DDX1

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

-Mondor's syndrome (thrombosis of superficial vein)

-Herpes Zoster (varicella virus in DRG, dermatome pattern, vesicles)

Strain: contract/stretch, pecs, intercostals, serratus anterior

Trigger point: reference point of pain for one muscle, pain at end-range stretch

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

• 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)
• GI

• Rest & decrease cough, sneezing
• Stay mobile
• stretch
• Slow full breaths to decrease scar tissue form....

Corticosteroids inject....

• -Exertion
• - < 10 min
• -Rest & nitro good
• - ST depression on EKG
• - Negative enzymes
• - Due to athero

• -Occurs @ rest
• - > 10 min
• - Nitro usually helps
• - ST depression or elevation
• - Unstable due to athero
• - Prinzmetal due to vasospasm

• - 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

• - 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

• - Atrial source may respond to a vagal stimulation
• - Evaluate patient for associated murmurs
• -Resting and stress ECG
• - Echocardiogram for suspected MVP

• -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?

• - 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)

• - 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

• - Effects all aspects or respiration
• - Sources are pulmonary & extra including: neuromuscular, skeletal deformity, pleural
• - Rales are more prevalent

• - Centrilobular
• - Blockage of distal bronchioles
• - Decreased CNS sensitivity to CO2= cyanosis
• - Not in apparent distress
• - Chronic cough--> smoker

• - Panacinar
• - Destrution of distal alveoli
• - 25% of body energy to breath
• - Thin, frail; flushed
• - Breaths through pursed lips
• -Barrel-chest appearance

• - Onset childhood
• - family hx of allergy
• - Testing: spirometry, allergy
• - Monitor with peak flow meter
• - Distinguish from hyperactive airway

• - Usually adult > 40
• - Prolonged URI, smoking, toxins
• -No allergy relation

• - Younger siblings
• - exposed to daycare
• - exposed to animals first 6 months
• - Exposed to TB, measles, hep A
• - Exposed to rural area

• - Urban area
• - Antibiotic use
• - Western lifestyle with diet
• - Dust mites + cockroaches

• - Epinephrine
• - Beta agonists (valine)
• - Methyl-Xanthines (theophyline)

• - Cromolyn sodium (intal)
• - Leukotrine receptor antagonist (zafirlukast)
• - Beta 2 agonists (salmeterol)
• - Oral and aerosol corticosteroids

• - 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

• - 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

• - 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

• - Appendicitis
• - Pelvic inflammtory disease
• - Ectopic pregnancy
• -Renal referral

• - Chilelithiasis
• - Hepatitis
• - Fitz-hugh-Curtis
• -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

- Hx: RLQ pain with anorexia with pain before vomitting

-Exam: psoas sign

Sensitivity: Rovsing's / anorexia/ pain prior to vomitting/ fever

Specificity: Psoas sign/ fever/ rebound tenderness

• - 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

- 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

• - 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

• 1. supersaturaiton
• 2. Nidus
• 3. crystal growth & aggregation
• 4. stone size increase

• - normal calcim
• -decreased animal protein
• - decreased salt intake
• - normal calcium

- 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

• - 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%

• - 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

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

• - 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

• - Constipatin & diarrhea
• - Decrease in peristaltic activity (contraction of smooth muscle)
• - Stress + food triggers
• - Stool w. mucus
• - Tx: no medical--> herbs + diet

• - 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

• - Primary & secondary
• - Primary: baseline, normal discomfort w. period
• - Secondary: abnormal structure, sharp increase of pain
• - MC--> endometriosis
• -DX: US, MRI, surgical

• - 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

Osmotic: non-digested material like lactose, sorbital, manitol, magnesium antacids

• Secretory: bacteria
• enteroinvasive--> salmonella, shigella, campylobacter
• enterotoxic--> staph, e.coli, clostridium

• - Fecal leukocytes= enteroinvasive
• - Viral: adenovirus, rotavirus
• - Dysentry & Giardia
• - Chronic diarrhea= lab for blood, cysts
• - IBS
• - Non-bloody--> antobiotics, drugs, malabsorption, endocrine, IBS

- Ineffective filling--> diabetes, drugs, GI disease

- Ineffective emptying--> from learning habit, local pathology w. painful defecation

- Common--> low back ptnt

- 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

-Infection/ neurologic: dysuria, nocturia, urgency

• - Prostate
• - Congenital --> children
• - Drugs
• - Signs: dribbling, minor stream, hesitancy

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)

-Unstable bladder

- Gardnerella

- Trichamonis

- Candida

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)

• 1. pre-menarchial
• 2. Menarche
• 3. Reproductive years
• 4. Peri-menopausal
• 5. Menopause

- 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)

• -regular
• - crampy
• - premenstrual s/sx
• -pelvic pathology

• - Irregular
• -No prodrome
• - Painless
• - Endocrine in nature

- 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

- Amsler's grid

• - Neuralgias: trigeminal, glossopharangeal, sphenopalatine ganglion
• -Sinusitis
• -Eye
• -TMJ
• -Oral cavity
• -Headache

• - 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

- Pain: internal + external

-Hearing loss

-Tinnitus

- Infection: external + internal

-TMJ

-Teeth

-C-spine

-BAd-fitting glasses

• - Trauma? (direct or cervical)
• - S/SX of upper resp. infection?
• - Dizziness?
• -Chewing? (dental, tmj)
• -Neck movement?
• -Air travel or swimming?
• - Skin lesions?

• - Sudden, gradual, recurrent
• -Unilateral or bilateral
• -Dizziness
• -Hx of meds
• -Hx of systemic disease
• -Hx of occupational or enviromental noise

• - Aminoglycosides
• - hi-dose erythromycin
• -NSAIDS
• -Furosamide (lasix)
• -Vancomycin

• - Difficulty with:
• -->listening on telephone
• -->following conversation incrowds
• -->accents or women's voice
• -->very load seeming sounds unilaterally

• - * Whisper test
• - Audioscope in office to measure loss
• - Tests to differentiate conductive vs. neural--> Rhine + Weber
• - Audiologic test
• -Brainstem evoke resposne
• - Special imaging

• - Presbycusis
• -Otosclerosis
• -Congenital
• -Meniers
• -Labyrinthitis
• -Otitis media
• -Cholesteotoma
• -Cerumen impact

• - 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

- If coomplaint is other than ringing--> determine if objective

-Use stethoscope--> listen for bruits & murmurs

-Use two connected stethoscopes--> is it audible to urself?

• - mild trauma
• -dry environment
• -nose picking
• -constant nose blowing

• - hypertension
• -major trauma
• -anticoagulant meds

• - Blood dyscrasia
• - Leukemia

Anterior: most common mild bleeding

Posterior: profuse and dificult to control

• - Third most common presenting complaint of primary care
• -3-4% of all visits

• - Tonsilar exudates
• -pharyngeal exudates
• -exposure to strep throat infection in past 2 weeks

• - Absence of tender cervical lymph nodes
• -no tonsilar enlargement
• -no exudate

- No single element of history or physical exam can sufficiently diagnose or exclude strep throat.

- Tx: antibiotics

- recent cough and oral temp. >101= further diagnostic testing--> rapid antigen test or throat culture

• - managed symptomatically
• -likely not to have strep