Oral Boards Clinical Findings

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Oral Boards Clinical Findings
2011-07-10 14:49:43
Oral boards

oral boards
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  1. 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)
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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)
  16. Hemolytic Anemias
  17. 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


    • 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
  18. 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
  19. COM
    • Symptoms
    • Conductive hearing loss
    • Drainage
    • Pain with acute exacerbations

    • Signs
    • Perforation of TM with purulent aural discharge
  20. 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
  21. 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
  22. 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
  23. 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.
  24. 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
  25. 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)
  26. 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
  27. 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
  28. 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
  29. 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
  30. 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


    • Physical exam findings
    • Weight loss, muscle wasting
    • Lymphadenopathy
    • Peripheral neuropathy
    • Xanthem rash, Candidiasis
    • Neuro changes, mood, behavior, concentration, memory
    • Fever, hairy leukoplakia, Apthous ulcers
  31. 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
  32. 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
  33. 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
  34. 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
  35. Hypothyroidism
    • Symptoms: MWF SHAWL CDCDM
    • Malaise,
    • Weakness,
    • Fatigue

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

    • Cold intolerance
    • DOE
    • Constipation
    • Depression
    • Menorrhagia


    • 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
  36. 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)
  37. 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
  38. 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
  39. 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
  40. 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


    • 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

  41. Angina (stable and unstable)
    • 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

    • 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
  42. 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
  43. CHF

    • 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


    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