What are the descriptions of Cardiac & Non-Cardiac chest pain?
Cardiac: Diffuse, Substernal, radiate to left arm or jaw, exertion, 10-30 min
Non Cardiac: Brief-continuos, localized, non-radiating (dermatome), reproducible (neuromuscular), organ referal not reproducible
What are the findings associated with non-cardiac chest pain in relation to the skin?
-Mondor's syndrome (thrombosis of superficial vein)
-Herpes Zoster (varicella virus in DRG, dermatome pattern, vesicles)
What are the findings associated with muscular non-cardiac chest pain?
Strain: contract/stretch, pecs, intercostals, serratus anterior
Trigger point: reference point of pain for one muscle, pain at end-range stretch
For non cardiac chest pain, what are the ribs findings?
Fracture: posterolateral most common, compression pain, oblique xray
Tietze's syndrome: unilateral pain, costochondral junction of upper rib, older females smoke
Slipped rib or rib subluxation
What is the finding for non-cardiac chest pain that is referred?
- Thoraci facet
- C-spine OA
- Pleural: hx of URI, local unilateral pain, chest film & recumbent for fluid level
- Esophageal spasm: mimics angina, hot + cold food rxn, responds to nitro (smooth mm. relax)
What are some things that can benefit tx of rib fx?
- Rest & decrease cough, sneezing
- Stay mobile
- Slow full breaths to decrease scar tissue form....
What would be a tx for Tietzes syndrome?
What are the findings for stable angina?
- - < 10 min
- -Rest & nitro good
- - ST depression on EKG
- - Negative enzymes
- - Due to athero
What are findings for Unstable & Prinzmetal angina?
- -Occurs @ rest
- - > 10 min
- - Nitro usually helps
- - ST depression or elevation
- - Unstable due to athero
- - Prinzmetal due to vasospasm
What are some findings and descriptions of manual therapy for Stable Angina?
- - Randomized prospective study
- - 275 ptnts referred for coronary angiography were divided into cervicothoracic angina positive or negative
- - 75% of the CTA positive reported improvements in pain and general health whereas 22%-25 of negative groups reposrted improvement
- - Pain intensity improved in both groups
- - SF-36 changes only found in CTA positive group
What are the findings and details associated with Palpitations?
- - Patients report: heart beats loud, feel heart skip beat, heart racing
- - Determine frequency
- -Situational occurance
- - Use of medications
- - Whetther tachycardia is abrupt in onset
- - How often hear a loud heartbeat?
- - Confirmation= EKG
- - * Halter monitor--> monitor ptnt over 24 hours
What are findings asssociated with Tachycardia?
- - Atrial source may respond to a vagal stimulation
- - Evaluate patient for associated murmurs
- -Resting and stress ECG
- - Echocardiogram for suspected MVP
What are the sx/s of difficulty breathing (Dyspnea)?
- -Difficulty due to pain on full inspiration: direct trauma, muscle strain
- - More of a sense of tightness or pressure: radiation into arm or jaw, headaches, dizziness, joint pains
- - with exertion?
- - POsition related?
What are the respiratory S/Sx ?
- - Cough common with many resp.
- - Chronic non-productive cough in 75% of cases:
- `post nasal drip
- `chronic bronchitis
- `hyperactive airway disease
- ` GI reflux
- - Sputum = non specific indicator
- - Wheezes indicate obstruction (narrowed airway)
What are the Obstructive respiratory disorders?
- - Exhalation most effected
- - Obstruction due to mucus or bronchial constriction
- - Decrease in FEV1
- - Increased residual volume
- - Wheezes and rhonci
- - Asthma, chronic bronchitis, emphysema, and bronchiectasis
What are the restrictive respiratory disorders?
- - Effects all aspects or respiration
- - Sources are pulmonary & extra including: neuromuscular, skeletal deformity, pleural
- - Rales are more prevalent
What are the Blue Bloater clinical appearance of COPD?
- - Centrilobular
- - Blockage of distal bronchioles
- - Decreased CNS sensitivity to CO2= cyanosis
- - Not in apparent distress
- - Chronic cough--> smoker
What are the pink puffer clinical appearance of COPD?
- - Panacinar
- - Destrution of distal alveoli
- - 25% of body energy to breath
- - Thin, frail; flushed
- - Breaths through pursed lips
- -Barrel-chest appearance
What are the findings of extrinsic asthma?
- - Onset childhood
- - family hx of allergy
- - Testing: spirometry, allergy
- - Monitor with peak flow meter
- - Distinguish from hyperactive airway
What are the findings of intrinsic asthma?
- - Usually adult > 40
- - Prolonged URI, smoking, toxins
- -No allergy relation
What things favor Th1 helper cell responses which is non-inflammatory?
- - Younger siblings
- - exposed to daycare
- - exposed to animals first 6 months
- - Exposed to TB, measles, hep A
- - Exposed to rural area
What things favor the inflammatory Th2 helper cel response?
- - Urban area
- - Antibiotic use
- - Western lifestyle with diet
- - Dust mites + cockroaches
What are some acute phase asthma meds?
- - Epinephrine
- - Beta agonists (valine)
- - Methyl-Xanthines (theophyline)
What are some prophylactic asthma meds?
- - Cromolyn sodium (intal)
- - Leukotrine receptor antagonist (zafirlukast)
- - Beta 2 agonists (salmeterol)
- - Oral and aerosol corticosteroids
What are the guidelines for exercise Induced Bronchospasm?
- - Warm up 45-60 min before event
- - Exercise in warm humid air
- - Avoid intense workout make short
- - Sports of short burst activity
- - Breath through nose
- - Control breathing
Describe the aspects of heart burn...
- - Due to irritation of esophagus
- - lower esophageal sphincter incompetence or loss of tone
- -Foods decrease tone: fatty, coffee, chocolate
- - Drugsthat are sympathomimetic
- - Hiatal hernia 2ndary cause
What are the associated findings with abdominal pain?
- - Organ pain centrally
- - Parietal peritoneum or capsule of organ irritated= pain localized
- - Pain radiates from back of groin= renal/ureter problem
- - Gynecologic causes=menstrual cycle
- - Sudden pain= blockage of non intestinal lumen, rupture of organ, major vascular problem
What part invovled in lower right quadrant of acute abdominal pain?
- - Appendicitis
- - Pelvic inflammtory disease
- - Ectopic pregnancy
- -Renal referral
Whats invovlved in right upper quadrant of acute abdominal pain?
- - Chilelithiasis
- - Hepatitis
- - Fitz-hugh-Curtis
WHat are findings of Appendicitis?
- - Begins as central pain over 6-12 hours
- - Localizes due to peritoneal irritation
- - nausea/vomiting/WBC increase
- - Rebound tenderness or Rovsings
- - US disgnostic
- -TX: laproscopic removal
What are the important Hx findings and exam most specific for Appendicitis?
- Hx: RLQ pain with anorexia with pain before vomitting
-Exam: psoas sign
What are the most highest occurring sensitivity & specificity clinical findings for appendicitis?
Sensitivity: Rovsing's / anorexia/ pain prior to vomitting/ fever
Specificity: Psoas sign/ fever/ rebound tenderness
What are the ccauses of pelvic inflammatory disease, s/sx, dx, and tx??
- - Due to Chlamydia or ghonorrhea
- - S/SX: fever, chills, lower unilateral ab pain, ab pain worse at end/ after period
- - Exam: sensitive
- -DX: culdocentesis
- - TX: antibiotics w. complication of Fitz-Hugh-Curtis disease
What are general findings and associations with ectopic pregnancy?
- 1% all pregnancies--> 99% in fallopian tube
- - Signs of early pregnancy; breast tender, morning nausea
- - Missed period w. spotting
- - Pelvic exam 1st--> pregnancy test--> diagnostic US
What are the findings and associations with kidney/ureteral stones?
- - More common in males, humid climate, summer
- - Dehydration
- -Severe pain w. nausea + vomitting
- -US best
- -TX: stones to pass if small enough, use lithotripsy, surgery
What are the steps to having a stone formation?
- 1. supersaturaiton
- 2. Nidus
- 3. crystal growth & aggregation
- 4. stone size increase
What is a good diet form to preventing kidney stones?
- - normal calcim
- -decreased animal protein
- - decreased salt intake
- - normal calcium
What are the findings with Cholelithiasis and Tx & Dx?
- common in women, diabetics, Native Americans, oral contraceptive
- - Cholesterol stones most common
- - Bilirubin stones--> hemolytic anemias
- - Severe pain, nausea, vomiting, refferal inferior border of scapula
- - Dx: US
- -Tx: laproscopic removal, lithotripsy, dissolving stone chemically
What were findings for acute cholecystitis?
- - US
- - Specificity-->Murphy's sign w. lab of fever w. leukocytosis
- - ALT, AST, alkaline phosphatase, & bilirubin not sensitive or specific
- - Dx: US--> specificty 80% & sensitivity 88%
What are the associated findings and information about Hepatitis?
- - Viral infection, meds, alcohol
- - A, B, C types
- - MIld symptoms with A--> resolve w. jaundice
- - A--> contaminated food, water
- -B & C---> blood, saliva, vaginal fluid, contaminated needles, sex
- - Testing time sensitive
What are the causes and further findings of Epigastric pain?
Causes: reflux esophagitis, peptic ulcer, pancreatitis
- - Pain is recurrent, on empty stomach, relief from antacid
- - pain on full stomach--> worse with recumbency= reflux
- - Severe pain radiate to back-->hx: alcohol= pancreatitis
- Tx: antacids + H2 antagonists
Discuss the association of chronic recurrent abdominal pain....
- - Differentiate--> location, diarrhea, constipation, change in menstrual cycle
- - Low ab pain w. bouts of diarrhea--> irritable bowel syndrome (IBS)
- - Diarrhea primary--> IBS
- - Menstrual cycle association--> sharp pain--> endometriosis + other pelvic pathology
What are findings of IBS?
- - Constipatin & diarrhea
- - Decrease in peristaltic activity (contraction of smooth muscle)
- - Stress + food triggers
- - Stool w. mucus
- - Tx: no medical--> herbs + diet
What are the findings of Inflammatory Bowel Disease (IBD)?
- - Crohns + Ulcerative colitis
- - HLA B-27 w. some peripheral joint pain
- - Crohns= transmural involvement of small intestine, skip lesions
- - UC= superficial w. heavy bout diarrhea
What are the findings w. Dysmenorrhea?
- - Primary & secondary
- - Primary: baseline, normal discomfort w. period
- - Secondary: abnormal structure, sharp increase of pain
- - MC--> endometriosis
- -DX: US, MRI, surgical
What are the findings of Diverticulitis?
- - Herniation of mucosa/submucosa into colonic muscle wall
- - Primarily--> Western society, 1/3 over 60, lack fiber
- - Low abdominal pain, low grade fever, bloody stool, leukocytosis
- - Hospitalization for acute cases
What are the two major mechanisms of Diarrhea?
Osmotic: non-digested material like lactose, sorbital, manitol, magnesium antacids
- Secretory: bacteria
- enteroinvasive--> salmonella, shigella, campylobacter
- enterotoxic--> staph, e.coli, clostridium
What are findings with Diarrhea?
- - Fecal leukocytes= enteroinvasive
- - Viral: adenovirus, rotavirus
- - Dysentry & Giardia
- - Chronic diarrhea= lab for blood, cysts
- - IBS
- - Non-bloody--> antobiotics, drugs, malabsorption, endocrine, IBS
What are the two mechanisms that are invovled with constipation, discuss both?
- Ineffective filling--> diabetes, drugs, GI disease
- Ineffective emptying--> from learning habit, local pathology w. painful defecation
- Common--> low back ptnt
Discuss dysfunctional voiding...
- Bladder body contracts w. parasympathetic activity--> beta-adrenergic stimulation causes detrusor relaxation & alpha-adrenergic stimulation--> baldder neck tightening
- - Voiding in senior--> bladder capacity, elasticity, loss cortical inhibition
- - Young--> void fluid before 9pm
- -Old--> void after 9pm
What are the findings associated with irratative bladder dysfunctional voiding?
-Infection/ neurologic: dysuria, nocturia, urgency
What are the associated findings of obstructive bladder in dysfunctional voiding?
- - Prostate
- - Congenital --> children
- - Drugs
- - Signs: dribbling, minor stream, hesitancy
What are the four relations of urinary incontinence & discuss each..?
Stress incontinence--> pelvic floor laxity--> hormone change, drugs, obesity, coughing
Urgency incontinence--> infection, inflammation, neurologic cause
Overflow incontinence--> obstruction
Total Incontinence--> neurologic pathology (cauda equina)
What is detrusor instability?
What are the 3 types of Vaginal discharges?
Discuss the 3 types of Vaginal discharges...
Gardnerella- 50-60% watery, gray, foul smelling, tx: flagyl
Trichamonis: high vaginal pH, fould smelling, pelvic exam--> strawberry cervix, Tx: flagyl
Candida: diabetes, antibiotics, corticosteroids, extreme pruritis w. scant discharge & curd like, TX; OTC (chlortrimazole)
What are the five stages of Vaginal bleeding?
- 1. pre-menarchial
- 2. Menarche
- 3. Reproductive years
- 4. Peri-menopausal
- 5. Menopause
Discuss the stages of Vaginal bleeding and their significance
- 1 & 5: abnormal; 1--> abuse & 2--> cancer
- 2 & 4: normal--> fluctuating hormonal levels
- - 3: abnormal--> more than 20 days (polymenorrhea)
- --> Less 42 days (Oligomenorrhea)
- --> longer than 8 days (menorrhagia)
- --> between periods bleeding (metrorrhagia)
What are the findings w. ovulatory vaginal bleeding?
- - crampy
- - premenstrual s/sx
- -pelvic pathology
What are the Anovulatory findings w. vaginal bleeding?
- - Irregular
- -No prodrome
- - Painless
- - Endocrine in nature
What are the different visual dysfunctions and their causes?
- Loss of central vision--> cataract, retinal detach
- Loss of peripheral--> glaucooma, retinis pigmentosa
- Flashes of light--> migraine, vitreoretinal traction
- Halos--> glaucoma, corneal disease
- Transient loss vision--> amaurosis fugx, multiple sclerosis, papiledema
- Diplopia (monocular)--> cataract, refractive error
-Diplopia (binocular)--> vascular, tumor, myesthenia gravis, multiple sclerosis
- Distorted vision--> migraine, macular degeneration
What type of test is used to test a persons central visual field?
- Amsler's grid
WHat are the areas of facial pain?
- - Neuralgias: trigeminal, glossopharangeal, sphenopalatine ganglion
- -Oral cavity
What are some of the history clues of facial pain?
- - Neuralgias: Short, sharp, recurrent pains
- - Sinus pain: deep, dull, change in atmospheric pressure and bend forward
- -TMJ: Front of ear, open mouth
- - Dental: chewing, hot/cold, sweet foods
What are the forms of ear complaints?
- Pain: internal + external
What are the causes of ear pain?
- Infection: external + internal
Name the types of questions you would ask for ear pain....
- - Trauma? (direct or cervical)
- - S/SX of upper resp. infection?
- - Dizziness?
- -Chewing? (dental, tmj)
- -Neck movement?
- -Air travel or swimming?
- - Skin lesions?
What are some associations of hearing loss?
- - Sudden, gradual, recurrent
- -Unilateral or bilateral
- -Hx of meds
- -Hx of systemic disease
- -Hx of occupational or enviromental noise
What are some Ototoxic drugs resulting in bilateral hearing loss?
- - Aminoglycosides
- - hi-dose erythromycin
- -Furosamide (lasix)
What are some patient Hx clues for hearing problems?
- - Difficulty with:
- -->listening on telephone
- -->following conversation incrowds
- -->accents or women's voice
- -->very load seeming sounds unilaterally
What are some tests for hearing loss?
- - * Whisper test
- - Audioscope in office to measure loss
- - Tests to differentiate conductive vs. neural--> Rhine + Weber
- - Audiologic test
- -Brainstem evoke resposne
- - Special imaging
What are some hearing loss disorders?
- - Presbycusis
- -Otitis media
- -Cerumen impact
What are some S/sx to look for in determining Tinnitus?
- - Localized to an ear or ears &/or it is central
- -Complain has:
- --> ringing
- -->rushing or pulsating
- -->fluttering (tensor tympany)
- -->clicking or popping (tmj)
- * 1/3 of the time can't figure out why
What other tests and checks can you perform to determine Tinnitus?
- If coomplaint is other than ringing--> determine if objective
-Use stethoscope--> listen for bruits & murmurs
-Use two connected stethoscopes--> is it audible to urself?
What are some common causes of Epistaxis?
- - mild trauma
- -dry environment
- -nose picking
- -constant nose blowing
What are some significant causes of difficulty to control Epistaxis?
- - hypertension
- -major trauma
- -anticoagulant meds
What can you consider if a patient has persistent, recurrent and undiagnosed epistaxis?
- - Blood dyscrasia
- - Leukemia
What is difference between anterior bleeding and posterior bleeding of the nose?
Anterior: most common mild bleeding
Posterior: profuse and dificult to control
What is some common knowledge of sore throat?
- - Third most common presenting complaint of primary care
- -3-4% of all visits
What are some positive findings for strep throat?
- - Tonsilar exudates
- -pharyngeal exudates
- -exposure to strep throat infection in past 2 weeks
What are some negative findings for strep Throat?
- - Absence of tender cervical lymph nodes
- -no tonsilar enlargement
- -no exudate
What is a found conclusion of strep throat?
- No single element of history or physical exam can sufficiently diagnose or exclude strep throat.
What is known for high risk strep throat patients?
- Tx: antibiotics
What should be done for patients with moderate risk of strep?
- recent cough and oral temp. >101= further diagnostic testing--> rapid antigen test or throat culture
What should be recommended for low risk strep patients?
- - managed symptomatically
- -likely not to have strep