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Introduce yourself
Cardio/vascular
1.
2.
3.
4.
5.
6.
htn
calf claudication
3rd degree heart block
post MI mgmt
chest pain
palpitations/arrythmia
Pain description
Ever had any CP before?
Quality: heavy, burning, tightness, stabbing, pressure
Precipitating/ Aggravating: walking level/uphill - quantify, food, cold
Alleviating: rest, NTG (in 10 min)
Radiation: arms, jaw, epigastrium
Onset
Site
Associated Symptoms
N, V, diaphoresis, palpitations, dyspnea, orthopnea, PND
PMH
Also, previous cardiac disease
Meds
Resp
1.
2.
3.
4.
5.
6.
7.
percussion breath
sounds
advent.
sounds
pneumo
decr. over
affected
side
contralat
shift
hyper
resonant
decr.
absent
none,
none
possible
pleural rub
atelectasis
decr. over
affected
side
decr. or
absent
crackles,
bronchial
breath
sounds
above
level of
atelect.
Inspection
Face distress, nasal flaring, pursed lips
Cyanosis (frenulum/lips, finger/toes/nose)
Posture ( usually leaning fwd, elbows resting on knees)
voice
sounds
may have
egophony
above
level of
atelectasis
GI
1.
2.
3.
4.
5.
6.
7.
dysphagia
transaminitis
rlq pain and crohns - examine
hematemesis/melena
liver exam
diarrhea (infectious)
jaundice and fatigue
General appearance
Vitals
CNS status: alert or decreasing LOC
Abdomen: + RECTAL for melena, OB positive blood
Signs of chronic liver disease
Hands
Clubbing, leuconychia (pale nail)
Dupuytrens contracture, palmar erythema, spider nevi, tattoos, hepatic flap, pallor, scratch marks,
generalized pigmentation
Eyes and face
Melena history
See upper GI bleed
35 year old with abdo cramps and diarrhea for 2 weeks - History
ID:
HPI:
history of diarrhea:
quantify: volume, frequency (is it really diarrhea? defn: increase in fluidity and/
frequency)
quality: colour, consistency, presence of melena, hematochezia (blood = cathartic)
associated symptoms: tenesmus, relief with defecation, urgency, nausea/vomiting
history of cramps: OPPQRST
Onset: sudden vs gradual
Position: where are the cramps
Provocating/alleviating factors: foods, (chocolate, peppermint, caffeine), alcohol, drugs,
stress, activity, etc.
Quality: what do the cramps feel like (true crampy pain vs sharp/dull, etc)
Radiation of pain
Symptoms associated: fever, myalgias, weight loss, chills (and those above)
Temporal profile: progression of symptoms with time
risk factors for infectious: daycare worker/children at daycare, outbreaks
4 mechanisms of diarrhea
abnormal intestinal motility
increased permeability causing fluid/electrolyte secretion
impaired intestinal absorption
intraluminal nonadsorbable osmotically active solutes
Etiology of Acute diarrhea:
Infectious
bacterial (salmonella, shigella, campylobacter, vibrio cholerae, enteropathogenic Ecoli,
C.diff, yersinia, Vibrio parahemolyticus)
Viral (enterovirus, hepatitis-associated virus, parvo-virus like agents, orbivirus, Norwalk
virus)
Fungal (candida, actinomyces, histoplasma)
Nephro
1. oliguria renal failure
Pre-renal
Volume depletion intake?
Renal
Glomerular nephritides
Tubular interstitial pyelo, hypercalcemia
ATN recent surgery
Nephrotoxic agents antibiotics, contrast dye, anaesthetics, NSAIDs, chemo
Vascular problems emboli, renal vessel thrombosis
Post-renal
Obstruction stones, tumour, BPH, strictures, clots, retroperitoneal mass
Bladder rupture trauma
Heme
1.
2.
3.
4.
5.
6.
purpura/epistaxis
low blood counts + peripheral neuropathy
haemolytic transfusion reaction/error
lymph node exam, lymphoma
asymptomatic anemia
spleen exam, read peripheral smears and protein electrophoresis
Rheum
1. back pain
2. joint pain
Back Pain
Med
30 year old man with a six month history of worsening back pain associated with
morning stiffness, improvement of the stiffness with exercise. Do a focused physical
exam.
Findings: limited movement of the back. Reflexes, sensation, strength all normal.
Straight leg test negative, no signs of cauda equina.
Questions: what is the most likely diagnosis? What other diagnoses are possible
considering the history (other than back pain)?
35 yo 5yr hx of backpain and morning stiffness - px
Inspection
-difference in height of shoulders, iliac crests, skin creases
-genus varum/valgus, popliteal swelling (Bakers cyst)
-posture
-spinal curvature: normal is cervical concavity, thoracic convexity and lumbar concavity
(in ankylosing spondylitis get loss of normal lumbar lordosis and increased thoracic
kyphosis)
-skin abnormalities: psoriasis, scars
-muscle bulk: buttocks, hamstrings, gastrocnemius
Palpation
-do with patient prone
-spinous process with thumbs, fist percussion, muscle spasm
Range of Motion
-patient supine
C-spine:
-flexion - chin to chest
-extension: look at ceiling
-rotation: chin to shoulder
-lateral bending: cheek to shoulder
T-spine:
-chest expansion measured at nipple line (T4) should be 5 - 6 cm
L-spine (decreased mobility in ankylosing spondylitis and OA):
-forward flexion: touch the floor with legs straight
-stabilize pelvis for extension, rotation and lateral bending
-lateral flexion: finger to fibula distance
-rotation: to stabilize patient put one hand on iliac crest, other on opposite shoulder
Gait:
-normal: hip abductors of weight bearing joint contract and raise opposite pelvis
-Trendelenberg/waddling gait: pelvis drops on opposite side when weight is placed on
the affected side (dislocated hip, weak abductors)
-heel walking (dorsiflexion) and toe walking (plantarflexion)
Supine
-straight leg raising
-check SI joint:
flex hip and knee against abdomen and hyperextend opposite knee, looking for SI pain on
hyperextended side
sacral compression
Prone
-femoral stretch: bend knee until fully flexed or pain in anterior thigh
-hip extension
Lateral Decubitus
-sacral compression test (SI joint)
-power: hip abductors, gluteus medius (L5)
-rectal exam for sphincter tone, perianal sensation
-offer to also do a neurological exam for power, sensation and reflexes and they will
refuse
*check SI joint thoroughly since sounds like ankylosing spondylitis scenario, also check
for extra-articular manifestations of ank/spon:
-anterior uveitus, (30%), aortitis, aortic regurgitation, cauda equina syndrome
History and physical of joint RA, OA
History
Age
Gender ( males mostly seronegative)
Pain: worse with rest = inflammatory, other pain qs
Morning stiffness: >60 min = inflammatory, <30-60 min = non-inflammatory
Distribution of joint involvement
Symmetrical, asymmetrical
Large/small
Peripheral/central (spinal dist)
Upper/lower limbs
Temporal profile of disease activity (eg. OA slowly and steadily progressive, vs. gout, intermittent
exacerbations and remissions)
Degree of disability: functional capacity and ADLs
Treatment
Family history: AS, SLE, RA
PMH: DM, IBD, psoriasis, GU/GI infections, renal disease
Meds: diuretics, cyclosporin, hydralazine, procainamide, anticonvulsants
Extra-articular features: (too many to list! Constitutional, skin, mucous membrane lesions,
urethritis, Raynauds, conjunctivitis, GI, pleuropericardial pain, etc.)
ROM: active, passive, against resistance ( to detect lesions in tendons and to measure power)
Supporting Structures: look for instability
Also: neuro, power, vascular, skin lesions
Inflammator
y
opaque
low
>2,000
Infectious
clear
high
<200
NonInflam
clear
high
<2,000
<25%
<25%
>25%
>50%
opaque
low
>50,000
%PMN
multiple joint
OA: conservative (weight loss, PT, OT, rest); acetaminophen, NSAIDs
for inflammation, intraarticular steroids; surgical options later
RA: conservative (education, OT, PT), NSAIDs for short term and
start on a DMARD with appropriate baseline tests; corticosteroids for
acute flares or bridging to onset of DMARD