clin int exam #2

mental status changes can't miss

infxn: UTI, PNA, meningitis, sepsis hypoglycemia anion gap metabolic acidosis CVA/stroke SAH brain mass head trauma hypoxia wernicke encephalopathy seizure

dysuria

urosepsis, renal cancer, bladder cancer, penile cancer, endometriosis, PID, vaginal cancer, Behcets, reactive arthritis, neuro dz (MS, Parkinson's)

most common form of syncope

vasovagal

red eye ddx

No referral: Chalazion Hordeolum Blepharitis Pterygium Subconjunctival hemorrhage Conjunctivitis Viral Bacterial Allergic FB/abrasion Episcleritis Referral: Scleritis Uveitis Acute angle closure glaucoma Endophalmitis Keratitis Extraocular causes Periorbital cellulitis Orbital cellulitis

spirometry positive response

. A positive response is considered an increase of 12% as compared to the patient's baseline FEV1 or forced vital capacity (FVC) and is suggestive of asthma.

causes of jaundice 4 main categories

1. impaired bili metabolism (excess production, impaired metabolism, impaired conjugation) 2. impaired secretion of bile 3. liver disease 4. obstruction of bile ducts

4 forces causing edema

1. pressure in vessels override semiperm membrane pushing volume into extravasc space 2. lymphatic drainage obstructed 3. capillary mem perm increased 4. blood protein concentration decreased

hearing loss ddx

Conductive causes: Cerumen Otitis externa Trauma SCC (tumor) Psoriasis Chronic OM Otosclerosis Cholesteatoma Barotrauma TM perforation Sensorineural causes (MC) Presbycusis Noise induced Acoustic neuroma Menieres disease Meningitis Ototoxic meds MS/ other autoimmune Cerebrovascular disease Sudden sensorineural hearing loss Syphilis

A 20-year-old woman presents with recurrent, unilateral leg swelling. She has had multiple ultrasound examinations, all of which have been negative for deep vein thrombosis. Which of the following distributions of edema would be most consistent with a diagnosis of May-Thurner syndrome! A. Left leg B. Right leg not been to a primary care provider for some time but was recently seen at a community health tair and was told his cholesterol was "very high." Question: What is the most likely diagnosis? A. Congestive heart failure B. Diuretic-induced edema C. Nephrotic syndrome D. Hypothyroidism C. Legs only D. Arms and legs E. Arms only

A

A 45-vear-old woman presents to vour office with a 3-dav Distory ole ca Damn which is constant anc by activity. She has tried heat and acetaminophen, but nei- Question: What is the most likely diagnosis? A. deep venous thrombosis B.Intermittent claudication C. Muscle strain D. ruptured cyst

A

normal temperature

98.6 or 98.2+-0.4

A 45-year-old obese man was brought to your primary care clinic by a coworker who tound the patient contused in the office earlier that day. The patient acknowledged feeling unwell for the past several days, with low-grade fevers and chills, nausea, and right upper quadrant abdominal pain. He also reports a "yellow tinge" to his skin. He has no other past medical history, takes no medications or herbal supplements, is not sexually active, and denies alcohol or illicit drug use. On examination. he is found to have a blood pressure of 90/50 mm Hg and a temperature of 101.7°F and is tender to palpation in the right upper quadrant of his abdomen. What is this patient's presentation most consistent with? A. Ascending cholangitis B. Acute viral hepatitis C C. Nonalcoholic fatty liver disease D. Hepatic congestion from right-sided heart failure E. Chronic viral hepatitis B

A

A 56-year-old man presents to the emergency department (ED) with a complaint of chest pain that began 60 minutes earlier and has not resolved. He states he has never had a heart attack before. He is a current smoker and has smoked 1 pack per day for 30 years. He has been having intermittent episodes of chest pain off and on for the last 4 months, but today was the first time that the chest pain persisted prompting him to visit the ED. ADDITIONAL HISTORY The patient initially noticed the chest pain a few months ago while walking or climbing stairs. These episodes would resolve a few minutes after stopping and resting. In the last month, he has noticed that less effort would bring on the pain and has even noticed it while sitting watching televi-sion. Today, he awoke from sleep with chest pain that did not go away and so he came to the ED. Today's pain is a diffuse precordial burning and pressure that radiates to both

A

A 65-year-old man with a prior myocardial infarction presents tc your office with intermittent chest pain for the last 10 days. The pain is diffuse and precordial, increases with inspiration or lying down, and is relieved by sitting up and leaning forward. Some- times the pain can last for hours at a time. It is somewhat ditterent from his prior heart attack pain, but bothers him nonetheless and can bring on a sensation of shortness of breath when it is severe Three weeks ago, he had what felt like the flu, but this resolved after a few days. The pain is not clearly related to exertion. What is the most likely diagnosis? A. Pericarditis B. Unstable angina C. Musculoskeletal chest pain D. Pulmonary embolism

A

A previously healthy 45-vear-old man went home from work after lunch with fatigue and nausea. Shortly thereatter, he developed severe vomiting. Which of the following is not an alarm symptom that merits possible hospitalization? A. Diarrhea B. Lip numbness C. Abdominal pain accentuated by jolting movements D. Large- volume hematemesis E Contusion

A

An otherwise healthy 36-year-old woman comes to your office because of constipation for 2 years. Although she has a bowel movement every day, she has to strain for several minutes to pass stool. She admits with embarrassment that she occasionally has to insert her fingers in her vagina and push posteriorly in order to evacuate the stoo. Her stools when hinally passed, are sometimes soft. She says over-the-counter laxatives "ust don't seem to do much." When she has tried enemas in the past. they have "staved inside" and have been ditticult to evacuate Which of the following questions would be most important to ask? A. Obstetric history B. Depression screen C. Medication list D. History of weight gain

A

You see a 28-year-old woman with recurrent episodes of facial swelling and edema involving her arms and legs. Despite an extensive dietarv history. the episodes appear to be unrelated to any food ingestion. She denies skin abnormali-ties, joint pain, muscle tenderness, dyspnea, or orthopnea. Her past medical history includes mitral valve prolapse and hypertension, for which she takes a diuretic. Her mother had sImmIlar symptoms as a teenager. Which of the following is the most appropriate next diagnostic test? A. C4 (complement) levels B. Antinuclear antibody (ANA) level C. Echocardiogram D. Invroid tunction tests

A

abdominal pain can't miss

AAA adrenal insufficiency aortic dissection appendicitis bowel obstruction diverticulitis endometriosis intussusception volvulus strangulated/incarc hernia hypercalcemia IBD intestinal ischemia MI upper/lower UTI kidney stone pyelonephritis pancreatitis glomerulonephritis ovarian (adnexal) torsion pregnancy/ectopic/abortion PID DKA parathyroid crisis trauma hepatitis splenic rupture wilms tumor malignancy primary sclerosing biliary (cholangitis, cholecystitis, ...)

A 48-year-old man who has been your patient for 14 years and is in good general health reports continued episodes of rectal pain that last a few seconds and then disappear completely. The pain seems to be worse with sitting than with standing or lying down. Which of the following symptoms suggests a diagnosis of proctalgia fugax? A.Anorecta vain associated with dvsuria and urinarv urgency B. Sudden, brief paroxysms of pain C. Bright red blood per rectum D. Intermittent anal discharge

B

scrotal pain ddx

Acute: Testicular torsion epididymitis/orchitis Testicular appendage torsion Prostatitis Testicular rupture Hematoma Fourniers gangrene Stragulated inguinal hernia HSP Scrotal abscess Urolithiasis Appendicitis AAA Constipation Non-acute: Varicocele Hydrocele Epidydimal cyst/spermatocele Inguinal hernia Testicular cancer Epididymitis Retroperitoneal tumor Neurogenic causes Idiopathic scrotal pain

A 5-year-old boy is brought in to the office by his mother because of 2 days of right ear pain. The mother reports that he has been crying and pulling on the ear. He has a temperature of 39.7°C. What is the most likely diagnosis? A. Otitis externa B. Otitis media C. Foreign body in the ear D. Malignant otitis externa

B

A 23-year-old woman presents to an urgent care center with a swollen, paintul right knee. The patient was playing soccer and ran into another paver. causing her to twist and fall immediate swelling of her knee. What is the most likely diaenosis? A.fracture B.ligamentous tear C.meniscal tear D. septic joint

B

A 24-year-old man with no past medical or surgical history presents to the emergency department with abdominal pain and fever of 101 F. Six hours ago, he felt nauseated and began to notice a vague periumbilical pain that is now severe (10/10), constant, and sharp, and has migrated to the right lower quadrant. On physical examination, he is febrile and restless. and he is tender in the right lower guadrant. What is the most likely diagnosis! A. Testicular torsion B. Appendicitis C. Ischemic colitis D. Pancreatitis F. Smallbowel obstruction

B

A 25-year-old woman is found wandering in the street, confused and unable to answer questions. Her roommate reports that for the last 2 or 3 days, she has become progressively more confused. She has had some fever and has had 2 or 3 episodes where she seemed to "blank out" for about a minute. Which of the following symptoms would be most concerning for meningitis or encephalitis? A. Blurred vision B. Fever C. Neglect of the left side of space D. A history of seizures

B

A 37-year-old woman comes to your clinic for"constipation," which she has had since childhood. She states that a work-up by her pediatrician turned up nothing. She reports in-termittent, crampy abdominal pain that reaches 8 out of 10 in severity and is relieved "mostly" by a bowel movement. She has a bowel movement nearly every day, but her stools are usually hard. When the pain occurs, her stools are "really hard." She was recently laid off from her job and has noted an increase in her abdominal pain and hard stools. A. Inflammatory bowel disease B. Constipation-predominant irritable bowel syndrome C. Slow transit constipation D. Defecatory disorder

B

A 45-year-old man comes to your office with a 2-week history of left ear pain. The ear pain began shortly after an upper respiratory infection. He describes the pain as "a pressure" and also notes "crackling" in the ear. The patient reports that he cannot hear well with his left ear; he describes sounds as being "muffled" on the left but normal on the right. He has had no fever and feels well, apart from being frustrated by his ear problem. He tried a decongestant that helped. A. Acute otitis media B. Serous otitis C. TMJ dysfunction D. Temporal arteritis

B

A 60-year-old gentleman presents to you with a 3-day history of constant perianal pain and bright red blood seen in the tollet bowl. his mornin. he noticed a sma swollen mass at his anus when washing in the shower. He experienced a similar episode of pain and bleeding several months ago, which he attributed to hemorrhoids, but his symptoms today are far more severe ADDITIONAL HISTORY The patient is otherwise healthy and has no history of a serious medical condition such as Crohn's disease or cancer. He has been in a monogamous relationship with his wife for almost 40 years and has never had a sexually transmitted infection. He describes his current pain as excruciating and constant throughout the day. He estimates the amount of blood in the toilet bowl to be about 1 tablespoon. He has not had anv other drainage trom the area and denies anv recent fevers or chills. Upon further questioning, he endorses chronic constip

B

A 60-year-old man sees you with concerns about hearing loss. On further questioning, he cannot remember an acute onset of hearing loss and believes it has been gradual over time. Which of the following features would make you the most concerned for acoustic neuroma? A.l Fever B. Unilateral hearing loss C. Rapidly progressive hearing loss D. Fluctuating hearing loss E. Itchy ears

B

A 67-year-old man with type 2 diabetes presents to your primary care practice following 3 weeks and vomiting. His wife insisted he se skin and eyes are yellow. He has not ooser. out he has no other complaints. take herbal supplements, has never received a blood trans- 0 c3 vIe yarn vI cyaicue wany luI uver ow years. vi vlysica examination, he is not cachectic, but the sclerae are icteric and his skin is visibly jaundiced. No palpable masses or ten- ADDITIONAL HISTORY derness are present on abdominal examination. On further questioning, he denies fevers, chills, and abdominal pain. He reports moderate anorexia and states that his urine is dark and his stools are becoming lighter in color. There have been no outbreaks of food-borne illnesses where he lives, and he has not traveled outside of the United States recently. He has a history of heavy alcohol use in the past but quit 15 years ago. His only medication is metfo

B

A 70-year-old man lives with his daughter. She is awakened one night and has him wandering in the kitchen with the pots in disarray. He cannot explain clearly what he is do ing. and she is worried because this is a dramatic change for him. She takes him to see you for immediate evaluation ADDITIONAL HISTORY On focused questioning, the daughter reports that the pa- tient hASTAIeR ACCASIONAIN OVer ThAASOw WAAKS HAMAS been more confused over the last few days and has had a lew episodes of urinary incontinence. Although he has had some memory problems for a year or 2, he has been unable to dress himself or to tend to hygiene only in the las ew davs. He nas aso nag some neadaches over rhe last few days. He has not had any fever or any change in Question: What is the most likely diagnosis? A. Meningitis B.Subdural hematoma from trauma C.Unwitnessed selzure with postictal confusion D. STOKe

B

A 75-year-old man presents to your office for a routine office visit. During the visit, you inquire about hearing loss. He wasn't planning on discussing this but reports that he has trouble understating the television or when someone speaks in a whisper; his family is concerned that he doesn't hear as well as he used to. He hasn't been attending social events or family gatherings recently because he feels embarrassed having to ask people to repeat words or phrases. what was his dx? A. menieres disease B. presbycusis C. acoustic neuroma D. MS

B

Mrs. Jones, a 23-year-old GIPO woman, sees you at 30 weeks of gestation because of severe pain with defecation. Pain occurs with howe movements. and she has noted blood on the toilet paper. Which of the following is the most helpful when distinguishing between an anal fissure and a thrombosed external hemorrhold: A.The color of the blood B. tender lump C. Pain that wakes the patient up at night .D. Constitutiona svmotoms

B

You see a 45-year-old male construction worker for a periodic health examination. On review of symptoms, he reports subjective hearing loss. Concerned about noise-induced hearing loss, you assess for modifying symptoms. Which sounds or situation would you expect the patient to be LEAST likely to have difficulty with? A. High-pitched sounds B. Low-pitched sounds C. With background noise D. TV or radio E. A conversation in a group of people rather than one-on-one

B

dyspepsia ddx

Benign: Functional dyspepsia PUD GERD Esophagitis gastritis/duodenitis Biliary tract disease Gastroparesis IBS Pancreatitis Meds Celiac disease Lactose intolerance Metabolic disturbances (thyroid) Serious causes: Cancer duodenal/gastric ulcer Infiltrative disease of the stomach (crohns) Ischemic colitis Hepatoma Pancreatic cancer Ischemic heart disease

A 20-year-old college student presents to student health clinic with a davs of revers. runny nose. sore throat. and malaise She has no abdominal pain, nausea, or vomiting, and she denies taking any medications, alcohol, supplements, or illicit drugs. On examination. she has a temperature of 100.3°F. She has pharyngeal erythema without exudates, and there is mild bilateral anterior cervical lymphadenopathy. Her sclerae are icteric and her abdomen is nontender without hepatospleno-megaly. On further questioning, she recalls having similar episodes of her eyes turning yellow when she was sick ever since she was a child; in those instances, her eye color always returned to normal once her illness resolved What is the most likely diagnosis? A. Biliary colic B. Acute intermittent porphyria C. Gilbert syndrome D. Cirrhosis E. Hemochromatosis

C

A 22-year-old college student who is on the swim team reports 1 week of left ear pain. She noted a slightly yellow, watery discharge from the ear on her pillow this morning, which prompted her to make an appointment. She has no fever and mentions that the pain is worse when she pushes on the tragus.What is the most likely diagnosis? A. Perforated eardrum from otitis media B. Temporomandibular joint dysfunction C. Otitis externa D. Infected upper third molar tooth

C

A 35-year-old male consultant tells you of several months of bilateral ear discomfort that is more pronounced on the left than the right. The pain is worse in the morning and worse when he chews. He has been working long hours recently to meet a deadline. What is the most likely diagnosis? A. Serous otitis B. Temporal arteritis C. Temporomandibular joint dysfunction A. Referred pain from tight neck muscles

C

A 48-year-old healthy obese woman comes to your clinic with a 1-day history of nonradiating epigastric burning pain that started 2 hours after eating lunch. which she rates as a 4 on 10-point pain scale. She describes similar pains in the past few months but never as severe. The pain is worse when lying flat in bed at night and has been relieved in the past by antacids. She denies fevers, weight loss, changes in her bowel movements, or radiation to her back. Physical examination demonstrates normal vital signs and is onlv notable for mild epigastic tenderness Which of the following disorders do you suspect? A. Cholecystitis B. Pancreatitis C. Peptic ulcer disease D. Aortic dissection E. Celiac sprue

C

A 54-year-old man comes to your office because of worsening "leg swelling."The swelling began 3 months ago and has steadily increased since that time. He also notes polyuria and generalized fatigue. A; CHF B;diuretic induced edema C;nephrotic syndrome D;hypothyroidism

C

A 55-year-old obese woman with diabetes mellitus and hypertriglyceridemia visits you for routine follow-up. On examination, the patient is febrile and has normal vital signs but has scleral icterus. Her skin is normal, and the abdomen is obese with mild hepatomegalv but no tenderness. Which of the following disorders do you suspect? A. Acute cholecy saus B. Carotenemia C.Nonalcoholic fatty liver disease D.HELLE syndrome E. Acute viral hepatitis

C

A 60-year-old male smoker was brought to the ED after passing out while standing up. He regained consciousness a tew minutes later but oftered complaints of chest vain and dyspnea. The chest pain is right-sided and sharp and worsens with inspiration and cough. His cough is mildly productive and at times blood-tinged. On further questioning, he had felt generally well prior to this episode, although he had knee surgery 6 weeks ago. What is the most important diagnostic consideration? A. Pericarditis B. Pneumonia C. Pulmonary embolism D. Myocardial infarction F Pneumothorax

C

A 65-year-old retired male bricklayer presents with bilateral anterior knee pain that has worsened over the past month. He reports intermittent knee pain for the past 5 years. He denies swelling. warmth. fever. or ervthema. There is no history of trauma. The pain worsens with climbing stairs and when standing from a seated position what is his dx? A. ligament tear B.patellar fracture C.patellofemoral syndrome D.septic joint

C

A 67-year-old man comes to your office for constipation. He says. , "I just don't get it, Doc. I've been as regular as a clock all my life, but for the last few weeks, I've been getting more and more bound up." He relates increasing abdominal pain nausea, loss of appetite, and an Il-Ibs weight loss. He has noted some blood on the toilet tissue and in his stools Which of the following is the most likely diagnosis? A. Hiypothvroidism B. Depression c. Colon cancer D. Diverticulitis E. Spinal cord process H Stricture

C

An 80-year-old man is brought to see you for the sudden onset of confusion earlier today. On questioning, the caregiver mentions that he has had some memory symptoms for a number of months but that "this is different." He has had some difficulty sleeping, and the caregiver thinks he might have taken medication for this. The caregiver has not noticed any weakness or jerking movements but is unsure as to whether he has had a fever. Which of the following features, if present, would be an alarm symptom in him? A. Disorientation to the location or time B. Having word-finding trouble and making up new words C. Having pain with neck movement D. Having periodic jerking movements in the arms and legs

C

Ms. Valenti is a 33-year-old patient of yours without significant medical history. She scheduled an urgent care visit to discuss hearing loss and a sensation of pressure in her ear that began 2 days ago. After further questioning, you are concerned for possible sudden sensorineural hearing loss. Which of the following symptoms is NOT usually associated with SSNHL? A. Tinnitus B. Vertigo C. Fever D. Unilateral hearing loss E. Rapidly progressive hearing loss

C

Your patient, a 77-year-old gentleman with a smoking history of 100 pack-years, presents with several months of dull rectal pain and tenesmus. This has been associated with blood in the stool and recently with signincant consupaton. Which of the following additional symptoms is most concerning for rectal cancer? A. Sharp, stabbing pain with defecation B. Vesicles in the perianal region C. Weight loss D. Recurrent respirator intections

C

chest pain can't miss

CP w/ syncope - arrhythmia, pericardial tamponade aortic dissection PE MI spontaneous PNTX PNA

inflammatory dermatoses ddx

Cant miss DRESS GVHD Erythrodermic psoriasis SLE Dermatomyositis SJS/TEN HSV Zoster Gonococcal Rocky mountain Ecthyma gangernosum TSS Necrotizing fasciitis Urticaria

cough ddx

Chronic allergic rhinitis Post nasal drip Asthma GERD COPD/bronchitis Bronchiectasis Lung cancer Meds (ace/BB) Idiopathic Red flag symptoms: hemoptysis (cancer, TB), fever/sputum (pneumonia, abscess), chest pain (PE)

2. A 55-vear-old overweight woman presents to clinic with nausea, vomiting, and abdominal pain. She had no prior gastrointestinal symptoms until about 10 hours ago when she developed increasingly severe upper abdominal discomfort, followed ov nausea and nonblood emesis and sublective fever and chills, but no jaundice. Which of the following can best establish or exclude a diagnosis of acute cholecystitis? A. Physical examination showing right upper quadrant tenderness with inspiratory arrest (Murphy sign) Chapter 38 Nausea and Vomiting 395 B. Liver chemistry panel (aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase, total and direct bilirubin, albumin) C. Complete blood count D. Right upper abdominal ultrasonography B. No further testing needed

D

A 33-year-old overweight woman presents with recurrent nausea and vomiting. For about 20 years, she has had a near continuous sense of nausea with episodes of nonbloody vomiting. She has no abdominal pain and cannot establish a pattern to the vomiting. Treatment with antiemetics and proton pump inhibitors is not helpful. She brings a large stack of outside medical records documenting repeatedly normal endoscopic, pathologic. and radiologic evaluations Which of the following is most likely to yield a diagnostic and therapeutic benent to this patient. A. Referral for esophagogastroduodenoscopy B. Helicobacter pylori antibody testing C. Computed tomography scan of the abdomen and pelvis D. Detailed psychosocial history with attention to possible trauma 20 years ago E. Upper gastrointestinal radiographic series

D

A 62-year-old man with a history of hyperlipidemia, hyper-tension, and coronary artery disease presents to your primary care practice with abdominal pain for 6 months. His pain gets worse after eating meals ADDITIONAL HISTORY The patient characterizes his pain as dull and crampy and rates it as a 5 on a 10-point pain scale. His pain is nonra-diating and is localized to the epigastric and periumbilical areas. The pain worsens about an hour after each meal and gets better after vomiting. All foods tend to trigger his pain. He denies blood or bile in his emesis. Since the onset of his pain, he has lost 20 lbs. He denies fever, chills, or blood, mucus, or fat in his stool. He denies heartburn or previous abdominal surgeries. He is a school teacher who stopped smoking 10 years ago and drinks alcohol socially. He does not use illicit drugs, and he has no family history of heart disease, diabetes, or malignancy. His medicat

D

A 62-year-old man with hypertension presents with edema for 1 month in both lower extremities, extending from the ankles to mid-shins. He denies dyspnea, abdominal swelling, fatigue, weakness, or changes in exercise tolerance. He reports con supation but no alarrned and no urinary symptoms. ris only medication is amlodipine Which of the following is the most appropriate diagnostic step? A. Liver enzymes and coagulation studies B. Echocardiogram C. invroid tunction tests D. Discontinue amlodipine

D

You see a 55-year-old woman in the office who reports intermittent chest pain for the last 3 months. She has continued to work as a medical coder but has stopped exercising since she noticed these pains. Which of the following features would suggest that her chest pain is not related to myocardial ischemia? A. Relationship to effort B. Squeezing quality C. Association with dyspnea D. Pain is shard and increases with insuiration

D

knee pain can't miss

DVT -> PE cellulitis

mild persistent asthma treatment

Daily low dose inhaled glucocorticoid with short-acting beta-antagonists (SABA) as needed.

A 30-vear-old alcoholic man with no past medical or surgical history is brought in by ambulance to the ED with severe (7/10) epigastric abdominal pain. The pain started 5 hours after the ingestion of a large meal. It radiates to the back and is associated with nausea and nonbloody, nonbilious emesis. He denies any problems or pain with urinating. On physical examination, he is febrile, tachycardic, and tender without rebound in the epigastrium and left upper quadrant What is the most likely diagnosis? A.Peptic ulcer disease B. Cholecystitis C. appendicitis D. Nephrolithiasis E. Pancreatitis

E

ear pain ddx

Internal Otitis media Eustachian tube dysfunction (serous otitis) Barotrauma External Otitis externa FB Furuncle Mastoiditis Referred Dental (3rd molar) TMJ Cervical spine Neuralgia Tumor 4 serious dx: malignancy, malignant external otitis (necrotizing), temporal arteritis, mastoiditis

fever ddx

Infection: Bacterial Viral Parasitic Fungal Rickettsial Malignancy Lymphoma Leukemia Hepatocellular Renal cell Pancreatic Inflammatory SLE rheumatic fever GCA Wegener's RA Polyarteritis nodosa IBD Gout Other PE Drug fever Factitious fever Sarcoidosis Adrenal insufficiency Hyperthyroidism Pancreatitis Cant miss: CNS infection, NMS, heat stroke, meningitis, septic shock, rickettsial disease, bacterial endocarditis, encephalitis, adrenal insufficiency, PE, pneumonia

sore throat ddx

Infectious: GAS (and other bacterial causes) Viral pharyngitis (rhinovirus, parainfluenza) Herpetic stomatitis Epiglottitis Gonococcal Mononucleosis Abscess Lemierre syndrome Ludwigs angina HIV Candidiasis Influenza Diphtheria Herpangina Syphilis secondary TSS Non-infectious Sinusitis Allergic rhinitis Thyroiditis cancer/lymphoma GERD Systemic Stills disease Wegners granulomatosis Sarcoidosis

normal bilirubin level VERSUS jaundice detectable bili level

NL < 1.5 jaundice > 2

anion gap calculation

Na - (Cl + HCO3)

dysphagia ddx

Neuromuscular: Stroke Cerebral palsy MS Myasthenia gravis Amyotrophic lateral sclerosis Parkinsons disease Myopathies Dermatomyositis Huntington's chorea Structural: Zenker diverticulum Tumors Cervical spondylosis Vertebral osteophytes Pharyngeal webs Iatrogenic causes: Radiation therapy Corrosive pill injury Anticholinergics Motor disorders: Achalasia Diffuse esophageal spasm Nutcracker esophagus Scleroderma Sjogren syndrome Muscular dystrophies Mechanical: Tumors Strictures Schatski ring Esophageal webs Eosinophilic esophagitis FB Left atrial enlargement Infectious: Candidal esophagitis herpes esophagitis CMV

vaginitis

PID, TSS, erythema multiforme, UTI, malignancy (vulvar, vaginal, cervical), FB, rectovaginal fistula

dyspnea

PNTX, PE, PNA, anaphylaxis/angioedema, MI, cardiogenic pulm edema, ARDS, epiglottitis, Guillain-Barre, myasthenia gravis, DKA, aspirin OD, carcinoid tumor

headache ddx

Primary: Tension Migraine w or w/out aura Cluster Benign exertional Chronic daily HA Secondary: Viral syndrome Medication induced TMJ Sinusitis Cervicogenic Cant miss: GCA, brain tumor/met, stroke, subarachnoid hemorrhage, AV malformation

erectile dysfunction ddx

Psychogenic Vascular Drug induced Hormonal/DM Neurogenic urologic/renal Sleep disorder

syncope

Structural cardiovascular disease - ACS, hypertrophic cardiomyopathy, aortic dissection... Arrhythmias - tachy, brady, heart block Pulm HTN PE Major volume loss Vertebrobasilar transient ischemic attack Severe autonomic insufficiency

tinnitus ddx

Subjective (MC): Cochlear origin CNS Conductive causes Vascular causes Objective: Pulsatile Tumors (acoustic neuroma) Cerumen Clonic muscular contractions Carotid narrowing Cant miss: menieres disease, tumor, venous stenosis, otosclerosis, toxins, MS, stroke, GCA

routine mammo screening

ages 40-49 based on individual ages 50-74 routine every 2 years

urinary incontinence ddx

Urge: Overactive bladder Prostatic hypertrophy Bladder or urethral irritation (UTI) Stress: Weakness of pelvic floor Incompetent sphincter Overflow: Bladder outlet obstruction Ineffective detrusor contractions Functional: Environmental Sedation Diuretics Metabolic disorders Psych disorders Immobility Detrusor inhibition CNS disorders Can't miss: UTI, stroke, severe retention, hemorrhagic cystitis, fistula, IBD, pelvic floor prolapse

pelvic pain

acute PID, ectopic pregnancy, adnexal torsion, appendicitis, endometrial cancer

posterior knee pain ddx

baker cyst hamstring pain DVT

nausea/vomiting can't miss

bowel obstruction appendicitis pyelonephritis pregnancy ovarian torsion head trauma brain mass meningitis hyperemesis gravidarum AFL of preg MI upper GI bleed - mallory weiss, peptic ulcer, varices peritonitis hypovolemia - electrolyte imbalance food-borne toxins - botulism, ...

most common kidney stones

calcium oxalate

hemoptysis

cancer, infection (lung abscess, PNA, TB, fungal, alveolar hemorrhage syndrome)

what type of syncope is induced by being in the supine position?

cardiac syncope

dizziness

cerebrovascular dz, arrhythmia, brain tumor

jaundice can't miss

cholangitis gallstone dz acute hepatitis sepsis budd-chiari right sided heart failure hepatic encephalopathy seizure hypoglycemia hypersplenism DIC hemolysis hyperemesis gravidarum AFL of pregnancy eeclampsia HELLP syndrome malignancy (pancreatic or hepatobiliary)

anorectal pain can't miss

colon cancer intraperitoneal infection IBD perirectal/pelvic abscess

constipation can't miss

colorectal ca spinal cord tumors/trauma bowel obstruction/ileus strictures diverticulitis pancreatitis pregnancy/ectopic ovarian ca PID UTI appendicitis

abnormal bleeding

ectopic preg, GYN cancer, severe bleeding diathesis, vaginal hemorrhage

may thurner disease

edema resulting from compression of the left iliac vein as it crosses under the aorta

nephrotic syndrome triad

edema, hypercoagulability, hypercholesterolemia

starling law

fluid flow across membrane edema = K[(P in - P out) - (Onc in - Onc out)] K = vessel permeability P in = intravascular hydrostatic pressure P out = interstitial hydrostatic pressure Onc in = intravascular oncotic pressure Onc out = interstitial oncotic pressure

reynolds pentad

for ascending cholangitis: jaundice, abdominal pain, fever, hypotension, mental status changes

leg/foot swelling & pain can't miss

fracture cellulitis osteomyelitis DVT vasculitis aortic dissection arterial thrombosis hemorrhage compartment syndrome

edema can't miss

ischemic heart disease; CHF DVT -> PE anaphylaxis malignancy liver failure

hematuria

malignancy (RCC), chronic infection (UTI, STI), ureteral calculus, cyst rupture, renal infarct, glomerulonephritis, Wegeners, goodpasture, bleeding disorder

breast complaints

mastitis, abscess, breast cancer

lateral knee pain ddx

meniscal tear IT band syndrome fib head fx

medial knee pain ddx

meniscal tear anserine bursitis

anterior knee pain ddx

patellar fx patellofemoral syndrome prepatellar bursitis patellar tendinitis

risk factors for confusion in hospitalized pts

physical restraints malnutrition >3 meds added bladder catheter any iatrogenic event

amenorrhea

pregnancy, pituitary tumor, anorexia

which is higher, rectal or oral temp?

rectal is 1 degree higher

flank pain

sepsis, cholecystitis, PNA, AAA, hemorrhage, PE, pancreatitis, malignancy, endocarditis w/ septic emboli, bowel obstruction, nephrolithiasis, renal infarct

which type of diabetes is most at risk for DKA

type 1 because of complete lack in insulin production

fever and rash ddx

viral Measles (rubeola) Varicella Cytomegalovirus Mono Rubella (german measles) Roseola Parvovirus B19 HFM Herpangina Pityriasis rosacea Covid bacterial Scarlett fever Ritters disease TSS Meningococcemia Multiple etiology Uritcaria Erythema multiforme HSP Other Kawaskai hypersensitivity/drug reaction Tick borne illness Rocky mountain spotted fever Ehrlichiosis Dengue fever Zika virus

classifications of asthma

· Intermittent: symptoms occur fewer than 2 days a week, attacks do not interfere with daily activities, nighttime symptoms occur <2 days per month, lung function tests (not during an asthma attack) are 80% or more of expected. · Mild persistent: symptoms occur >2 days per week, attacks interfere with daily activities, nighttime symptoms occur three or four times per month, lung function tests (not during an asthma attack) are 80% or more of expected. · Moderate persistent: symptoms occur daily, attacks interfere with daily activities, nighttime symptoms occur more than one time per week, lung function tests (not during an asthma attack) >60% but <80% of expected. · Severe persistent: symptoms occur throughout every day, attacks interfere with daily activities, nighttime symptoms at least weekly but possibly nightly, lung function tests (not during an asthma attack) are 60% or less of expected.