:1 diagnostic.
Anorexia, DM, Crohn's, SLE, GN, CF,
pituitary adenoma, adrenal diseases &
thyroid dysfxn.
Could this be a thyroid dysfunction? Palpate thyroid gland and CNS Imaging: If both
Have you noticed changes in the texture of your hair Hyperthyroidism - heat intolerant lymph nodes: FSH, LH low indicative of
or skin? Hypothyroidism - cold intolerant enlargement, bruits, pituitary problem. Use
Are you bothered by hot or cold temperatures? lymphadenopathy. contrast CT or MRI to
determine ABN.
Have you had any changes in your energy level / Inc thyroid fxn - restlessness, diarrhea Perform breast exam:
bowel function? Dec thyroid fxn - constipation, fatigue sexual maturation level,
axillary hair, galactorrhea.
Could this be caused by hyperprolactinemia?

Are you able to express a discharge or liquid from Nipple d/c not associated with Perform pelvic exam: Pelvic U/S & Vaginal
your nipples? breastfeeding or medications (dopamine maturation of female U/S: presence of uterus
antagonists/ estrogens). genitalia, secondary sex & size, endometrial
Is there increased stimulation to your nipples? Galactorrhea - from clothing irritation, characteristics. thickness, fibroids,
sexual activity, LN dissection, herpes Absence of vagina, cervix tumors, cysts.
Have you had any surgery or disease of the breasts or uterus.
or chest wall? Outlet problems, assess
Could the hyperprolactinemia be caused by Meds such as phenothiazines or vaginal walls.
medications? contraceptives cause amenorrhea (inc Bimanual examination -
prolactin, induce estrogenic effect, toxic to enlarged ovaries,
What prescription medicines are you taking? ovaries) position/size of cervix / Progesterone Challenge
Heroin and methadone lead to menstrual uterus. Test (Prog. Withdrawl
Have you used any street drugs? What kind of drugs abnormalities. Test): administer
have you used? progesterone (oral/IV). If
Is a pituitary tumor causing the amenorrhea? +ve patient will bleed,
Have you experienced any visual changes? Hyperprolactin state - pituitary tumor --> functioning outflow tract,
may cause headache, visual defects (optic intact HPO axis.
Are you having an increased number of headaches?
chiasm & nerves compressed)
Is this a problem of the HPO Axis?
Have you experienced any problems with infertility? Main cause = failure of ovulation. Estrogen &
PCOS b/w ages 15-30. Progesterone Challenge
test: +ve if flow w/in 2-
Do you have excess hair on your face or chest? 50% of women w/ PCOS are hirsute & 7days, indicates
obese, difficulty conceiving. LH elevated. inadequate estrogen
Androgen excess - truncal obesity, acne, production.
male pattern baldness
Are you having menopausal symptoms (Hot flashes, Estrogen deficiency - menopausal sx. May
vaginal dryness)? see dyspareunia, dysuria. Prolonged may
lead to osteopenia.
Did you hemorrhage during childbirth? May lead to amenorrhea - Sheehan's Chromosome Analysis:
syndrome. abnormalities in
Is this a problem of the uterus? Endometriosis, incomplete abortion, or development.
Have you had a miscarriage or abortion, uterine aggressive curettage of uterus can lead to
infection, or any surgery or procedure involving your denuding of endometrial layer, scarring &
uterus? Asherman's syndrome.
What symptoms support a structural outflow Incomplete outflow tract (imperforate Endrometrial Biopsy
problem? hymen/ cervical os) - dysmenorrhea w/
Do you have a cyclic abdominal bloating or absence of menses Basal Body Temp.
cramping? Charting
Have you been amenorrheic since you had a Stenosis of cervical os - can occur after Progesterone Levels
cervical procedure? surgeries (cervical biopsies)
Maturation Index

Page 11 of 52
DDX: AMENORRHEA Breast tenderness, morning sickness, urinary Globular, enlarged uterus; soft, bluish colour B-hCG pregnancy test positive; U/S
Pregnancy frequency. cervix positive.

Constitutional Problems: No menstruation at age beyond 16 years; more than 5 Breast stage 1 persists beyond age 13.4; pubic Prolactin normal; TSH, T4 normal;
Delayed puberty years b/w initiation of breast growth and menarche. hair stage 1 persists beyond 14.1. CBC, UA normal; chemistry profile
normal; bone age normal; skull
radiograph normal

Anorexia nervosa / bulimia Mean age 13-14; fear of being fat; low self-esteem; Amenorrhea before or after weight loss; TSH normal; prolactin normal; FSH
depression; isolation; overachiever; food is a parental cachexia; low body fat; short stature; yellow, dry, & LH usually low; glucose normal;
battleground; preoccupation; hair loss; abdominal cold skin; acrocyanosis; increased lanugo hair; ECG: bradycardia, low-voltage
bloating, pain, constipation. hypotension, systolic murmurs, often mitral valve changes, T wave inversion and
prolapse. occasional ST depression.

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

Congenital or Chronic Congenital; short stature; infantile sexual Characteristics: webbed neck, low set ears, Karyotype (45,X)
Disorders: development. shieldlike chest, short fourth metacarpal
Turner's syndrome

Cushing's syndrome Weight gain; weakness; back pain Moon face, acne, hirsutism, purple striae of Cortisol increased; 17-ketosteroids
abdomen increased; CT adenoma
Thyroid dysfunction Hypothyroid: delayed growth, weight gain, fatigue, Hypothyroid: dry skin, fine hair, galactorrhea; Hypothyroid: TSH high;
constipation, cold intolerance; hyperthyroid: wt loss, hyperthyroid: moist skin, hyperpigmentation over Hyperthyroid: TSH low; T3 high; T4
nervousness, heat intolerance bones, thin hair, goiter high
Polycystic Ovary Syndrome Infertility Hirsutism; obese; enlarged ovaries U/S: enlarged overies w/ multiple
fluid filled cysts; Testosterone high.
Uterine and Outflow Tract Monthly bloating, cramping and pelvic pressure; no Fibrotic hymen without patent opening; stenotic Clinical diagnosis by history and
Problems: menses; cryotherapy or other procedure to cervix cervical os findings
Imperforate hymen/ stenotic
cervical OS

Asherman's syndrome History of uterine infection; tuberculosis, Pelvic exam normal PCT negative; E and PCT negative;
schistosomiasis; uterine iatrogenic scarring; curettage, hysteroscopy adhesions
Hypothalamic-pituitary- Hot flashes, night sweats, insomnia, mood changes Pale, dry vaginal mucosa; few rugae FSH and LH high; estradiol low
Ovarian Axis Problem:

Sheehan's syndrome Recent history of postpartum hemorrhage and shock Hair loss; depigmentation of skin; mammary and Pituitary and end-organ hormones
during delivery genital atrophy low; hemoglobin low
Medications/ chest wall or Breast nipple d/c; history of dopamine antagonists, Nipple discharge: bilateral; multiduct; milky, clear Wet mount or hemoccult of nipple
nipple stimulation estrogens, or illicit drugs; stimulation to nipples; or yellowish discharge discharge: -ve for RBCs; prolactin
exercise or sexual history of chest wall surgery or high; cone-down view of sella
herpes zoster turcica; MRI or CT with contrast

Pituitary adenoma Delayed puberty; history of visual changes, increasing Visual defects; galactorrhea Prolactin high; cone-down view of
headaches sella turcica positive; MRI or CT with
contrast positive

Page 12 of 52
Is this lump likely to be malignant? Malignant lesion = single, hard, painless Inspect breast & nipples: Ultrasound:
Breast Lumps lump, unchanged by hormonal cycle, arms at side, on hips, differentiates solid from
How long has the lump been present?
& Nipple progressive increase in size elevated above head, cystic.
Benign lump = unchanged, sometimes bending forward. Look for
Discharge Is the lump changing (eg. Getting bigger, worse, resolves w/in 2-3 menstrual cycles dimpling, asymmetry, Mammography: for
more painful?) inversion. nonpalpable lesions
Is the lump in 1 breast or lumps in both? Malignant = solitary unilateral
Benign = bilateral, identical quadrants
When was your last menstrual period? Cyclic cysts less common after menopause Observe skin of breasts MRI: evaluates abnormal
therefore warrant investigation. and nipples: erythema, lesions on mammogram,
Peri/post menopausal at greater risk for prominent vessels, good for dense breast
CA. eczema, pigmented lesions tissue
Is there any discharge from the nipple? Ductal CA - nipple d/c w/ a lump (eg
(Paget's), crack, exudate,
Paget's - mass w/ bloody d/c.)
80-90% of breast lump Have you recently been treated for a breast Masses after ABC's suspicious for Fine needle aspiration
found before diagnosis infection? malignancy & require biopsy. Palpate breasts & & Cytological Exam:
through clinical breast Does the person have additional risk factors for Inc risk of malignancy if: nipples: feel for lumps, differentiates solid vs.
exam. Risk of breast CA breast cancer? - Hx of epithelial hyperplasia, ductal nodules, feel tail of cystic (in-office)
acceralerates after age carcinoma in situ (DCIS) or lobular Spence.
50. Nipple d/c associated Have you ever had breast cancer? carcinoma in situ (LCIS)
w/ pregnancy, breast Do you have a family history of breast cancer (first - tumors in adolesents more likely to be Palpate lymph nodes: Stereotactic or needle
feeding or estrogenic degree relative)? metastasis than primary tumor supra/infraclavicular, localization biopsy: for
meds. Have you ever had ovarian, endometrial, colon, or - 75% of all cases occur >50 yrs old axillary. Note size, poorly defined masses
thyroid cancer? - previous hx of breast biopsy for benign consistency and mobility.
Do you have a family history of ovarian, endometrial, breast disease (LCIS) Assess nipple well:
colon or prostate cancer? - genetic mutation (BRCA1, BRCA2 genes) depress nipple ino areola -
Core needle biopsy: for
- Hx of CA (Ovarian, endometrial, colon, should move easily.
Have you ever received radiation to the chest or had thyroid) difficult to palpate
malignancy in childhood? Examine Nipple for masses
- Family Hx (First deg. relatives)
discharge: uni/bilateral,
Is this condition more likely to be benign? single/multiple ducts, take Excisional biopsy: gold
How old are you? Fibrocystic breast changes b/w 20-30 sample of d/c . standard for masses.
Fibroadenomas b/w 15-39
Intraductal papilloma & ductal ectasia b/w
Breast carcinoma b/w 40-70
Have you had lumps before? Do you have a history Fibrocystic breasts - Painful, mobile lumps Transluminate breast Microscopy: of nipple
of cystic breast changes or lumpy breasts? that increase in size & tenderness, discrete masses: solid mass will d/c reveals "fat cells" of
borders changes correspond with not transluminate galactorrhea, leukocytes,
menstrual cycle (malignant) RBCs.

Does this lump feel like other lumps youve had? Cyclical changes correspond w/ benign
Do the lumps come & go or change with your disease along w/ clear fluid aspirate from Characterize lump: depth
periods? cyst. of lesion, contour, shape, Cytological smear: may
No changes of tissue on mammogram or flutuation, firmness, expose cancerous cells
Have you ever had a mammogram or u/s? Why was
it done? What were the results? U/S. mobility.
Have you ever had a lump drained or biopsied?
What was the diagnosis? Ductography: for the
Have you had breast implants? Ruptured implant pushes augmented cause of nipple d/c
breast tissue away from chest wall.
Could this lump be mastitis related to lactation? Breast masses in lactating women usually Serum PRL levels:
associated w/ mastitis & a blocked duct. elevated can produce d/c
Have you recently had a baby? Usually caused by Staph aureus.
CA in lactating women rare.
Are you currently breast feeding/ suckling? Thyroid functioning
Are your nipples sore, cracked or pierced?? May be site for infection test: TSH high in hypoT
Is your breast painful or hot? Areas of redness? Mastitis - painful, hot, red breast cause of
Inflammatory BR CA - swollen heavy, hyperprolactinemia
edematous breast (m/c in non lactating
Have you had a fever? sign of infectious mastitis - associated w/
lactation & breast feeding
Is this normal lactation?
When was your last menstrual period? How frequent Fibrocystic changes manifest as
are your cycles? spontaneous multiple duct d/c.
Is it possible you are pregnant? What are you using Pregnancy - m/c cause of galactorrhea;
for birth control? bloody d/c due to vascular engorgement
When was your last delivery or miscarriage? How Normal lactation - milky, non purulent d/c
long were you pregnant? Mastitis/ sub aerolar abscess - purulent d/c
(DDx w/ inflammatory CA by use of ABCs)
BCP - clear, serous or milky d/c
Did you breastfeed? For how long? When did you
Duct ectasia/ Papillomatosis - green/brown
Is the nipple discharge clear or milky? Bloody d/c - benign or cancerous

How long have you had the nipple discharge? New onset d/c requires further
Is the discharge related to high prolactin?
What medications are you taking? Discontinuation should elimate d/c
Do you jog or run? If yes: Do you wear a sports bra? Stimulation inc. PRL levels along w/
Do your nipples rub on your clothing? marijuana.
Are your breasts fondled, squeezed, or suckled
during sexual activity?
Do you have a thyroid condition? responsible for galactorrhea (eg. hypoT,
What medical / health problems do you have? pit. Adenoma, Cushing's, cirrhosis)
If a newborn: has d/c been present since birth? Witch's milk - effects of maternal estrogen
Can nipple d/c be a sign of malignancy? Spontaneous - concerning, lactation,
Is the nipple d/c spontaneous or must it be systemic
expressed? Unilateral spontaneous d/c - intraductal
papilloma or CA
Does it come from one or both nipples? Unilateral - ass. w/ intraductal papilloma /
Does it come from one or multiple nipple ducts? Single duct w/ intraductal papilloma / CA
Do you also have a breast lump? May be benign or malignant. Futher
Are you post menopausal? Higher incidence of CA

Page 13 of 52
Single Breast Mass: Usually older than 35; unilateral new lump Single, hard, nontender, fixed lump; borders Diagnostic mammogram;
Cancer irregular or not discrete; may be erythema, ultrasound; tissue biopsy
dimpling, increased vessel patterns; may have
nipple discharge

Cysts Younger age, often younger than 35; often multiple round or elliptical; soft or fluctuant; mobile Clinical exam; FNA:Clear aspirate;
mammogram; U/S: cysts
Fibroadenoma Common in adolescence Single, sharply circumscribed mobile lump Diagnostic mammogram;
ultrasound; biopsy
Abscess History of mastitis Single mass; irregular shape; chronic abscess Biopsy
may be nontender
Fat necrosis May have history of injury at site Single, fixed and often irregular tumour Biopsy
Lipoma May have others on arms, trunk, buttocks, or back; Single tumours; smooth, well-defined; fluctuant Biopsy
usually nontender consistency

Tuberculosis History of Tb, Positive PPD, or chest radiography; Single; irregular shape; nontender Biopsy
immunocompromised patient status

Ruptured implant History of augmentation; change in shape or size of Nodule palpated best when patient is sitting Diagnostic mammogram; U/S; MRI
Inflammatory Breast Mass:

Mastitis and acute abscess Primigravidas more often than gravidas; >1wk after Red, warm, tender; usually unilateral, one fourth Culture positive for S. aureus, E.
delivery; breast feeding; tender nipples of breast, or one lobule; breast engorgement; Coli, Strep; Elevated WBCs
fever; nipple discharge: pus
Inflammatory Breast cancer History of mastitis or inflammory process of breast Entire breast swollen; fever rarely present; Biopsy
axillary lymphadenopathy
Multiple or Bilateral Breast Lumps:
Fibrocystic breast changes Multiple breast lumps of both breasts; cyclic changes Bilateral nodularity; dominant lumps; tender, FNA; Ultrasound; Mammogram
that worsen at time of menses mobile

Nipple Discharge:
Intraductal Papilloma Bloody nipple d/c; usual age is 40-50yr Unilateral; subareolar Diagnostic mammogram; ductogram

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

Neonatal Discharge (Witch's Milky d/c 1-2 wk after birth Enlarged breast tissue, milky d/c lasting 1-2 wk None
milk) after birth
Hyperprolactinemia Milky or clear nipple d/c; amenorrhea; Hx of meds: Spontaneous, unilateral or bilateral, multiduct; Serum Prolactin levels; MRI if
estrogenic, dopamin depleters;hypoT; pregnancy; clear or milky nipple d/c indicated
postabortion; nipple stimulators; visual changes
Male Breast Disease: Hx of clothing rubbing nipple (eg. Jogging); swelling or Red, warm, tender; usually unilateral, one fourth Culture positive for S. aureus, E.
Acute Mastitis lump of chest wall; tenderness of site of breast, or one lobule; breast engorgement; Coli, Strep; Elevated WBCs
fever; nipple discharge: pus

Cancer Family Hx of male breast cancer; painless lump of Induration, retraction of nipple or mass in nipple Mammogram; FNA; tissue biopsy
chest wall well; fixed, nontender; lymphadenopathy

Page 14 of 52
What does this px mean by "diarrhea"? Inspect General Fecal leukocytes: found
Diarrhea How frequent is the stool? Typical 1-3x/day to 2-3x/week. Appearance in inflammatory bowel
disease, UC, Crohn's
Most cases are of viral What is the volume of stools? SI - large volume watery, infrequent, no Assess hydration status:
origin and are self-limiting. urgency, intolerance increased thirst, rapid
Osmotic/ malabsorptive: LI - usu bacteria induced inflammation, pulse, dry mouth,
nonabsorbable water Are the stools formed or liquid? less watery, mucous, colon CA, IBS decreased urine output, Fecal occult blood
soluble solutes. Secretory: turgor & mobility, fontanel, testing: RBCs indicate
At what intervals does the diarrhea occur? Malabsorption - continous / intermittent
imbalance b/w fluid peripheral perfusion bacteria or protozoa
secretion & absorption.
IBS - alternating constipation / diarrhea
Exudative: mucosal
inflammation or Is this an infant, is there risk of dehydration? Temperature: elevated
ulceration. How many wet diapers has the child produced in the Dehydration = < 6 wet diapers/24hrs or increases water loss Fecal Immunochemical
past 24 hours? >4hr without urination Fever > 37.8C Test (FIT): uses Anti-b's
Does the infant seem thirsty? Increase thirst, irritability, crying = DeH2O Weight: note wt loss - to detect human blood
failure to thrive, protein
Does the child have tears when crying? Mild dehydration - tears present; mod-
severe - no tears present malabsorption, etc.
If this is an adult, is there risk of dehydration? Observe abdominal Fecal fat: restrict fat &
contour: distension collect stools.
How many times have you urinated in the past 24 Related to rate of fluid loss Auscultate Abdomen: D-Xylose Absorption
hours? Ss/Sx: thirst, dry mouth, dry eyes, detect presence of bowel test: malabsorption vs.
Are you thirsty? frequency & volume of urination, weakness sounds maldigestion.
Do you have a dry mouth or dry eyes? Palpate abdomen for
Is this an acute or chronic problem? Acute adults: infectious cause(viral), self tenderness: peritonitis Stool pH: 5 indicates
How long have you had diarrhea? limited, <2wks (rigid abdomen, rebound malabsoption
Have you had this problem before? Acute children: loose/liquid d/t infection or tenderness, +ve iliopsoas,
congenital anomaly obturator.
Chronic Adult: >2wks, parasites, meds,
Does the presence or absence of blood help me IBS, lactose, IBD Wet mount: assess for
narrow the cause? Chronic children: >3wks, formula bacteria, cysts, ova,
intolerance, infex, Giardia, malabs, IBD larvae, trophozoites

Is there any noticeable blood in the stool or tissue? Hemorrhoids - bright red blood Perform DRE: look for
How much? upper GI bleed - black, tarry stools fissures/lacerations, feel
What colour is the blood? Infants - blood in stool = hemorrhagic for impacted stool C. difficile toxin assay:
disease toxin causes necrosis of
What colour are the stools? Red: blood, food, drugs, food colouring Palpate lymph nodes: colonic epithelium
Green-black: grape drinks, iron lymphadenopathy
Dark gray: cocoa, chocolate associated w/ lymphoma
Pale gray/white: cholestasis, jaundice, and AIDS
Green: bile salts, chlorophyll veggies
What does the presence or absence of pain tell Malabsorptive - pain & flatulant stools Stool culture: detects
me? Self limiting viral - pain, D/N/V, fever, common bacteria
Are you having any abdominal pain or gas with the tenesmus
Where is the pain? Generalized: diffuse inflammation Stool for ova &
What does the pain feel like? UC: entire abdomen or lower abdomen parasites: requires fresh
Is the pain constant or does it come and go? IBS: over sigmoid colon stool
Self limited diarrhea - mild cramping
Does the pain awaken you at night? Giardia antigen test:
Does the pain interfere with you activities (eg. Work, Serious organic disease (HIV, diabetes) - tests for antigen 65
sleep, eating)? persistent diarrhea that awakens patient
What do the associated symptoms tell me? Indirect hemagluttinin
Do you have any fever? Did you measure your Cardinal manifestation of disease (GI tract, assay: detects antibodies
temp? What was the highest temp? RTI)
Do you have any vomiting? Viral gasteroenteritis, food poisoning, main CBC w/ diff: may
cause of dehydration indicate presence of
What occurred first: the diarrhea or vomiting? Diarrhea before vomiting = bacterial chronic disease, anemia,
etiology inflammatory dz.
Could this be caused by exposure to others or to Orofecal contamination & diaper; greater
contaminated food? risk if attending daycare
If a child: Does the child attend daycare? Peripheral blood smear:
If a child: Are any of the other children in day care ill? Food bourne infxn: if acquired at social examines cellular
gathering contents
Have you been around others who have similar BUN & creatinine:
symptoms? indicates severe illness &
Could this be the result of exposure to animals?

What pets do you have? Campylobacter - infected dogs or cats Endoscopic studies:
Have you had contact with or have you handled Salmonella - infected turtles when cause cannot be
dogs, cats, turtles? determined
Could this be caused by exposure to More susceptible to infxn if travel, camping
contaminated water? (E.Coli, Giardia, Shigella, Salmonella,
Have you travelled recently? Where? Campylo, Cryptosporidium)
Could sexual activities explain the diarrhea? Shigella: in patients who engage in anal
Do your sexual practices include anal sex? sex
Could this be a result of an immune problem? Proctitis:
IgA & IgGpain, tenesmus
deficiency and mucus
- frequent cause of
Have you been diagnosed with an immune system chronic diarrhea in children
problem? Enteropathy - AIDS, chemotherapy
Do you have frequent colds or other illnesses?
Are you receiving chemotherapy?
Could this be caused by medications?
Have you taken any ABCs recently? Which ones? Pseudomembranous colitis (C.Difficile):
ABCs disturb normal flora of gut
What prescription medicines are you taking? Antacids (Mg), ABCs, methyldopa, Anti-
What over-the-counter meds/preparations are you inflams, laxatives, B-Blockers, Colchicine,
currently using? salicylates

Page 15 of 52
DDX: ACUTE Diarrhea
Viral gastroenteritis (eg. Abrupt onset 6-12 hr after exposure; nonbloody, In children may see severe dehydration; None
Norwalk or rotavirus viral watery diarrhea; lasts <1wk; nausea/vomiting, fever, hyperactive bowel sounds, diffuse pain on
agents) abdominal pain, tenesmus abdominal palpation

Shigella (gram negative rod; Acute onset 12-24 hr after exposure; lasts 2-3 days; Lower abdominal tenderness, hyperactive bowel Fecal leukocytes, positive stool
fecal-oral transmission; large amounts of bloody diarrhea with abdominal sounds, no peritoneal irritation culture
common in day care setting; cramping and vomiting
common in gay bowel
S.aereus food poisoning Acute onset 2-6hr after ingestion; lasts 18-24hr; large Hyperactive bowel sounds
(gram-positive cocci; from amounts of watery, nonbloody diarrhea; cramping and
improperly stored meats or vomiting
custard filled pies)

Clostridium perfrigens food Acute onset 8-20 hr after ingestion; lasts 12-24hr; Hyperactive bowel sounds, diffuse pain on Fecal leukocytes, negative
poisoning (Gram-positive rod; large amounts of watery, nonbloody diarrhea; abdominal palpation anaerobic cultures of stool
from contaminated food) abdominal pain and cramping

Salmonella good poisoning Acute onset 12-24 hr after exposure; lasts 2-5 days; Fever of 38.3-38.9C (101-102F) common; Fecal leukocytes, positive stool
(gram-negative bacilli; moderate to large amounts of nonbloody diarrhea with hyperactive bowel sounds, diffuse abdominal culture, WBC count normal
ingestion of contaminated abdominal cramping and vomiting pain
food, poultry, eggs)
Campylobacter jejeni (gram Acute onset 3-5 days after exposure; lasts 3-7 days; Fever, lower quadrant abdominal pain Fecal leukocytes; positive stool
-ve rod; fecal-oral moderate amounts of bloody diarrhea culture
transmission; household pet)

Vibrio cholera (gram -ve rod; Acute onset 8-24 hr after ingestion of contaminated Cyanotic, scaphoid abdomen, poor skin turgor, Fecal leukocytes, negative stool
fecal-oral transmission; food; lasts 3-5 days; large amounts of nonbloody, thready peripheral pulses, voice faint culture
ingestion of contaminated watery, painless diarrhea; can be mild or fulminate
water, seafood or food)

Enterotoxic E.Coli (gram -ve Acute onset 8-18 hr after ingestion of contaminated No fever; dehydration is major complication Fecal leukocytes; positive stool
rod; fecal-oral transmission; food/water; lasts 24-48hr; moderate amounts of culture
ingestion of contaminated nonbloody diarrhea; pian, cramping, abdominal pain;
water or food) adults in US generally do not develop this
Entamoeba histolytica Acute onset 12-24 hr after ingestion of contaminated Right lower quadrant abdominal pain; in small IHA: Antibodies to E.Histolytica;
parasite (cysts in food & food or water; large amts of bloody diarrhea; number of cases hepatic abscess forms positive titer is > 1:128
water, from feces) abdominal cramping & vomiting
ABC-induced (begins after Mild, watery diarrhea: crampy abdominal pain Diffuse abdominal pain on palpation; fever absent Usually not needed
taking ABCs)

Pseudomembranous colitis M/c ampicillin; Sx range from transient mild diarrhea- Lower quadrant tenderness, fever CBC: leukocytes; sigmoido/
(C.difficile ABC induced) active colitis w/ bloody diarrhea, ab pain, fever colonoscopy, C.diff toxin assay or
stool culture; C difficile toxin
Hemolytic uremic syndrome Children < 4yr w/ Hx of gasteroenteritis; Hx of bloody Fever, irritability; may have oliguria or anuria CBC, platelet count, renal fxn test,
(HUS) diarrhea, fever and irritability periph. Blood smear; -ve stool

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

UC (distal colon most Hx of sever diarrhea w/ gross blood in stools, no Overt rectal bleeding; initially no fever, weight CBC show leukocytosis or anemia,
severely affected & rectum growth retardation; few complaints of pain; age of loss, or pain on palpation of abdomen; moderate ESR elevated; stool cultures to rule
involved) onset 2nd & 3rd decades w/ peak I adolescence; colitis: wt loss, fever, ab tenderness out other causes of diarrhea;
postive family history colonoscopy
Crohn's (associated w/ Hx of chronic bloody diarrhea w/ ab cramping, tender Wt loss, rare gross rectal bleeding, fistulas Colonoscopy w/ biopsies
uvetitis, erythema nodosum) & rectal bleeding; in children Hx of growth retardation, common
CHO malabsorption wt loss, mod.
Bloating, Diarrhea,
flatus, diarrheaab pain, anorexia
exacerbated by ingestion of Diffuse abdominal pain Trial elimination of offending foods
certain disaccharides (lactose, milk products); may
Fat malabsorption follow viral
Greasy, gasteroenteritis
fatty, malodorous stools; associated w/ Rectal prolapse, poor wt gain, abdominal 73 hr fecal fats; sweat test
deficiencies of vit K, A & D; cystic fibrosis distension
Toddler's diarrhea 3-4 stools/day; some contain mucus; rare >4-5 yrs Physical exam & growth normal Clinical diagnosis
Celiac sprue/ PRO Increased stool frequency, looseness, paleness & Failure to thrive, abdominal distension, irritability, Clinical findings, improvement on
hypersensitivity (rxn to protein bulkiness of stool w/in 3-6 mo of dietary onset; muscle wasting gluten-free diet, CBC, anemia, folate
in wheat, rye, barley & oats) children are lethargic, irritable and anorectic; peak deficiency, radiograpy, biopsy
frequency 9-18mo
Giardia parasite (primary Watery, foul diarrhea; common in daycare; among Low-grade fever, wt loss; chronic form: fatigue, Giardia antigen test
cause of chronic diarrhea in travellers and in male homosexuals growth retardation, steatorrhea

Page 16 of 52
Could this be related to a surgical procedure? Surgery can result in dumping syndrome
after eating: inadequate mixing and
Have you had surgery recently? digestion
- also stagnation & bacterial overgrowth
Is this diet related?
How much apple juice or how many sodas do you High carb content drinks lead to
drink in a day? malabsorptive diarrhea
Do you drink milk or eat milk products? Malabsorptive osmotic diarrhea
Protein hypersensitivity: 2-3 wks after
starting cow's milk or soy formulas
Do you eat wheat products? Gluten enteropathy or hypersensitivity
What have you had to eat in the past 3 days? Loose stools: low fiber diet
Could this be caused by food preparation
Have you recently eaten raw or undercooked poultry, Salmonella/ C. jejuni: undercooked poultry
shellfish or beef? E.Coli: undercooked beef/ unpasterized
Have you recently ingested unpasterized milk? milk
Norwalk virus: shellfish
Do you prepare poultry and/or beef on the same Food poisoning if 2 or more persons ill
surface as other foods? from same food; infected food or toxic
Is anyone else you know ill with similar sxs? substances (lead, mercury)
Is there any family predisposition that may point
to a cause?
Have you or anyone in your family been diagnosed CF leads to fat malabsorption & produces
with cystic fibrosis? fatty, foul smelling diarrhea
Does anyone in your family have a history of chronic IBD genetically linked
diarrhea, UC, or IBD?

Page 17 of 52
Cryptosporidium sp. /Isospora Recurrent episodes; variable amounts watery, Wt loss, severe right upper quadrant abdominal Stool for O &P
belli protozoan parasites nonbloody diarrhea; amounts can be massive pain with biliary tract involvement
(fecal-oral; ingestion of
contaminated water or direct
oral anal contact)

Postgastrectomy dumping Following GI surgery, diarrhea occurs after meals; Diaphoresis and tachycardia Upper GI series
syndrome diarrhea occurs after meals b/c of increased transit of
food through colon
Diabetic enteropathy Nocturnal diarrhea, postprandial vomiting, fatty stools Findings associated w/ diabetes Diagnosis of exclusion in diabetic
from malabsorption persons
HIV enteropathy (direct infxn Insidious onset, recurrent large amounts of nonbloody Findings associated w/ HIV infection Testing for HIV
of mucosa & neuronal cells in diarrhea, mild to moderate nausea / vomiting
GI system)

Medication induced Mild to moderately severe nonwatery, nonbloody No specific findings related to diarrhea Usually not needed

Page 18 of 52
Is this really constipation? Normal = 3-12 Plot growth curve in Fecal occult blood
Constipation How many stools are there per day? Constipation <3 BM/wk children: slow growth may testing: ulcerative or
Complete failure to What is the consistency of the stool? Hard, dry stools charac of constipation indicate megacolon malignant lesions, screen
evacuate the lower colon Is the constipation acute or chronic? for colon CA
Recent onset suggests lifestyle or phys Perform abdominal
associated with difficulty When did the constipation start? health changes (Meds, diet, activity) exam: contour, distension,
defecating, infrequent auscultate, masses,
How long have you been constipated? Is this an Chronic ass w/ lack of dietary fiber and Fecal Immunochemical
BMs, straining, ab pain, individual episode or is it chronic? tenderness, hernias.
bulk or systemic disorders (DM, hypoT) Test (FIT): uses Anti-b's
pain on defecating. Can
At what age did the constipation first begin? Colon CA = new onset >40yrs to detect human blood
be acute or chronic. protein
Infants: inadequate fluid/fiber
If the constipation is acute, what conditions Perform DRE: look for
should I consider? fissures/lacerations, feel
Have you been ill recently? Have you have a fever? Dehydration & fever cause hardening of for impacted stool, rectal CBC: Hematocrit & Hb
stools prolapse, sphincter tone below normal
Reflex ileus sometimes seen w/
Do you have any chronic health problems? Renal acidosis / Diabetes insipidus Perform focused neuro Serum electrolytes:
Medical dz can cause constipation b/c of exam: Test relevant DTRs hypokalemia,
neurological gut dysfxn (myopathies, & superficial reflexes. hypocalcemia (causes of
endocrine, electrolytes) Inturruption of T12-S3 constipation)
nerves causes loss of
If the constipation is chronic or recurrent, what Dec. peristalsis: diets that lack bulk,
voluntary control of
should I consider? roughage, inadequate fluids (<6
What do you usually eat in a day? glasses/day), inc. calcium (formation of Serum Thyroid
How many glasses of liquid do you drink/day? calcium caseinate in stools) Stimulating hormone:
High proteinBM
b/cstimulate movement. inc TSH = hypoT (cause
What are your usual bowel habits? Postponing of time constraints
How active are you? Lack of PA reduces peristaltic reflex of constipation)
What medications are you taking? Narcotics, imipramine, diuretics, Ca
channel blockers, anticholinergics
Do you use laxatives? How often? How long have Use of stimulants to empty colon removes Urinalysis
you used laxatives? peristalsis stimulus for 2-3 days.
How can I further narrow the causes? Anoscopy: indicated if
What does your stool look like? Is the stool size Aganglionic megacolon: infreq. Small, hard DRE detects hemi's,
large or small? What is the general shape of the stools fissures, strictures,
stool (eg. Small, round, ribbonlike)? Ribbonlike: IBS or narrowing of colon masses
Is the stool formed or liquid? Lack of fluids/fiber = dry hard stools
Have you had any involuntary loss of stool? Fecal incontinence in elderly Flexible sigmoidoscopy
Does the constipation alternate with periods of characteristic of IBS (stools described as & colonoscopy
diarrhea? hard and pellet-like)
What else do I need to consider? Hirschsprungs dz: no urge to defecate b/c
Do you have the urge to defecate? stool accumulates in lower rectum Barium enema: contrast
Do you have any urinary tract symptoms? voiding problems may be abdominal mass technique to detect
diverticula, polyps,
Do you have any nausea or vomiting? Intestinal obstruction: bilous vomiting in
Is there any pain with defecation? Obstruction
Intermittent, in adults: vomiting
recurrent pain ass.w/pain
w/ Colon transit studies:
constipation severe chronic
IBS: crampy lower ab pain w/ distension constipation
Diverticulosis: noncrampy dull pain on left
Hemorrhoids/fissures: pain w/ defecation
Is there any bleeding with defecation? How much? Hemorrhoids /fissures - bright red blood
upper GI bleed - black, tarry stools
What colour are your stools? Are the stools very Red: laxatives or vegetables
dark coloured or black? Black/ dark brown: iron & bismuth (from
If this is a child, is there anything else I need tofunctional megacolon 2o to constipation:
consider? involuntary passage of feces
Is there fecal soiling of underpants? Also fear of toilet/ coercive toilet training
Is there crying with defecation? Crying w/ fissure or large hard stools
If an infant: Is there a Hx of delayed passage of May indicate Hirschsprung's disease
meconium stool?
Has the child begun to drink milk? Cow's milk common cause of constipation
Has the child recently started toilet training? Stool witholding develops sometimes
Does the child have urinary frequency? May result in constipation
Is there a family history or genetic
Is there a family Hx of constipation or IBS? Genetic predisposition seems to exist.
Have you experienced any of the follwing symptoms DSM IV criteria for Generalized Anxiety Ask: dyspnea, chest None noted
WITH anxiety/worry more days than not for at least 6 Disorder discomfort, fatigue,
months: -Patients will often report sense of doom restlessess, sleep
1) Restlessness, keyed up, on edge and fear of losing control disturbance
Anxiety 2) Being easily fatigued
3) Difficulty concentrating or mind going blank
Physical findings:
tachycardia, palpitations,
4) Irritability and diaphoresis
5) Muscle tension
6) Sleep disturbance

Page 19 of 52
Simple constipation Low dietary fiber & bulk; inadequate fluid intake; Normal abdominal and rectal examination; may None if resolved; consider
physical inactivity; pain before and w/ bowel feel fecal masses in colon and rectum sigmoidoscopy if not resolved
movements; anorexia
Functional constipation Preschool and school-age children; Hx of abdominal Palpable stool in LLQ; large dilated rectum w/ Abdominal radiography, unprepped
pain and stool soiling. packed stool; external sphincter intact barium radiography
IBS Onset in young adulthood; alternating diarrhea and May have tender, palpable colon Sigmoidoscopy if indicated
constipation; mucus in stools
Obstipation/ impaction Passage of hard stool 3-5 day interval; diarrhea, small Hard feces in rectal ampulla; may have palpable Sigmoidoscopy if indicated
stools; common in those confined to bed feces filled bowel
Slow transit Common in older adults; physical inactivity; decreased Normal abdominal and rectal examination FOBT or FIT to rule out tumors
stool frequency; stool dry & hard
Hirschsprung's disease Delayed passage of meconium at birth; no urge to Empty rectal ampulla on examination Colonoscopy

Anorectal lesions Rectal pain on defecation; Hx of hemorrhoids; blood On rectal exam: Hemorrhoids, fissures, tears, Anoscopy
on stool, on toilet tissue, or in toilet abrasions; increased sphincter tone

Drug induced Hx of chronic laxative use; Hx of taking med that Normal rectal and abdominal exams None if resolved; consider
produce constipation sigmoidoscopy, barium enema if not
Tumors Diarrhea more common than constipation; recent May have palpable abdominal mass or CBC, FOBT or FIT, sigmoidoscopy,
onset: pain & abdominal distension, stool leakage, organomegaly colonoscopy, barium enema
urgency; late onset: wt loss, anorexia; increased
increased incidence over age 40; uncommon in

Page 20 of 52
Define the Nature of the Problem Inspect Ears and nose Sleep diary: keep for 1-2
What kind of sleep problem are you having? Sleep disorders include: sleeplessness Inspect mouth, throat, weeks. Record bedtime,
(insomnia), disturbance of behaviour neck (tonsils, adenoids) - total sleep time, time until
Insomnia associated with sleep (parasomniacs), checking for obstruction for sleep onset, times they
excessive sleepiness (hypersomnia) sleep apnea wake, quality of sleep, etc
Auscultate LU: asthma
Are you having difficulty falling asleep? Often related to poor sleep hygiene CHF is risk factor for sleep
practices, use of stimulants or medications, apnea
disruption of circadian rhythms, pain, Palpate abdomen: GERD
anxiety upper abdominal pain

Are you having difficulty staying asleep? Sleep disrupted d/t physiological factors,
illness, depression, pain, meds or alcohol
How long has the problem been going on? Acute/transient (few days) - d/t stress,
illness, environmental disturbance, jet lag
Short term (weeks)
Chronic (months to years) - d/t sleep
disorder, mood disorder, medications,
sleep disturbance
Is this a specific Sleep Disorder? Sleep labs
Do you have a creeping, crawling or uncomfortable Restless leg syndrome: sxs increase in evening, esp when person is Polysomnography -
feeling in your legs that is relieved by moving the lying down and still overnight sleep study for
legs? 1-2 nights
Does the bed partner report patients arms and or Common > 65yoa.
legs jerk during sleep? Periodic Limb movement disorder: b/l repeated, rhythmic jerking or
Do you snore loudly, gasp, choke, or stop breathing Obstructive sleep apnea: loud snoring and restless sleep patterns. May
during sleep? report insomnia and excessive daytime sleepiness
Passive parental smoking can be a risk factor for snoring in children
(smoke provoke mucosa --> narrowed pharynx --> snoring)
Do you have difficulty staying awake during the day Narcolepsy: excessive daytime sleepiness.
or doze off during routine tasks (driving)? Adults: fall asleep during tasks like driving
Child: difficulty getting up in am, when awakened appear confused,
aggressive (phys or verbal), fall asleep at school, doing hmwk,
watching TV
Do you have episodes of muscle weakness? Cataplexy: episodes of sudden muscular Ask: Do you lean against
weakness and atonia; emotional trigger wall for support b/c legs
Could the Sleep Problem be Secondary to an feel rubbery?
Have you been ill recently? Children: OM, chronic otitis, upper airway obstruction
GERD, COPD, PUD, CHF - paroxysmal nocturnal dyspnea
Do you have a chronic health condition? Anything causing nocturia
What medications do you take? anidepressants, decongestants, bronchodilators, b-blockers, thyroid
meds, phenytoin, methyldopa, corticosteroids, antihistamines
Do you have depression or anxiety? Depression: early morning waking
Anxiety: trouble falling asleep
Could this be related to Sleep Hygiene?
What is your bedtime routine? Is it consistent? - can cause disruptive rhythms
What else do you do in your bedroom? Work or watching TV can cause disruptive envt
noice can affect sleep, decrease REM
Do you consume alcohol, nicotine, caffeine, diet pills alcohol shortens total sleep time and exacerbate GERD and sleep
(with ephedrine) before bed? apnea
Alcohol withdrawal in heavy drinker can be assocaited with
restlessness and sleep disturbance
Do you exercise before bed? avoid for 1-2 hours before bedtime
How do you put your child to sleep? Child who is put to bed when they are still awake will learn to use self-
comforting methods so even if they wake in the middle of night, they
will fall back asleep
Toddlers fearful of separation must establish routine
Where does your child sleep? Sleeping with parents can be disruptive if parents move
Should be quiet and dark room
Could this be lifestyle related?
Are you a shift worker? Interruption of circadian rhythm
Do you sleep in the same bed each night? Affects quality of sleep, increase light sleep, shorter REM
Do you travel frequently? Jet lag
Could this be age related?
How old is patient? Newborns: 20 min - 4 hrs
What age was child when problem began? School age - 8 hrs/night
Does your child wake up screaming at night? Night terrors - inconsolable for up to 30 min and then falls asleep
Does your child have problems going to bed? again, happen within first few hours of sleep, not readily awakened, no
Does your child refuse to go to sleep? recolleciton of event
Nightmares - can be consoled, child is awake, and dream is
Could this be conditioned insomnia?
Are you able to fall asleep easily in places other than Usually insomnia develops initially in response to psychosocial stressor
the bedroom? Can fall asleep outside bedroom but awake in bed

If a child: what do they do when they wake up at Children need to develop self-comforting behaviours
night? Conditioned to feeding after waking at night, can prevent development
of more mature circadian rhythm
If a child: what do you have to do to get them back
asleep? usually once/night and 15 min. Takes great effort to wake person and
they have little or no memory of episode
Sleep walking?

Page 21 of 52
DDX Insomnia
Restless leg syndrome Irresistable urge to move legs in bed Normal None

Periodic limb mvmt > 65yoa, rhythmic jerking of legs or arms while asleep Normal None

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

Narcolepsy Excessive sleepiness, cataplexy refer to sleep specialist

Secondary to illness or GERD, COPD, PND, CHF, prostatitis, nocturea, consistent with medical condition consistent with medical condition
medications depression or anxiety

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

Lifestyle shift work, travel, jet lag normal sleep diary

Night terrors Inconsolable awakening occuring early in sleep, both normal both none
lasting 15 min, no memory of event

Nightmares Occur later in sleep cycle, dream is remembered

Night awakening Single to repeated awakening at night Use medical examination to eliminate associated depends on examination

Sleep refusal child refuses to sleep normal none

Conditioned insomnia identify intial trigger with persistent problem physical exam to r/o underlying condition sleep diary

Somnanbulism sleep walking in early sleep cycle normal None

Trained night crier child unable to soothe self normal none

Trained night feeder Hx of frequent feedings on awakening at night normal none

Page 22 of 52
HTN Dx: depend on two or more blood pressure
HTN readings taken at each of two or more visits after
initial screening
Definition is 140/90 Stage 1 HTN is defined as a systolic blood pressure BP!!!
of 140-159mmHg and a diastolic blood pressure of CV exam
120-139/80-89 is preHTN, 90-99mmHg Resp exam
follow up annually Stage 2 HTN is defined as a systolic blood pressure Vision changes
greater or equal to 160mmHg, or a diastolic blood Peripheral
pressure greater or equal to 100mmHg neuropathy/pulses

Presenting Condition
What have previous blood pressure readings been? A gradual rise in blood pressure with age is
normal, but a sudden increase could
suggest a secondary cause or malignant
Have there been any symptoms or signs of clinically Episodes of weakness or dizziness
overt cardiovascular disease? (cerebrovascular disease), angina pectoris
(coronary artery disease), or dyspnea
caused by pulmonary edema (congestive
heart failure). Such episodes could show
that hypertension is already causing target
organ damage and that it should be treated
more aggressively
Does the patient have diabetis mellitus? Diabetic patients with hypertension are
particularly at risk of cardiovascular
disease and should be treated more
aggressively than nondiabetic patients
Have you been experiencing headaches? Contrary to popular opinion, headache is
not a characteristic symptom of
hypertension, although it may be
associated with severe hypertension

Have you been experiencing heat or cold Such symptoms may point to underlying
intolerance, sweating, slow or fast heart rate, or hyperthyroidism or hypothyroidism as a
palpations? cause of hypertension, or
How much alcohol do you drink? Excessive alcohol consumption can raise blood
Excessive consumption of sodium chloride
Is your diet high in salt? Do you cook with a lot of salt? and caffeine can raise the blood pressure
How much salt do you add at the table? How much coffee
and tea do you drink?
Do you eat regular amounts of licorice? Licorice has mineralocorticoid properties
similar to aldosterone, and excessive
intake can directly cause hypertension
Is the patient obese? Obese patients are at an increased risk of
hypertension and should be encouraged to
lose weight
Do you smoke? Smoking increases cardiovascular risk, and
a diagnosis of hypertension is a good
opportunity for advice on giving up
Do you have a history of anxiety? Anxiety disorders, especially panic
disorder, can result in significant episodic
elevation of blood pressure
What medications do you take? Specifically, estrogen therapy, such as oral
contraceptives, can be associated with
Is there a family history of hypertension? Essential hypertension has a strong
genetic component, and the lack of a
family history increases the likelihood of a
secondary cause
Is there a family history of other cardiovascular Patients with a family history of
disease? cardiovascular disease are at an increased
risk of complications of hypertension

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

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

Page 23 of 52
Page 24 of 52
What Does the Patient Mean by Dizziness? Take VS and BP, MRI brain - acoutis
Describe how you feel when you are dizzy Vertigo - patient or env't is spinning orthostatic HoTN neuroma or central cause
Neoplasms and progressive vetibule loss of vertigo. Order if
produces changes in vestibular fuction. sudden onset or with
Dizziness Slow onset and manifest as imbalance severed headaches,
Do you feel as though you or the room is spinning? Loss of balance, lack of coordination with General appearance: looks direction-changing
absence of vertigo - result of degenerative, ill (labyrinthitis) nystagmus, or neurlogical
neoplastic, vascular, or metabolic disorder signs
Do you feel your balance is off? Acute nausea and vomit:
vestibular neuronitis
Includes vertigo, Do you feel like you are about to faint? Vision exam: change in
lightheadedness, loss of visual acuity/ new
balance. Needs visual, corrective lenses may
vestibular, and sensory cause transient imbalance
Central: neopastic or In Children: parents may describe as trouble Maybe peripheral neuropathy or Ear Exam: look for signs of CT - persistent vertigo
vascular, CNS walking, irritable, or behaviour differences dysfunciton of vestibular or cerebellar infection (serous otitis, OM) and in all cases with
Peripheral: inner ear or system Cholesteatoma: shiny additional sigsn of
vestibular appraratus Do you feel lightheaded? Or about to faint? Near syncope white irregular mass, foul- neurological disturbance
smelling d/c With renal failure, HTN,
In elderly: have you previously been diagnosed with orthostatic hypotension is most common Look at TM: trauma hematological malignancy
blood pressure irregularities? cause of dizziness in the elderly - d/t Rinne and Weber tests: with sudden onset
abnormal BP regulation sensorineural loss
lateralizes to unaffected
Does the Vertigo Result from a Systemic Cause? CV problems common cause of vertigo. ear; AC > BC (but both
May be vasomotor instability decreasing reduced)
What other medical problems do you have? systemic vascular resistance, venous EEG - vertigo with
return - can lead to transient decline in alterations of
cardiac output consciousness
Would you describe yourself as anxious or nervous? Psychogenic dizziness. Sxs are vague and CN VIII - nystagmus CBC - anemia
include fatigue, fullness in head, Glucose levels - DM
lightheadedness, feeling apart from env't. BUN - renal failure
Do the episodes occur with any specific activity or When turning, especially when rolling in Neurological exam: CN, Syphilis - 2nd or 3rd like
movement? bed usually d/t vertigo. cerebellar function (gait, Meniere's diseases
Disequilibrium - unsteady while walking balance), rapid-alternating
Is the vertigo central (brainstem or cerebellar) or mvmts, sensory and motor
peripheral (vestibular) in origin? function

Do you have migraine headaches? H/a - vascular related cause of central

vertigo. Often with migraines
Do you have other symptoms that bother you? Central vertigo nearly always have CV exam: HR and rhythm,
neurological sxs (double vision, facial auscultate carotid and
numbness, hemiparesis) temporal arterires for bruits
Cerebellar causes also will have loss of for CVS cause of vertigo
balance, motor dysfunction, coordination
Peripheral origin - no additional
neurological symptoms
Do you have nausea and vomitting? Suspect peripheral vestibular apparatus
Common with vestibular neuronitis and

When do the episodes occur? If first arising in morning, usually vestibular disorder
If turning in bed - benign positional vertigo (BPV)

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

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

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

Do you have ringing in your ears?

What Else Should I Consider? Salt retaining or oxotoxic: vertigo, lightheadedness, or unsteadiness
Psychotropic drugs - vertigo
AntiHTN drugs - HoTN
Sedatives, alcohol, anticonvulsants - disequilibrium

What medications are you taking?

Are you now or have you recently been ill? Vestibular neuronitis - recent viral infxn
Currently ill - labyrinthitis (ass w/ concomitant bac/viral infxn)
Sinus/ear infxn, middle ear infections: dysfunction of vestibular apparatus
Have you had any recent injury to your head? Did Temporal bone fracture, whiplash can cause labyrinth damage
you have dizziness before the head injury?
Have you had any previous ear surgery? Cholesteatoma: hx of chronic middle ear infections, otorrhea, conductive hearing loss. Prior
procedures can produce peripheral vertigo b/c vestibular apparatus disrupted

Page 25 of 52
Central Causes
Brainstem/cerebellar problems elderly, acute onset, recurrent vertigo, tinnitus, ataxia, double vision, coordination problems, MRI
hearing OK sensory/motor deficits, nystagmus, impaired RAM
and finger-finger testing
MS 30-40yog maybe normal MRI

Migraine h/a hx, other migraine sxs maybe have sxws of vertebrobasilar vascular MRI
Peripheral Causes adults, with position changes, recurrent episodes, nystagmus provoke position changes
BPV lasts sec-min, > no motion NO tinnitus

Benign paroxysmal vertigo of children, preschoolers, sudden onset with crying vomitting, pallor, sweating, nystagmus, no LOC, hypoactive or abset response to
childhood neurological, audiological can be normal caloric testing

Meniere's Disease sudden onset, lasts hours, recurrent, tinnitus and nystagmus, fluctuating hearing loss, low tones,
fullness in ears sensorineural
Vestibular neuronitis sudden onset, previous viral infection nausea and vomitting, nystagmus

Labryinthitis sudden onset, lasts hours to days current illness, nystagmus, hearing loss audiometry
maybe tinnitus, n/v
Acoustic neuroma adults, gradual onset, mild vertigo, persistent tinnitus, u/l hearing loss, poor speech discrimination MRI
facial numbness, weakness

Perilymph fistulas history of trauma, hearing loss nystagmus and vertigo, sensorineural hearing audiometry

Otitis/sinusitis pain in ear or face, Hx of infecitons, gradual onset of serious otitis, OM, tenderness on sinus, purulent
vertigo nasal d/c, NO nystagmus

Systemic Causes vague sxs, recurrent, anxious, other psychiatric normal neurological and auditory exams hyperventilation to reproduce the
Psychogenic diagnosis vertigo

CV CV hx, antiHTN meds orthostatic BP, dysrhythmias, carotid/temporal depends on px and conditions
Neurosyphylis vertigo, tinnitus, fullness in ears Various clinical sxs, papilledema, aphasia,
monoplegia/hemiplegia, central nervous palsies,
pupillary abN, Argyll-Robertson pupil, focal
neurological deficits

Page 26 of 52
Is This Really Syncope? Distinguish syncope from dizziness, ECG to rule out cardiac
vertigo and resyncope where loss of cause Event
Did you lose consiousness? consciousness and postural tone does not Monitoring or
Syncope Did you have any prodromal symptoms?
Prodromal symptoms of sweating, vertigo,
Continuous Loop
Monitoring Used in
nausea and or yawning associated with patients with suspected
syncope. Aura and tongue biting cardiac arrythmia and
associated with seizures syncope Doppler
Syncope is the reversable What precipitated the event? Or What were you Loss of consciousnes precipitated by pain, Observe Hydration
loss of consciousness and doing when the event occurred? exercise, urination, defecation or stressful Status Studies Detect
postural tone that results events is probably not a seizure. Breath- Dehydration leads to hemodynamics of intra
from a sudden decrease holding spells in children causes syncope syncope and extracranial arteries.
in cerebral perfusion and are usually precipitated by pain, anger, Treadmill testing Stress
a sudden startle or frustration. Syncope test for arrythmias
that occurs with rest or in supine suggests Echocardiography For
seizure or arrythmia. Syncope with no people with exercise
warning suggests cardiovascular origin. induced syncope to rule
If you lost consciousness, how long did it last? Disorientation after event, slowness in out left ventricular outflow
returning to consciousness and tract obstruction
unconsciousness lasting longer than 5 Electrophysiological
minutes indicate seizure studies Test for
Was there any limb jerking during the event? Rhythmic movements during event suggest arrythmias
seizure, although they can occur with Baseline Blood Testing
Did anyone see you faint? History from witness give you useful info.
Does This Require Immediate Referral? Presence of structural heart disease Perform Heart and Lung Electroencephalograph
increases risk of sudden death. Exam Look y For seizure CT Scan
Hospitalization required if history of for cardiac cause for neurological cause
coronary artery disease, congestive heart Perform a Neurological Toxicology Screen for
Do you have a history of heart disease? unexplained syncope
failure or ventricular arrythmia. Aortic or Exam
mitral stenosis or prosthetic valves may Perform a Abdominal Tilit-table
cause syncope. Complete heart block is exam testingSimulate syncope
leading cause of syncope. Examine extremities for and if positive indicates
signs of thromboembolism neurogenic cause
Do you have a congenital heart problem?
Are you having chest pain and/or shortness of Obstructive mechanical blockage may be
breath? caused by pulmonary embolism, cardiac
ischemia or myocardial infarction with
pump failure
Did this occur after exercise? Syncope after exercise is of cardiac origin
until proven otherwise. Syncope after
exertion ina well-trained athlete who has no
heart disease is of vasovagal origin.
What Do Associated Symptoms Tell Me? Supraventricuar and ventricular
tachycardia are associated with syncope
What other Sx did you have or are you having? and sudden death.Ventricular fibrillation is
always fatal unless reversed with electrical
Did you have/ have you been having palpitations? defibrillation.
Have you had headaches? Pain of migraine headaches can affect
brain stem and cause sycope. Headache
continues after consciousness has been
regained and is associated with other
migraine symptoms
Have you had vertigo, dizziness, diplopia or other May accompany migraine or transient
vision changes? ischemic attack
Is This Neurocardiogenic in Origin? vasovagal syncope is neurocardiogenic
Did this occur in response to a specific situation (eg., and tends to occur in families. Often
stressful event, urination, defecation?) precipitated by emotional stress, fear,
extreme fatigue or injury and can occur
without any antecedent cause. Warm
temperature, anxiety, blood drawing and
What position were you in when you fainted? Sitting, crowded rooms can cause peripheral
standing or lying flat? vasodilation. Situational syncope can occur
Are you an athlete? Do you have a history of any in response to urination, defecation, cough
heart problems? or emotional stress. Post-tussive
Is This Orthostasis? syncopefollows paroxysmal coughing
caused by increased intrathoracic
What medications are you taking? 10% of syncopal episodes are caused by
prescription medication, over the counter
Have you recently started taking blood pressure medications, and recreational drugs that
medicine or increased its dose? produce orthostasis, bradycardia or
prolonged QT interval.
What other health problems/conditions do you have? Diabetes may induce hypoglycemia. Also
anemias and chronic GI bleeding from an
ulcer can cause syncope. Pregnancy,
prolonged bed rest and dehydration can
lead to orthostatic hypotension.
Is This Explained by Other Factors? Psychogenic syncope often associated
Have you had this before? How often? with repeated episodes in which
Did it occur with suddden head turning? unpredictable motor reflexes appear with a
If a child: Has the child had Kawasaki disease? lack of pathological reflexes. Carotid sinus
hypersensitivity produces a cardioinhibitory
response that results in a profound drop in
heart rate or may induce an abrupt
vasopressor response with a drop in blood
pressure. Children who had Kawasaki
disease are at risk for coronary heart
disease which may present as chest pain
associated with exercise.
Do you have Lyme Disease? Lyme Disease can cause dysrhythmia in
the form of heart block which can lead to
What Other Things Do I Need to Consider? syncope.
A family history of idiopathic hypertrophic
subaortic stenosis is a risk factor for
Do you have a family history of sudden death? sudden death. Family member who had MI
before age 30 is also risk for sudden death.

Do you have a family history of fainting? Neurogenic syncope is common in families

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

Page 27 of 52
Cardiac Causes Organic Shortness of breath, chest pain, palpitations, exercise May have bradycardia or tachycardia, cyanosis, Refer, electrocardiogram, Holter,
heart Disease and Arrythmias associated Loud S2, S3; murmur, lift echocardiogram, Doppler studies,

Neurocardiogenic Causes Emotional event, standing for long periods, crowded none tilt table test
Vasovagal room, warm environment

Situational occurs with cough, micturition, defecation, swallowing none None

Breath holding infants 6 mo to 5 yrs, associated with anger, pain, cyanosis or pallor None
brief cry. Breath is held, loss of consciousness, may
have twitching
Hyperventilation Anxiety or fear induced event, shortness of breath none None

Couch syncope History of asthma, coughing paroxysm awakens child wheezes None
from sleep, becomes flaccid with clonic muscle
spasm, loss of consciousness
Orthostasis Position change from lying/sitting to standing. Hypotension on testing orthostatic blood pressure 20 mm Hg drop in systolic pressure
Orthostatic hypotension Pregnancy, prolonged bedrest on standing

Medication Related History of antidepressants, antiarrythmic agents, beta- Depends on underlying condition None
Prescribed medications blockers, or diuretics
Drug induced History of use of illicit drugs Arrythmia may be present Toxicology screen
Neurological Causes Headache, vomiting, photophobia, positive family Usually none, nystagmus, photophobia None
Seizure history
convulsion, incontinence, postical phase usually none, nystagmus electroencephalogram

Psychiatric Causes Symptoms consistent with depression, anxiety, panic none psychiatric evaluation
Mental disroder

Hysterical reaction Adolescent, event occurs with audience present. none None
Gentle fall, memory or incident exact

Unknown no diagnostic characteristics none workup negative

Page 28 of 52
ABDOMINAL PAIN Is this an acute Condition??
subjective feeling of long ago did the pain start? acute onset of pain that is getting General Appearance CBC
discomfort. Was the onset sudden or gradual?? prgressively worse may signal surgical visceral pain = restless and inc WBC -
emergency (severe 6-12hr form the onset move about - obstr, stones, infection/inflam
= emerg) ex. ectopic preg, perforation, gastroenteritis inc neutrophils - bacterial
obstruction, ruptured aortic anuerysm, parietal pain = lie still, don't infection
intussiception want to move -
appendicitis, rupture,
children - do they look sick,
3 processes produce: How severe is the pain (1-10) acute and severe could mean emergency lethargic withdrawn Urine/serum HCG
to RO pregnancy

1. tension in the GI from Child? What is their level of activity? avoidance of favourite activities indicates ESR -
mm contraction or an organic problem inflam, or tissue injury,
distension pregnancy

2. Ischemia does the pain wake you from sleep? serious! Vitals Urinalysis
An organic dz wakes a child from rest fever - acute inflam eval of KI infection, stone,
condition, mc renal or lung failure or systemic
infection process

3. Inflammation of the course of the pain? Getting worse/better? pain that is severe and progressing = bad, Abdominal Musculature Urine culture
perotineum likely an emergency rigid - perotineal irritation suspect UTI
may require surgery

pain can also occur from last BM? obstipation occurs with complete Test for STI's
within or outside the obstruction but diarhea may present with all types
abdominal wall partial obstruction.

had this pain before? chronic pain may be bc potential emerg Colour of skin Fecal Occult Blood Test
event is brought into check but is not Cullen's sign - ectopic preg RO GI bleeding
resolved. If >1yr consider IBS or or pancreatitis
colorectal, endometrial or inflam causes Grey-Turners sign -
where is the pain? 1.visceral pain - perceived midline - dull
deep, diffuse. Orginates from epigastric, Imaging
periumbilical and hypogastric causes from
intraabdominal extraperotineal organs. Ultrasound
2. paritoneal pain - localized and sharp.
Originates from the intraperitoneal organs.

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

related to activity?/ triggers? relieved by defecation or diet changes -->

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

vomiting? if vomit precedes pain unlikely a surgical Aucultate bowel sounds

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

Stool characterisitics blood = in the intestinal tract Percuss

diarrhea may preceed perforation of unexpected dullness
children - diarhhea may suggest acute

Page 29 of 52
1. Ectopic preg women childbearing age hemorrhage, shock and lower abd peritoneal HCG + ultrasound ruptured
sudden spotting and cramping in lower quad after irritation. Enlarged uterus and cervical motion ectopic preg = sugical emerg
missed period tenderness

2. peptic ulcer perforation sudden severe, intense, steady epigastric pain that Pt lying still. Epigastric tenderness, rebound Radiograph - surgical emerg
radiates to sides, back and shoulder. tenderness, abd mm rigid, bowel sounds decr.
Hx pain < empty ST

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

4. peritonitis sudden severe pain, diffuse and worsens with gaurding. Rebound tenderness, bowel sounds CBC with differential.
movement/cough decr. Abd radiograph

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

6. mesenteric adenitis fever, pain in RLQ, other sx suggestive appendicitis pain in RLQ, may be pharyngitis and cervical CBC with differential. Adenovirus
adenopathy found in surgical specimen.

7. cholecystitis/lithiasis colicky pain changing to chronic pain. RUQ pain may tender to palpation or percuss on RUQ. GB CBC with differential.
radiate to scapula. N/V and hx of daark urine or light palpable in some. Murphy's ss +ve US
stools Abd radiograph
serum amylase and lipase

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

9. UTI/pyelonephritis Urinary sx of UTI. Back pain with pyelonephritis. altered voiding pattern, malodorous urine, fever Urinalysis

10. PID LQ pain that incr in severity. May have irreg bleeding, abd tenderness, adnexal tenderness, guarding, WBC, ESR elevated
vaginal dc and vomiting - MC in sex active women rebound tenderness, feverm vaginal dc cultures and gram staining.

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

12. Ileus abd distention, vomiting, obstipation and cramps minimal/absent peristalsis on auscultation gaseous distention of isolated
segments of small and large
intestines shows on radiographs

13. Intussusception sudden onset pain in infants fever, vomit, jelly stools abd films

Page 30 of 52
Clues to implicate organ?? Palpate
start gentle and finish with
Do you have GI symptoms? gas, bloating, diarrhea, constipation, and area of pain. Rebound
changes in bowel habits/stools or eating habits? rectal bleeding - usu pain intestinal origin tenderness and gaurding -
heartburn and dysphagia - esophagitis peritoneal irritation.
Palpate LV, GB (murphy's
pain relieved by defecation/burping? pain relieved by defecation/flatus - IBS sign), SP, KI, aorta, BL

Pain or difficulty with movement, limited ROM, pain produced by MSK and refered to abd

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

how do you feel? mood? Energy? Dx of mental not organic pain

health disorder?
Other Palpate groin

Meds? Palpate Hernias

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

weight loss? colon cancer? Test for peritoneal

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

camping recently or chikd in day care? untreated water ingestion - parasite Perform pelvic Exam in
parasites also transmitted in day cares women/Genital prostate
exam on men

Check peripheral pulses

Page 31 of 52
14. malrotation/ vulvulous infants billous emesis abd films

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


1. IBS begins in adolescence. Unremarkable Proctosigmoidoscopy
Hypogastric pain, crampy. Variable infrequent barium enema
duration, assoc with bowel function. Gas bloating stool positive for blood
distention relief with passing flatus/feces. failure to improve after 6-8 wk
2. lactose intolerance crampy pain after eating dairy Unremarkable trial elim of dairy

3. diverticular dz older pt. localized pain abd tenderness, fever Barium enema, elevated ESR,

4. constipation colicky or dull and steady pain. Does not progress or fecal mass palpable. Stool inrectum none
worsen. if habitual/lifelong constipation -
barium enema if metabolic or
systemic cause suspected

5. dysmenorrhea premenstrual pain. Decr with age. normal pelvic exam GYN consult

6. uterine fibroids pain related to menses, intercourse palpable myomas pelvic USG if neoplasm cannot be
7. hernia localized pain incr with exertion hernia noted proctoscopy, barium enema is
strangulation suspected
8. ovarian cysts young adnexal pain and palpable ovarian cysts pelvic USG

9. abd wall disorder trauma bruising or swelling, no GI/GU sx CT uf internal dz


10. esophagitis/GERD burning, gnawing pain in mid epigastrium. Pain after Unremarkable upper gastro series
eating. May be relieved after antacids radiogrpahy or endoscopy if sx
11. Peptic Ulcer burning, gnawing pain. Soreness. Empty feeling or may have epigastric tenerness on papl upper gastro series, endoscopy,
hunger. MC with empty ST, stress and alcohol. gastric analysis
Relieved with food. Pain steady, mild or severe in the
12. Gastritis constant burning pain the in epigastric are. May N/V Unremarkable pt should respond to therapy
diarrhea or fever. Alcohol, NSAIDs and salicylates
13. Gastroenteritis diffuse crampy pain with N/V diarrhea, fever hyperactive bowel sounds. Dehydration if very no dx test needed
14. Functional Dyspepsia vague complaints of indigestion, heartburn, gas, abd Unremarkable CBC, fecal occult blood test (FOBT)
15. recurrent abd pain children 5-10 yo. Enviro pr psycholog stress. Unremarkable CBC, urinalysis, ESR, FOBT

Page 32 of 52
Have you had a fever or chills? systemic inflammatory response - acute Inspection: ill appearance Urine Dipstick: Specific
condition such as pyelonephritis or lithiasis likely to have upper UTI gravity, leukocyte
of Urinary system such as pyelonephritis, esterase, nitrites, protein,
urolithiasis. Lower glucose, ketones, blood
problems are fever-free
and appear well.
Problems in Have you had nausea or vomiting? Accompany a UTI, pyelonephritis, or Also, neonates with UTI's Microscopic Urinalysis:
Females and lithiasis. Systemic inflammatory response may present with Jaundice. color, sediment, RBC's,
indicating an acute presentation WBC's, Casts
Have you and acute pain in the abdomen or back? Upper UTI and pyelonephritis. Urinary Vitals: Hypertension is KOH and Wet Mount: if
tract stones can cause localized back pain seen in patients with you suspect
that radiates to the thighs nephritis vulvovaginitis

Are you positive for HIV? Or receiving chemo? immunocompromised individuals are Palpate and Percuss: the Ultrasonography: renal
susceptible to infections flanks and costovertebral US to assess size and
angle for pain, this may contour of KI, bladder US
indicate renal capsule to assess for tumors of
distention the bladder or thickening
of the bladder wall.

In an infant: has the infant been irritable with In babies, UTI may present as irritability, Pain the lower quadrant - Radiography: urinary
lethargy? anorexia and weight loss. lower ureter involvemnet calculi

Have you had any recent injury? Hematuria can be caused by injury to the Suprapubic tenderness
flanks lower UT

Have you been hit recently? Domestic violence can cause blood in the Deep palpation for any
urine d/t trauma masses

Are you sexually active? And how frequently do you Acute bacterial cystitis d/t frequent sexual distended bladder rises
engage in this behavior? intercourse, use of diaphragm or above the symphysis and
spermicidal gel. is a sign that the bladder
isn't emptying. Enlarged
bladder may cause pain.

Page 33 of 52
DDX Common causes of Urinary Problems in Females and Children
Uncomplicated UTI Dysuria, frequency, mild Nausea, nocturia, urgency, NO fever; appears well; no CVA tenderness; may Urine dipstick: + blood, +leukocyte
voiding small amounts; neonates and young infants have suprapubic tenderness; Note: neonates and esterase, +nitrites, microscopic
present with anorexia, irritability, fever young infants may present with failure to thrive, analysis: RBC's WBC's no casts;
bacteremia urine C&S; in children, voiding
cystourethrogram and renal US are

Urethritis Dysuria; vaginal d/c, Hx of new sex partner, frequent Appears welll has no CVA tenderness or fever Urine dipstick: may have + blood, +
sex, partner with urethritis, multiple sex partners leukocyte esterase, + nitrites, urine
culture; molecular testing vaginal

Vulvovaginitis Hx of vaginal itching, dc, burning, dryness, inflamed or atrophic labia, vaginal or cervical d/c Microscopic exam, vaginal cultures,
postmenopausal molecular testing

Interstitial cystitis Frequent painful urination, hematuria, most often appears well and has no physical findings; urinalysis usually negative, x-ray and
middle-age women, often frustrated b/c no cause has suprapubic tenderness, may be present cystometric studies to rule out other
been previously found for long standing and urological disease, cystoscopy
persistend symptoms

Pyelonephritis fever, chills, back pain, n/v, toxic appearance, some feels and looks ill, fever, CVA tenderness, Microscopic examination, WBC's
patients also have frequency and dysuria abdomen may be tender may have white cell casts or
bacterial casts, urine C and S:
E.coli, klebsiella, proteus mirabilis,
enterobacter, blood cultures

Urolithiasis Pain, hematuria, may have symptoms of secondary may have CVA tenderness, loosk ill during urinalysis, gross or microscopic
infection, renal colic, pain that radiates to inner thigh, periods of acute pain, may have abdominal hematuria, WBC's with or without
nausea, vomiting distention bacteria, crytstalline structures may
be present, noncontrast helical CT

Poststreptococcalglomerul Hx of skin or thorat infection 1-3 weeks prior, lethargy, Hypertension, perioribital edema, CVA U/A: +proteinuria, +hematuria,
onephritis anorexia, vomiting, abdominal pain tenderness, may have dyspnea, cough, pallor +ASO titer, serum C3 low early in
Chemical Irritation Hx of bubble baths, soaps, lotions, sprays, urgency, No fever, erythematous labia, urethral opening hematuria common, gross
dysuria hematuria, unusual and casts never

Page 34 of 52
Vaginal What kind of vagnitis might this be?
What is the amount, color, and consistency of your
Green, offensive smelling: T. vagnitis.
Purulent: gonorrhea and chlamydia.
Note vital signs
Fever in serious infection
Potassium Hydroxide
(KOH) and wet mount.
Discharge discharge? Moderate white, curd-like: candida. BV is
thin and either white, green, gray or
such as PID (uncommon in
Whiff test is + for BV.
Look for hyphae:
and Itching Do you have itching, swelling, or redness?
Vagnitis causes inflammation --> erythema Perform oral exam look
candida. Clue cells for
and edema. Candida has itching. for oral thrush
Is there an odor? Fishy: BV (positive whiff). Foreign body. Perform an external Test for pH - normal is
Is this likely a sexually transmitted infection? MC in women of childbearing age (12-50) genitalia examination less than 4.5. Above this:
with a new partner. check lymph nodes BV, trich, or atrophic
Are you sexually active? Do you have multiple (inguinal), erythema, Funal culture or
partners? Do you have a new partner? excoriations and sabouraud agar culture
induration. Discharge in
Common vaginal Have you had sex against your will? (Child: has
labial folds.
infections pospubertal: anyone touched your private parts?)
Trichomonas, Candida What form of protection do you use? How often? Perform an internal Herpes culture
and bacterial vaginosis Have you or your partner(s) ever been tested or Recent treatment may indicate tx failure vaginal examination look Tzank smear - for herpes
treated for a STI? at the cervix and vaginal
Do you have any rashes, blisters, sores, lumps, or Vesicles: herpes. Warts are common (M walls Modified diamond's
bumps in the genital area? contagiosum may extend to thighs). culture - for trich (rarely
Painless ulcer suggests syphilis (solitary) used)
Most common cervical Can this be vaginitis that is not related to an Perform a bimanual Thayer-Martin culture -
infections: Chlamydia, STD? examination - POSITIVE for gonorrhea
Neisseria gonnorrhea, CERVICAL MOTION is
Have you ever been told you have diabetes or Could be immunocompromised DNA probe for
and herpes simplex from PID and warents
Cushing's syndrome or that you are positive for HIV? Chlamydia, Gonorrhea,
immediate evaluation,
Have you been ill recently? Chickenpox, scarlet fever, measles can and herpes
treatment, or referral to
cause vaginitis prevent scarring, ectopic
Are you taking antibiotics, hormones, or BCPs? Associated with candida. (Alter pH and pregnancy, and infertility Serology for syph
Postmenopausal women Have you received chemotherapy? flora) Urinalysis
have discharge related to Does the itching seem to be worse at night? Pinworms! Microscophy and skin
atrophic vaginitis (def of Describe some of your recent activities Bike riding, pools/hot tubs, tight fitting scraping for scabies and
estrogen) pants --> moisture/heat and mechanical pubic lice
irritation or infection
Is the patient premenarche? Predisposed due to nonestrogenized Perform a vaginal-rectal Scotch tape test - for
vagina and lack of hair and labial growth exam pinworms (Enterobius)
Is the condition acute, recurring, or chronic? After new partner suggests acute STI. Acetic acid test for HPV
Assoc with condoms/jelly suggest
How long have you had this? Is it getting better or sensitivity to the product. Related to FSH - to determine pre-
worse? bathing: chemical irritation menopause
Have you ever had these symptoms before?
How many episodes have you had in the past year?
Are the episodes related to any particular activity or
If this is acute, could it be related to a previous
Have you been tested and treated for this condition Watch for self-diagnosis of a "yeast
recently? infection"
What medication was prescribed? How long ago? Can have tx failure if stop taking meds.
Did you take all of the medication?
What other prescriptions were you taking at that May have drug interactions
If this is chronic, what should I suspect?
Do any family members or sexual partners have Transmission of candida, M. contagiosum,
vaginal or urinary infections? Any itching, rashes, herpes, lice, pinworms. Also poor hygiene.
sores, lumps or bumps?
Do you have a new or untreated partner?
What are your sexual practices? Vaginal, oral, and/
or anal sex?
How many yeast infections have you had this year? Consider diabetes or immunocompromised
state (HIV) if more than 3x candida/yr.
What are other possible causes for this vagnitis? local irritation, altered flora. Perfumes,
douches, sprays, lubricants, bubble baths
What are your personal hygiene practices? all are offenders in allergic vaginitis.
Do you douche? Changes flora and pH. Also
scented/coloured toilet paper can irritate.
Direction of wiping is also important
(microbes from anus to vagina)
Have you changed brands of contraceptive May cause allergic inflammation
Could you have forgotten to remove your diaphragm Itching, burning, foul, purulent discharge.
or tampon? Also assoc with vaginal bleeding.
Are there any associated symptoms that point to
a cause?
Do you have burning or pain with urination? Atrophic vaginitis: dysuria, dyspareunia,
Frequency, hesitation, nocturia? vaginal dryness.
Do you have painful intercourse? Endometriosis or PID, or fibroids. STIs
Do you have any abdominal or pelvic pain? leading to PID.
Infant: is there an eye infection? Gonorrhea or chlamydia
Infant: is there a cough? Pneumonia assoc with chlamydiosis

Page 35 of 52
Vag Discharge DDX
Physiolocial discharge Increase in discharge; no foul odour, itching, or edema Clear or mucoid, pH <4.5. Up to 3-5 WBCs; epithelial cells,

Bacterial vaginosis Foul-smelling discharge Homogenous, thin, white or gray discharge, pH Presence of KOH "whiff" test,
>4.5 presence of clue cells, <lactobacilli
Candida vulvovaginitis Priuritic discharge Whie, curdy, pH 4-5.0 KOH prep: mycelia, budding,
branching yeast, pseudohyphae

Trichomoniasis Watery discharge; foul odour Profuse, frothy, greenish discharge; red friable Round or pear-shaped protozoa;
cervix; pH 5.0-6.6 motile "gyrating" flagella
Atrophic vaginitis Dyspareunia; vaginal dryness Pale, thin vaginal mucosa; pH >4.5 Folded, clumped epithelial cells

Allergic vaginitis New bubble bath, soap, douche, etc. Foul smell, erythema, "lost tampon"; pH<4.5 WBCs
Foreign body Red and swollen vulva; vaginal discharge; past history Bloody, foul smelling discharge WBCs
of use of tampon, condom, or diaphragm
Chlamydia Partner with non-gonococcal urethritis; asymptomatic May or may not have purulent discharge DNA probe; >10 WBC's/HPF

Pelvic inflammatory disease Bleeding, abdominal pain, fever, and vaginal Cervical motion test and adnexal tenderness; WBC, culture, DNA probe, gram
(PID) discharge; increasing amount of dicharge and may also have guarding and rebound tenderness staining
bleeding after sex
Itching and lesions DDX History of painless ulcerative lesion; rash on palms Chancre: usually 1, painless ulceration; VDRL, RPR, FTA-ABS
Syphilis and soles; warty growth on vagina or anus condylomata lata: flat, whitish papule or plaque;
maculopapular rash: palm, soles, body

Genital warts Mild-to-moderate itching, foul vaginal discharge; child: Moist, pale-pink, verucous projections at base; Acetic acid test: white
history of sexual abuse; adult: new or multiple located on vulva, vagina, cervix, or perianal area
partners; past history of warts
Herpes History of prodromal syndrome, paresthesias, Grouped vesicles on a red base, erode to ulcer; if Viral culture; Tzank smear
burning, itching, may have mucoid vaginal discharge on mucous memb, exudate forms, if on skin,
crusts form; redness, edema, tender ing lymph
Molluscum contagiosum History of contact with infected person; if inflamed: Flesh-coloured, dome-shaped papules, some None
itching with umbilication; usually 2-5cm in diameter

Page 36 of 52
Was onset abrupt or gradual? Abrupt & shortlived = transient ischemic
MENTAL STATUS EXAM CBC- infxn, or anemia
Does it chenge in a 24 hr. period? attack. DEMENTIA = insidious onset - What is the date? may contirbute to
Sudden over a few hours = delirium - Repeat words after me: confusion
house, car, lake.
Confusion/ Fluctuating symptoms in delerium
More stable symptoms in depression and - What is this? (pointing to
Forgetfulness dementia pencil)
Is pateint alert and aware? Yes = dementia and depression NEURO exam Serum folate and B12
No/decreased alertness = delirium deficiencies may cz
Cranial nerves: i.e. sense reversible dementia
Has the aptient seen, heard, felt things that are not Hallucinations common in delirium of smell often impired in
there? Uncommmon in dementia and depression dementia; slurred speech S-syphilis
(although can occur in late stage dementia) Rapid alternating Mvmt: r/o neurosyphilis
Rhomberg's, DTR
Hx of head trauma?
(hyperreflexia in dementia); Urinalysis - r/o infxn
Medications? Numerous drugs, illicit and pharmaceutical Language (apahsia in
can alter mental states. dementia) Lumbar puncture - r/o
Meds interactions meningitis

Tremor and gait disturbances at rest? Associated with Parkinsons, HIV

encehalopathy, liver dz, medication rxns,
head trauma

H/A, fever, n/v? H/A, N/V assctd. With stroke and tumor nd
trauma Abdomen: inspect, percuss
Fever in infxn, OH withdrawl for CVA tenderness. May
systemic cz of confusion
i.e.urinary retention- UTI
CVA tender-pyelonephritis
What specific problems with mental abilities or Delirium = global cognitive losses involving
Large Liver= hepatic
tinking have you noticed? memory, thinking, perception and
judgement. Also irritability, disoriented,
Early Dementia = seletive cognitive losses,
poor hygiene, socially withdrawn,
Depression= fewer cognitive losses

Does patient have any chronic health concerns? HIV, alcoholism, renal failure, liver disease,
severe anemia, COPD, CVD, predispose
elderly to the development of confusion

Fatigue Is this really fatigue? Discriminate b/w fatigue & weakness. Pxs Psych screening for
describe muscle weakness instead. depression & anxiety
CBC w/ diff: may
indicate presence of
Tell me what you mean by fatigue? anemia (Hb, hematocrit),
chronic blood loss
The sensation of profound Is the fatigue physiological? Erratic eating patterns, over/undernutrition, Note general appearance inflammation or infxn
tiredness that is not Tell me about you lifestyle habits (Exercise & diet)? missed meals, caffeine, stress, -demeanor
relieved by rest or sleep Tell me about your sleep pattern. employment.
Lack of adequate sleep. Need b/w 6-8 hrs Vitals - fever, inc. HR/BP,
and is not associated with adults; adolescents 8-9hrs; kids 10 hrs. orthostatic hypoT, BMI
prolonged activity. Early am waking/ Xs sleep = sx of
Chronic fatigue lasts more Do you require naps? depression
Inspect skin, hair & nails Ferritin - stored iron (low
than 6 months and onset Do you feel rested when you wake up in the am? - for signs of hypo/hyperT, in iron def. anemia)
is slow & progressive. When was your last menstrual period? Fatigue = early sx of pregnancy, post child nail biting, skin lesions Total Iron Binding
birth, perimenopausal (night sweats/ hot (mono, Lyme dz) Capacity- indirect
flashes = disrupted sleep) measure of transferretin
Do I need to consider an organic cause? 1st sign of HIV, hep, AIDS - STI contracted Examine Nose, eyes, UA- infxn or systemic dz,
Do you practice saf sex (if sexually active)? from semen or blood. & through sex mouth & throat - hematuria, pyuria,
Have you ever had hepatitis? practices that damage mucous membranes inflammation, lymph leukocytes,
Do you take any medication? Fatigue = side effect nodes, mucous ESR - rate at which
Do you drink alcohol or use street drugs? alcohol , marijuana use result in fatigue - CV exam - heaves, bruit, blood settlesin
CAGE questionnaire heart sounds, PMI anticoagulated blood; inc
What other clues can help me rule out an organic increased app may indicate hypoglycemia Examine LU - RR, A/P, in inflammation (infxn,
cause? dec. app. May indicate infectious process fremitis, rales, wheezes RA)
Have you noticed a change in appetite? Wt loss - malignancy, infxn, poor nutrition Examine Abdomen - Fasting Blood glucose-
Do you have any joint tenderness or pain? seen in juvenile rheumatoid arthritis (JRA) bowel sounds, Palpate >126mg/dl suggests
Have you noticed increased urination? DM type 2 = fatigue, poly (light & deep); rigid diabetes
dypsia/phagia/uria abdomen (peritoneal
What other symptoms have you experienced? Sx such as muscle aches, abdominal pain, Hepatic fxn - AST/ALT
irritation), LV, KI, SP for
general lethargy, dry skin & nails, SOB w/ for general inflammation
exertion of liver (hepatitis)
Could this have an environmental cause? Heavy metals & pesticides may cause MSK exam- joints for TSH - level identifies
Where do you work? fatigue & neurological sx inflammation & swelling, hypoT
Have you been exposed to any toxins? Lyme disease (malaise, chronic fatigue test stamina (fatigue level) HIV infxn - enzyme
Have you been camping? before skin manifestations) Neuro exam - Cognitive & linked immunosorbet
What else do I need to know about fatigue? Psychological - Often related to stressful physical fxn (attn span, assay to R/O infxn
Describe the onset & pattern of your fatigue. When event & may have sudden onset. judgement, memory), CN, TB skin test - mantoux
did you first notice this? Matabolic - slow, progressive onset relflexes, cerebellar, motor for Tb antibodies
How severe is the fatigue? May limit social fxning, rec. activities Monospot- detects
What makes the fatigue better or worse? Psych - usually < am, > w/ phys. Activity heterophil Ab not specific
Organic - not relieved w/ sleep or rest to EBV
Have you had a fever? Seen w/ infectious dz Chest Radiograph-
Prolonged fever - chronic infxn, pneumonia, heart size,
inflammatory dz, malignancy fluid (CHF)
How you had any bleeding? Heavy menses may lead to anemia, also
GI ulcers, polyps, bowel CA
If I suspect a psychological cause, what else do I Stressful events inc risk of depression
need to know? Muscle atrophy w/ inactivity can lead to
Describe your stress level and how you cope with fatigue
stress in your life.
Have you recently had a stressful event in your life? Family Hx of depression increases risk of
Do you or anyone in your family have a problem with depression
anxiety or depression? m/c women b/w 20-30
How are you doing in school? Dec academic performance & dec.
productivity may be early sx of dpression
Overachievers may be compensating &
hiding depression

Page 37 of 52
DELERIUM reduced attn span; disorganized thoughts; decreased depends on underlying cz
level of consciousness; irritability; memory tremors
impairment; disoreintation; perceptual disturbances; affected speech (slow, incoherent etc)
hallucinations; sudden onset,short lived tremor, difficult motor relaxation
less abrupt and less severe than delerium; apatheic,
drowsy; disoreintation especially TIME, less for place,
CONFUSION never for Self; diurnal variation less than delirium;

DEMENTIA Insidious onset; stable course through day and night ; poor hygeine; weight loss; language difficulty; DSM IV
patient is alert; orientation often impaired; incontinence; irritability 1. Memory Impairment
hallucinations absent until late stages; fragmeted 2. One or more of the following:
sleep; "near miss" answers on Mental status exam a) Aphasia
c) Agnosia
d) Disturbance in planning,
organizing, sequencing
3. These defects casue impairment
in social or occupational functioning

DEPRESSION abrupt onset confusion; some diurnal variation; more

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


Physiological causes Adolescent and younger adult, history of overwork, Normal examination None
psychological stress, disturbed sleep, poor diet

Psychological causes: Feeling sad, angry, irritable; Decreased academic None DSM-PC, DSM-IV
Depression: Children performance; Somatic complaints

Depression: Adults Loss of interest in usual activities; Feelings of Depressed affect; normal examination Depression screening instrument
worthlessness; Sleep problems
Anxiety Numerous somatic complaints, breathlessness Tachycardia, palpitations, diaphoresis None

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

Medications Hx of allergies treated with antihistamines; meds for Nasal congestion, cough, injected conjunctiva Evaluate medication choices
hypertension, heart disease, chronic pain
Heart Failure Dyspnea, wt gain, fatigue, cough Anxiety, JVP, displaced PMI, rales ECG, chest radiograph, ABGs
Cancer Fatigue, unexplained wt loss Observe, palpate & percuss all systems for CBC to rule out anemia,; leukocyte
lumps, lesions or consolidation; PE may be count
Mononucleosis (EBV) Young adult; slow onset of malaise, low-grade fever, normal
Palatine petechiae, posterior cervical Positive monospot; CBC w/ diff;
mild sore throat lymphadenopathy, spleenomegaly >50% leukocytes
Hepatitis Jaundice, anorexia, fatigue, faver may be reported Jaundice, wt loss, athralgia, akin rash Bilirubin increased; hepatitis panel
Fibromyalgia Female 20-50 yr, Hx of depression, sleep disturbance, Palpation of trigger pts will produce pain; normal None
chronic fatigue, general muscle and joint aches physical exam
Chronic Fatigue Syndrome Fatigue greater than 6 mo, sudden onset of flu-like Physical exam may be normal, cerival & axillary CBC, ESR
symptoms that persist or recur lymphadenopathy

Page 38 of 52
Is the pain related to an urgent problem that Muscguloskeletal injury can rainge from Symptoms of coldness, Complete Blood Cell
needs immediate treatment to avoid disability or simple muscular strain to a significant severe pain or paresthesia Count Evaluates for
death? fracture associated with nerve or vascular warrant physical exam anemia associated with
Have you had a recent injury? Priority of recent trauma is to assess
Limb Pain injury.
vascular and neurological integrety of the
immediately to assess
need for emergency
chronic disease, infection
or neoplasm. Altered
treatment. Ask specifically WBC count may indicate
Do you have any other symptoms, such as fatigue, Suggests systemic disorder such as about the mechanism of infection or leukemia.
fever or swollen joints? infection or rheumatic disease. injury and also wether or Erythrocyte
What is the severity of the pain? Unrelenting diffuse pain, often occurring at not the patient heard any Sedimentation Rate
night, is an indication of bone involvement noise to assess if there is a Elevated when
Does the pain occur with exercise or rest? Claudication and neurogenic pain increase broken bone inflammation is present.
with activity and decrease with rest, more Non-specific Joint
immediately for vascular causes and more Aspiration Assess
slowly for neurogenic causes synovial fluid for elevated
WBC, gram stain, culture
What does the location of the pain tell me? and sensitivity, crystal
analysis, presence of
Where does it hurt? Location of pain provides a clue for Always observe for glucose and consistency.
identifying the site where the pain symmetry and then
Is the pain localized or generalized? originates
Local pain receptors signal the site of functionally assess limbs
irritation and an increase in sensitivity and joint bilaterally
(hyperesthesia) results. Referred pain beginning with unaffected
Could this be caused by a sprain or strain? generally involves the muscle chains, side. Order the exam so
nerve pathways, and vessels. Unilateral, painful tests are done last.
circumscribed limb or quadrant pain
involves autonomic nerve fibers. Bilaterla
pain is more likely to originate from
systemic involvement. Diffuse pain with
inconsistent distribution may be the result
of psychosomatic conditions such as
depression and anxiety
Describe how the injury occurred? Strain involves injury to muscles and Observe patient walking, Radiography Obtain at
tendons, whereas sprains involve injury to removing coat, getting into least two radiographic
ligamentous structures. Both produce sitting position. Look for a views, anteroposterior
ripping or tearing sounds. limp. Have the patient and latera becausae
Did you hear a noise with the injury, such as a A fracture produces diffuse swelling around locate the pain. Note any injuries are not always
ripping or cracking sound? the injured vone soon after injury. deformities apparent on a single
Deformity will be present if the fracture is view. MRI and CT usually
displaced. ordered by specialists.
MRI good for spone, joint
Were you able to use the limb after the injury? Barotrauma --> acute serous otitis. Failure Assess vital signs.
and soft tissue imaging.
of eustachian tube to open and equilibrate Elevated temperatures are
CT good for bone
--> fluid collection in middle ear. seen in neoplastic,
If there is no history or trauma or a precipitating systemic and infectious
event, what else is causing the pain? processes such as
osteomyelitis, septic
arthritis and septic hip in
Describe your usual daily activities at home, work Overuse: repetitive microtrauma results children and rheumatic
and with hobbies from cumulative injury or overuse. disease.

How does the pain afect your activities? Activities: a person may adapt to chronic Inspect skin and nails.
musculoskeletal problems by using an Lyme disease has a target
assistive device such as a cane or by lesion and rash on the
limiting activities. trunk. Look for puncture or
abcess which may be
Do you have other illnesses? Presence of coronary artery disease Antinuclear Antibodies
source of infection. Look
increases the risk of arterial insufficiency Postive with RA ans SLE
for ecchymosis and
and associated caludication pain. Rheumatoid Factor
bruising indicating trauma.
Peripheral neuropathy associated with Positive in 80% of RA
In joint pain with injury, what do I need to know Look for swelling and
diabetes can produce a burning pain or patients C4 Complement
about the specific joints involved? redness of joints.
'pins and needles' sensation, esp. lower Increased in active
Upper extremities: Shoulder, wrist, elbow key extremities. Measure limb inflam. Disease and
questions circumference and length. autoimmune disorders
Is the pain in your dominant limb? Pain in the dominant hand may indicate Palpate extremties and such as juvenile RA
repetitive microtrauma or overuse. joints
Did you fall on an outstretched hand or arm? Breaking a fall with an outstretched arm is Perform passive and active
Did you overuse a joint? a common mecahnism of injury for a ROM of all limbs. Test for
fracture or dislocation of the hand or wrist muscle strength with
RROM. Neurological exam
of dermatomes and
Lower extremities: Knee, ankle C-Reactive Protein
Elevated in RA and
infection Lyme Titer
How is the pain affected by weight bearing or Continuing with activity means the injury Enzyme-Linked
activity? did not totally disrupt any ligamentous Immunosorbent Assay
structures. Serology (ELISA) May
detect anti-bodies for B.
Did you feel a sense of 'giving way?' An inability to straighten or ben the knee burgdoferi.
suggests a mechanical blockage

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

What position was your leg in when you hurt your A sudden change in direction or sudden
knee? stop may put more force on the ligaments
Could this be musculoskeletal joint disease? than they can dissipate, resulting in acute
What does the pain feel like? sharp, piercing, stabbing, cutting, pinching, gnawing pain --> nerves and skin. Dull, tearing,
boring, burning, cramping are common terms to describe pain arising from deeper structures such
as muscles, joints, and internal organs. Pulsating, pounding, throbbing, or hammering --> vascular
pain. gradually increasing sensations of pressure, tension, heaviness and calf pain --> venous
obstruction. Severe pain that develops over 1 to 4 days is typical of osteomyelitis or septic arthritis
in children, which is an emergency
What does the history of swelling tell me?

is there any swelling? Swelling is always abnormal.

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

Page 39 of 52

Tenosynovitis Repetitive trauma activities; pain with movement Swelling over tendon, crepitus none
History of overuse; aching pain over affected bursae Local tenderness, swelling, limited joint motion,
Bursitis that radiates along the limb muscle weakness none
Fibrositis Pain in trigger sites throughout body, joint stiffness, Fatty, fibrous nodules in muscles, palpation of none
disturbed sleep trigger points elicits pain

Osteomyelitis Presentation depends on age, location of infection, Fever, chills, vomiting, pain localized over Increased WBC, ESR, C-reactive
trauma, penetration, invasive procedure; refusal to affected area but progressively worsens; soft protein, radiographs
bear weight (hip); constant pain tissue injury or abcess

Joint Inflammation Older adults, asymettrical joint pain and stiffness that DIP, PIP joints enlarged, Heberden's nodes. ESR; radiograph may reveal
Osteoarthritis improves throughout the day, history of repetitive joint Limited cervical spine ROM osteophytes, loss of joint space
trauma, obesity

Rheumatoid arthritis Morning stiffness of small joints, symmetrical Fever, rehumatoid nodules, ulnar deviation of Increased ESR, positive rheumatoid
involvement, anorexia, weight loss wrists factor, anemia on CBC, radiograph
shows bony erosion

Juvenile rheumatoid arthritis Fatigue, weight loss, failure to thrive, refusal to walk, Fever, rash, guarding of joints, limited ROM; joint Elevated WBC, ESR; positive
joint pain and stiffness swelling, nodules rheumatoid factor and antinuclear

Septic arthritis History of systemic infection, malaise, diaphoresis, Fever, red, swollen joint, limited ROM WBC, culture of joint aspirate, ESR,
refusal to bear weight (hip), acute joint pain C-reactive protein, ultrasound of
Gout Acute pain of large joint, asymmetrical, males over 30 Inflamed swollen joint, tophi, sodium urate Increased serum uric acid level,
years, history of gout crystals ESR, WBC

Musculoskeletal Pain
Related to Trauma and
Shoulder dislocation History of trauma, pain Limited rotation, arm abduction and hand Radiograph of shoulder
Acromioclavicular joint injury History of trauma, pain Limited shoulder movemnt; obvious deformity Radiograph of shoulder

Bicipital tendonitis History of overuse of biceps; pain worse with Positive Yergason's test; pain localized over the radiograph (Fisk view)
movement intertubercular groove
Rotator cuff tear Acute: younger persons, history of trauma, severe Acute: inability to raise arm side-ways, shrug radiograph may reveal humeral
pain; chronic: older, pain worse with overhead shoulders; chronic: tenderness over AC joint, displacement or spurs
movement, sleep disturbance crepitus, weakness in external shoulder rotation
Olecrenon bursitis repetitive motion of or pressure to the elbow, localized warmth, redness and swelling over joint, full ROM radiograph to rule out fracture of the
pain olecranon process
Lateral humeral epicondylitis History fo repetitive contraction of extensor and Tenderness over later epicondyle; palaption none
supinator muscles, pain over lateral epicondyle that roduces pain, motion does not; supination
progresses against resistance worsens pain
Subluxation of radial head Occurs in children, pain in the elbow or arm The afected arm is flexed and the hcild cries radiograph of elbow
when attempts are made to move the joint

Wrist fracture History of fall on an outstretched hand, pain and Palpation of snuffbox increases pain; observe for Three-view radiographs to determine
swelling of forearm and wrist joint deformity scaphoid or Colle's fracture

Finger fracture History of trauma or fall, joint tenderness Joint swelling, instability Three-view radiographs (PA. lateral
and oblique)

Ganglion Noticeable lump on dorsal surface of wrist Gelatinous filled, nodule, soft, transilluminates none

Slipped capital femoral Children during rapid growth spurts, knee pain worse Limitation of medial hip rotation, limp Radiograph of epiphyseal plate
epiphysis with activity
Transient synovitis of the hip Children less than 10 yrs, history of upper respiratory Tenderness on palpation over anterior hip; hip Ultrasound, ESR
infection, limp, pain in the anteromedial thigh and movement increases pain and is limited; low-
knee grade fever.
Legg-Calve-Perthes disease Boys 3-11 yrs, groin or medial thigh pain, limp Decreased ROM of hip AP and frog lateral radiograph of the
hip; LCPD may show increased
density of the femoral head
Iliopspas tendinitis History of repetitive flexion of hip; pain worse with With patient sitting, place the heel of affected leg none
movement on the knee of the other; test is positive if pain is

Chondromalacia patellae Adolescent females; history of knee trauma or Tenderness to palpation over knee Four-view radiographs of knees to
misalignment, knee pain worse with activity rule out arthritis
Patellar tendinitis History fof overuse, especially running or jumping; Q angle greater than 10 degress in males, 15 none
dull, achy knee pain; click degrees in females, clicking or popping with knee

Page 40 of 52
Limb Pain Is this an acute or chronic problem? Pain hours after injury is usually acute extensor injury or pveruse. Severe ligament sprain
manifests immediately. Chronic problems compound each other whereas intermittent or episodic
Continued pain is characteristic of diseases of the musculoskeletal system
When did the pain first occur?

When did you first notice a problem? Problems with activities of daily living are

How is activity affected? What will this tell me?

What are your usual activities? Repetitive microtrauma in lower extremities is due to inappropriate rate and intensity of training,
shoe wear and playing surfaces

What activity makes the pain worse? Intraarticular lesions usually worsen with joint motion and sports activities. Intraosseus tumors are
less sensitive to joint motion.

What movements make the pain worse? In children with septic hip pain increases with movement

What does joint stiffness or locking tell me? Stiffness is felt after being in one position for too long. Locking of the knee is an abrupt
occurrence where they somplain that something 'gets in the way' of fully extending the knee.
Have you had any joint stiffness?

Does activity make the stiffness worse or better? common feature of inflammatory arthropathy eg RA or SLE

Do you have any locking of the knee? Sign of chronic unstable meniscus tear

What does a history of a limp tell me? limping is a pathological alteration of a smooth, regular gait pattern and is never normal

Is there pain with the limp?

Did the limp come on suddenly? Limp after strenuous running may indicate stress fracture

is the limp constant or intermittent? neuromuscular diseases can result in progressive and painless muscle weakness or spasticity
that affects ambulation in a variety of ways

what is the effect of running or climbing stairs? quadraceps weakness causes difficulty climbing stairs

Could this be caused by systemic disease?

Have you been treated with any antibiotics lately? antibiotics can cause serum sickness in children. Fluoroquinoline antibiotics can produce
tendinitis or tendon rupture in adults

have you had any recent immunizations? transient arthralgia may occur 6-8 weeks after receiving MMR. Recurrent or permanent arthritis
may follow rubella vaccination, esp. adult females

has the fever been constant or intermittent?

does the pain awaken you at night? report by an adolescent of night pain is a red flag for intraosseous pain of a bone tumour.
Growing pains may also awaken a child. Growing pains are bilateral
is the pain worse ar night?

do you have a skin rash?

Could the pain be caused by Lyme Disease? Lyme disease is an infection caused by tick-borne spirochete borrelia burgdorferi. Symptoms
involve arthralgias, particularly knee joint
have you been camping or out in the woods?
have you noticed any skin rash? target lesion
What does past medical history tell me? Sickle cell anemia, IBD, Crohn's, hypo and hyperthyroidism, or collagen vascular diseases are
Have you had anything like this before? frequently associated with skin rashes, psoriasis and limb or joint pain
Do you have a chronic disease?
Could you have been exposed to any sexually Gonorrhea may disseminate to the musculoskeletal system in 1-3% of ppl with disease. more
transmitted disease? than 80% develop arthritis
Have you been treated with cortisone? cortisone-induced necrosis of the hip
Have you had a recent cold or upper respiratory sickle cell anemia can cause hip pain . Viral infections may cause diffuse myalgia
Is this likely a mixed condition? pre-existing systemic disorders can result in acute injury. A clue is that the extent of the injury
seems out of proportion with the precipitating activity

Page 41 of 52
Limb pain DDX cont'd: History of valgus stress to knee; limp; pain Effusion and point tenderness over knee; valgus AP and lateral radiographs may
Medial collateral ligament and varus pressure to assess instability reveal a ligament avulsion of femoral
sprain origin
medial meniscus tear History of twisting injury to the knee, pain, diffculty Positive McMurray's test, clicking or locking Four-view radiographs to rule out
flexing; bearing weight, clicking or catching of knee during joint movement bony deformity
with movement
Anterior cruciate ligament tear History of twisting or extension knee injury; audible Swelling; positive Lachman's test radiograph to rule out fracture
Osgood-Schlatter disease Adolescent males, knee pain and swelling aggravated Tenderness, warmth, swelling over anterior tibial Radiograph with knee rotated inward
by activity, limp tubercle may show soft tissue swelling
Baker's cyst Fullness or swelling of posterior knee, aggravated by Negative Foucher's sign; normal joint none
walking examination; positive Homan's sign in ruptured
Ankle Sprain History of inversion stress with audible pop, Swelling, soft tissue trauma, able to perform Radiograph needed only with
immediate swelling active ROM with ligament sprain tendernes over lateral malleolus to
rule out fracture
Shin splints Ache or pain over medial tibia that is worse with tenderness over medial tibia AP and lateral radiographs may
exercise, history of running show a stress fracture; a bone scan
will be positive with increased
uptake along the medial tibia
Achilles tendinitis Pain and tightness over Achilles tendon, especially Tenderness over Achilles tendon; pain worse with Lateral ankle radiograph reveals
with walking or running dorsiflexion of ankle, calf weakness enlarged posterosuperior tuberosity
of calcaneus
Plantar faciitis History of chronic weight bearing, aching feet, muscle Misalignment of foot structures, sepecially talus, none
spasms, obesity calcanues, and plantar ligaments
Muscle Pain (Myalgia) Viral Hisotry of upper respiratory infection, malaise, chills, Fever, I;;-appearing adult or child Viral serum titer
Infections cold symptoms, general muscle aches

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

Normal examination orpatient response to none
history of depressioin or anxiety examination maneuvers disproportionate to
physical findings or subjective complaints
Fibromyalgia Female 20-50 yrs, history of depression, sleep Palpation of trigger points will produce pain; none
disturbance, chronic fatigue, general muscle and joint normal physical examination
Systemic Disorders Acute Hip pain in children, refusal to walk Fever, hepatosplenomegaly, bruising CBC
Sickel cell disease African-American, family history; appears after 6 mo Normal examination Hemoglobin S genotype
of age; acute pain with swelling of hands and feet,
abdominal pain, decreased appetite, malaise
Systemic lupus erythematosus Female, transient arthritis of small joints, malar rash Normal examination may habe joint tenderness Kidney function tests, antinuclear
on palpation antibody, CBC
Lyme arthritis History of exposure to endemic areas of deer tick, Asymmetrical swelling, warmth of joint, erythema Serum IgM and IgG antibodies, ESR
chills, diffuse joint pain and swelling, often the knee is migrans, may have myocardial involvement
Neuroblastoma Under 5 yrs, pain in bones Unexplained fever Urine for vannillylmandelic or
homovanillic acid; CT scan
Osteogenic sarcoma Persons 10-25 yr, intermittent pain of lower femur, Tenderness over affected area Radiograph, serum alkaline
upper tibia, limp phosphatase
Nerve Entrapment History of sleeping with arm against head, morning Bruit over supraclavicular fossa; pallor, EMG
Syndromes Thoracic shoulder pain, pain worse with lifting, paresthesia; decreased pulses of upper extremity, weakness,
outlet syndrome rounded shoulder posture skin and nail atrophy
Carpal tunnel syndrome History of repetitive upper extremity motion; Positive Phalen's and Tinel;s sign, weakness of none
paresthesia, weakness, or clumsiness of hand; hand, dry skin over distribution of median nerve
symptoms worse at nights
Peroneal nerve compression History of pressure to the knee from a cast, sports Unilateral foot drop none
injury, or trauma; pain over head of fibula; clumsy gait

Tarsal tunnel syndrome Pain in ankle and proximal foot, weakness of toe Tapping posterior tibial nerve elicits pain none
flexors, ill-fitting shoes
Neuritis Pain and sensory loss, usually of lower extremities; Decreased sensory and pain sensation Liver function tets, hemoglobin A1C
history of alcohol ingestion, diabetes to rule out diabetes

Page 42 of 52
What Clues Indicate This Is a Potentially Serious, Need to know if patient is fully oriented Observe the Patient Complete Blood Cell
Life-Threatening Headache? before proceeding. Can screen with a Mini- Any patient who complains Count Detects
Mental Staus Exam. If patient shows a of headache and exhibits major blood dyscrasias.
mental status deficit, immediate an ataxic gait, Hypoxia secondary to
emergency treatment is indicated uncoordinated movements, severe anemia can cause
How did the headache begin? Onset of sudden severe headache with or reduced mental headache. Blood
Headache neurological signs is an emergency; the alertness should be Cultures Do if patient
patient needs immediate emergency immediately transported to has fever, headache,
treatment an emergency center for nuchal rigidity and altered
neurological evaluation mental status
What is your age? Have you had this type of New onset headache in children or elderly
CT Scan Detects
headache before? or persons over 50 years of age is a
intracranial disease. DO
warning sign of a serious cause
for new-onset headache
A subjective feeling of On a scale from 0 (no pain) to 10 (worst pain ever) New, severe headache or headache Take Vital Signs and or if headache is
pain caused by a variety how severe is the pain? different than prior occurences and Obtain Growth associated with
of intracranial and headache that progressively worsens are Parameters Fever neurological signs.
extracranial factors warning signs of serious causes may be the only sign of Lumbar Puncture Do if
Is there a history of recent trauma to the head? Trauma may cause subdural or eppidural infection. Bradycardia and infection is suspected but
bleeding. Anyone who experienced head narrowing of pulse contraindicated if
trauma must be carefully observed for at pressure are signs of increased intracranial
least 24 hours for signs of neurological increased intracranial pressure Erythrocyte
damage pressure. In children, Sedimentation Rate
plotted height and weight Non-specific for
Was there a loss of consciousness? Higher chance of neurological signs
significantly below average temporal arteritis
Do you notice any other symptoms associated with Headache associated with infection considers hypothalamic
headache pain? presents with fever and possibly stiff neck. neoplasm. Macrocephaly inflammation Skull
Radiograph Do for
Intracranial hemorrhage associatedw ith may indicate post-traumatic
confusion, vomiting, lethargy and focal hydrocephalus or brain headache
neurological signs. Brain tumours in tumour
children associated with vomiting, recurrent
morning headaches, reflex asymmetry and
Do you have any chronic health problems? Persons with AIDS have increased risk of
cryptococcal meningitis, encephalitis or
generalized sepsis. Persons treated with
anticoagulants or elderly are at increased
risk of headache from a serious cause.
Headaches secondary to metabolic
disorders can be result of hyponatremia,
uremia, hypoglycemia or hypercapnia
After Determining the Headache Is Not Serious, A moderately intense, constant throbbing Palpate and Percuss the
How Can I narrow Down the Causes? headache is associated with dilatation of Skull Focal tenderness
What does it feel like? cervical arteries. Severe pain indicates an and induration seen on
Where does it hurt? expanding
Pain lesion.
secondary to Migraine
trauma orpain is steady
inflammation tension type headaches.
is felt at near the site of trauma. Tension Tenderness over nodular
headaches can feel like a 'hatband' temporal arteries indicates
distribution. Orbital pain is present with temporal arteritis. Brain
increased intraocular pressure. Periorbital abcesses cause pain with
pain may be present with sinusitis, localized traction and
migraine or trigeminal neuralgia. TMJ pain tenderness on percussion.
may be present. COntraction of muscles of Auscultate the Cranium
head and neck cause nonpulsatile pain. Intracranial arteriovenous
malformations mimic
migraine. Evaluate for
What makes it worse? Triggers such as sound, odour and cranial bruits over orbit and
estrogen fluctuations are associated with skull
migraine. Food triggers such as chocolate
and cheese can trigger migraines.
Migraines are worse with activity. Stress
can trigger any type of headache.

How long have you had this headache? Tension type headaches and migraines
last less than 24 hours. Cluster headaches
are less than 3 hours
Can you tell when it is coming on? Auras can occur before, during or after Inspect the Ears, Eyes,
headaches and last no more than 30 Nose, Mouth and TMJ
minutes. Other prodromal symptoms Looking for signs of
include fatigue, depressed or euphoric sinusitis, infection, eye
mood, increased or decreased appetite, changes, TMJ problems,
constipation or diarrhea and yawning. facial paralysis/weakness
How does the pain afect your activities? Activities: a person may adapt to chronic
What Does the Chronicity of Pain Suggest? musculoskeletal problems by using an
How frequently do you get a headache? assistive
A patient device such asheadaches
with constant a cane or byfor Perform Opthalmoscopy
more than 3 months may demonstrate Look for papiledema and
papilledema, bilateral or unilateral cranial hemorrhage. Optic disc
nerve VI palsies, gait or balance atrophy sugggests chronic
disturbances or spasticity of the lower intracranial pressure or
extremities. Continuous headaches for four lesion at optic chiasm.
weeks or more without these symptoms is
of psychogenic origin.
Can you describe any pattern to the headache? headaches throughout the day indicate Assess Cranial Nerve
tension type.Sinus headache gets worse Function May provide
as the day goes on and when leaning evidence for more serious
forward then get better at night. causes of headaches
Headaches associated with ypertension secondary to inflammation,
are occipital, worse on waking and lessen traction or metabolic
as the day goes on. Meningeal imbalance.
inflammation produces pain that fluctuates
throughout the day with no clear pattern.
Migraines are episodic. Cluster headache
pain is short often less than one hour and

Page 43 of 52
Primary Headache Without Common in adults, bilateral pain, general or localized Normal physical examination; neck muscle None
Structural or Systemic in bandlike distribution; history of anxiety, stress or tightness or fasciculations may be palpated
Pathology Tension depression
(muscle) headache

Migrain without aura More common in children; unilateral, throbbing pain; photophobia and phonophobia none
(common) nausea

Migraine with aura (classic) Pain precipitated by environmental stimuli; visual nausea and vomiting, photophobia and None
disturbances (scintillating scotoma) precede pain phonophobia

Mixed headache Throbbing, constant pain during waking hours; muscle Mix of findings related to tension and migraine None
tightness; family history of migraine headache pain

Cluster headache Rare in children; abrupt, nighttime onset; unilateral Ipsilateral rhinorrhea, nasal stiffness, conjunctival None
periorbital pain that is severe injection, sweating, ptosis

Benign exertional headache Sudden onset related to physical exertion, Valsalva or normal ysical exam May need to distinguish from
coitus subarachnoid hemorrhage with CT

Secondary Headaches With

Structural or Systemic

Infectious Origin Frontal, upper molar, or periorbital pain: cough, Low or no fever, pain on palpation of frontal, Radiographs (Waters view)
Sinusitis rhinorrhea maxillary sinuses; purulent nasal or postnasal
Dental Disorders Localized pain in jaw and top of head Malocclusion, caries, abcesses of teeth present, dental referral
gum disease

Pharyngitis Sore throat Fever; infection of the posterior pharynx Throat culture
Otitis media ear pain, pain with swallowing Fever, red, bulging tympanic membrane None
Meningitis Severe headache, chills, myalgias, stiff neck; toxic Positive Kernig's and Brudzinski's signs; fever, Lumbar puncture
child or adult photophobia, petechial rash may be present;
mental status changes

Neurogenic Origin Persons over 55 yrs; bursts of sharp pain over the Normal physical examination; stimulation of None
Trigeminal neuralgia face innervated by the affected nerve; triggered by triggers may provoke pain
stimulus to the affected nerve

Page 44 of 52
How long does the headache last? Examine the Neck Do
full ROM and assess
stiffness which may
Have you had this kind of headache before? Acute-onset headaches must be evaluated indicate muscle tension or
for organic causes. Subacute and chronic meningitis
Do you use alcohol? Take any medications? ones are usually caused by vascular Test for Meningitis eg
inflammation or muscle tension. Migraines Kernig's sign. Assess
usually begin between 10 and 30 yrs. New Deep Tendon Reflexes
onset migraines in adults over 50 yrs is for cerebral lesions.
unusual. Tension headaches usually begin
What Associated Symptoms Does the Patient Associated with migraines. Vomiting can Assess Motor Strength
Have? be a sign of increased intracranial and Coordination of
pressure. Headaches from tumours Extremities
Do you have any nausea or vomiting? produces early morning vomiting without Asymmetrical increase in
nausea. muscle tone on affected
DO you notice any vision changes? Auras procede migraines. Cluster side, contralateral to the
headaches associated with ipsilateral hemisphere lesion
conjunctival injection, lacrimation and suggests a cerebral lesion.
edema of eyelid. If person exhibits forearm
drift with arms extended
Does light bother you? Often present with migraines but not and eyes closed may have
tension headaches. Present in meningitis a motor neuron or
cerebellar disturbance with
Are you dizzy? 1/3 people with migraines have vertigo expanding intracranial
What Do the Aggravating and Alleviating Factors Meningeal irritation headaches are better lesion.
Suggest? with lying down. Tension headaches
respond to analgesics. Rest relieves
migraines but not tension headaches in
Does anything make the headache better? children. Sleep, rest in dark quiet room Have Children Draw a
relieves migraines in adults. Increased Picture of Their
headache with sneezing or coughing may Headache Help
indicate benign headache or lesion at level to diagnose type of
Does anything make the headache worse?
of foramen magnum that is not clinically headache eg. Children will
present yet. Migraines are worse withe draw flashes of light for
What Does Family History Indicate? xertion. Cluster headaches are worse lying migraine aura.
down. Headaches wrose in morning and
better on rising indicate tumour. Benign
Does anyone else in the family have headaches? Tension type headaches have no family
history. Migraine headaches have positive
family history
Is There Anything Else That Woud Help narrow Meningitis indicated. Lumbar punctures
the Cause or Causes? can cause headache in 25% of people.
Have you been ill recently? Chronic infection predisposes to brain
Have you taken any medications or vitamins? abcess. Penetratin skull fractures allow
bacteria to enter. Melanomas can
Could you have been exposed to carbon monoxide? Exposure may cause severe, throbbing,
generalized headache. Occupation
exposure to toxins should be assessed.
Winter headaches may be due to faulty
kerosene or gas heater.

Page 45 of 52
Optic neuritis Acute onset of pain with extraocular movement, Diminished visual acuity, decreased pupillary opthalmology, referral
followed by blurred vision reflec, hyperemia of the optic disk; pain with
extraocular movement
Cervical spine disorders May have a history of trauma; occipital pain, muscle Normal physical examination or pain associated Cervical spine radiograph
stiffness with neck motion
Temporal arteritis Age>50 yr; sharp localized temporal pain; malaise, fever, weight loss; tender over a nodular temporal Elevated ESR (>50); immediate
anorexia, history of polymyalgia rheumatica artery referral for treatment
Metabolic Origin History of exposure, throbbing headache, mild nausea, vomitting, change in mental status, Blood gases and
Carbon monoxide poisoning dyspnea lethargy, loss of consciousness carboxyhemaglobin level
Severe hypoglycemia History of diabetes or medication, alcohol and food Normal physical examination or pallor, sweating, Blood glucose level; may need self-
ingestion; generalized headache, dizziness, sense of and weakness monitoring of blood glucose to
not feeling well establish pattern
Drug withdrawal Pattern of headache associated with stopping normal physical exam blood chemistry
medication or substance use
Dietary ingestion Mild to moderately severe headache after ingestion of normal physical exam blood chemistry
foods or medication

Cardiovascular Origin Sudden-onset headache that is progressive, Papilledema, vomiting, asymmetrical reflexes, CT scan
Intracranial tumour exacerbated by coughing or exercise; worse in weakness, sensory deficit, or other neurological
morning; history of trauma increases risk deficit
Hydrocephalus Progressive headache, vomiting, irritability Rapid enlargement of head, bulging fontanels CT scan and referral
Subdural hematoma History of head trauma, bleeding disorders, child unequal pupils, photophobia, neurological CT scan and neurosurgical referral
abuse; adult over 35 yrs; sudden onset of 'worst ever' chnges, seizures
headache, often over the eye, transient loss of
Pseudotumour cerebri Teens, menopausal women, history of vitamin A or Papilledema may be present CT scan, neurology referral to
tetracycline ingestion; progressive headache assess risk related to lumbar
Brain abcess teens, menopausal women, history of vitamin A or fever, seizures, focal neurological findings CT scan
tetracycline ingestion; progressive headache correlated with extent of the lesion
Intracerebral hemorrhage Risk factors; persons over 50 yrs, with AIDS, on If conscious, abnormal neurological findings Emergency transport for immediate
anticoagulation therapy, or with hypertension correlated with extent of lesion evaluation (CT scan) and possible
surgical treatment

Page 46 of 52
Lower Back Do you have a fever? The presence of a fever indicates an
inflammation; spondyloarthropathy or
Assess the overall Plain radiographs
appearance of the patient. Bone Scan MRI,
Pain systemic infection. Ask for chills, weight
loss, fever. Also, may inquire about
Gait, symmetry, posture. CT scan

intravenous drug use or

immunosuppressed conditions.
Have you experienced any trauma? Acute trauma to the spinal cord can result Perform range of motion of CBC - detect anemia as
in a fracture, dislocation or misalignment or the spine. Straight Leg well as other conditions
the muscles, ligaments and IVD. Spinal Raising, Deep tendon that might manifest as
cord injury should be suspected with reflexes, muscle strength back pain, such as tumor
anyone whose level of consciousness is or infection.
impaired after an accident.
Do you have any other health problems/been treated Assess for systemic diseases (metabolic, Urinalysis - assess kidney
for cancer? inflammatory diseases and fibromyalgia). and metabolic function,
Patients with a history of cancer are more including infectious
susceptible to spinal tumours. process, rule out

What is your age? In the absence of trauma a sudden and

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

Are you on any medications? Long-term use of corticosteroids can lead

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

Where does it hurt? Sciatica is usually sharp, burning pain that

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

When did the pain start?/Duration of the pain? Pain that is mild and or short duration (1-2
weeks) is rarely serious. Back pain lasting
longer than 4 weeks needs to be re-
evaluated for further diagnostic studies. In
children back pain that is present for more
than 3 weeks is often due to organic and
serious causes.
Does the pain interfere with your sleep? Night pain is often a worrisome symptom
that often signals a serious problem such
as tumor, infection or inflammation.
Genreally muscular issues are relieved at
night. Nighttime back pain is unusual and
indicates the need for a complete and
thorough work-up.
Does the pain travel? 2 types - (1) pain referred from the spine
into areas lying within the lumbar and
upper sacral dermatomes. (2) pain referred
from the pelvic and abdominal viscera to
the spine. Pain from the upper lumbar
spine usually radiates to the anterior
aspects of the thighs and legs, and that of
the lower lumbar spine radiates to the
gluteal regions, posterior thighs and calves.
Visceral disease usually stays with in the
abdomnial cavity (flanks). Gallbladder pain
radiates around the trunk to the right
scapula. Position does not affect the pain.

Page 47 of 52
Spinal fracture major trauma, impact or fall, strenous lifting, elderly palpable tenderness over site of fracture considered an emergency;
minor fall, treated as a medical emergency radiographs

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

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

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

Aortic Aneurysm severe acute-onset not related to activity or intact aneurysm will be a visible pulsatile midline emergency surgical referral
movement, increased risk in persons over age 30; upper quadrant abdominal mass; in a dissected
anxiety, sweating confusion aneurysm upper extremity pulse and pulse
pressure are asymmetrical; posterior thoracic
pain may be felt
Gallstones Increased incidence with age; steady, intense pain in normal physical; positive Murphy's sign on surgical referral
RUQ with radiation to right scapula or shoulder; palpation of abdomen
belching, bloating, fatty food intolerance

Pyelonephritis ill-appearing, sweating, nausea, back/flank pain. H/A fever; cloudy malodorous urine, CVA tenderness Urinalysis, urine culture

Page 48 of 52
Is This Really A Fever? Fever in a Child Less Complete Blood Cell
Than 2 Months Old Count Leukocytosis
Fever in the first 2-3 with a left shift suggests
How do you know you have a fever? . months of life is relatively bacterial infection.
Fever uncommon but when it
does occur it is usually
Atypical lymphocytes are
characteristic if viral
Has the temperature been measured? How? Should be measured throughout day with a significant and often infection. Immature
thermometer to monitor fever due to ominous neutrophils suggest
diurnal variations in body temperature leukemia.
An elevation of Should Sepsis or Meningitis Be of Concern? Observe the Patient Erythrocyte
temperature above Do they appear ill, Sedimentation Rate
normal daily variation and Has there been any recent head traumas? Elevation indicates
Entrance for infection especially at base of dehydrated or lethargic? inflammatory condition,
is a symptom of an skull Look for toxic signs and
underlying process responsiveness in children non-specific
Have you had recurrent ear infections? May have mastoiditis spreading to
Have you had contact with anyone else who had Increased risk of contacting it Take Vital Signs and
meningococcal disease? Note Temperature
Adults - oral temp. Children
Have you had any headache, lethargy, confusion or Characteristic meningitis symptoms. Any and infants - rectal temp.
stiff neck? patient with minimal neurological signs and Temp > 40 degrees celsius
symptoms should be evaluated for is a marker for bacterial
meningitis infection though people
If an infant: How old is the baby? Fever in infants less than 2 months is
with these high temps do
uncommon but is serious. May be infection
not necessarily have major
or indicator of underlying anatomical
diseases. Extreme fever of
defect. UTI and bacteremia are indications
> 41.5 degrees celsius is
of abnormal urinary tract structure. Infants
rarely due to infection and
with galactosemia may present in first
is more likely seen in drug
weeks to 1 month of life with gram-
fevers, CNS injury,
negative sepsis. Infants can get sepsis
malignant hyperthermia,
from delivery instruments. All infants
stroke and HIV
younger than 2 months with fever are
considered to have sepsis or meningitis
until proved otherwise
What Does a Pattern of Fever Tell Me? In adults, fevers in acute processes Observe Skin and Antistreptolysin Titer
usually resolve in 1-2 weeks. Fevers that Mucous Membranes indicates
last 3 weeks or longer, that exceed Look for rashes. Presence streptococcal antigen
temperatures of 38.4 degrees celsius and of a petechial rash is a HIV Testing
that remain undiagnosed after a week of serious infection that Urinalysis Urine
intensive diagnostic study are classified as requires immediate referral Culture and Sensitivity
fevers of uknown origin. In children there and hospitalization, may Stool for
are three types of fevers. Short-term fever indicate meningococcemia Leukocytes Stool
is of short duration, readily diagnosed and or Rocky Mountain spoted Culture and Sensitivity
resolves within 1 week. Fever without fever. Stool Sample for
localizing signs is of brief duration and is ova and Parasites
not explained by history or physical exam Sputum for Acid-Fast
findings. Fever of unknown origin is usually bacilli Sputum for
greater than 38.5 degrees celsius that lasts Gram Staining
longer than 2 weeks o more than four Sputum for Culture and
How long have you had the fever? occasions. Sensitivity
Cultures of Discharge

What has the highest temperature been? When did Dehydration and febrile seizures are Examine the Head and
this occur? related to height of fever. Temperatures Neck Sinuses, ears,
greater than 41.1 degress celsius seen in tympanic membrane, eyes
heat illness, central nervous system and fontanels
disease or these in combo with infection.
Higher the fever, greater likelihood of
Is the Fever Caused by a Localized Infection? Palpate Lymph Nodes
Anterior cervical - suspect
viral or bacterial
pharyngitis. Preauricular or
Do you have frequency, burning or urgency with UTI commonly produces systemic postauricular - suspect ear
urination? symptoms including fever infection. Posterior cervical
Are you having any unusual vaginal/penile UTIs can produce discharge. So can pelvic - suspect mono. DNA Probe for
discharge? inflammatory disease in women. These Supraclavicular - suspect Gonococcus and
also produce fever neoplasms. Axillary - Chlamyia Blood
suspect breast Cultures for septicemia
Do you have any face or sinus pain? Acute sinusitis produces fever inflammation, local Lumbar Puncture
infection, neoplasm. for meningitis
Localized Radiographic Imaging
lymphadenopathy - May detect infiltrates,
suspect local infectious effusions, masses or
process. Generalized nodes.
lymphadenopathy -
Do you have nasal discharge? What colour? Viral upper respiratory tract infections immunosuppression such
produce fever as HIV or neoplasm.
Do you have a cough? Is it productive? What colour
is the sputum?
Do you have ear pain? Fever can be present in otitis media Examine the Lungs and
Check for respiratory
Is your throat sore? Viral and bacterial pharyngitis produces infection. Sputum colour:
fever. GI tract infection produces fever. yellow/green - bacterial.
Connective tissue disorder, osteomyelitis Brown - check smoking
Are you having any nausea/vomiting, diarrhea? and septic arthritis produce fever. Apthous history. Blood streaked -
ulcers with pharyngitis and cervical Uri or bronchitis.
Do you have any joint pain? lymphadenopathy seen in children with Hemoptysis - tumour,
periodic children. trauma, pulmonary
Do you have any apthous ulcers?
Can The Diagnostic Possibilities Be Narrowed or Prodromal Rash can occur with varicella, Palpate Breasts if
a Cause Be Eliminated? rubella, erythema infectiosum (1 day), Indicated
Have you noticed a rash? scarlet fever (2 days), rocky mountain Examine
Perform Gitonitourinary
spotted fever (3 days), measles (4 days), System if Indicated
roseola infantum (5 days) Examine
Status Musculoskeletal
Do you ache all over? Fever localized to a site without general system if indicated
body manifestations are often bacterial in
nature. Fever accompanied by muscle
aches, malaise and respiratory symptoms
are often viral in nature.
Does the Patient Have a Increased Risk for Chronic conditions compromise immunity and increase susceptibility to infection. Recent surgical
Complications? procedures can provide a locus for occult infection and also induce an inflammatory response
which causes fever without infection
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URI Any age group; systemic symptoms; often known fever < 38.7 degrees C; cough; nonpurulent None
contact with ill others sputum; erythema of pharynx, viral exanthem

Gastroenteritits nausea, vomiting, diarrhea; abdominal cramping Mild fever; abdomen may be diffusely tender None

UTI Female>male; burning urgency, frequencyin adults; CVA tenderness with upper UTI; fever with upper U/A; urine C and S; CBC if suspect
systemic symptoms/bedwetting in children UTI upper UTI

PID May have pelvic or lower abdominal pain May have suprapubic tenderness; cervical CBC; culture, DNA probe
discharge; CMT, adnexal tenderness

Prostatitis Perineal discomfort, frequent urination, chills and Prostate tender to palpation; fever Segmental urine specimens; C and
malaise S of urine; C and S of prostate

Pharyngitis Sore throat; may or may not have other upper Erythematous pharynx; may have pharyngeal or CBC; culture; rapid strep test if
respiratory symptoms tonsillar exudate or ulcers; may have palatine suspect strep; Monospot if suspect
petechiae in mononucleosis; lymphadenopathy mono

Sinusitis facial or sinus pressure or pain; headache Purulent nasal discharge; sinuses tender to Radiographs or CT scan of limited
percussion; headache or pressure worsens on value
bending forward

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

meningitis nonspecific symptoms; nausea, vomiting, irritability Petechiae, nuchal rigidity, positive Kernig's and Lumbar puncture
Brudzinski's signs, bulging fontanel in infant

Osteomyelitis Pain in affected bone or joint Swelling or tenderness over affected joint Culture; CBC; radionuclide scan,
Kawasaki disease Under 5 yrs; males>females; fall and spring High fever, spikes; persists despite antibiotic WBC increased, shift to left, slight
therapy; may have seizures; fever for 5 days with anemia, thrombocytosis, positive C-
at least 4 of the following: bilateral conjunctival reactive protein, ESR increased,
hyerpemia, mouth lesions, edema, erythema, serum IgM, IgE increased.
Factitious fever Vague or no symptoms Normal physical
desquamation ofexam; no weight loss;
skin, nonvesicular pulse rate Discrepancy betweel oral/rectal
normal (not consistent with
rash, cervical lymphadenopathytemperature temperature and urine temperature;
elevation) repeated monitored temperature-
taking does not support previous

Roseoloa infantum Irritable child with fever for 4-5 days Normal physical examination; when fever breaks, None
rash appears
Fevers without localizing signs No other specific symptoms Physical exam usually normal initially, repeat Urinalysis, urine C/S, chets x-ray,
exam in 24 hours as needed BC, rule out systemic disease,
Enterovirus Mild nonspecific febrile illness lasting 2-5 days; non-exudative pharyngitis with or without None
summer and early fall peaks lymphadenopathy frequently observed
Occult bacteremia Fever in children older than 3 month No localizing signs, child appears well Blood culture, WBC

Periodic fever in children Abrupt fever on periodic basis (about every 6 wks); Cervical adenopathy, apthous stomatitis WBC and ESR elevated
last about 4 days; child aged 2-5 yrs, malaise

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Chronic conditions compromise immunity and increase susceptibility to infection. Recent surgical
procedures can provide a locus for occult infection and also induce an inflammatory response
Do you have any chronic health problems? which causes fever without infection
Have you had any recent surgery?
Have you been diagnosed with an infectious disease Prone to relapse or reoccurrence
Are you sexually active? How many partners? High-risk sexual activity increases risk of HIV and pelvic inflammatory disease

Are immunizations up to date? More likely to contract illness if not immunized

Does anyone in the family have TB or hepatitis? Exposure increases risk of infection. Inquire about constitutional symptoms such as cough or
night sweats (TB) or malaise and abdominal discomfort (hepatitis)
Does the Parent Report a Behaviour Change in In infants and children, behaviour changes may be the only indication the hcild is ill. Mildy ill
the Child? infants are alert, active, smile and feed well. Moderately ill infants may be fussy or irritable but
Is the child sleepier than normal? continue to feed, are consolable and may smile. Severely ill infants appear listless, cannot be
Is the child more irritable? consoled and feed poorly or not at all
How is the child acting?
Could the Fever Be Caused by Something
Acquired While Traveling?
Have you been out of the country recently? Risk of amoebiasis, malaria, schistosomiasis, typhoid fever or hepatitis

Have you been in the woods or camping recently? Risk of ticks, Q fever, tularemia, Rocky Mountain spotted fever, Giardia or Lyme disease
Could the Fever Be Medication Related or
Caused by Poisoning?
What medications have taken recently? Medications may hide an occult infection or induce a fever. Immunosuppressent medications
predispose to infection. Some medication interfere with thirst recognition and sweating. Aspirin
overdose can cause a fever.
Describe the foods you have eaten in the past 3 Food poisoning fever may occur up to 72 hours after ingestion of contaminated food
Could the child have eaten a poisonous plant? Plants containing alkaloid atropine (Nightshade, Jessamine and Thornapple) cause dilated pupils,
flushed skin and fever
Could Exposure to Animals Explain the Fever?

Has a cat scratched you recently? Cat Scratch Disease is a bacterial infection of gram-negative bacillus transmitted by cats. Single
node or regional adenopathy and low grade fever are present.
Have you been around any other animals? Dogs - brucellosis and leptospirosis. Rabbits - tularemia. Birds - ornithosis, histoplasmosis,
psittacosis. Hamsters and cats - lymphocytic choriomeningitis

Could This Be the Result of a Recent

What immunizations have you had recently? History of immunization followed by 4 hours of high fever indicate adverse reaction. MMR may
cause elevation of temperature 10-14 days after.
Could The Fever Be Caused by Heat Exposure?

Were you overdressed? Is the infant overbundled? Classic heatstroke occurs when the person is unable to dissipate the environmental heat burden

Do you have air conditioning or windows that open? During a heat wave a person may become overheated if they don't have air conditioning

How warm is the room you live/sleep in? Windows may not open due to safety reasons and cause overheating

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