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TIPS

Introduce yourself

Always confirm age, occupation


Allow patient to state their chief complaint
Always ask about: pmh, meds, allergies, smoking, alcohol, family history
Dont forget to drape

Cardio/vascular
1.
2.
3.
4.
5.
6.

htn
calf claudication
3rd degree heart block
post MI mgmt
chest pain
palpitations/arrythmia

EXAMINE 20 Y.O FEMALE WITH HYPERTENSION


PEP: DDX, INVESTIGATIONS, WHAT TO DO IF YOUR INVESTIGATIONS ARE
NORMAL
EXAMINE MAN WITH CALF CLAUDICATION
PEP: INTERPRET EKG, RISK FACTORS, INVESTIGATIONS
CHB
Med
3. 80 yo lady collapses at mall, LOC, brought to ER by ambulance, granddaughter with
her to answer questions. BP 80/40, HR 40. Manage.
Findings: patient complained of shortness of breath, heart pounding, dizziness just
before fainting. Has history of hypertension, no other cardiac history. EKG shows third
degree heart block. Granddaughter mentions that shes on digoxin, but the nurse
wouldnt give me the level. Youre supposed to treat this as an acute coronary/ACLS
station.
57 yo man one month post MI
History
- chest pain - OPQRST, pleuritic, same type as before?
- exercise tolerance and CCS/NYHA class (based on <> 2 blocks on flat surface)
- palpitations, SOB, orthopnea, PND, diaphoresis, Nx/Vx
- cardiovascular risk factors - DM, HTN, smoking, prev MI, fam hx MI, incr. chol also
ask re: obesity, sedentary lifestyle, depression
- medications - compliance with meds, difficulty in taking meds?

- if DM - glucose control, sx of hyper/hypoglycemia


- exercise routine, daily activities, ADL's
PEP
- Treatments that will affect likelihood of re-infarction
1. Risk factor modification
- glycemic control - HBA1C, daily accuchecks, optimize insulin OHA therapy
- weight loss, diet modification (Healthy heart diet)
- exercise
- blood pressure control - use beta blockers
- stop smoking
- lipid lowering agents - do fasting lipid profile, if total chol >5.5 or LDL > 2.6 HMG CoA reductase inhibitors
2. Pharmocotherapy
- thrombolysis if meets indications and no contraindications
- anticoagulation - aspirin, heparin/coumadin (3 months)
- beta blockers - reduce mortality
- ACE-inhibitors - reduce mortality, especially good if hx CHF
- nitrates - symptomatic control only
- Define primary, secondary and tertiary prevention
Primary Prevention - preventing disease before it occurs, thereby reducing the incidence
of disease (eg immunization, dietary recommendations)
Secondary Prevention - early detection of disease in an asymptomatic period before it
progresses and the treatment which may occur as a result of screening
Tertiary prevention - attempts to reduce complications by treatment and rehabilitation,
which are carried out primarily by the exsting health care system.
1) Chest pain CAD, angina history

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

CAD Risk factors


Smoking, DM, HTN, hyperlipidemia, fam hx (first degree relative male<55 yo, female<60 yo)

PMH
Also, previous cardiac disease

Meds

Woman with acute MI complains of chest pain


History
chest pain
associated symptoms: nausea, vomiting, SOB, diaphoresis
previous history of chest pain
cardiac risk factors
past medical history
family medical history
medications, allergies
social: smoking, alcohol
Physical Exam
general appearance
vitals
chest exam
cardiac exam
Investigations
CBC, lytes, BUN, Cr, AST, LDH, Bili, PT, PTT
CK/CK-MB or Troponin I, ECG
Indications for thrombolysis
ST elevation > 1mm in two contiguous leads
new bundle branch block
within 12 hours post onset of pain; the earlier the better < 6 hours
Contraindications for thrombolysis
recent major surgery (within 2-4 weeks)
active internal bleeding or bleeding diathesis (not including menses)
history of hemorrhagic strokes or any recent stroke
marked hypertension (BP>180) or diastolic >100
known intracranial neoplasm, AVM, or aneurysm
CPR >10 min of chest compressions within 3 weeks
pregnancy
Indications for Angioplasty
trend toward lower mortality, less reinfarction, fewer strokes when compared to
thrombolysis

as effective but not superior to thrombolysis plus ASA


considered for those in which contraindications exist for thrombolysis
emergent in all patients with shock

60 yo with palpitations, irregular rhythm and fatigue - hx


HPI:
-symptomatology: onset, provocation/alleviating factors, temporal profile, i.e. constant
vs episodic, temporal association of fatigue with palpitations, associated symptoms of
chest pain, dyspnea, diaphoresis, orthopnea, PND
-search for precipitant/etiology: ask about symptoms of MI, CHF (as above), cardiac risk
factors (HTN, DM, smoking, FHx, hyperlipidemia), history of valvular disease/rheumatic
fever, medications, physical or emotional stress, hyperkinetic circulatory states
(hyperthyroidism, anemia, etc), pneumonia/respiratory disease (hypoxia can triggerask
about cough, sputum, dyspnea, wheeze)
-hx of embolic events secondary to arrhythmia: TIA, CVA
-if not first onset: previous investigations, findings, therapy, etc.
PMHx:
-if not done above: Meds, Smoking
-EtOH (causes cardiomyopathy)
hx of medical illnesses (past hx of cardiotoxic treatments for systemic disease?)
hx of surgeries, post-op cardiac complications?
FHx: heart disease (significant is first degree male relative < age 55, female < age 60)

Resp
1.
2.
3.
4.
5.
6.
7.

SOB and sputum


hiv with SOB
pneumonia
PE post sx
Coumadin mgmt
developed hemoptysis, on coumadin for afib, wants another doctor (cleo)
resp exam emphysema, consolidation, dec lung volume

TAKE HISTORY FROM MAN WITH SOB AND SPUTUM


PEP: ER RX, INVESTIGATIONS, ADVICE RE: PREVENTION
A. HIV patient with increasing exercise intolerance and dyspnea, now dyspneic at rest.
Physical exam.
B: interpret CXRay, Ddx, Rx
Pneumonia
Med
4. 42 year old male presents with cough, temp and pleuritic pain on right side of chest.
Do focused physical.
Findings: vitals stable except high temp. Decreased breath sounds on right, no tenderness
to palpation.
Questions: interpret CXR (RML consolidation). What is diagnosis and what is etiology
(CAP, S. pneumoniae)? Write a script.
30 M presents with cough, sputum, pleuritic chest pain. Do physical exam.
PEP: (1) Interpret CXR (RML infiltrate)
(2) What is the diagnosis (CAP)
(3) What is the most likely pathogen (S. pneumoniae)
Female 63 years old 4 days post GI surgery with 15 minutes of SOB. Physical exam.
Woman in 60's discharged 4 days ago from hospital with PE. Was on 5 mg of coumadin
OD, discharged with INR of 2.0. INR today 1.0. Counsel and manage.
56 M presents with hemoptysis. On coumadin for A fib. Has long standing hemoptysis
but now worse. Ex-smoker. No chest pain, no DVT risks. Hx and Px. Question:
examiners asks what he would do if he is dissatisfied with care and wants to go to another
physician. Hx and Px.
60 yo m, lawyer, on coumadin for afib, presents w hemoptysis of 1 tbsp, veryworried.
Take a history and appropriate physical. o/e: no findings. He turnes out to be a smoker.
Hasn't had any bleeding. INR has not been checked in one month and he is getting
coumadin from family doctor, dose between 5 and 7. No constitutional symptoms. At
nine minutes: examiner asks you what you do when the next day the patient calls saying
he is unhappy with the care you have given him and wants a copy of his chart.

37 yo man to be exmained for decreased lung volume in left hemithorax - focus


posterior chest
Physical Examination :
Inspection - resp. distress (?paridoxical), cyanosis, indrawing, tracheal tug, chest
movement (symmetry), use of accessory muscles
Palpation - tactile fremitus --> increased transmission of sound with atelectasis
--> decreased transmission of sound with pneumothorax
- chest excursion --> look for symmetry
- trachea midline vs shifted
Percussion - diaphragmatic excursion, normal being 3-5cm.
- percussion - areas of dullness, tympanic if pneumothorax
Auscultation - poor air entry if pneumo
- bronchial breath sounds and crackles above area of atelectasis
PEP :
- diaphragm sits at the 10th thoracic spinous process posteriorly
- PE - vitals include tachycardia, tachypnea, hypotension
chest wall trachea
movement shifted

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

ipsilat shift dull

decr. or
absent

crackles,
bronchial
breath
sounds
above
level of
atelect.

2) Respiratory exam emphysema

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

Neck accessory muscles


Chest AP dia., deformities, indrawing, assymetry
Resp rate and pattern
Hands clubbing (not seen in emphysema), nicotine stains
Palpation
Trachea position and mobility
Chest excursion
Diaphragmatic excursion
Tactile fremitus
Percussion
Lungs hyperresonant? compare sides
Loss of cardiac dullness
Auscultation
Breath sounds
Vocal resonance
FET: normal individuals can empty their chest from full inspiration in 4 seconds or less. The end
point of FET is detected by auscultating over the trachea in the suprasternal notch. Prolongation
of the FET to more than 6 seconds indicates airflow obstruction
Dont forget R middle lobe, anterior and posterior chest

Respiratory exam consolidation


See #6 above for more complete exam
Salient features:
Purulent sputum
Tachypnea
Reduced movement of affected side
Trachea central
Impaired percussion note
Bronchial breath sounds
crackles
Post-exam probe: DDx LLL crackles
Congestive heart failure
Obstructive lung disease
Interstitial fibrosis
Pneumonia
Atelectasis
Pulmonary embolus
Bronchogenic carcinoma
Bronchitis
Bronchiectasis
Non-cardiogenic pulmonary edema

Respiratory physical exam


Physical
General Appearance
Vitals: RR

Inspect: cyanosis, accessory muscle use, AP diameter


Palpate: tracheal deviation, respiratory excursion
Percussion: diaphragmatic excursion, lung areas
Auscultate
Special tests: tactile fremitus, whisper pectoriloquy, egophony
PEP
crackles at bases: atelectasis, pneumonia, upper border of effusion, pulmonary edema
pneumonia - community acquired
not severe, < 65 years: S. pneumoniae, Mycoplasma, Chlamydia
treatment: macrolides, or tetracycline/doxycycline
not severe, > 65 years +/- comorbid: Above + H. flu, Klebsiella, Staph,
Legionella
treatment: extended gm negative coverage = cefuroxime,
clarithromycin
treat iv. until afebrile 48-72 hours then switch to p.o.
treat Strep for 10 days
treat atypicals for 21 days

GI
1.
2.
3.
4.
5.
6.
7.

dysphagia
transaminitis
rlq pain and crohns - examine
hematemesis/melena
liver exam
diarrhea (infectious)
jaundice and fatigue

TAKE HX. FROM MAN WITH DYSPHAGIA


PEP: SHOWN BARIUM SWALLOW, DESCRIBE XRAY FINDING, GIVE DX, GIVE
WORKUP
A. 26 year old male refused life insurance because of elevated LFTs. Focused history.
B. Ddx, other tests would order.
40s man presents with elevated AS T (200) and ALT (200) (ALP 110, bili 26) on
screening at time of insurance. Wants test repeated. 12 drinks on weekend. CAGE
equivocal. Never drank more. IV heroin as teens. Is a janitor at a hospital. Had
perinatal jaundice but nothing since. Previously healthy. Never transfused. No FMHx.
History only.
MEDICINE
PEP: 1. What is his diagnosis (acute hepatitis)
2. What are the three likely etiologies (HBV, HCV, alcohol)
3. What is your reporting responsibility at this time (none, but if HBV or
HCV, must report to public health)
Crohns patient with RLQ pain: examine and AXR
5. 60s man p/w hematemesis. Physical examination.
PEP: Diagnostic possibilities, management
Man with hematemesis GI bleed
History
GI bleed: how much, circumstances (ie. retching, spontaneous)
previous history of bleed, PUD
associated recent symptoms: nausea, vomiting, hematemesis, heartburn, dysphagia,
diarrhea, constipation, melena, hematochezia, jaundice
resulting symptoms: anemic, fatigue, SOB, lightheaded, syncope
risk factors for PUD: NSAIDs, steroids, smoking, alcohol, anticoagulants
constitutional symptoms: fever, weight loss, night sweats
past medical history: abdominal OR, aortic grafts
medications, allergies
social: smoking, alcohol
Physical

General appearance
Vitals
CNS status: alert or decreasing LOC
Abdomen: + RECTAL for melena, OB positive blood
Signs of chronic liver disease

43 yo man requires a Liver Examination


Examination of the liver:
Upon inspection --> 5-5-5 rule :
5 signs in chest/head - spiders, jaundice/scleral icterus, parotid gland hypertrophy,
gynecomastia, fetor hepaticus
5 signs in hands - palmar erythema, clubbing, terry's nails, dupretryn's, asterixis,
leukonycia
5 in abdomen/pelvis - testicular atrophy, hepato/splenomegaly, ascites, caput
medusae, hemrrhoids
- inspect patient's abdomen and look for distension
- percussion of liver - normal span 6-12cm (MCL)
- palpation of liver - feel along inferior costal margin, can extend across midline!!!
PEP - 3 auscultatory finding caused by the liver heard directly over liver
1. Hepatic bruit - high/turbulent flow over liver - hepatocellular ca, alc hepatitis
2. Hepatic friction rub - inflammation of liver
3. Venous Hum (epigastric) - soft humming noise with systolic and diastolic
components, indicates increased collateral circulation between portal and systemic
venous systems, as in hepatic cirrhosis
PEP - Viruses that cause hepatitis and 2 with fecal oral spread
- Hep A,B,C,D,E, EBV, CMV
- Hep A and E and transmitted thru fecal-oral spread, both of which do NOT cause
chronic hepatitis
Focused liver exam alcoholic

Hands
Clubbing, leuconychia (pale nail)
Dupuytrens contracture, palmar erythema, spider nevi, tattoos, hepatic flap, pallor, scratch marks,
generalized pigmentation
Eyes and face

Icterus, cyanosis, parotid enlargement, fetor hepaticus


Chest
Spider nevi, loss of axillary hair, gynecomastia
Abdomen
Splenomegaly, ascites, hepatomegaly, caput medusae
GU
Testicular atrophy, loss of pubic hair
Leg edema

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)

Protozoal (giardia lamblia, entamoeba histolytica, cryptosporidium, Isospora belli,


blastocystis hominis)
Helminthic
Toxic
bacterial toxin (food poisoning): staph, clostridia, E.coli, pseudomonas
chemical poisons: lead, mercury, mushrooms, arsenic
Dietary
irritating foods, alcohol, drugs, nonabsorbable sugar substitutes (sorbitol, mannitol)
Miscellaneous
appendicitis, diverticulitis, GI hemorrhage, pseudomembranous colitis, fecal impaction,
ischemic colitis, HSP, Stevens-Johnson syndrome
25 yo male with Crohns disease and abdo pain - px
-make sure you prepare patient properly: lighting, adjust head of bed so patient lying flat
Inspection:
Extra-abdominal:
General appearance:
anorexia, weight loss, severe wasting due to malabsorption
Head & neck:
mouth for ulcers
eyes: uveitis, chorioretinitis, iridocyclitis
Skin, especially over legs:
rashes: erythema nodosm, erythema multiforme, pyoderma gangrenosum
thrombophlebitis
Abdominal Inspection
contour: flat, scaphoid (malnourished), protuberant (fat, fluid, feces, flatus, fetus, fatal
growth/aneurysm), distended (lower = pregnancy, fibroids, ovarian tumour, upper =
gastric dilation, left lobe of liver)
scars (past hx surgery)
visible peristalsis (bowel obstruction)
visible pulsations (aneurysm, probably normal in thin person)
hernia
Auscultation
bowel sounds
-must listen for full 5min before saying absent
-increased = early pyloric/intestinal obstruction, diarrhea
-absent - ileus, (also uremia, spinal cord injury)
-can also listen for bruits (renal/iliac, liver in hepatic CA/alcoholic hepatitis), venous hum
or friction rubs over liver and spleen (rub only, meaning infarction)
Percussion
-ask about pain first

-percuss lightly in all 4 quadrants


-usually tympanic, identify air in stomach and bowel, and suprapublic dullness
Palpation
-watch patients face, ask patient to point to area of max tenderness
-peritoneal inflammation: cough, suck in abdomen
a) light palpation
-areas of tenderness, guarding, masses
b) deep palpation
MASS: consistency, contour, size, mobility, pulsation, tenderness
Liver percussion
-start below umbilicus in midclavicular line and percuss upward to find lower border
-start at nipple line and percuss down to find upper border
Liver palpation
-place hand well below lower border of liver dullness and press gently in and up
-ask patient to take deep breath
-if palpable edge, find the medial and lateral edges
Spleen (see previous exam)
Kidney (wont be part of Crohns physical exam)
60 yo with one week hx of fatigue and jaundice - hx
ID: age, sex, occupation (may have hx of occupational toxin-induced liver disease)
HPI:
constitutional symptoms: fevers, chills, weight loss, appetite
nausea, vomiting
abdominal pain (recurrent epigastric/RUQ suggests biliary)
polyuria, polydipsia, polyphagia (sudden onset Type I DM)
dark urine, pale stools, pruritus
hx of drug and EtOH use
hx of hepatitis, travel hx, sexual hx
relationship of jaundice to meds, anesthetics, etc.
family history jaundice (hemolytic disorders, Wilsons, Gilberts, A1-AT defcy)
PMHx:
-current meds, smoking, EtOH, allergies
Medical conditions:
-diabetes (higher risk pancreatic CA)
-ulcerative colitis (sclerosing cholangitis, bile duct carcinoma), IBD (ileum poorly
reabsorbs bile salts)
-thyroiditis, other autoimmune disease (RA, vasculitis) for primary biliary cirrhosis
Previous surgery:
-terminal ileal resection (no bile salt reabsorption)

Nephro
1. oliguria renal failure

35 yo female with hx of oliguria - ie Renal Failure


Think pre-renal, renal and postrenal causes
History
- amount of urine output
- prerenal - symptoms of hemorrhage, heartfailure, sepsis, infection, vomiting, diarrhea,
fever, chills, NSAIDS, ACE-I's
- ie blood loss, melena stools, hematemesis, chest pain, dyspnea, orthopnea, PND,
palpitations, syncope, dizziness, abdo pain etc.
- renal - medications causing renal failure - radiocontrast, gentamicin, chemotx agents,
aminoglycosides, rifampin, cimetidine, allopurinol, thiazides, furosemide
- malignant HTN (H/A, blurry vision), pyelo (flank pain), HUS (skin lesions,
abdo pain)
- prolonged hypoperfusion (as above)
- postrenal - BPH, stones (flank pain), urinary retention in past, Achol. meds, diabetes
Associated symptoms - dysuria, flank pain, obstructive urinary symptoms, abdo pain,
hematuria, foamy urine(protein)
Past medical history - past episodes, recent UTI (post strept GN)
meds - as above
PEP - admitting investigations
- CBC, lytes, BUN, creatinine, glucose, urate, Ca, Mg, Phosphate
- Urine microscopy, C/S, culture, electrolytes, osmolality, creatinine
- 24 hour urine collection for protein, creatinine, pH, osmolality
- abdominal ultrasound
- Foley In/Out
- important initial causes of oliguria to consider include :
- CHF, hemorrhage, pulmonary edema, sepsis
Oliguria history CHF

Pre-renal
Volume depletion intake?

Poor cardiac output (CHF, tamponade, MI, PE)


Sx:?DOE, orthopnea, PND, ankle edema
Precipitants: MI, HTN, valvular heart disease, congenital heart disease, pericardial disease,
cardiomyopathy, PE, fluid overload, sodium retention, salt overload, dysrhythmia, beta
blocker, renal disease, anemia, fever and infection, pregnancy, noncompliance with meds or
diet.
Risk: CAD, HTN, cardiomyopathy
Shock/sepsis fever, chills, focus of infection

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

EXAMINE YOUNG WOMAN WITH PURPURA AND EPISTAXIS


PEP: HX, DX, INVESTIGATIONS
Neuro/heme topic:
60 yo m came to MD a few days ago NFW. Your office partner did a
CBC; MCV 120, anemic, low WBC, low plts. Take a relevant hx. O/E: Peripheral
neuropathy, probs walking at night. Tingling. Some mental symptoms.
No consitutional illnesses as far as I can remember. No ETOH. Written: give most likely
dx, give 2 other possibilities for the neuropathy (I said peripheral neuropathy 2ndary to
lymphoma, gastric, causing b12 deficiency, or DM). Give 2 tests you want. Pt tells you
he is a bus driver and he has forgotten to make 2 pickups this week. How do you counsel
him?
Hemolytic transfusion reaction / error
Head and Neck Exam / Examine Lymph Nodes above the diaphragm
Examination of LN's above diaphragm
- examine the following --> occipital, post auricular, pre-auricular, cervical chains
(posterior, superficial, deep), tonsillar, submandibular, submental, SUPRACLAVICULAR (inspire to feel properly)
--> EPITROCHLEAR (medial surface of arm, 3cm above the elbow),
AXILLARY
PEP - DDx lymphadenopathy
Infection - Bacterial, viral (mono, CMV, cat scratch, HIV), parasitic (toxo), spirochetal
(syphilis), mycobacterial (TB, MAC), fungal (actinomycosis, cryptococcosis
Drug reaction - serum sickness, phenytoin
Malignancy - solid tumors with mets eg. H/N cancer (cervical), GI tumors
(supraclavicular), breast cancer (axillary), anal ca (inguinal), LYMPHOMA!!
Misc - sarcoidosis
PEP - staging for hodgkin's disease
I - single lymph node region (LNR)

II - two or more LNR's on the same side of the diaphragm


III - LNR on both sides of the diaphragm, spleen may be involved
IV - diffuse involvement of extra-lymphatic sites
To stage properly, order : CBC, diff, coags, U/A, CXR, CT chest, abdo and pelvis, BM
aspirate and bx, consider lymphangiogram and gallium scan
Examine for lymphadenopathy above the diaphragm

Describe: size, consistency, tenderness, mobility


Areas
H&N
Occipital, p. auricular, p. cervical, superficial and deep cervical, tonsillar, submaxilllary,
submental, ant. Auricular, supraclavicular, infraclavicular also look inside mouth
Breast/Axilla
Epitrochlear
90 degree flexion of patients arm feel in fossa about 3 cm proximal to medial epicondyle of
humerus, in groove between biceps and triceps

old woman with asymptomatic anemia History


ddx of anemia:
decreased RBC production
-lack of essential nutrient (B12, folate, iron)
-marrow injury (radiation)
-marrow inhibition (drug, immunologic agent)
-marrow replacement (neoplasm, fibrosis)
-hereditary defect
-endocrine problem (hypothroid, hypopituitary, renal failure/low erythropoeitin)
-idiopathic (refractory)
RBC loss (bleeding)
-acute
-chronic with secondary iron deficiency
RBC destruction (hemolysis)
intracorpuscular defect
-abnormal Hb (S)
-defective globin synthesis (thalassemia)
-defective heme synthesis (prophyria)
-defective enzyme (G6PD)
-membrane defect (hereditary spherocytosis)
-PNH
extracorpuscular defect
-primary = autoimmune
-secondary:
physical agent (microangiopathy)

chemical agent (drug)


infection (malaria, septicemia)
neoplasm (especially lymphoma)
connective tissue disease (lupus)
splenomegaly
immunization (newborn, transfusion)
HISTORY
ID: age, sex, occupation
HPI: how was anemia picked up (i.e. why had CBC done)
-r/o symptoms: fatigue, SOB, chest pain, palpitations, has her family commented on her
being pale or jaundiced
-look for cause:
ask about diet: B12 and iron (meats), folate (greens)
alcohol intake
medications: antacids decrease Fe absorption
source of bleeding (melena, hematochezia, menorrhagia, hematuria)
fevers, chills, nightsweats, weight loss
travel (malaria-endemia areaOK, I know this one is a stretch for asymptomatic)
past history of anemia: therapy employed, response to treatment
family history of anemia, jaundice, gallbladder disease, splenectomy
PMHx:

any medical or surgical illnesses


smoking, drug allergies

Spleen examination: 2 blood films and protein electrophoresis


Inspection: spleen enlarges diagonally and crosses midline (kidney enlarges vertically)
Palpation:
1) support the behind the spleen with your left hand (on the left lower rib cage
posteriorly), and press in toward the spleen starting at the RLQ (with right hand)
-ask pt to take a deep breath and feel the tip of the spleen as it comes down to meet your
fingers (if you feel it, its big)
reposition the patient on his/her right side (allows the spleen to fall forward) with his/her
hips and knees flexed (fetal position lying on right side)
Percussion: last intercostal space in the anterior axillary lineshould be tympanic
-percuss through a cycle of respirationif it changes from tympanic to dull with
inspiration, this means the spleen is enlarged (because as you breathe in, the spleen
moves down and occupies the space under where you are percussing, thereby changing
the sound from tympanic to dull)
PEP; 2 blood films and protein electrophoresis
-protein electrophoresis: probably for myeloma, see spike indicating monoclonal protein
production
-possible blood films they want us to know
macrocytosis (macrocytic anemia): oval shaped, well-hemoglobinized, big RBCs

microcytic anemia: with target cells suggests thalassemia


hemolytic anemia: macrocytes and microspherocytes with polychromasia (more purple)
sickle cell
aplastic anemia (marrow full of fat cellslooks empty)
hypersegmented PMNs (>4-5) as seen in megaloblastic anemia (folate/B12)
AML: blasts with big, multiple nucleoli, Auer rod in cytoplasm
ALL: blasts with hardly any cytoplasm, big nuclei
CLL: lots of small, well-differentiated lymphocytes, smudge cells
infectious mono: big lymphocytes with indented cytoplasm
spherocytes: small, round RBCs with no central area of pallor
myelofibrosis: tear-drop RBCs (poikilocytes)
Multiple myeloma: plasma cells, Rouleaux
Hodgkins: Reed Sternberg cell (owls eyes)

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.)

Physical Exam (compare affected joint to normal)


General appearance of patient, evidence of extra-articular features, adenopathy, organomegaly, etc.
Inspection: swelling, redness, deformity, muscle atrophy
Palpation: warmth, joint line tenderness, stress pain, effusion, crepitus

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

55 year old woman with joint pain - history


joint pain: location, onset/duration, swelling, function of joint, ADLs
characteristics: morning stiffness, worse after rest/activity
course: have you ever had it before (chronic/subacute/acute)
pattern of joint involvement: other joints
extra articular features: skin, eyes, bowel, kidney, lung involvement, urethritis,
cervicitis, SI joints, enthesitis
constitutional symptoms
past medical history
family history (arthritis, collagen vascular diseases)
medications, allergies
social history: smoking, alcohol, sexual history
PEP
comment on x-rays of her hands
RA: periarticular osteopenia, symmetrical erosions at ulnar styloid, 1st, 2nd
MCP & PIPs
OA: joint space narrowing, subchondral cysts, subchondral sclerosis,
osteophytes, at the DIP, PIP and 1st CMC
discuss initial management
single joint: synovial fluid aspiration for crystals, cells, C&S
Normal
colour
viscosity
WBC/mm

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

Woman with hand pain, swelling in fingers


joint pain: location, onset/duration, swelling, function of joint, ADLs
characteristics: morning stiffness, worse after rest/activity

course: have you ever had it before (chronic/subacute/acute)


pattern of joint involvement: other joints
extra articular features: skin, eyes, bowel, kidney, lung involvement, urethritis,
cervicitis, SI joints, enthesitis
constitutional symptoms
sexual history
past medical history
family history (arthritis, collagen vascular diseases)
medications, allergies
social history: smoking, alcohol
PEP
xray: periarticular osteopenia, erosions
management of RA
patient education, exercise, PT, OT
symptomatic treatment: NSAIDs, corticosteroids (intraarticular/systemic)
DMARDs
Hydroxychloroquine (antimalarial): dose 400 mg/day
six month trial
hyperpigmentation, myopathy, rash, diarrhea, retinal toxicity
baseline Ophthalmologic exam q 3 months
Methotrexate (folic acid antagonist)
starting dose 7.5mg/week p.o., injection, increased to
25mg/week
response within 6-8 weeks
GI, stomatitis, rash, alopecia, myelosuppression,
hepatotoxicity, pulmonary toxicity
contraindications: sulfa containing Abx and HIV infection,
alcohol abuse
CBC monthly, Liver q2months
Sulfasalazine
dose of 1g BID-TID
six month trial
rash, myelosuppression, GI, heartburn, dizziness, headache
CBC with differential and chemistry profile monthly