-
Osteoarthritis
- 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)
-
Osteoporosis
- 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
-
Disc herniation
- 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
-
Lumbar Strain/Sprain
- 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
-
Spinal Stenosis
- 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
-
Degenerative Dementia
- 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
-
Vascular Dementia
- 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
-
TIA
- 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
-
CVA
- 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
-
Depression
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
-
Hep A
- 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
-
Hep B
- 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
-
Hep C
- 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
-
Obesity
- 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
-
IDA
- 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)
-
Hemolytic Anemias
LOOK AT CHART IN BOOK
-
Thalassemia
- 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
-
AOM
- 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
-
COM
- Symptoms
- Conductive hearing loss
- Drainage
- Pain with acute exacerbations
- Signs
- Perforation of TM with purulent aural discharge
-
Serous OM
- 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
-
Acute sinusitis
- 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
-
Viral rhinitis
- 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
-
Strep pharyngitis
- 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.
-
Ulcerative colitis
- 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
-
Crohns
- 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)
-
PUD-Gastric
- 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
-
PUD: Duodenal
- 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
-
ARF
- 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
-
CRF
- 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
-
HIV/AIDS
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
-
Tension HA
- 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
-
Migraine
- 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
-
T1DM
- 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
-
T2DM
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
-
Hypothyroidism
- 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
-
Hyperthyroidism
- 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)
-
Pneumonia
- 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
-
COPD
- 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
-
Asthma
- 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
-
HTN
- 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
-
Angina (stable and unstable)
- 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
-
MI
- 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
-
CHF
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
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