Oral Boards Clinical Findings

• Symptoms JIP
• Joints affected: DIP, PIP, 1st CMC (thumb joint), 1st MTP, knees, hips and spine
• Joints not affected: MCP, wrists, shoulders, elbows, ankles
• Insidious onset – initially is just articular stiffness usually lasting less than 15 minutes
• Insignificant morning stiffness (<30-60min after awakening)
• Progresses to localized, unilateral joint pain and stiffness - worsens with use/weight bearing; relieved by rest
• PE findings: BCSTD
• Bony enlargement (Heberdon’s @ DIP; Bouchard’s @ PIP)
• Crepitus
• Synovial effusions (Cold effusions) - minimal
• Tenderness to palpation; may have limitation of motion of affected joint or joints
• Decrease ROM/stiffness
• Deformity (lack of full extension)

• Symptoms : BAT
• Backache of varying severity
• Asymptomatic until fractures occur
• T12 is site of spontaneous fracture (due to center of gravity)
• PE findings: LID
• Loss of height
• Increased abdominal skin folds- “love handles”
• Dowager’s hump

• Symptoms: SLPN DLS
• Sensory loss in affected dermatome
• Low Back pain w/ buttock and leg pain (non-pulsating pain)
• Pain radiating below the knee that increases w/ valsalva maneuver
• Numbness and tingling in toes and feet
• Decreased muscle strength and atrophy over time
• Limit in ROM, especially flexion
• Sciatica
• Signs: PAD
• Positive straight leg raise test and sitting root test
• Antalgic gait
• Depressed reflexes

• Symptoms: PILL
• Pain that lasts 10-14 days
• Inability to maintain normal posture due to stiffness/pain
• Low back pain around the low back that can radiate into the upper buttock, but NOT into the legs
• Low back muscle spasms with activity and rest
• Signs: ADAPT
• Absence of lordotic curve (reverse lordotic curve)
• Decreased ROM in lower back
• Absence of neurological involvement
• Paravertebral muscle spasms of the L/S spine
• Tense, hard, warm paravertebral muscles

• Symptoms
• Pt typically complain of leg pain or trouble walking, numbness, “legs giving way”
• Pain will originate in low back but will extend below buttock into the thigh (90% of pt)
• 50% below the knee
• Pain combined w/ LE aching and numbness worsen with ambulation and extension; also brought on by prolonged standing
• Symptoms often BILATERAL
• Sign: PURE
• PE often unimpressive: rare pos straight leg test or decrease DTR
• Unsteady gait (seems more significant to pt than observer)
• ROM of spine exhibits pain w/ EXTENSION -> relieved by laying supine or with extension

• Symptoms
• Memory impairment with at least one of the following:
• Language impairment, apraxia, agnosia, impaired executive function
• Very early: MDS
• minimal memory loss, decreased activity, social withdrawal
• Early: VICAR PI
• Visuospatial deficits, instrumental ADLs are the first to go, circumlocutions, abstract reasoning ability, recent memory loss, personality changes (apathy, labile affect), impaired judgment
• Middle-late: PORCH SAD
• Personality changes (withdrawn, beligerent, socially inappropriate)
• Orientation loss
• Remote memory loss,
• Confabulation,
• Hallucinations/delusions

• Sundowning
• Anxiety/advanced intellectual impairment
• Depression,
• Late: AIRWARD
• Aphasia
• Incontinence, inability to sit up, hold head up or track objects with the eyes
• Recurrent infections
• Weight loss
• Apraxia
• Rigidity
• Dysphagia
• Signs
• Memory loss
• Failure of screening with clock draw and 3-item word recall (i.e. “mini-cog test”) > proceed to Folstein MMSE if failure
• Deficits in 2 or more areas of cognition, at least one being memory (others: executive function, visuospatial function, language)
• No disturbance of consciousness
• Psychomotor slowing
• Late: primitive reflexes appear

• Symptoms
• Multi-Infarct Dementia: Recurrent strokes result in stepwise progression of disease
• Hx of discrete episodes of sudden neurologic deterioration

• Diffuse White Matter Disease:
• Insidious in onset and progress slowly, features that distinguish it from multi-infarct dementia, but other patients show a stepwise deterioration more typical of multi-infarct dementia

• Early symptoms: SCAMPED
• Spatial deficits
• Changes in personality
• Apathy
• Mild confusion and memory deficits
• Psychosis
• Executive deficits
• Depression

• Later symptoms
• Marked difficulties in judgment and orientation and dependence on others for daily activities; euphoria,
• elation, depression, or aggressive behaviors as dz progresses

• Advanced disease: urinary incontinence and
• dysarthria with or without other pseudobulbar features (e.g., dysphagia, emotional lability)

Physical exam findings

• Multi-Infarct Dementia
• Focal neurologic deficits
• Hemiparesis
• Unilateral Babinski reflex
• Visual field defect
• Pseudobulbar palsy - impaired chewing, swallowing, slurred speech, emotional outbursts

• White Matter Disease
• Pyramidal and cerebellar signs à may present as gait disorder

• Symptoms: CAM
• Carotid -weakness and heaviness of contralateral arm, leg, or face with possible numbness
• Abrupt onset, rapid recovery (less than an hour)
• Most Sx develop in the cortex both motor and sensory

• Vertebrobasilar ischemia V-CAPD
• Vertigo
• Change in vision
• Ataxia,
• Perioral numbness
• Diplopia, dysarthria

Emboli to the retinal artery cause unilateral blindness which, when transient, is termed "amaurosis fugax"

• Signs NBC
• Normal PE when it is conducted after the TIA
• Neuro deficits depend on the artery involved
• Bruits in the mid-cervical area with reduced or absent arm pulses
• Cardiac abnormality

• Flaccid weakness
• Sensory changes
• Hyperreflexia
• Extensor plantar response on affected side

• General signs and symptoms of CVA: SMASH
• Speech disturbance (aphasia, dysarthria)
• Motor dysfunction
• Apraxia/Agnosia, altered consciousness
• Sensory dysfunction
• Headaches

• Intracranial Hemorrhage:
• Abrupt onset of severe HA, hemiplegia, and decreased level of consciousness

• Subarachnoid Hemorrhage:
• Abrupt onset of HA, “worse HA of life,” photophobia, nuchal rigidity, alteration of conciousness

• Lacunar Infarct: I C DC
• ipsilateral ataxia,
• contralateral motor or sensory deficits,
• dysarthria,
• clumsy hands

• Cerebral Infarcts
• Ophthalmic artery- usually asymptomatic but can cause amaurosis fugax

Internal carotid artery- severe contralateral hemiplegia, hemianesthesia, and hemianopia

Anterior cerebral/communicating artery- Weakness in contralateral arm and weakness/sensory loss in contralateral leg, confusion, personality changes

• Middle Cerebral Artery
• - contralateral hemiplegia, hemisensory loss, and homonymous hemianopia with eyes deviated toward lesion

Anterior: expressive aphasia (hard to get words out), contralateral paralysis, and loss of sensation

Posterior: Wernicke’s aphasia, homonymous visual field deficit, confusion, dressing apraxia

Posterior cerebral artery occlusion- Thalamic syndrome

Contralateral hemisensory disturbance and spontaneous pain

• Vertebral
• Incomplete occlusion: diplopia, visual loss, vertigo, ataxia, weakness or sensory losses in limbs, nausea, tinnitus, syncope

• Complete occlusion: leads to coma with
• pinpoint pupils, flaccid quadriplegia, and sensory loss

• Posterior inferior cerebellar artery -
• Ipsilateral anesthesia of face, limb ataxia/numbness, Horner’s syndrome

Cerebellar artery - Vertigo, N/V, nystagmus, ipsilateral limb ataxia and contralateral sensory loss

Symptoms: SIGECAPS

• Physical exam findings: PPPALM
• Psychomotor retardation or agitation (slowed speech, sighs, long pauses)
• Poor concentration
• Poor abstract reasoning
• Asymptomatic
• Lack of eye contact
• Memory loss

• Symptoms: SLOGAN C
• Sx Subside over 2-3 weeks
• Liver tenderness
• Onset may be abrupt or insidious
• General malaise, myalgia, arthralgia, easy fatigability, upper respiratory symptoms, and anorexia
• Abdominal pain> mild/constant in RUQ or epigastrum; often aggravated by jarring or exertion
• Nausea and vomiting

Complete clinical and laboratory recovery by 9 weeks (acute, fulminant hep A rare)

• Signs
• Jaundice is rare
• Fever
• Splenomegaly occurs in 15% of patients
• Hepatomegaly—rarely marked—present in over 50% of cases

• Symptoms
• Onset may be abrupt or insidious
• Prodrome of anorexia, nausea, vomiting, malaise
• Tender hepatomegaly
• Malaise, myalgia, arthralgia, fatigability, upper respiratory symptoms
• Abdominal pain usually mild/constant in the RUQ or epigastrium

• Signs
• Fever, Jaundice, Hepatomegaly

• Symptoms
• Can be Asx
• N/V, anorexia (frequently assoc with changes in olfaction and taste)
• Fatigue, malaise
• Dark urine/ Clay-colored stool
• Abdominal pain
• Joint pain

• Signs
• Jaundice (symptoms precede by 1-2wks)
• Fever
• RUQ pain upon palpation
• Splenomegaly and cervical adenopathy in 10-20% pts with acute hepatitis

• Symptoms: LDLDL
• Large body habitus
• Difficulty in doing daily activities and ambulating
• Lethargy, fatigue, dyspnea
• Diaphoresis with minimal exertion
• Large joint pain

• Signs: B CAPER
• BMI > 30
• Comorbid conditions
• Abdominal circumference >102 cm in men and > 88 cm in women
• Pattern of obesity-may vary from truncal distribution without limb involvement to involvement of every segment of body
• Excessive amounts of subcutaneous adipose tissue with occasional “yellow striae”
• Recurrent fungal infections under the skin

• Symptoms
• Depends on severity and chronicity of the anemia

• Common to all anemias: PET
• palpitations, pallor, easily fatigability, tachycardia, tachypnea on exertion.

Severe deficiency: skin/mucosal changes (smooth tongue, brittle nails, and cheilosis), dysphagia (from esophageal webs from Plummer-Vinson syndrome), pica (ice chip cravings)

• Signs
• Mild: may have syncope and tachycardia, present with pallor

• Advanced tissue iron deficiency:
• Cheilosis (fissures at corner of the mouth)
• Koilonychia (spooning of the fingernails)

LOOK AT CHART IN BOOK

• Overall: Anemia: pallor, fatigue, decreased exercise
• intolerance

• Alpha:
• Silent carrier: Hematologically normal
• α-thalassemia trait: patients are clinically normal and have a normal life expectancy. Mild microcytic anemia

HbH disease: Severe microcytic hemolytic anemia with signs of hemolysis- pallor and splenomegaly may be present

• Bart hydrops fetalis: incompatible
• with life

Beta:

• b-Thalassemia major:
• Severe anemia and bony deformities (abnormal facial structure: chipmunk face, frontal bossing); copper-colored skin; hemolysis (jaundice/icterus,
• hepatosplenomegaly), osteopenia and pathologic fractures; growth failure

• b-Thalassemia intermedia: Milder
• phenotype; hepato/splenomegaly, bony deformities, (pronounced forehead), watch for hematochromatosis (Fe burden).
• In children: maxillary marrow hyperplasia and frontal bossing, thinking fx of long bones and vertebrae. Can be aggravated by onset of puberty, infection, development of splenomegaly/hypersplenism

• b-Thalassemia minor:
• Mild microcytic anemia, clinically normal

• Clinical findings:
• Signs of anemia:
• mucosal surfaces, conjunctiva, and nail beds may be pale to light blue from lack of oxygen,
• tachycardia, hypotension, palpitations,
• pallor, splenic enlargement, jaundice

• Symptoms
• Otalgia
• Aural pressure
• Decreased hearing
• Fever
• URI
• Vertigo and tinnitus

• Signs
• Hypomobile, erythematous, bulging or retracted TM
• Air/fluid in middle ear
• Nystagmus
• Loss of hearing (Weber/Rinne)
• Mastoid tenderness due to the presence of pus within the mastoid air cells

• Symptoms
• Conductive hearing loss
• Drainage
• Pain with acute exacerbations

• Signs
• Perforation of TM with purulent aural discharge

• Symptoms
• Not usually associated with symptoms, although can have otalgia and aural fullness
• Conductive hearing loss

• Signs
• TM dull and hypomobile
• Air bubbles behind the TM

• Symptoms
• Facial pain/pressure; pain may be unilateral and may refer to the upper teeth
• Retro-orbital pain/pressure
• Headache, cough
• Nasal congestion, PND

• Signs
• Recent viral URI
• Purulent nasal discharge
• Tenderness on palpation to affected sinuses
• Fever
• Transillumination may show opacification of the sinus

• Symptoms
• Appear as immune system begins to fight infection
• Nasal congestion, watery rhinorrhea (purulent = bacterial) and PND
• Mucosal edema, increase in mucus production
• Headache
• Sneezing, cough and sore throat
• Malaise

• Signs
• May have a normal PE
• Erythematous, edematous mucosa
• Clear to yellow nasal discharge
• TM may show fluid

• Symptoms: STAMP N
• Sore throat, pain on swallowing
• Tender cervical adenopathy
• Acute onset of fever >38 degrees C
• Malaise and nausea
• Pharyngotonsillar exudates
• NO COUGH

• Signs
• Pharynx, soft palate and tonsils are hyperemic, tonsils hypertrophied and edematous.
• Presence of purulent exudates.

• Symptoms:
• Bloody diarrhea is hallmark
• Rectal bleeding, tenesmus and passage of mucus
• Crampy abdominal pain, bloody diarrhea (fecal urgency), 4-6 stools/ day
• Anorexia, N/V, weight loss

Proctitis: fresh blood or blood stained mucus, tenesmus, urgency with feeling of incomplete evacuation, constipation

Extension beyond rectum: blood mixed with stool or grossly bloody diarrhea; When dz severe, pts pass a liquid stool containing blood pus and fecal matter

Mucus and pus in stools

• Extra-intestinal Manifestations
• Erythema nodosum
• Pyoderma gangrenosum
• Sacroilitis
• Uveitis, scleritis, iritis
• Hepatitic steatosis

• Signs
• Tender anal canal and blood on rectal examination (hematochezia)
• Tenderness to palpation over the colon, may have fever

• Symptoms: FACADE MOWING PG
• Low grade fever, fistulization with or without infection
• anorexia,
• cramping
• abdominal pain
• diarrhea
• energy loss

• malaise
• oral apthous lesions
• wt loss,
• Intestinal obstruction
• Nephrolithiasis with stones
• Gallstones

• Perianal disease – anal fissures, perianal abscesses, fistulas
• Gallstones

• Signs: ATRIAL JH
• Abdominal distension
• Tender, abdominal mass with abscess formation
• RLQ mass and tenderness
• Iritis
• Anal fissures or perianal abscess
• Loud borborygmi

• Joint swelling
• Hepatosplenomegaly (uncommon)

• Symptoms BNP PD
• Bloating, belching, vomiting
• Nausea, Anorexia, Wt. loss
• Pain worsened by food

• Perforation more likely in GU à rigid board-like abdomen, guarded,
• rebound tenderness, hypotension
• Dyspepsia = m.c. symptom - dull, gnawing, ache/pain,
• “hunger-like”, localized to epigastrum

• Physical exam findings: MEH
• Melena
• Epigastric tenderness on palpation
• Heme positive stool

• Symptoms: PEN
• Pain is rhythmic, periodic, often relieved by food and antacids
• Epigastric pain (dyspepsia) is the hallmark symptom- dull, gnawing, ache described as “hunger-like”
• Night time waking

• Physical exam findings: HOE
• Heme positive stool, Melena
• Obstruction (more likely DU): succession splash from retained gastric contents, abd distention
• Epigastric tenderness on palpation

• Symptoms
• N/V, diffuse abdominal pain
• Altered MS
• Malaise, Fatigue, Edema

• Physical exam findings
• Hyperkalemia, Arrhythmias
• Azotemia, Asterixes, Encephalopathy, Confusion
• Bleeding/clotting disorders from platelet dysfunction
• N/V, Malaise
• Pericardial effusion, cardiac tamponade, pericardial friction rub, rales from hyperperfusion

• Symptoms F MIND PPD
• Fatigue, weakness, malaise
• Metallic taste
• Irritability, difficulty concentrating, altered MS,
• N/V, Anorexia
• Depression

• Pruritis, Edema
• Paresthesias
• Decreased libido

• Physical exam findings: PURCHASED W
• Pericardial friction rub
• Uremic fetor/uremic frost
• Rales
• Cardiomegaly, CP from pericarditis
• HTN
• Asterixes, myoclonus
• SOB/DOE
• Easily bruised skin/jaundice
• Decreased urine output
• Weight loss

Signs and Symptom

• Systemic Complaints – fever, night sweats, wt loss (esp. muscle mass), Anorexia/N/V
• Pulmonary Disease – Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis, Histoplasmosis, Cryptococcal infection, community acquired pneumonia (H. Influenzae), Sinusitis, Kaposi sarcoma

CNS Disease – Toxoplasmosis, CNS lymphoma, AIDS: Dementia Complex, Cryptococcal Meningitis, HIV: Myelopathy, Progressive Multifocal Leukoencephalopathy (PML)

• PNS Disease – Peripheral neuropathy, inflammatory
• polyneuropathies, sensory neuropathy, mononeuropathy

• Rheumatologic Manifestations – Arthritis (large
• joints), Reiter syndrome, SLE, psoriatic arthritis

Myopathy – Infrequent with ART, but proximal muscle weakness typical

CMV Retinitis

• Oral Lesions – Oral canditasis, hairy leukoplakia
• (caused by EBV), angular chelitis, Apthous ulcers, gingival disease

GI Manifestations – Candidal esophagitis, hepatic disease (due to mycobacterial dz, CMV, Hep B, Hep C, and lymphoma), biliary disease, enterocolitis (campylobacter, Salmonella, Shigella, CMV, Adenovirus, protozoans)

Endocrine Manifestations – Hypogonadism, Adrenal gland m.c. affected

Skin Manifestations – Herpes simplex infections, Herpes Zoster, Molluscum contagiosum caused by pox virus, Staph folliculitis, superficial abscesses (furuncles), bullous impetigo

• HIV-related Malignancies – KS, non-Hodgkin lymphoma, primary lymphoma of the brain, invasive cervical carcinoma assoc. with AIDS; Hodgkin
• disease, anal dysplasia and squamous cell carcinoma

• Gynecologic Manifestations – vaginal candidasis,
• cervical dysplasia and neoplasic, PID

CAD

• Physical exam findings
• Weight loss, muscle wasting
• Lymphadenopathy
• Peripheral neuropathy
• Xanthem rash, Candidiasis
• Neuro changes, mood, behavior, concentration, memory
• Fever, hairy leukoplakia, Apthous ulcers

• Symptoms
• Tight “band-like” or “vise-like” pressure, may persist for days, assoc. with anorexia

Pain typically bilateral, occipital, or frontal; non-throbbing

Pain builds gradually, slowly, fluctuates, and may persist for hours to days

• NO focal neurologic symptoms, NO N/V/photophobia, NO aggravation with
• movement

• Physical exam findings:
• Neuro exam is normal
• Possibly tightness of posterior neck muscles

• Symptoms
• Without Aura
• Pulsatile lateralized HA that’s worse with exercise
• N/V, anorexia, photophobia, blurred vision, phonophobia
• Multiple attacks, eventually resolving on their own

• With Aura
• Premonitory sensory, motor, or visual symptoms; visual is m.c.
• Scotomata and/or hallucinations in central visual fields fortification spectrum

May have focal neuro disturbances during HA usually resolving within 18 hours

Physical Exam Findings: none – there should not be any neurologic deficits

• Symptoms
• Polyuria, Polydipsia, Polyphagia with wt. loss assoc. with random plasma glucose > 200 mg/dL
• Blurred vision – due to elevated glucose
• Vulvovaginitis or pruritus (in women)
• Fatigue, weakness – due to K+ loss, muscle catabolism
• Paresthesia – from neurotoxicity of sustained hyperglycemia (resolve when glycemic levels return to nml)

• Signs/Physical Exam
• Decreased muscle mass and sub-q fat
• Dehydration, Postural Hypotension from low plasma volume
• Peripheral neuropathy
• Fruity breath-acetone of DKA

Symptoms: CF POW

• Chronic skin infections - pruritis/candida
• Fatigue
• Polyuria, polydipsia, polyphagia
• Polyuria, polydypsia, polyphagia
• Obese may be asymptomatic initially
• Weight loss

• Signs CHAND
• Central obesity (waist to hip ratios of >0.9 male, 0.8 in female); Change in visual acuity
• HTN may be present
• Atherosclerosis, dyslipidemia in the obese
• Neuropathy, cardiovascular complications
• Delivery of babies > 9lbs., polyhydramnios, preeclampsia

• Symptoms: MWF SHAWL CDCDM
• Malaise,
• Weakness,
• Fatigue

• Slow mentation
• HA
• Arthralgias/myalgias
• Weight gain
• Lethargy

• Cold intolerance
• DOE
• Constipation
• Depression
• Menorrhagia

SIGNS

• Thick tongue
• Anemia
• Thinning of lateral eyebrows
• Thin and brittle nails and hair, pallor
• Effusions into pleural/peritoneal/pericardial cavitty was well as joints
• delayed DTRs and brady cardia

• Goiter, puffy face and eyelids in myxedema
• Hard pitting edema, hypotonatremia, possible hypothermia
• Children: Cretinism

• Symptoms
• Feeding problems, floppy baby, macroglossia, hoarse cry, low hairline, inactive, failure to thrive

• Physical Findings
• Mental retardation, hypotonia, short stature, thick neck, protruding tongue

• Symptoms
• Nervousness, heat intolerance, sweating, fatigue, weakness, muscle cramps, dyspnea, loose stools (diarrhea), wt. loss despite increased appetite
• (due to increased metabolism), irreg. menses, decreased libido, palpitations

• Physical exam findings
• Stare, lid lag, proptosis, resting tremor, moist/diaphoretic skin, hyperreflexia, fine hair, palmar erythema,

• +/- thyroid enlargement with bruit, tachycardia, A-fib,
• exophthalmos, pre-tibial myxedema, dermopathy, (only in Grave’s dz = infiltrative ophthalmopathy)

• General Symptoms
• Fever, Fatigue, HA
• Productive cough (purulent sputum),
• Hemoptysis, Dyspnea, Chest discomfort, Pleurisy
• Sweats, chills, rigors (in first few hours)
• N/V, Abd. pain, Anorexia
• In elderly more atypical- loss of appetite, fever and fatigue

• General Signs: BARFED ICE
• (Breath sounds bronchial or tubular,
• Adventitious breath sounds,
• Respiratory excursion decreased,
• Fremitus [vocal] increased,
• Elevated temp/pulse/RR,
• Dullness to percussion,
• Ill and Cyanotic appearing,
• Elderly (decreased temp and appetite, fatigue)

• Pneumococcal signs and symptoms
• same as CAP
• Rusty colored sputum, Bronchial breath sounds,
• rigors w/in 1st few hours

• Haemophilus signs and symptoms: same as CAP
• Legionella signs and symptoms
• same as CAP
• Pleuritic chest pain and toxic appearance
• Delerium, Benign self-limited disease to multi-organ failure, ARDS

• Klebsiella signs and symptoms
• acute onset of CAP symptoms/signs
• Thick gelatinous sputum

• Mycoplasma signs and symptoms
• same as CAP
• Retrosternal CP
• Extrapulmonary symptoms BRANCHS
• Bullous myringitis,
• rash, renal failure
• arthritis/arthralgia,
• neuro. symptoms,
• cervical adenopathy
• hematologic abnormalities,
• strep pharyngitis

• General
• Excessive cough with sputum production
• Dyspnea -> initially only with heavy exertion; in severe dz happens with rest

• Emphysema predominant: MC WALNUT
• Major complaint severe dyspnea
• Cough rare with clear mucoid sputum

• Weight loss
• Accessory muscle use during respiration
• Lung exam quiet without adventitious breath sounds
• No peripheral edema
• Uncomfortable at rest
• Thin
• Bronchitis predominant (blue bloater): CHOMP
• Cyanotic, Comfortable at rest
• Hemoptysis
• Overweight
• Major complaint chronic cough
• Peripheral edema

• Productive mucopurulent sputum
• Chest noisy with rhonchi and wheezes
• Hemoptysis
• Dyspnea mild
• Frequent exacerbations from chest infections

• Symptoms
• Some pts have brief attacks and other have continuous symptoms
• Can be worse at night
• Episodic wheezing
• Difficulty breathing,
• Chest tightness, Cough
• Excess sputum production

• Signs: PRAWNH
• Prolonged forced expiratory phase (FEV1/FVC< 75%)
• Reduced breath sounds with prolonged expiration in severe episodes
• Allergic skin manifestations
• Wheezing during normal breathing or a prolonged forced expiratory phase indicate airflow obstruction
• Nasal mucosal swelling, secretions and polyps
• Hunched shoulders and accessory muscle use

PE normal between exacerbations

• Symptoms
• Asymptomatic for many years
• HA most common symptom
• Accelerated HTN > leads to somnolence, confusion, visual disturbances, N/V
• In Pheo > HTN in attack along with anxiety, palpitation, diaphoresis, HA, N/V, tremor
• In Addison’s à HTN with weakness, polyuria and nocturia due to hypokalemia

Signs

• Blood pressure ³140/90, based upon 3 or more BP readings taken at least 1 week apart
• Delay in LE pulses suggests coarctation of the aorta

• Heart
• Left ventricular heave indicates hypertrophy
• Aortic insufficiency found upon ascultation and US
• Presystolic S4 gallop due to decreased compliance of the LV

• Retina
• Copper or silver wiring, exudates, hemorrhages, papilledema



• CHRONIC STABLE ANGINA
• Symptoms: RADAR
• Radiates to the left jaw, neck, shoulder, and/or arm
• Activity precipitates it, its relieved with rest, typically lasts 15-20 min
• DOE, dizziness, palpitations
• Attacks >30 min suggest development of unstable angina or MI
• Angina discomfort = left-sided, squeezing, burning, pressing, aching or indigestion
• Relieved by nitro

• Signs: HALM
• HTN or hypotension à indicates more severe ischemia
• Atherosclerotic findings: xanthalamsa, decr. peripheral pulses, incr. BP or retinopathy from HTN, neuropathy of DM
• Levine sign (fist over mid chest)
• Mitral regurg from papillary muscle dysfunction
• S3 or S4 gallop

• UNSTABLE ANGINA
• Symptoms
• Left-sided CP with radiation to left jaw, neck, shoulder, arm
• Dyspnea, nausea, diphoresis, syncope, confusion dizziness, palpitations
• Symptoms rest or with minimal exertion
• More severe pain, arrhythmias
• Atypical presentation of no chest pain in females and diabetics
• UA may present as change in previously stable angina– i.e. more freq., occurs or with less exertion
• NSTEMI pain lasts > 20 min. and may or may not resolve with nitro

• Signs L SMASH
• Levine sign (fist over mid chest)

• S3 or S4 gallop
• Mitral regurg from papillary muscle dysfunction
• Atherosclerotic findings: xanthalamsa, decr. peripheral pulses, incr. BP or retinopathy from HTN, neuropathy of DM
• Signs of LV dysfunction: hypotension, weak distal pulse, basilar rales, S3 gallop
• Signs of RV dysfunction: hypotension, JVD, clear lung fields
• HTN or hypotension à indicates more severe ischemia

• Symptoms LMP COGNACS WDDD
• Left sided pain or tightness lasting > 30 min. with radiation to left neck, jaw, and arm

Little relief with nitro; pt tries to find position of comfort

Most infarctions occur at rest in early morning

Pain more severe than angina; pain builds rapidly and hits peak over a few mins. more

• Cough
• Orthopnea
• Generalized weakness
• N/V
• Anxiety
• Cold sweat
• Syncope

• Wheezing
• Dyspnea
• Dizziness
• Diaphoresis

Signs: MJ SHARK

• Mitral regurgitation suggests papillary muscle dysfunction or rupture
• JVD suggests R. sided HF

• S4; S3 with CHF
• HTN or hypotension (shock)
• Arrhythmias/Bradycardia
• Respiratory distress (wheezing, rales) and cyanosis indicate CHF
• Kussmaul sign with RV infarction

SYMPTOMS

• L-sided HF: SINN
• SOB (m.c.), DOE, orthopnea, PND
• Increased renal perfusion (in recumbent position), Nocturia
• Nonproductive or pink frothy cough (worse in recumbent position)

R-sided HF: HERNIA

• Hepatic congestion
• Edema,
• RUQ pain,
• Nausea,
• Impaired GI perfusion,
• Ascites
• anorexia,
• Acute exacerbations --> may be caused by changes in therapy, increased salt or fluid intake

SIGNS: SCHLEPP

Some pts comfortable, others dyspneic/tachypnic in conversation or minor activity

Cachexia or cyanosis in long stand CHF

Hypotension, cool extremities, and MS changes in severe CHF

Heart à S3 gallop, paradoxical splitting of S2, parasternal lift in pulm. HTN, enlarged PMI suggests hypertrophy

Lung exam à basilar rales, pleural effusions, expiratory wheezing and rhonchi

Pitting peripheral edema

Peripheral signs of HF detected in neck, lungs, heart, abdomen and extremities

Pressure on liver--> increased JVD; Ascites or liver enlargement