1
Q
Acute MI/ Unstable Angina History
A
– Pain does not change with deep breath or change in position, but can increase with exertion. – Chest, jaw, arm pain/pressure can radiate or not. – Shortness of breath, dyspnea on exertion. – Nausea, vomiting, diaphoresis, ankle swelling.
2
Q
Acute MI/ Unstable Angina PE
A
- CV exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses (radial and feet)
- check for peripheral edema
- lung exam
- abdominal exam
3
Q
Acute MI/ Unstable Angina Findings
A
- troponin
- CXR
- ECG
- stress test
4
Q
Acute MI/ Unstable Angina S&S
A
Chest pain travels to shoulder, arm, back, neck or jaw
- in center or L side of chest and lasts for more than a few minutes
- SOB, nausea, faint feeling, cold sweat, feel tired
- occur due to CAD -> rupture of atherosclerotic plaque
- risk factors: HTN, smoking, diabetes, lack of exercise, obesity, hypercholesterolemia, poor diet
5
Q
Acute MI/ Unstable Angina Treatment
A
- Aspirin (immediate & long-term treatment)
- Nitroglycerin or opioids (help with chest pain)
- supplemental O2 (w/ low O2 levels and SOB)
- Angioplasty or thrombolysis
- Bypass surgery (with blockages of multiple coronary arteries & diabetes)
6
Q
Aortic Dissection History
A
-Often complain of tearing, crushing pain shooting straight through to the back
– Long standing hypertension common.
7
Q
Aortic Dissection PE
A
- CV exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses (radial and feet)
- check for peripheral edema
- lung exam
- abdominal exam
8
Q
Aortic Dissection Findings
A
Widened mediastinum on CXR. Unequal peripheral pulses. S4 gallop.
9
Q
Aortic Dissection S&S
A
- risk factors: aging, atherosclerosis, blunt trauma to chest, HTN
- sudden onset chest pain (sharp, stabbing, tearing, ripping) that can move to the back
- anxiety & feeling of doom; faint/dizzy; heavy sweating; pale skin; rapid, weak pulse; SOB & orthopnea
- weak pulse in one arm compared to other (also different BPs)
10
Q
Aortic Dissection Treatment
A
- Surgery
- beta-blockers (treat HTN)
- strong pain relievers
11
Q
Pulmonary Embolus/ DVT History
A
– Chest pain is usually pleuritic, shortness of breath with minimal exertion, sudden
onset, may or may not have cough/hemoptysis and low grade temperature but typically no temps over 101.
– Long air/car trip, +FHx miscarriage/CVA, Oral contraceptive use, smoker
-Dizziness/faint.
12
Q
Pulmonary Embolus/ DVT PE
A
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
13
Q
Pulmonary Embolus/ DVT Findings
A
CXR usually NORMAL, but can have atelectasis, pleural effusion. Lung sounds usually normal. Typically have tachycardia & tachypnea. May have hypotension or low O2 sat.
14
Q
Pulmonary Embolus/ DVT S&S
A
- risk factors: stasis (extended travel or bed rest), hypercoagulability (estrogen, smoking, polycythemia, genetic, surgery), damage to vessel walls (prior DVT, trauma to lower leg)
- chest pain that worsens when taking a deep breath
- maybe cough/ hemoptysis
- SOB worsens w/ activity
15
Q
Pulmonary Embolus/ DVT Treatment
A
- PREVENTION!
- anticoagulation (warfarin)
- thrombolytic therapy (tissue plasminogen activator/ tPA)
16
Q
Congestive Heart Failure History
A
– Have shortness of breath and DOE. May or may not have cough with
pink frothy sputum (no frank hemoptysis), chest congestion, edema. Don’t usually have chest pain unless also having/recently had an MI.
– Usually have orthopnea, and feel better sitting up – ask them how many pillows they use to sleep with.
– May or may not have PND (paroxysmal nocturnal dyspnea), peripheral
edema.
17
Q
Congestive Heart Failure PE
A
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
18
Q
Congestive Heart Failure Findings
A
CXR with congestion and/or pleural effusion. High B natiuretic peptide. JVD, heart murmurs, peripheral edema. SOB with movement and position.
19
Q
Congestive Heart Failure S&S
A
- risk factors: CAD, HTN, alc abuse, disorders of heart valves
- > L vent hypertrophy -> edema
- drugs/foods that cause sodium retention -> worsening of CHF (NSAIDs, diabetes meds, Ca channel blockers)
- Congested lungs
- > DOE, dyspnea at rest or lying flat
- Fluid/water retention
- > edema
- dizziness, fatigue, weakness
- rapid/irreg heartbeats
20
Q
Congestive Heart Failure Treatment
A
- fluid restriction & decrease in salt intake
- > diuretics (furosemide/ Lasix)
- ACE inhibitors
- diet and exercise, stop smoking, control HTN/cholesterol/diabetes
21
Q
COPD exacerbation History
A
Shortness of breath, DOE, wheezing, change in sputum color/frequency/amount.
– Smoking history, barrel chest, pursed lip breathing, prolonged expiratory phase.
Typically no fever, and diffusely decreased breath sounds with or without
wheezing. May have clubbing, cyanosis.
– Ask about occupational exposures.
22
Q
COPD exacerbation PE
A
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
23
Q
COPD exacerbation Findings
A
CXR: flattened diaphragms, rightward shifted heart.
- purulent exudate w/o PNA
- lung fxn test
- spirometry
24
Q
COPD exacerbation S&S
A
-risk factors: SMOKING
25
COPD exacerbation Treatment
- Smoking cessation, avoid dust
- diet and exercise
- O2 therapy
- Inhaled bronchodilators
- Corticosteroids
26
Pneumonia History
Cough, fever (typically over 101), change in sputum color/frequency/amount.
– Pleuritic chest pain, shortness of breath, DOE, look/feel toxic.
– +/- hemoptysis
27
Pneumonia PE
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan's sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
28
Pneumonia Findings
Elevated WBC (infection). Order a CXR. Crackles on auscultation.
-mucus test
29
Pneumonia S&S
- cough w/ sputum (rusty, green, or tinged with blood)
- fever
- tachypnea, SOB, tachycardia
- shaking & chills
- chest pain, gets worse with cough, breathe in
- nausea/vom
- tired
30
Pneumonia Treatment
- antibiotics
- fever reducers
- cough meds
31
GERD, PUD, GI bleeding History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
32
GERD, PUD, GI bleeding PE
```
Cardiovascular exam (including heart exam, checking JVD, carotid
pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and
abdominal exams. Examine the skin for signs of liver
disease (jaundice, telangiectasia, asterixis, palmar
erythema, Dupuytren’s contracture.
```
33
GERD, PUD, GI bleeding Findings
GERD:
- ambulatory pH probe test
- XR of upper digestive system
- endoscopy
- manometry
34
GERD, PUD, GI bleeding S&S
GERD:
-risk factors: obesity, hiatal hernia, preggers, smoking, asthma, diabetes, delayed stomach emptying
- heartburn, may spread to throat
- chest pain
- dysphagia
- dry cough/ sore throat
- acid reflux (regurgitation of food/liquid)
- lump in throat sensation
PUD:
-risk factors: use of NSAIDs, excessive alcohol intake, smoking, infected with H. pylori, have other illness
- burning pain in middle or upper stomach btwn meals
- bloating, heartburn, nausea/vom
- severe: dark/black stool (bleeding), vom blood, weight loss
35
GERD, PUD, GI bleeding Treatment
- antacids (neutralize stomach acid)
- H2 receptor blockers (reduce acid production)
- PPIs (block acid production & heal esophagus)
- surgery to reinforce or strengthen LES
-maintain healthy weight, avoid food/drink triggers, eat smaller meals, elevate head of bed, stop smoking
PUD:
- avoid triggers
- PPI, antibiotics
36
Cholecystitis or symptomatic cholelithiasis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
37
Cholecystitis or symptomatic cholelithiasis PE
```
Cardiovascular exam (including heart exam, checking JVD, carotid
pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and
abdominal exams. Examine the skin for signs of liver
disease (jaundice, telangiectasia, asterixis, palmar
erythema, Dupuytren’s contracture.
```
Murphy's
38
Cholecystitis or symptomatic cholelithiasis Findings
- Blood test
- abdominal ultrasound or CT
- hepatobiliary iminodiacetic acid (HIDA) scan (tracks production and flow of bile from liver to small intestine)
39
Cholecystitis or symptomatic cholelithiasis S&S
- severe pain in RUQ
- pain radiates to R shoulder/back
- tenderness over abdomen
- nausea/ vom/ fever
- symps occur after a meal (large or fatty)
40
Cholecystitis or symptomatic cholelithiasis Treatment
- fasting
- antibiotics for infection
- pain meds
- surgery: cholecystectomy
41
Appendicitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
42
Appendicitis PE
```
Cardiovascular exam (including heart exam, checking JVD, carotid
pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and
abdominal exams. Examine the skin for signs of liver
disease (jaundice, telangiectasia, asterixis, palmar
erythema, Dupuytren’s contracture.
Psoas sign, heel jar, rebound tenderness, obterator test, McBurney's point.
```
43
Appendicitis Findings
- CT scan/ ultrasound
- urine test (rule out UTI)
- rectal exam
- blood test
44
Appendicitis S&S
- Dull pain near navel/upper abdomen that becomes sharp as it moves to RLQ
- loss of appetite
- nausea/vom
- abdominal swelling
- fever
- inability to pass gas
45
Appendicitis Treatment
- Appendectomy
| - prevent with fiber
46
Diverticulitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
47
Diverticulitis PE
```
Cardiovascular exam (including heart exam, checking JVD, carotid
pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and
abdominal exams. Examine the skin for signs of liver
disease (jaundice, telangiectasia, asterixis, palmar
erythema, Dupuytren’s contracture.
Psoas sign, heel jar, rebound tenderness, obterator test, McBurney's point.
```
48
Diverticulitis Findings
- blood test
| - CT/XR
49
Diverticulitis S&S
- LLQ pain/tenderness, worse with movement
- fever, chills, bloating, gas
- diarrhea or constipation
- nausea, sometimes vom
- loss of appetite
50
Diverticulitis Treatment
- pain meds
- anti-spasmodic drugs
- antibiotics
- surgery
-liquid/low fiber foods
51
Pancreatitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
52
Pancreatitis PE
```
Cardiovascular exam (including heart exam, checking JVD, carotid
pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and
abdominal exams. Examine the skin for signs of liver
disease (jaundice, telangiectasia, asterixis, palmar
erythema, Dupuytren’s contracture.
```
53
Pancreatitis Findings
- Pancreatic fxn test (measure amylase and lipase)
- glucose tolerance test
- ultrasound and CT
- biopsy
54
Pancreatitis S&S
- Upper abdominal pain that radiates into the back; may be aggravated by eating, esp high fat foods
- swollen and tender abdomen
- nausea, vom, fever
- tachycardia
- risk factors: gallstones and heavy alcohol drinking
55
Pancreatitis Treatment
- IV fluids and pain meds
- if gallstones -> cholecystectomy or bile duct surgery
- chronic: give pancreatic enzymes or insulin; low-fat diet
- surgery
- stop smoking/drinking
56
Migraine History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
57
Migraine PE
Full Neurologic exam (including ophthalmic exam looking at
optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
58
Migraine Findings
- blood tests
- CT/ MRI
- spinal tap (underlying condition)
59
Migraine S&S
Migraine
- begin in childhood/early adulthood
- triggers: hormonal changes in women, foods/additives, alcohol, stress, intense physical exertion, changes in environ, meds
- 4 stages: prodrome, aura, headache, postdrome (may not experience all)
- prodrome: 1-2 days before migraine
- > constipation, depression, food cravings, hyperactivity, irritability, neck stiffness, uncontrollable yawning
- aura: before or during migraine
- >visual (flashes of light), touching, movement, speech disturbances
- headache: 4-72hrs
- >pain on 1 or both sides of head, pulsating/throbbing; sensitivity to light, sounds, smells; nausea/vom; blurred vision; lightheadedness (sometimes followed
60
Migraine treatment
- NSAIDS
- Triptans (constrict blood vessels and block brain pain pathways)
- Ergots
- anti-nausea meds
- opioids
- glucocorticoids
- Preventive: antidepressants, anti-seizure, Botox
61
Tension Headache History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
62
Tension headache PE
Full Neurologic exam (including ophthalmic exam looking at
optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
63
Tension headache Findings
-CT/MRI
64
Tension Headache S&S
- dull, aching head pain
- sensation of tightness/pressure across forehead or on the sides/back of head
- tenderness on scalp, neck, shoulder muscles
- not associated with visual disturbances, nausea or vom
- caused by stress
Episodic: 30min – 1wk; occur less than 15 days a month for at least 3 months
Chronic: lasts hours, may be continuous; occur 15+ days a month for at least 3mo
65
Tension Headache Treatment
- pain relievers
- triptans (have both migraines and episodic tension headaches)
- narcotics (rarely used bc of side effects and potential for dependency)
- preventive: antidepressants
66
Cluster Headache History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
67
Cluster headache PE
Full Neurologic exam (including ophthalmic exam looking at
optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
68
Cluster headache Findings
-CT/MRI
69
Cluster headache S&S
- excruciating pain (in or around 1 eye; may radiate to other facial areas)
- sharp, penetrating, burning one-sided pain
- restless
- redness & swelling in eye on affected side
- stuffy or runny nasal passage in nostril on the affected side
- sweaty, pale face
- maybe nausea, sensitivity to light/sound, aura
-Smoking, drinking, FHx
70
Cluster headache treatment
- O2
- triptans
- Octreotide (synthetic somatostatin)
- local anesthetics
- Preventive: Ca channel blockers, corticosteroids, ergots, melatonin
71
Stroke/TIA history
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
72
Stroke/TIA PE
Full Neurologic exam (including ophthalmic exam looking at
optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
73
Stroke/TIA Findings
- Blood test
- CT/MRI
- Carotid ultrasound
- Cerebral angiogram
- ECG
74
Stroke/TIA S&S
- Sudden numbness or weakness of face, arm, leg (esp on 1 side of body)
- Sudden confusion, trouble speaking, or understanding speech
- Sudden trouble seeing in 1 or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache w/ no known cause
75
Stroke/TIA Treatment
- Blood thinners
- Aspirin, tPA
- rehab
76
Herniated disc +/- radiculopathy history
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
77
Herniated disc +/- radiculopathy PE
Full Neurologic exam (including ophthalmic exam looking at
optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
78
Herniated disc +/- radiculopathy Findings
- XR (rule out other causes)
- CT/MRI
- myelogram
- nerve tests
79
Herniated disc +/- radiculopathy S&S
- lower back disc: pain in butt, thigh, calf, some foot
- neck disc: shoulder and arm pain
- numbness or tingling
- weakness
-risk factors: weight, occupation, genetics
80
Herniated disc +/- radiculopathy Treatment
- OTC pain meds
- narcotics
- nerve pain meds
- muscle relaxers
- cortisone injections
- physical therapy
- surgery
81
MSK History
– Onset, location, character of pain will determine additional questions
and exam.
– Tailored history and exam to the cc and where their pain is. Single or multiple joints/areas affected. Symmetric vs non-symmetric? Morning stiffness duration? Heat/cold intolerance, weight gain/loss? Symptoms of inflammation?
82
MSK PE
ALWAYS compare both sides (bilateral exams) and examine one joint
above and below (when possible). Directed by chief compl aint, but always examine bilaterally, and one joint up and down from affected area.
- Neuro, skin,
musculoskeletal, cardiovascular, and lung exams will be directed/focused by the patient’s history.
83
MSK Findings
- blood tests (rheumatoid arthritis)
- X-rays
- CT/MRI
84
MSK Treatment
- Physical therapy
- Splint to immobilize joint
- Use heat or cold
- Reduce workload, increase rest
- reduce stress
- acupuncture
- NSAIDs
- Strengthening and conditioning exercises
- Strengthening exercises
85
Diabetes History
- Age, eating patterns, exercise hx
- Hx of diabetes-related complications
- >microvascular: eye (blurry vision, visual disturbances), kidney (polyuria, urine output), nerve (tingling, numbness, pain)
- >macrovascular: cardiac (chest pain, palpitation, DOE, lower ext. swelling)
- >other: sexual dysfunction, gastroparesis
- Hx of smoking, HTN, obesity, eating, endocrine disorders
- FHx of diabetes & other endocrine disorders
86
Diabetes PE
- height and weight
- BP
- fundoscope
- thyroid palpation
- skin exam (acanthosis nigricans and insulin injection sites)
- foot exam (pulses, monofilament sensation)
- patellar and Achilles reflexes
- cardiovasc, lung, ab, neuro exams
87
Diabetes Findings
- HgA1c
- thyroid fxn test
- fasting plasma glucose and random plasma
- fasting lipid profile
- urinanalysis
- liver and pancreas fxn test
- ECG
88
Diabetes S&S
Polyuria, Polydipsia, Polyphagia, Weight loss
-Hyperglycemia: blurred vision, lower extremity paresthesias
89
Diabetes Treatment
- lifestyle: diet and exercise, weight loss
| - meds: metformin, ACE inhibitors, aspirin
