House MDs Diagnosis Note:

[Not For Sale]

The first qualification for a physician is

hopefulness
James Little (18361885)

>>>TABLE OF CONTENTS<<<
1) Advice for Physicians in Training: 40 Tips
From 40 Docs
2) Emergency Medicine 100 Secrets
3) Dx Note: Internal Medicine & Pediatrics
a) Vital Signs
b) Medical History
c) Physical Examination
d) SOAP Notes Format
e) Differential Diagnosis
4) Ward Note: Formulas & IV Drips
5) Clinical Chemistry & Hematology
a) Electrolytes
b) Electrolyte Imbalance
c) General Clinical Chemistry
d) CBC & Hematology

>>Advice for Physicians in Training: 40

Tips From 40 Docs<<


ON BEING A DOCTOR

You can be an excellent physician without
a stethoscope or a prescription pad, but not
without good communication skills.
Communication is your most important tool.
Tailor your words to the patient & listen
more than you speak. Remember that the
physicians who most often run afoul of
patients & families (and their lawyers) are
those who communicate poorly or not at all.

A thorough history almost always trumps a
thorough physical examination. Osler said
Listen to the patient. He is telling you the
diagnosis. He was right.

Awareness of what you dont know - and in
particular how you deal with not knowing will define the sort of physician you are
perhaps more than anything else.

No one expects you to have all the
answers, not even your patients. The 3
most valuable words in your vocabulary are
I dont know. Using these words with
colleagues & patients demonstrates
honesty & awareness of your limitations.

Project confidence to your patients. Its
therapeutic. But dont be overconfident,
and be wary of colleagues who are.
Overconfidence is a dangerous quality in a
physician.
ON THERAPEUTICS

Dont underestimate the ability of drugs to
cause harm. They will be responsible for
some of the most common problems you
will see in practice. Sometimes this harm
will be obvious, but often it will not.

There are only two good reasons to do
something to a patient (or more correctly,
for a patient): to make them feel better or to
help them live longer. If an intervention a
drug, a device or a procedure carries no
realistic prospect of either, its not worth
doing.

Read guidelines, but remember: Theyre
guidelines, not instructions. Its difficult to
overstate the importance of this point.
ON UNCERTAINTY AND ERROR

Being wrong is unpleasant, but its part of

the job. Expecting perfection of yourself or

your colleagues is a recipe for unhappiness.
When you make a mistake (and you will),
own up to it. Nothing good ever comes from
covering it up.
Uncertainty is everywhere in medicine - in
diagnosis, prognosis and therapeutics. Be
thankful for that, because without it,
medicine would be algorithmic and boring.
Uncertainty is where the science of medicine
ends and the art of medicine begins.
Some of what you have been taught is
wrong. The problem is that no one can tell
you what those things are just yet. Retain a
measure of healthy skepticism, particularly
about things that seem surprising, counter
intuitive, or too good be true.
Don't rush to fit a patient into a diagnostic
category just because it's the one you're
most comfortable with. Realize that your
initial diagnosis is often wrong. Let time be a
test if you can let it.

ON CAREER CHOICES

When choosing a career path, remember
that the best job has you spending most of
your time doing things that get you excited
about coming to work each day. Dont
choose a career path based primarily upon
where the jobs are, and certainly not based
upon money.

Dont over-plan your career. Do have a
sense of what type of medicine you want to
practice and where, but these things can
change in short order. If you are good at
what you do and people like working with
you, opportunities will arise.

Dont be in a rush to complete your training,
especially if you are uncertain about the sort
of career you want. Extending your training
buys you time to mature as a physician and
as a person, and might open doors that
would otherwise be closed.

Competitive specialty programs value
content expertise, but generally prefer
residents who are hardworking, reliable and
good-natured to those whose primary
attribute is knowledge.

If you dont gain acceptance into your
training program or job of choice, recall the
words of the 14th Dalai Lama: "Remember
that sometimes not getting what you want is



a wonderful stroke of luck."

Great things can happen when plans go
awry.
When choosing your first real job, dont
underestimate the value of living close to
where you work.
And take note of the personalities of your
prospective colleagues; you will spend a lot
of time with them. Medicine is full of smart
people. Gravitate toward the nicer ones.
Some trainees harbor the idea that great
medicine is limited to academic centers.
This is wrong.
Community-based medicine is full of
outstanding physicians who have fulfilling
careers and are loved by their patients.

ON TIME

Time is your most precious resource. Its
nonrenewable, and its important to protect
it. Do not be afraid to say no when asked
to assume new responsibilities, particularly
in the early stages of your career. There is
no shortage of work to be done, and senior
colleagues will often turn to younger, more
energetic people to do it.

Do say yes to some requests, particularly
those that present opportunities for
learning or other personal betterment. You
didnt get to where you are by shirking
responsibility or by avoiding challenges.
Say yes and no in good measure.
ON MONEY

Spend less than you earn. There will be
temptation to live beyond your means,
particularly in the early years of practice.
Pay off debt as quickly as possible. Buy
disability and, particularly if you have
dependents, life insurance. (This is a dull
but essential point.)
ON PROFESSIONAL RELATIONSHIPS

During residency, your work relationships
are fleeting. When you enter practice, they
immediately become long-term. Be kind to
the nurses, the physiotherapists and the
pharmacists, the ward clerks and porters.
We are all in this together.

Drug reps are not your friends. They have
a job to do, and their objectives are often at
odds with your obligations to your patients.

Drug reps tend to exaggerate a drugs

benefits and minimize its harms. Decline free
samples, which are nothing more than
marketing devices, and skip the fancy
educational dinners, which will only make
you feel cheap. (And if they dont, you might
want to think about that.)

Helping patients and families deal with death
is one of the most rewarding aspects of
practicing medicine. Becoming comfortable
talking about death, however, is not easy,
and physicians who are good at it didnt get
that way overnight. When you find one who
is, observe and emulate them.
ON PERSONAL WELLBEING

Have a personal physician who isnt you.
Youre just not that objective.

Medicine is busy, tiring work, and its easy to
neglect your physical fitness. Find an
enjoyable way to exercise several times
each week. This will have secondary
benefits for your mental wellbeing.

Dont sacrifice family events for work if you
can avoid it, but do choose a partner who
understands your commitment to your work.
This will make it easier when youre late for
dinner or working on evenings or weekends,
as will sometimes be the case.

Medicine is your major. Try to have a
minor at least one other important activity
in your life. This could be an interest of a
medical nature (advocacy, volunteerism,
blogging etc.) or not (a musical instrument,
sport, travel or other hobby pursuit.) Having
a minor offers balance and enrichment, and
will make you a better doctor.
ON MENTORSHIP AND GUIDANCE

Mentorship is critical, particularly during
subspecialty training and the first five to ten
years of your career. Recognize that
mentors are not the same as role models,
who are simply people you wish to emulate.

True mentors want you to succeed and are
guided by your interests rather than theirs. A
good mentor has been around and knows
things you dont, including which rules can
be broken and which ones cannot. The best
mentors will sometimes tell you things you
don't want to hear. Time often proves them
right.


You can have several mentors - a clinical

mentor, a teaching mentor, a research
mentor, even a work-life balance mentor.
The mentor-mentee relationship can be
formal or informal, and the only
unacceptable number of mentors is zero.
MISCELLANEOUS

Most of the fun in medicine is at the
bedside. Try to get out from behind the
computer as much as possible (there is
little fun to be had there) and spend more
time with the patients.

Keep every letter and card of thanks from
patients and their families. If you are
acknowledged in an obituary, clip and save
it. Read these things periodically. They are
affirmations that you are making a
difference in the lives of others.

When you think youre having difficult day,
remember: your patients have it worse.
You werent just diagnosed with leukemia,
you arent eating hospital food, and youre
going home to sleep in your own bed.

Don't wait until your mother, father, spouse
or child is sick to understand what a drag it
is to be a patient. The waiting, the
uncertainty, the pain, the misery, the lack
of information or time for questions. Try to
put yourself in each patients shoes every
day, even if just for a moment. With
practice this will help you see every case
as interesting in its way. Thinking otherwise
is a betrayal to the person in front of you.

Never lose sight of how fortunate you are.
You get to decide what you will do for a
living, where you will work, and with whom.
You have smart, like-minded colleagues,
you get to use your brain to solve problems
for the whole of your career & your
occupation affords you the respect of
people you dont even know.

Remember how much your work matters,
because health is important to everyone.
You get to cure disease sometimes and
offer comfort when you cannot. What you
do makes a real difference in the lives of
others, allowing you to leave the world a
better place than you found it. And as if all
that wasnt enough, you actually get paid to
do these things.

[Memo]

<Emergency Medicine 100 Secrets>

1. When formulating the differential diagnosis,
ask What is the most serious possible cause
of this patients presenting signs & symptoms?
2. When uncertain of the diagnosis,
communicate this truthfully to the patient &
indicate it in the final ED diagnosis
3. Before discharging a patient from the ED,
ask, Why did the patient come, & have I made
the patient feel better?
4. Familiarity with the indications & limitations
of rescue airway devices is essential
5. Preoxygenation is a critical component of
rapid sequence intubation because it will
prevent significant hypoxia despite several
minutes of apnea during the intubation process
6. When evaluating results of a research paper,
the smaller the number needed to treat, the
more effective the intervention or treatment
7. When in doubt, remember that a p value
less than 0.05 is generally considered
significant, the difference found by chance
alone being 1 in 20
8. Consider HIV/AIDS in patients at risk who
present with an illness or infection, particularly
those with opportunistic infections or extreme
presentations of common diseases
9. In febrile patients, a white blood cell or band
count is rarely useful in differentiating between
bacterial & viral illnesses
10. A foreign body in the airway should be
suspected in a child with sudden onset of
respiratory symptoms & lack of response to
appropriate treatment
11. The diagnosis of gastroenteritis cannot be
made without the presence of both vomiting &
diarrhea
12. Spinal epidural abscess should be
suspected as the cause of back pain in
immunocompromised patients & IV drug users

who present with localized spinal tenderness &

fever
13. An afferent pupillary defect points to a defect
of the retina or optic nerve
14. Perilimbic flush suggests iritis or glaucoma,
not conjunctivitis
15. When a mandible fracture is suspected, a
panoramic radiograph of the mandible is the
least expensive & most accurate film to assess
the patient
16. Documenting adherence to evidence-based
guidelines is helpful in defending against a
malpractice claim
17. In patients with a high suspicion for bacterial
meningitis, administer antibiotics promptly before
the lumber puncture is performed & after blood
cultures are obtained
18. Consider Kawasakis disease in children
presenting with 5 days of fever
19. The initial objectives in treating an asthma or
chronic obstructive pulmonary disease (COPD)
exacerbation are to relieve significant hypoxemia
(oxygen), reverse airflow obstruction (b-agonists
1 ipratropium), & to reduce of the likelihood of
recurrence (corticosteroids)
20. There is no increased risk for a serious
bacterial illness in a child with a simple febrile
seizure
21. Continuous positive airway pressure (CPAP)
or bi-level positive airway pressure (BiPAP) may
well reduce the need for endotracheal intubation
in both the ED & prehospital arenas
22. The most important tool in assessing patients
in whom you suspect ischemic heart disease is
the history. The second most important tool is
the history. The third most important tool is, well,
you get the picture
23. Serum lactate is a useful marker to assess
the extent of systemic hypoperfusion & response
to resuscitation

24. It is not always necessary to identify a

dysrhythmia prior to treating it. Assume all wide
complex tachycardia with hemodynamic
instability is ventricular tachycardia (VT)
25. An external pacemaker can be used if a
permanent pacemaker malfunctions
26. The diagnosis of atrial fibrillation (AF) can
be made clinically by palpating a peripheral
pulse & simultaneously auscultating the heart
or visualizing the cardiac rhythm; AF is the only
dysrhythmia that results in a pulse deficit
(fewer beats palpated than observed or
auscultated)
27. Every ED should have an interdisciplinary
evidence-based guideline for the management
of acute stroke
28. Do not acutely lower the mean arterial
pressure (MAP) more than 20% to 25% in
patients with hypertensive encephalopathy
29. It is not necessary to gradually empty the
bladder when treating an episode of acute
urinary retention
30. The indications for emergency dialysis are
acute pulmonary edema, life-threatening
hyperkalemia, & life-threatening intoxication or
overdose by agents normally excreted by the
kidneys

35. Consider syncope as a cause of fall in a

geriatric patient
36. Patients with myocardial infarction may get
symptomatic relief from antacids, & patients with
esophageal disease may get symptomatic relief
from nitroglycerin. Antacids & nitroglycerin are
therapeutic medications, not diagnostic tests
37. Any complaint of abdominal pain in an
elderly patient should be taken seriously even if
they have normal vital signs & no guarding or
rebound tenderness on abdominal examination
38. A neutropenic fever is a single temperature
greater than 38.3C & an absolute neutrophil
count less than 1,000/mm2
39. Intussusception occurs between 3 months &
3 years of age
40. Bilateral retinal hemorrhages in an infant
strongly suggest child abuse (shaken baby
syndrome)
41. Ketamine provides sedation, analgesia, &
amnesia while protecting the cardiovascular
status & airway reflexes, making it an ideal agent
for procedural sedation in children
42. Because of the fast helical computed
tomography (CT) scanners of today, many
infants & children can undergo this diagnostic
procedure without sedation

31. When a patient with end-stage renal

disease presents with shortness of breath,
volume overload is by far the most common
cause, even when physical examination &
chest X-ray are not diagnostic

43. Mesenteric ischemia should be considered in

any patient who has severe abdominal pain out
of proportion to the physical examination, often
requiring large doses of narcotics

32. In a young woman presenting with rash,

fever, & diarrhea, consider toxic shock
syndrome & examine for a retained tampon

44. Dermal exposure or ingestion of hydrofluoric

acid can result in profound hypocalcemia,
hypomagnesemia, & hyperkalemia

33. Doxycycline is the drug of choice for most

severe tick-borne infections, & it should be
used empirically & early in the febrile, severely
ill patient with a possible tick exposure

45. The most important action to take in the

event of an attack of weapons of mass
destruction is simply self-protection by donning
appropriate personal protective equipment

34. A febrile patient returning from the tropics

has malaria until proved otherwise

46. Sodium bicarbonate (12 mEq/kg) should be

considered for all poisoned patients with
ventricular dysrhythmias or a wide QRS

47. Secure the airway early in the management

of patients with significant soft-tissue neck
injuries

59. If using antibiotics to treat abscesses,

assume Methicillin-resistant Staphylococcus
aureus (MRSA) as the causative agent

48. Consider a computed tomography

angiography (CTA) of the neck in patients with
facial or cervical spine fractures

60. Amphetamine & cocaine toxicity should be

treated with IV benzodiazepine in incremental
doses titrated to adequate control of heart rate,
blood pressure (BP), & temperature

49. Hypotensive, tachycardic patients with

penetrating chest trauma should be
immediately evaluated for tension
pneumothorax & pericardial tamponade
because emergent treatment can be life-saving

61. b-blockers are contraindicated in the

treatment of stimulant toxicity because they may
potentiate alpha effects & cause coronary artery
vasoconstriction & hypertension

50. A suicide attempt should be considered in

patients with illogical explanations for serious
accidents

62. No diagnostic studies are indicated in an

asymptomatic patient exposed to smoke in a
nonenclosed space

51. Analyzing a mass gathering will allow

informed decisions about the needed levels of
staffing & equipment necessary to provide onsite care

63. In the presence of carbon monoxide (CO),

pulse oximetry will yield a falsely elevated
reading

52. A CT scan for appendicitis is negative

only if the entire appendix has been visualized
& is normal
53. Abdominal aortic aneurysm (AAA) can
mimic renal colic
54. Helical CT is the radiologic modality of
choice for diagnosing ureteral calculus
55. Consider testicular torsion in any male with
lower abdominal pain
56. Early goal-directed therapy in patients with
severe sepsis reduces short-term mortality by
10% to 20% compared with an unstructured
treatment regimen
57. Culture & antibiotics are not indicated in
non-immunocompromised patients with a
cutaneous abscess
58. Necrotizing fasciitis should be considered
in any patient with a soft-tissue infection who
has pain & tenderness out of proportion to the
visible degree of cellulitis

64. A BP greater than 140/90 in a pregnant

woman is suspicious for preeclampsia
65. A pregnant woman with hypertension &
seizures should be treated with IV magnesium
sulfate & consideration of emergent delivery of
the fetus
66. The most deceptive of serious hand injuries
is the high pressure injection injury from a
hydraulic paint or oil gun because despite a
seemingly innocuous appearance on initial
presentation, these injuries require aggressive,
surgical management
67. When allowing a patient to leave against
medical advice, consideration of the patients
ability to pay is not part of the equation. Only the
risks, benefits, & patients ability to understand
the risks & benefits are important
68. Be aware of the long-term cancer risk of
patients exposed to diagnostic radiation,
particularly those who are young or have had
multiple studies
69. With few exceptions, procedures performed
in the ED can be done with fewer complications
& greater success using ultrasound guidance

70. Any elderly patient with flank, back,

abdominal pain, hypotension, syncope, or
pulseless electrical activity (PEA) should have
an emergency ultrasound examination to
evaluate for an AAA

80. In almost all cases, trauma patients with

unstable vital signs & a positive ED-focused
abdominal sonography for trauma (FAST)
examination for free fluid should go directly to
laparotomy

71. IV bolus administration of epinephrine to a

patient with an obtainable BP & pulse can
result in ischemic cardiac pain, hypertension,
supraventricular tachycardia (SVT), & VT

81. In patients with hyponatremia, to avoid

central pontine myelinolysis, serum sodium
should never be raised by more than 0.5 mEq/hr
or 12 mEq in 24 hours

72. Examine every patient with urticaria for

mucosal edema, stridor, wheezing, &
hypotension to rule out life threats associated
with anaphylaxis

82. Consider a retropharyngeal space infection

in a young child presenting with a history of fever,
refusal to drink, sore throat, & reluctance to
move their neck

73. A contaminated wound is one with a high

degree of bacterial inoculum at the time of
injury & not synonymous with a dirty wound

83. The concomitant ingestion of ethanol (ETOH)

with methanol or ethylene glycol protects against
toxic metabolites

74. Determination of pretest probability for

venous thromboembolism (VTE) is critical in
knowing when to initiate a diagnostic work-up
& how to interpret your test results

84. Myocarditis should be considered in a patient

with a sustained, unexplained tachycardia

75. A D-dimer assay is only useful to exclude

thromboembolic disease in patients with a low
pretest probability
76. The problem of error in medicine, & the
adverse events that sometimes follow, are
problems of psychology & engineering, not of
medicine
77. Emergency medicine, by its nature, has
more failure-producing conditions than any
other specialty in medicine
78. CT of the head will identify 95% of patients
with subarachnoid hemorrhage. Lumbar
puncture (LP) is recommended for patients
with a strong clinical suspicion, despite a
negative CT of the head
79. The patient with a posterior nasal packing
in place must be monitored in the hospital for
recognition of hypoxia or apnea secondary to
stimulation of the nasopulmonary reflex

85. Suspect ectopic pregnancy when there is no

evidence of intrauterine pregnancy (IUP) by
transvaginal ultrasound & the quantitative human
chorionic gonadotropin (HCG) concentration is
greater than 2000 IU/L
86. In a lucid patient with blunt abdominal trauma,
the clinical examination is the best guide for
selection of diagnostic tests
87. Obtain a CT scan of the head on any patient
on warfarin (Coumadin) with even a minor head
trauma
88. A single negative abdominal ultrasound
alone does not reliably exclude significant
intraperitoneal injury
89. Children manifest shock later than adults
with the same percentage of blood loss, yet
decompensate more quickly once this critical
volume is lost
90. In the case of vascular &/or skin compromise
of a deformed limb, urgent realignment &
splinting of the involved extremity should
precede radiography

91. Always exclude associated fractures of the

spine & lower extremities in patients with
calcaneal fractures
92. Never restrain a patient in the prone
position; restrain on their side to minimize risks
of aspiration & sudden death
93. Consider domestic violence in women with
depression, suicidal ideations, chronic pain,
psychosomatic complaints, or multiple ED
visits
94. As little as 2 weeks of chronic steroid use
(prednisone . 20 mg/day) will cause adrenal
suppression, making a patient more prone to
adrenal crisis
95. Lightning strike is the one exception to the
usual multicasualty incident (MCI) triage rules:
The first priority should go to those who are not
breathing & not moving because only those
who present in cardiac arrest are at high risk of
dying
96. The NEXUS criteria are 99.6% sensitive &
12.9% specific for significant cervical spine
injuries in adults
97. Follow potassium closely when treating
patients with Insulin
98. Glucose should not be withheld due to the
unfounded fear of precipitating Wernicke
Korsakoffs syndrome
99. Zoos usually keep antivenin on h& for the
exotic venomous animals in their collections
100. Transient ischemic attack (TIA) is a
harbinger of early acute stroke (up to 10% in
first 48 hours)

>>DIAGNOSIS NOTE<<
<Normal Vital Signs>
Adult
Blood
Pressure

Heart
Rate
300/RR
LargeBox
Rwave in
6sec*10

Resp
Rate

SPO2 (%)

Temp

HPN S2
HPN S1
Pre
HPN
Normal
Sinus
AV
junction
Ventricl
e
14-20
95-100
<94
Hypoxia
<90
Emerge
ncy
37C

Children

Findings of Potentially Serious Illness

Heart Rate > 120 or < 60 beats/minute
Respiratory Rate > 20 or < 10 cpm

>160/>=100
140-159/90-99

Systolic Blood Pressure < 90 mmHg

120-139/80-89

Temperature > 38 or < 35C

120-80
60-100

40-60
20-40

AnemicPtlooks
OK

Newbor
n 2
yrs
2-10
yrs
10 yrs adult

100 - 180

Hypoxia <94%
Altered Mental Status

60 - 140

Hypoglycemia or Hyperglycemia

50 - 100

100%
O2

<Adult >
>Blood Pressure
 HPN S2 >160/>=100
 HPN S1 140-159 / 90-99
 Pre HPN 120-139 / 80-89
 Normal 120-80
>Heart Rate
[300/RR LargeBox / Rwave in 6sec*10]
 Sinus
60-100
 AV junction
40-60
 Ventricle
20-40
 Newborn 2 yr
100 - 180
 2-10 years
60 - 140
 10 years -adult
50 - 100
>Resp Rate 14-20
>SPO2 (%)
 95-100
 <94 Hypoxia:AnemicPtlooksOK100% O2
 <90 Emergency
Temp
37C

A pressure of 110/70 mm Hg would usually be

normal, but could also indicate significant
hypotension if past pressures have been high
A fall in systolic pressure of 20 mm Hg or more,
especially when accompanied by symptoms &
tachycardia, indicates orthostatic (postural)
hypotension . Causes include drugs, moderate
or severe blood loss, prolonged bed rest &
diseases of the autonomic nervous system
Fever or pyrexia refers to an elevated body
temperature. Hyperpyrexia refers to extreme
elevation in temperature, above 41.1C (106F),
while hypothermia refers to an abnormally low
temperature, below 35C((95F) rectally)
Causes of fever include infection, trauma such
as surgery or crush injuries, malignancy, blood
disorders such as acute hemolytic anemia, drug
reactions & immune disorders such as collagen
vascular disease.
The chief cause of hypothermia is exposure to
cold. Other predisposing causes include reduced
movement as in paralysis, interference with
vasoconstriction as from sepsis or excess
alcohol, starvation, hypothyroidism &
hypoglycemia. Elderly people are especially
susceptible to hypothermia & also less likely to
develop fever
* Exception: Premature Babies w/t O2 Therapy in
Neonatal ICU SpO2 (89-94%) to avoid Retinal
Toxicity.
At Surgery, SPO2 of premature babies >95%, as
with all other Pts.

Hypovolaemia is the MC cause of a weak
pulse oximeter signal during anaesthesia.

Hypothermia should also be considered.

*The Medical History - Sections

"Chiefly History from the Past tells your
Family Social Review"
Chiefly History from the Past tells your
Family Social Review (CC, HPI, PMH,
FH, SH, ROS)
Chief Complaint in patient's own words &
duration
History of Present Illness including the
LOCATES
Past Medical History: A HISTORY
Family History - Pedigree, Genetic Ds,
Household Contacts. FamHx of CA, DM, HPN,
Heart Disease, Anemia, Arthritis
Social History: FLAMES
Review of Systems: General Endo-Head
LUvs BRass, Crass And Gas to Pass NEar the
Mass
CC = Chief Complaint in patient's own words
& duration
HPI = History of Present Illness including the
LOCATES:
L Location & radiation
O - Other associated symptoms
C - Character
A - Alleviating & aggravating factors
T Timing, constant/intermittent, happened in
past
E - Environment or setting
S - Severity or disability (0 - 10 scale)
PMH = Past Medical History: A HISTORY:
A - Allergies,
H - Hospitalizations
I Illnesses /Major - Immunizations
S - Surgeries
T- Trauma
O - Oral medications
R - Reproductive history, contraception
Y - Youth illnesses
FH = Family History - Pedigree, Genetic
Diseases, Household Contacts. Cover Family
History of Cancer, Diabetes, Heart Disease,
Hypertension, Anemia, Arthritis

SH = Social History: FLAMES

F - Family, Food, Friends
L - Lifestyle
A - Abuse of substances & of the body
M - Military, Marital or S/O relationships
E - Employment, Education
S - Spiritual/Religion, Sexual if appropriate
ROS Review of Systems:
SUBJECTIVE (Review of Systems)
General Survey-The General Survey begins with
the first moments of the patient encounter. How
do you perceive the patient's apparent state of
health, demeanor & facial aspect or expression,
grooming, posture, and gait? Height & weight,
usually recorded before the patient enters the
examining room, add important detail to the
General Survey.
Vital Sign:
 Blood Pressure
 Heart Rate
 Respiratory Rate
 Temperature & their Normal Ranges.
Pain, the 5th Vital Sign-This edition brings new
information on how to assess pain commonly
underdiagnosed and a major focus of caring for
patients in all health professions.

"General Endo-Head LUvs BRass, Crass And

Gas to Pass NEar the Mass"

peripheral edema, ascites, cold feet, phlebitis,

cyanosis

GEN = General & Skin: Weight Change,

Fever/Chills, Night Sweats, Rash, Itching, Mole
Change, Skin Cancer, Abnormal
Bleeding/Bruising, Anemia, Pica, HIV Risk
Factors, Lymphadenopathy, Lymph Node
Enlargement & Pain, Fatigue

AB = Abdominal : N/V, hematemesis, dysphagia,

indigestion, heartburn/dyspepsia/GERD, swelling,
jaundice, hematochezia, melena, change in stool
caliber, diarrhea, constipation, hernias,
hemorrhoids, peptic ulcer disease, surgery,
gallbladder disease, pancreatitis, liver disease,
alcohol intake, appetite/wgt change, BRBPR,
Abdominal pain/colic, icterus, change in bowels,
tenesmus, rectal pain

EN = Endocrine: Hot/Cold Intolerance, Thyroid

Goiter, Nodules or Radiation, Diabetes,
Increased Thirst or Appetite, Fatigue,
Polyphagia/Dipsia/Uria, Decrease Energy
HEENT =
 Head - Pain, H/A, Trauma, Vertigo,
Syncope, Seizures, Memory
 Eye Pain, Vision Change, Glaucoma,
Redness, excessive tearing/ Discharge,
cataracts, Visual Loss, Diplopia, Trauma,
Inflammation, Glasses
 Ear- pain, tinnitus, hearing loss, vertigo,
deafness, tinnitis, discharge, pain
 Nose - sinusitis, epistaxis, blockage,
discharge, obstruction, epistaxis
 Mouth - sores, gingival bleed, teeth, abn.
taste, jaw pain
 Throat - pharyngitis, hoarseness, postnasal
drip, ST, hoarseness, voice changes, URI
 Teeth cavities, abscess
 Gums- Bleeding, lesions
 Neck - swelling/stiff, adenopathy, goiter
LU = Lung : dyspnea, cough,
sputum/hemoptysis, wheezing, PPD, CXR,
pneumonia, asthma, bronchitis, smoking,
inhalation, orthopnea, pain, pleurisy, night
sweats, TB, #pillows
BR = Breast: nodule, discharge, chest wall or
breast pain tenderness, self exam, lumps,
pain, nipple discharge, last mammogram
CV = Cardiovascular : Exercise level,
orthopnea, PND paroxysmal nocturnal
dyspnea, DOE- dyspnea on exertion, chest
pain or discomfort, palpitations, syncope,
claudication, CV drugs, hypertension, DVT
blood clots, past heart disease. Rheumatic
fever, family history heart disease/clotting.
leg/foot ulcers, varicose veins, palpitations,

GU = Genitourinary: urinary frequency, urgency,

nocturia, hematuria, flow, hesitancy, pyuria,
incontinence, urethral discharge, genital lesions,
STD sexually transmitted diseases, UTIs, stones,
flank pain, family history renal disease, polyuria,
oliguria, dysuria/strangury, nocturia, pain
passage of stones, UTI, pyelonephritis & STD Hx
 Males: prostate, testicular mass/pain,
erectile dysfunction
 Females: age at menarche/menopause,
LMP, amount & duration of flow, pelvic pain,
vaginal discharge, abnormal bleeding,
amenorrhea, pelvic mass, pregnancies.
 Both: birth control method, sexual history.
PSY = Psychiatric: previous psych problems or
hospitalizations, interpersonal relationships,
mood swings, anxiety/nervousness, depression,
hallucinations, loss of control, vegetative
dysfunction (sleep, eating, pleasure activities),
substance abuse, suicidal thoughts & plans
NE = Neurologic: Headaches, seizures, episodic
neurologic symptoms (talking, walking, seeing,
smell, chewing, visual, facial weakness, hearing,
balance, speech & swallowing, taste) impaired
speech, paresthesias, weakness, head trauma,
stroke, dizziness, tremor, confusion, memory
loss, gait problems, atrophy, incoordination,
paresthesias, anesthesia, Autonomic:
incontinence, sweating, erythema, cyanosis,
pallor, temp sensitivity, Mental: relations w family,
lability of mood, hallucinations, delusions,
depression, somnolence, Insomnia
MS = Musculoskeletal: arthralgia/arthritis,
stiffness, swelling, muscle cramps, family history,
myalgia, heat/pain, podagra/gout, Fractures,
Bone pain, weakness, muscle atrophy, paralysis

OBJECTIVE (Physical Exam)

Vital Signs
General appearance: Age, Sex, Well
Developed/Nourished, Appears stated age,
NAD
Skin - pink-tan color, good turgor w/o lesions,
redness, cyanosis, edema or cicatrices;
Nails - no clubbing or deformities w good cap
refill
Head - normocephalic, no masses /lesions,
cicatrices, malar flushing
Eyes - visual fields intact (cut)by confrontation,
PERRLA , conjunctiva clear, sclera white,
anicteric, (1-2
beat nystagmus on lateral gaze.) EOMI, no
ptosis; fundi: red reflex present (B). discs flat w
sharp margins,
vessels present w/o crossing defects, retinal
hemorrhages
Ears - TM's non-injected(erythematous,
bulging), good light reflex, no protrusion or
retraction; Weber
midline, Rinne ac>bc, Whisper test 3:3
Nose - nares patent, no deformity, septal
deviation or perforation
Throat - pharynx non-injected, palate rises
symmetrically, gag present,
Mouth - buccal mucosa, moist and intact,
tonsils present, dentition intact, caries, tongue
midline w/o
fasciculations

present
(hyper/hypoactive, absent); no HSM
(hepatosplenomegaly), no bruits
Genitalia/rectum - no lesions, inflammation or
discharge from penis, rectum: no fissure,
hemorrhoids,
fistula or lesions in perianal area; sphincter tone
good; prostate not enlarged, no masses, nodules
or
tenderness. Stool brown, guaiac neg.
Pelvic - no vaginal/cervical lesions, uterus size &
position; no adnexal tenderness
Extremities - extremity size symmetry, temp
warm, All pulses present, no LAD, gait normal,
able to tandem walk, no Rhomberg's sign; joints
& muscles symmetry, swelling/heat, masses,
deformity or tenderness to palpation; full ROM;
muscle strength 5/5- able to Amitin flexion
against resistance & w/o tenderness, atrophy,
tremors or clonus; RAM (rapid, alt. movement)
finger-to-nose/heel-to-shin intact
Muscle Grading evaluate

D (deltoid)

T (triceps)

B (biceps)

WF (wrist flexion)

WE (wrist extension)

Quad(quadriceps)

PF (plantar flexion)

DF (dorsiflexion)
Scoring 0-5 out of 5 according to following scale:

Neck, Axilla & Breasts - no LAD

(lymphadenopathy), masses, or
thyromegaly/focal lump, carotid pulses
2+ & = (B), no bruits, supple full ROM trachea
midline, breasts symmetric, no retraction,
lesions, masses
or tenderness
C/L: Back, Thorax & Lungs - chest expansion
symmetric, CTA (clear to auscultation), eupnea,
no adventitious sounds (rales, crackles,
wheezes)
CV (cardiovascular) - RRR no m/r/g (systolic
ejection murmur, rubs, gallops)
Abdomen - soft non-tender w/o masses,
tympany to percussion in all 4 quads, BS

5 Normal Complete ROM against gravity with full

resistance
4 Good Complete ROM against gravity with
some resist
3 Fair Complete ROM against gravity

2 Poor Complete ROM with gravity eliminated

1 Trace Evidence of slight contractility. No joint
motion
0 Zero No evidence of contractility
Nervous - (LOC, DTR's, MMS) - CN II-XII
grossly intact, alert oriented, cooperative
Sensory - pinprick, light touch & vibration
intact; proprioception tested (unable to
differentiate sharp/dull mid-calf
DTR's - all 2+ & = (B); Babinski absent toes
upgoing, downgoing or equivocal
(inconclusive); plantar response in extensor on
(L); Naming & repetition intact; memory 3:3; (B)
Pronator drift - (R)>(L); gaze preference;
neglect; extinguishing sensory (light touch to
ea. ext then to both simultaneously):
extinguishes (L or R) side to direct sen. stim.
Reflex Grading evaluate biceps (C5, C6);
triceps (C6, C7, C8); brachioradialis (C5, C6);
patellar (L2, L3, L4); Achilles (S1, S2);
plantar/Babinski (L4, L5, S1, S2) based on
following scale:
4+ very brisk/hyperactive - clonus
3+ more brisk than average
2+ average/normal
1+ low normal/diminished
0 no response or equivocal
Cranial Nerve Evaluation (using specific
tests)
CN I (Olfactory) - smell mint leaves / tobacco
CN II (Optic) - visual acuity & fundoscopic
CN III (Oculomotor) - pupillary reaction
CN IV (Trochlear) - pupillary reaction
CN V (Trigeminal) - clench teeth, open jaw,
lip/chin test for light touch
CN VI (Abducens) - EOM
CN VII (Facial) - raise eyebrow/frown/show
teeth/smile/puff cheek
CN VIII (Acoustic) - whisper test; Weber/Rinne
tests
CN IX (Glossopharyngeal) - hoarseness,
tongue movement
CN X (Vagus) - saying "ah," & note palate and
uvula move upward
CN XI (Spinal Accessory) - shrug shoulders
CN XII (Hypoglossal) - inspect tongue for
atrophy/fasciculations

greatest diameter that appears to have necrotic

margins, a purulent-looking exudate at the base
of the wound, active rash or lesions, noncyanotic,
nondiaphoretic, Capillary refill is brisk, Intact
without petechia, Multiple cherry angiomas noted.
<HEENT>
No facial plethora, No signs of trauma,
Normocephalic & Atraumatic, Trachea midline.
No carotid or vertebral bruits, The patient has
mild left facial droop, Mucous membranes are
moist. Oropharynx clear. Tympanic membrane
on the left is gray with normal light reflex; the
right has some scarring, but is otherwise normal.
No evidence of infection.

<PHYSICAL EXAMINATION: SAMPLE>

<VITAL SIGN>
 Blood Pressure on Arrival 180/140
 BP now appears to have improved to 98/64
 Pulse Rate 112 Beat Per Minute & Irregular
 Respiratory Rate 21 Cycle Per Minute
 Temperature 36.5C, Axillary
 O2 Saturation 96% on 2 liters on room air
 Weight 182 pounds, which is stable.
 Height 5 feet 6 inches tall
<GENERAL>
A well-developed & well-nourished /morbidly
obese (XX)-year-old male/female, in a mild
amount of / no acute distress, nontoxic,
ambulatory, appears slightly older/younger
than his/her stated age, coughing, sitting in
exam chair / walks into the exam room with a
cane, an alert, oriented, pleasant, a chronically
ill-appearing, looks stable at this point, does
not seem anxious or depressed, Appropriate &
cooperative with exam, resting comfortably,
lying on the bed, in no acute distress, able to
speak in full sentences, a small-for-age with
obvious delays, no acute cardiopulmonary
distress, No cervical, supraclavicular or axillary
adenopathy on either side, exhibits no
lymphadenopathy
<SKIN>
Warm, dry, Normal color & turgor without rash,
No abnormal nevi, ecchymosis, petechiae,
suspicious lesions, with or without diaphoresis,
normal tone, a large decubitus about 3.5 cm in

<EYE>
No Conjunctival Pallor or Icterus, Conjunctivae
clear, Pupils are Equal, Round & Reactive to
Light & Accommodation [PERRLA] Bilaterally,
Extraocular movements intact, Pt does have
some photophobia bilaterally, but no papilledema
appreciable. No nystagmus, Extraocular
movements intact; however, with lateral
deviation of the right eye, pt has increased pain
on that side, Visual fields full to confrontation,
Fluorescein staining of the right eye visualized
under Wood's lamp revealed no evidence of
dendritic cells or obvious abnormalities,
Funduscopic examination normal
<EAR>
Tympanic membranes are clear bilaterally with
tympanostomy tubes in place, No evidence of
vesicles in the right ear; however, extremely
painful to touch. The otoscope placed in external
ear canal causes her a great deal of pain
<NOSE>
Sinuses are nontender
<MOUTH>
Midline is somewhat flattened with well-healed
cleft palate repair, Oropharynx clear,
unremarkable, moist mucous membranes/Buccal
mucosa was slightly dry, Oral cavity smooth,
pink & moist, no oropharyngeal erythema, no
exudate, without masses. Uvula midline, No
retropharyngeal swelling, Moist mucous
membranes, Positive drool present, without
ulceration, with 1 to 2+ tonsillar hypertrophy &

small crypts. No erythema or obstruction,

Dentition is intact without abscesses
<NECK>
Supple, pt had paraspinal tenderness upon
palpation of her levator scapulae muscle &
scalene muscles, No pulsatile mass noted, No
JVD or carotid bruits, No nuchal rigidity, No,
thyromegaly, cervical adenopathy or jugular
venous distention, Accessory nerve appears
intact, C-spine range of motion intact, No neck
stiffness, no meningismus, No palpable
lymphadenopathy, Moderately tender to
palpation with bilateral paracervical & trapezius
musculature. Trachea is midline, a tiny, peasized left posterior node present, Thyroid
nonpalpable
<C&L>
<BREASTS>
Examination of the left breast reveals a biopsy
site in the upper outer quadrant, Beneath this
biopsy site is about 3.5 x 3.5 cm of induration
consistent with a palpable hematoma, No other
abnormalities noted on left breast examination.
The right breast is soft and normal to palpation.
No skin or nipple changes, No axillary
lymphadenopathy, skin retraction or nipple
discharge. No masses palpated
Nipples everted. Right breast without masses
or tenderness. Left breast without masses or
tenderness. No discrete lumps or masses.
Axillary and epitrochlear nodes negative
<CHEST>
Bibasilar crepitations with diminished air entry,
no wheeze heard, Lung sounds clear to
auscultation with a normal respiratory effort, No
respiratory distress, Reduced air entry at the
lung bases, Did not hear any wheezing but did
have harsh breath sounds bilaterally with
slightly prolonged expiratory phase of
breathing, Unremarkable with symmetric chest
movement, no obvious masses or deformities,
Right subclavian line in place, Equal bilateral
breath sounds, normal chest wall excursion,
No wheezes, rhonchi or rales bilaterally, no
rubs, No accessory muscle use noted,
Respirations are even & unlabored, Decreased
breath sounds but essentially clear
<CVS>
Tachycardia/Bradycardic/Regular rate &

rhythm [RRR], Normal S1, S2. No S3, S4 or

murmur, rubs or gallops noted. The PMI is not
displaced, no Palpable Thrill. Carotids without
bruits. Pulses are 2+ and equal bilaterally. Brisk
capillary refill. Port site is clean, dry & intact.
<ABD>
Soft, Flat, nontender & nondistended,
Normoactive/Positive bowel sounds in all 4
quadrants, without masses, no guarding, no
rebound, no tenderness, no palpable
hepatosplenomegaly/organomegaly or rigidity
appreciated. G-tube site is clean, dry, intact.
Centrally obese, soft, Healed laparoscopic
incisions & midline vertical incision from the
umbilicus to the suprapubic area consistent with
surgical history. Had positive fluid thrill, Did have
vague tenderness diffusely without HSM, without
CVA tenderness. Shows ileostomy with a bag in
place. Initially, there were food contents within
the bag and I did not appreciate bleeding. Later
on, I did see a little bit of bright red blood oozing
from the ostomy site. Stoma, however, is pink
and there is no evidence of infection
<BACK>
BACK: Nontender, no CVA tenderness, no stepoff or point tenderness along the entire spine, no
edema, pt does have tenderness to palpation
along the lumbar region. Reveals a vague
midline tenderness to the cervical & lumbosacral
spine extending for approximately C2 through C4
as well as L2 thru L4, no obvious deformity or
step-off noted, exhibits full, but painful range of
motion of her neck & low back predominantly
with flexion & extension of both, capable of axial
rotation without deficit.
SPINE: Without bony tenderness or
paravertebral spasm
<GUT>
GENITOURINARY: Exam is significant for a
normal uncircumcised penis without lesions. His
testes are descended bilaterally without mass.
RECTAL EXAM: Normal rectal tone, deferred.
Exam is significant for normal resting & voluntary
sphincter tone. His prostate is flat, firm, nonnodular, and nontender. No masses. Guaiac
negative.
GYNECOLOGIC: Normal external genitalia:
Tanner stage V, normal, without lesion. Vagina is
pink with minimal rugae. Cervix visualized

midline. Pap obtained/performed, able to easily

put the brush into the os. Bimanual: Negative
for CMT, adnexal tenderness or masses, the
ovaries feel normal. Uterus retroverted, is
normal, no masses. Pt has a slight diminished
rectal sphincter tone.
PELVIC: External genitalia without nodes,
erythema, lesions, swelling. Internal
examination is with rugae. Cervix is
multiparous. Scant clear discharge noted.
Friable. Pap smear obtained. Digene HPV
testing obtained. On bimanual examination,
uterus is midline. Adnexa nontender & without
masses.

Pulses are symmetric and intact. Reveals full

range of motion of all extremities without deficit.
The patient exhibits strong distal pulses, brisk
capillary refill. Gait is normal with normal
alignment of the vertebral column and good
muscle tone of both upper and lower extremities.
Near full ROM of all the major joints. Normal bulk
and tone. Ambulates with a rolling walker and
transfers to exam table with one assist. There
are 2+ carotid pulses, femoral pulses, radial
pulses and pedal pulses.
With varicose veins of lower extremities. No
cyanosis, clubbing or edema. Peripheral
vascular system is intact.
No clubbing, cyanosis or edema.

<EXT>
Exam of the left lower extremity reveals no
obvious swelling, discoloration or deformity.
There is localized tenderness to palpation over
the medial femoral condyle area. There is no
joint effusion appreciated. The patient is able to
straight leg raise and is able to fully flex the
knee with some discomfort. There is no
ligamentous instability. There is no pain with
range of motion of the hip or ankle. The distal
neurovascular status is intact. The patient's
gait is fairly normal. She is overweight.
No cyanosis, clubbing or edema. Strength is
5/5 throughout and symmetric bilaterally. On
bilateral lower extremity exam, she has 5/5
strength but she does have objective
numbness in the bilateral lower extremities,
which is baseline for her due to her CIDP. No
evidence of ataxia. There is no pronator drift.
Reflexes 2+ symmetric bilaterally, upper and
lower extremities. No extremity swelling,
Peripheral pulses are palpable but no
peripheral edema, no calf tenderness or
evidence of tenosynovitis, Strength and
sensation is intact to upper and lower
extremities. DTRs absent upper extremities; 3+
knees, 2+ ankles. Good pedal pulses.
The patient had no cyanosis or clubbing. He
had bipedal edema, pitting, bilaterally.
The patient has bilateral lower extremity
edema. Warm, nonedematous. No obvious
deformity. Without upper or lower extremity
edema. No calf tenderness. No cyanosis, no
clubbing. He has no saddle paresthesias on
exam. No clubbing, cyanosis or edema noted.

<NEURO>
MENTAL STATUS / PSYCHIATRIC: Answers
questions appropriately, GCS was 15, Alert,
cooperative, oriented, follows complex
commands, fluent in speech / dysarthric, intact
attention At baseline, the patient is quite active,
smiling, moving around the bed. Normal /
appropriate mood and affect. Normal judgment,
conversant.
No focal deficits noted. Cranial nerves II through
XII are intact grossly. No focal neurologic deficits
/ no gross motor or sensory deficits. Gait is
normal. Deep tendon reflexes (DTR) in upper
and lower extremities are 2+ bilaterally.
Sensation is intact throughout to pinprick in
upper and lower extremities bilaterally / in all
extremities. Has 5/5 strength in upper and lower
extremities bilaterally, ambulates with a steady
gait. No facial droop. No pronator drift. No
dysmetria or ataxia. Symmetric patellar reflex.
Negative Babinski sign. Negative Romberg sign.
Normal steady gait. Sensation intact to all the
major dermatomes, except decreased to light
touch from the toes up to the lower to mid shins
bilaterally and circumferentially. Gait with
somewhat widened base support, slightly
unsteady, but uses a cane for gait stability
without gross ataxia.
Has intact long-term & short-term memory. The
pt able to register and remember 3/3 words.
Cranial Nerves: Pupils equal, round & reactive to
light and accommodation. Extraocular
movements full & conjugate. Face symmetric,
Facial sensation is intact. Tongue & uvula
midline.

Motor: The patient moves all extremities with

full strength of 5/5. No abnormal fasciculations
or tremors. Sensation intact to light touch &
cold stimulus.
Coordination: No limb ataxia with finger-tonose or heel-to-shin testing. DTRs normal
throughout. The pt has bilateral downgoing
toes with plantar reflex. Gait normal & steady
without assistance.
Visual fields intact, Positive corneal reflex. The
pt has no objective numbness in the V1, V2,
V3 distribution; however, the pt has painful &
burning sensation with palpation of these areas.
Hearing appears unimpaired. Pt has increased
pain to palpation of the pinna, tragus & with the
otoscope insertion of the external canal, a
slight amount of facial droop but no dysarthria.
Uvula & tongue both midline.
<SAMPLE>
Chief Complaint:
"swelling of tongue and difficulty breathing and
swallowing"
History of Present Illness:
77 y o woman in NAD with a h/o CAD, DM2,
asthma and HTN on altace for 8 years awoke
from sleep around 2:30 am this morning of a
sore throat and swelling of tongue. She came
immediately to the ED b/c she was having
difficulty swallowing and some trouble
breathing due to obstruction caused by the
swelling. She has never had a similar reaction
ever before and she did not have any
associated SOB, chest pain, itching, or nausea.
She has not noticed any rashes, and has been
afebrile. She says that she feels like it is
swollen down in her esophagus as well. In the
ED she was given 25mg benadryl IV, 125 mg
solumedrol IV and pepcid 20 mg IV. This has
helped the swelling some but her throat still
hurts and it hurts to swallow. Nothing else was
able to relieve the pain and nothing make it
worse though she has not tried to drink any
fluids because of trouble swallowing. She
denies any recent travel, recent exposure to
unusual plants or animals or other allergens.
She has not started any new medications, has
not used any new lotions or perfumes and has
not eaten any unusual foods. Patient has not
taken any of her oral medications today.
Surgical History:

s/p vaginal wall operation for prolapse 2006

s/p Cardiac stent in 1999
s/p hystarectomy in 1970s
s/p kidney stone retrieval 1960s
Medical History:
+CAD w/ Left heart cath in 2005 showing 40%
LAD, 50% small D2, 40% RCA and 30% large
OM; 2006 TTE showing LVEF 60-65% with
diastolic dysfunction, LVH, mild LA dilation
+Hyperlipidemia
+HTN
+DM 2, last A1c 6.7 in 9/2005
+Asthma/COPD
+GERD
+h/o iron deficiency anemia

Social History:
Patient lives in _______ with daughter _____
(919) _______. Patient does all ADLs and IADLs
with no/little assistance. She does own finances
and drives. Patient has 4 daughters that all live
in the area. Patient does not use tobacco,
alcohol, illicit drugs.
Family History:
Patient's Dad died of liver cirrhosis at age 57,
mom died of heart attack at age 60. She has 6
siblings who most died of cardiac disease. There
is no family history of cancer.
Allergies:
Sulfa drugs - rash
Cipro - rash
Benadryl causes mild dystonic reaction
Medications:
Theophyline (Uniphyl) 600 mg qhs
bronchodilator by increasing cAMP used for
treating asthma
Diltiazem 300 mg qhs Ca channel blocker used
to control hypertension
Simvistatin (Zocor) 20 mg qhs- HMGCo
Reductase inhibitor for hypercholesterolemia
Ramipril (Altace) 10 mg BID ACEI for
hypertension and diabetes for renal protective
effect
Glipizide 5 mg BID (diabetes) sulfonylurea for
treatment of diabetes
Omecprazole (Prilosec) 20 mg daily (reflux)
PPI for treatment of ulcers

Gabapentin (Neurontin) 100 mg qhs

modulates release of neurotransmitters to treat
diabetic neuropathy
Metformin 500 mg qam biguanide used to
treat diabetes
Aspirin 81 mg qam - prophylaxis for MI and TIA
Servant 1puff bid Fluticasone (Flovent) 2 puff bid - corticosteroid
to treat airways in asthma/copd xoperex
1.25mg and Ipratropium 2.5 ml nebulized qam
- anticholinergic to treat airways in COPD
Review of Systems:
Constitutional - NAD, has been generally
feeling well the last couple of weeks
Eyes - no changes in vision, double vision,
blurry vision, wears glasses
ENT - No congestion, changes in hearing,
does not wear hearing aids
Skin/Breast - no rashes
Cardiovascular - No SOB, chest pain, heart
palpitations
Pulmonary - hard to get a breath in but not
short of breath, no cough
Endocrine - No changes in appetite
Gastro Intestinal - No n/v/d or constipation.
Has not eaten because can't swallow solid
foods.
Genito Urinary - No increased frequency or
pain on urination. Some urge incontinence with
history of prolapse.
Musculo Skeletal - no changes in strengths, no
joint tenderness or swelling
Neurologic - No changes in memory
Psychology - No changes in mood
Heme/Lymph - Denies easy bruising
Physical Examination:
Vitals:
Temp 35.9
Pulse 76
O2 98% RA
RR 20
BP 159/111
General - NAD, sitting up in bed, well groomed
and in nightgown
Eyes - PERRLA, EOM intact
ENT - Large swollen tounge and cheek on left
side, tounge was large and obscured the view
of the posterior oropharynx
Neck - No noticeable or palpable swelling,

redness or rash around throat or on face

Lymph Nodes - No lymphadenopathy
Cardiovascular - RRR no m/r/g, no JVD, no
carotid bruits
Lungs - Clear to auscltation, no use of acessory
muscles, no crackles or wheezes.
Skin - No rashes, skin warm and dry, no
erythematous areas
Breast Psychiatry Abdomen - Normal bowel sounds, abdomen soft
and nontender
Genito Urinary Genital exam not performed
since complaints not related.
Rectal Rectal exam not performed since no
symptoms indicated blood loss.
Extremeties - No edema, cyanosis or clubbing
Musculo Skeletal - 5/5 strength, normal range of
motion, no swollen or erythematous joints.
Neurological Alert and oriented x 3, CN 2-12
grossly intact.
Pertinent Diagnostic Tests:
Na 140
K 4.5
Cl 109
Co2 23
BUN 29
Cr 1.0
Ca 9.9
Mg 1.4
Phos 3.6
PTT 26.7
WBC 9.9
Hgb 10.0
Hct 30.3
Plt 373
EKG - no signs of ischemia
Assessment: 77 yo woman presents with
significant angioedema in left side of tongue and
inner cheek. Possible causes of angioedema
include allergic anaphylaxis reaction, drug
induced, allergic contact dermatitis, viral infection,
drug induced, or a C1 inhibitor deficiency
disorder acquired or hereditary. Laryngeal
edema can also be caused by tonsillitis,
peritonsilar abscess or pharyngeal foreign body.
It is unlikely that the patient has edema caused
by abscess or tonsillitis since she does not have
any associated fever or other signs of infection
and the sudden onset of her swelling also argues

against this. It is not likely a foreign body since

ENT did not find anything when they scoped
her.
It is unlikely that it is caused by a mast cell
mediated etiologigy that increases vascular
permeability through mast cell degranulation
and release of inflammatory mediators include
allergic angioedema, autoimmune mast cell
release and direct mast cell release caused by
medications such as opiates and radiocontrast
media. It is not likely this type of reaction
because these etiologies are associated with
urticaria and pruritis, which the patient did not
have. Also the patient did not have any
exposure to a new pet, food, lotion or any other
allergen or medication that could cause an
allergic type reaction. The patient also does not
have any history of autoimmune disease or any
reaction similar to this in the past
It is more likely that the etiology is kinin-related
where angioedema results from generation of
bradykinin and complement-derived mediators
that increase vascular permeability since there
is no urticaria or pruritis. The most likely cause
is the Altace (ACEI) that the patient has been
taking caused an increase in bradykinin since it
decreases angiotensin 2 which degrades
bradykinin. Bradykinin can then interact with
vascular receptors increasing vasodilation,
vascular permeability, increased cGMP and
release of nitric oxide. This reaction occurs
in .1-7% of patients treated with an ACEI and it
typically involves the mouth, lips, tounge,
larynx, pharynx and sublottic tissues. Half of
these cases usually occur within a week of
starting the ACEI but can occur years later.
This is a class specific reaction not a drug
specific and ARBs can cause the same
reaction even though these drugs dont effect
the kinin metabolism. 50% of patients with
angioedema due to an ARB also had an ACEI
induced angioedema (Cicardi, M, Zingale, LC,
Bergamschini L, Agostoni, A. Angioedema
associated with agniotensin-converting enzyme
inhibitor use: outcome after switching to a
different treatment. Arch Intern Med 2004;
164:910). Deficiency of C1 inhibitor can cause
angioedema since levels of complement are
reduced and cause increased bradykinin. This
can be due to lack of C1 INH or adequate
amounts of nonfunctional C1 INH. Other
causes of angioedema include aspirin and

NSAIDs since inhibition of cox and enzyme

pathyway increases formation of proinflammatory leukotrienes.
Other possibilities in the differential of causes of
swelling include cellulitis, autoimmune conditions
including SLE, polymyositis, dermatomyositis
and sjorgrens syndrome. Hypothyroidism can
cuase puffiness of face and lips, hyperthyroidism
can cause an infiltrative dermopathy, superior
vena cava syndrome and tumors can cause
venous engorgement and swelling. It is not likely
one of these etiologies since the patient is on an
ACEI and the swelling is restricted only to her
tongue and throat typical of ACEI angioedema.

Plan:
++Swollen tongue:
- Give patient corticosteroid to decrease
inflammation and to protect against relapse after
initial improvement. 4 days of Dexamethasone
10 mg IV tid.
- Give patient antihistamine to block
inflammation as well. 4 days of Diphenhydramine
25 mg bid.
- ENT consult to rule out abscess or foreign
object
- Check C1 and C4 levels that would be
decreased if the patient had C1 inhibitory
complement deficiency
- TSH level to check for hypo/hyper thyroid
- Hold all oral home meds and keep patient NPO
until airway swelling is reduced and patient can
swallow easily
++Asthma/COPD
- continue albuterol and ipratropium nebs prn
- resume theophylline when patient can take oral
meds
++DM
- Not on oral home meds
- Patient is on corticosteroids that increase blood
glucose levels, so put patient on sliding scale
normal insulin to adjust for high sugars
- Resume neurontin for neuropathy when oral
meds can be taken
++HTN

- Continue patients BP control with Diltiazem

drip 5mg/hour
- HOLD altace (ACEI) that is
most likely the cause of angioedema
- Consider an alternative HTN medication to
replace the ACEI. Cant use a HCTZ because
of sulfa allergy. Also has asthma/COPD picture
so beta blocker may not work well either.
++CAD s/p PCI in 1999
- Resume simvastatin and aspirin when patient
is able to take oral meds
++GERD
- famotidine when oral meds are resumed

SOAP Notes Format

SOAP stands for Subjective, Objective,
Assessment, and Plan
Standard Elements of SOAP note
Date: 12/01/2015
Time:
Provider:
Vital Signs:
Height, Weight, Temp, B/P, Pulse

S: This ___ yr old fe/male presents for ____

History of Present Illness symptoms:
Review Of Symptoms/Systems: (For problem-focused
visit, document only pertinent information)
Past Medical History: (For problem-focused visit,
document only pertinent information)
Current Medications:
Medication allergies:
Social History: (For problem-focused visit, document
only pertinent information)
Family History: ((For problem-focused visit, document
only pertinent information)
Genogram: 3 generations with health problems, causes
of deaths, etc. or History of major health or genetic
disorders in family, including early death, spontaneous
abortions or stillbirths.
History of Present Illness:
Location:
Quality
Severity:
Duration:
Timing (Onset):
Timing (Frequency):
Context:
Relieved by:
Worsened by:
Associated signs & symptoms:
Social History:
Cultural Background:
Education Level:
Economic Condition:
Housing:
Number in household:
Marital Status:
Lives with:
Children:
Occupation:
Occupational Health
Hazards:
Nutrition:
Exercise:
Tobacco use:

Caffeine:
Sexual activity:
Contraception:
Alcohol/recreational drug use:
Past Medical History
Hospitalizations:
Surgical History:
T&A:
Appendectomy:
Hysterectomy:
Hernia:
Coronary Artery Bypass:
Other:
Chronic Medical Problems:
Hypertension
Diabetes
Coronary Heart Disease
Cerebrovascular Disease
Asthma or other COPD
Arthritis
Gout
Renal Disease
Thyroid Disease
Other:
Psychiatric History:
Depression
Anxiety
Substance Abuse
Other:
Immunizations:
Polio
Tetanus
Last PPD
Cholera
Childhood Illnesses:
Transfusions:
Allergies:
Review Of Symptoms (Systems):
Constitutional:
Eyes:
Ears, Nose, Mouth, Throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Skin and/or breasts:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:

Family History
Is there a family history of
Cancer:
Hypertension:
Hyperlipidemia:
Diabetes Type II:
Coronary Artery Disease:
Stroke:
Alzheimer's:
Depression:
Osteoporosis:
Domestic violence:

O:
(listed are the components of the all normal physical
exam)
General: Well appearing, well nourished, in no distress.
Oriented x 3, normal mood and affect .
Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising or
prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable
masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera nonicteric, EOM intact, PERRL, fundi have normal optic
discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl
appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed,
septum and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease.
No gingival inflammation or significant resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy
or exudate
Neck: Supple, without lesions, bruits, or adenopathy,
thyroid non-enlarged and non-tender
Heart: No cardiomegaly or thrills; regular rate & rhythm,
no murmur or gallop
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness,
organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no
CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or
masses palpable
Extremities: No amputations or deformities, cyanosis,
edema or varicosities, peripheral pulses intact
Musculoskeletal: Normal gait and station. No
misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of
motion, instability, atrophy or abnormal strength or tone
in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch,
and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote
memory, judgment and insight, normal mood
and affect.

Pelvic: Vagina and cervix without lesions or discharge.

Uterus and adnexa/parametria nontender without masses.
Breast: No nipple abnormality, dominant masses,
tenderness to palpation, axillary or supraclavicular
adenopathy.
G/U: Penis circumcised without lesions, urethral meatus
normal location without discharge, testes & epididymides
normal size without masses, scrotum without lesions.

A:
Assessment:
Includes health status and need for lifestyle changes.
Diagnosis and differential diagnosis:

P:
Laboratory:
X-Rays:
Medications:
Patient Education:
Other:
Follow-up:

<DIFFERENTIAL DIAGNOSIS>
Diagnostic Checklists
a. Possible to cover 99% of diagnostically
challenging complaints with a short list,
whereas 100% coverage would require a long
list.
b. Similarly, for each complaint, possible to
cover 99% of the diseases that cause it with a
short list.
c. No checklists for complaints that rarely pose
diagnostic challenges, either because the list of
causes is short (e.g., constipation, rectal
bleeding, breast lump, sore throat, nasal
congestion), the diagnosis is obvious (e.g.,
minor trauma, wart), or there is a single cause
that accounts for the overwhelming majority of
cases (e.g., hypertension, obesity).
d. The checklists do not include diagnoses that
are exceedingly rare in North America, or Dxs
that are obvious (e.g., major chest trauma as a
cause of chest pain), or Dxs where the
symptom is a late manifestation rather than a
presenting complaint (e.g., abnormal uterine
bleeding caused by end-stage renal disease).
e. The diagnoses are listed in approximate
order of decreasing prevalence (most common
diseases at the top), based on limited
published data and the authors' experience.
(Cherry DK, Hing E, Woodwell DA,
Rechsteiner EA. National Ambulatory Medical
Care Survey: 2006 Summary. National Health
Statistics Reports. Number 3. August 6, 2008.)
f. Unless otherwise specified, the checklists
address complaints by adults rather than
children.
g. These checklists may have four advantages
over more traditional differential diagnoses:
h. A shorter list, practical at the point of care
i. An indication of disease prevalence in
primary care
DDx: Differential Diagnosis
 () Ace of Spades = "Must-not-miss"
Diagnoses
 (*) Asterisk = Commonly Missed
Diagnoses
 Schiff GD, Hasan O, Kim S, Abrams R,
Cosby K, Lambert BL, et al. Diagnostic
error in medicine: analysis of 583
physician-reported errors. Arch Intern Med.
2009;169:1881-7
 Zwaan L, de Bruijne M, Wagner C, Thijs A,

Smits M, van der Wal G, et al. Patient record

review of the incidence, consequences, and
causes of diagnostic adverse events. Arch
Intern Med. 2010 Jun 28;170(12):1015-21)
*DYSPNEA - SHORTNESS OF BREATH:
"ACUTE DYSPNEA"
A - Asthma - Airway obstruction, Angioneurotic
Edema, Aspiration, Altitude sickness
C - COPD, Carbon Monoxide toxicity
U - Upper Motor Neuron Lesion or Event
T - Tracheal Obstruction / Tamponade
E - Endocrine: Hyperthyroid / Environmental
Inhalation
D - Deformed Chest Wall: Flail Chest
Y - hYperventilation syndrome
S - Sarcoid / Shock
P - 5 P's/Pleuritic Pain
 Pericarditis
 Pulmonary Embolus
 Pneumomediastinum
 Pleurisy/pneumonia
 Pneumothorax
N - Neoplasm
E - Edema/Pulmonary: Cardiac & Non-cardiac
A - Anemia, Acidosis: DKA, AKA, Salicylism
Dyspnea, Tachypnea (2/11/10)
*Pneumonia
*Heart failure
*Pulmonary embolus
*Myocardial infarction
*Anemia
*Tumor
Pneumothorax
Cardiomyopathy
Shock
Pleural effusion
Valvular heart disease
Pulmonary hypertension
Metabolic acidosis
Cardiac tamponade
Upper airway obstruction
Hyperthyroidism
Foreign body aspiration
Increased intracranial pressure
*Psychiatric, hyperventilation
Asthma, chronic obstructive pulmonary disease
Fever
Deconditioning
Physiologic dyspnea of pregnancy
Bronchitis

Interstitial fibrosis
Drugs (ASA)
Arrhythmias, atrial fibrillation
Abdominal distension, obesity
Myasthenia gravis
 Dyspnea = Lisud ang ginhawa
 Respiratory
 Aspiration
 Airway Obstruction
 Asthma
 COPD
 Acute Bronchitis
 Chronic Bronchitis
 Pneumonia
 Diffuse Interstitial Lung Disease
 Spontaneous Pneumothorax
:Presence of Gas in the Pleural
Space without Antecedent Trauma
 Acute Pulmonary Embolism
 Pleural Effusion
 Cor Pulmonale
 Cardiac
 Angina Pectoris
 Myocardial Infarction
 Cardiomyopathy
 Left Sided CHF
 Pericarditis
 Arrhythmia
 Systemic
 Anemia
 Acute
 Severe
 Chronic
 Metabolic Disorders
 Metabolic Acidosis
 Diabetic Ketoacidosis
 Acute Intoxications
 End-Stage Liver Disease w/t Ascites
 Pregnancy & Panic Attack

Description of
DYSPNEA
Chest Tightness
/ Constriction




Increased Work
or Effort of
Breathing




Air Hunger, Urge

to Breathe

Unable to get
Deep Breaths,
Unsatisfied

Heavy, Rapid
Breathing, More
Breaths

Pathophysiology of
DYSPNEA
Bronchoconstriction
Interstitial Edema
 Asthma
 Myocardial
Ishemia
Airway Obstruction
Neuromuscular Disease
 COPD
 Moderate-Severe
Asthma
 Myopathy
 Kyphoscoliosis
Increased Drive to
Breath
 CHF
 Pulmonary
Embolism
 Severe Airflow
Obstruction
Hyperinflation
 Asthma
 COPD
Restricted Tidal Volume
 Pulmonary
Fibrosis
 Chest Wall
Restriction
Deconditioning

() Ace of Spades = "Must-not-miss"

Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
COUGH & HEMOPTYSIS *COUGH:
"HACKING"
H - Hilar adenopathy: Sarcoid, TB, Hodgkins...
A - Aneurysm, Asthma, Bronchospasm,
Aspiration, Autoimmune Lung DZ
C - Congestive Heart Failure, Cerumen
Impaction
K - Killer Neoplasms
I - Infections: Viral, Bacterial, TB,
Fungal...Pnemonia/Bronchitis, Infarcted Lung PE, Inhalation - occupational
N - Nasal Drip
G - Growth on vocal cord
Cough, Dyspnea (Infant, Newborn) (2/16/10)

Sepsis

Pneumothorax

Pneumonia

Heart disease

Viral upper respiratory infection

Respiratory syncytial virus (RSV)

Transient tachypnea

Infant respiratory distress syndrome

Metapneumovirus

Asthma
Cough (6/2/10)

*Pneumonia

*Pulmonary embolus

*Heart failure

*Tumor

*Tuberculosis

Pertussis

Epiglottitis

Acute histoplasmosis

Sarcoidosis

Cystic fibrosis

Laryngeal tumor

Mitral stenosis

Foreign body

*Drugs (Angiotensin Converting Enzyme
Inhibitors, Beta Blockers, Amiodarone)

Viral upper respiratory infection

Postnasal Drip

Postinfectious, Postviral Cough

Bronchitis

Asthma, Chronic Obstructive Pulmonary
Disease

Gastroesophageal Reflux
External or middle ear disease
Aspiration, recurrent
Psychogenic
Interstitial Lung Disease
Bronchiectasis

*HEMOPTYSIS : "HEMOPTYSIS"
H - Hereditary hemorrhagic telangiectasia
E - Epistaxis
M - Mitral stenosis
O - Oropharyngeal lesion
P - Pulmonary Embolus, Pulmonary Edema,
Pulmonary hypertension
T - Tumors, carcinomas
Y - CYstic Fibrosis
S - Sequestration
I - Infection - Bronchitis, Bronchiectasis, fungus,
abcess, pneumonia, TB
S - Swallowed foreign body
 Cough & Hemoptysis
 Upper & Lower RT
 Laryngitis
 Tracheobronchitis
 Sinusitis
 Postnasal Drip
 Foreign Body / Chronic Aspiration
 Chronic Bronchitis
 Irritating Particles / Chemicals / Gas
 Bronchiectasis
 Asthma
 LUNG Parenchyma
 Bacterial Pneumonias
 Viral Pneumonia & Mycoplasma
 Pulmonary Tuberculosis
 Pulmonary Embolus
 Lung Abscess
 Lung Cancer
 Non-Respiratory Origin
 Left Sided CHF
 Mitral Stenosis
 Severe GERD (GastroEsophageal
Reflux Disease)
 Malignancies
 ACE: Angiotensin-Converting Enzyme
inhibitor

Pulmonary Medicine Clinical Pearl

 Oral exhaled nitric oxide level
measurements may be useful in guiding
step therapy in asthma, along with other
parameters of asthma control.
 Morbidly obese patients with difficult to
control asthma should be evaluated for
nocturnal hypoxemia, candidacy for
bariatric surgery/weight loss program &
anti-reflux measures. Asthma-related
symptoms may be significantly improved
by weight loss & interim use of
noninvasive nocturnal ventilation.
 Consider alternative diagnoses such as
vocal cord dysfunction, subglottic
stenosis, tracheobronchomalacia, &
foreign body aspiration in patients with
central, nonpositional wheezing that
does not easily improve with inhaled
bronchodilators.
 Consider checking an overnight oximetry
in patients with severe COPD, especially in
patients with pulmonary hypertension out
of proportion to their level of COPD.
 Nitrofurantoin can be associated with
acute pulmonary infiltrates that mimic
community acquired pneumonia with
fever, cough & alveolar infiltrates or a
less reversible presentation with
progressive interstitial fibrosis.
 Inhaled corticosteroids can have adverse
topical effects including reversible
dysphonia that is generally amenable to
several practical interventions.
 Patients with suspected ABPA/ABPM e.g.
with uncontrolled asthma & central
bronchiectasis, should be treated with
oral +/- high dose inhaled
corticosteroids.
 In patients with acute exacerbations of
COPD who are placed on oxygen at
hospital discharge, reassessment of long
term oxygen requirements should be
performed once clinically recovered back to
baseline or at 4-6 weeks.

Chest Pain *CHEST PAIN: "An Aching Heart

Can Play A Part"
A - AORTIC DISSECTION
A - ANXIETY: Hyperventilation Syndrome
(Diagnosis of Exclusion ! )
H - HEART: Angina - effort & spasm, Acute
Myocardial Infarction, Valvular - AI, MS, MVP,
IHSS
C - CHEST WALL:
Trauma
Fracture Strain
Herpes Zoster
Costochondritis
Tietzie's syndrome
Breast lesions
P - PLEURITIC PAIN: "5P's
Pericarditis
Pulmonary Embolus, Pneumothorax,
Pleurisy: infiltrate or inflammation,
Pneumomediastinum
A - ABDOMINAL: Peptic Ulcer Disease, Gall
Stones, Esophagitis, Reflux, Pancreatitis
P - PERICARDIAL DISEASE
 Chest Pain
 Cardiovascular
 Angina Pectoris
 Ischemic Cardiac Pain
 Myocardial Infarction
 Pericarditis
 Precordial
 Retrosternal
 Diffuse Aortic Aneurysm
 Valvular Disorders
 Pulmonary
 Pulmonary Hypertension
 Pulmonary Embolism
 Tracheobronchitis
 GI Irritation
 Reflex Esophagitis
 GERD (Gastro-Esophageal Reflux
Disease)
 Diffuse Esophageal Spasm
 Thorax
 Pleurisy: Increased Pain with
Inspiration & Movement
 Costochondral Diseases
 Neuritis
 Chest Wall Pain
 Anxiety

Palliative /
Provocative

Exertion

Pressi
ng

Region
/
Radiati
on
Retrost
ernal

Squee
zing

Shoulde
rs

Qualit
y

Exposure to
Cold

Tight

Jaw

Stress

Heavy

Neck

Burnin
g

Left
Arms

Sever
ity

Mild
Mode
rate
Disco
mfort

Timing

1-3 mins
2 to 10 mins
up to 20
mins

Symptoms

Disease

Dyspnea
Nausea

Stable Angina
Pectoris
(CSAP)

Swelling

Pressi
ng

Lower Levels
of Exertion

Squee
zing
Sever
e

Tight

10-20 mins

Unstable Angina
(UA)

At Rest
Heavy
Burnin
g
Pressi
ng

Nausea
Vomiting

Squee
zing
Unrelieved
by
Nitroglycerin

Often
Sever
e

Tight

20 mins to
several
hours

Sweating
Weak

Acute Myocardial
Infarction
(NSTEMI / STEMI)

Heavy
Heart Failure
Burnin
g

Arrhythmia

Pressi
ng
Squee
zing
Systolic Murmur
radiating to
Carotids

Tight

Aortic Stenosis

Heavy
Burnin
g

Relieved by
Sitting up or
Lean
Forward

Relieved by
Sitting up or
Lean
Forward

Sharp
Knifeli
ke

Underlying Illness
Precord
ial

Often
Sever
e

Persistent

Sever
e

Persistent

Pericardial
Friction Rub

Retrost
ernal
Crushi
ng

Tearin
g
Rippin
g
Knifeli
ke

To Left
Shoulde
r

Betwee
n
Shoulde
rs

Pericarditis
Precordial

Underlying Illness
Pericardial
Friction Rub

Pericarditis
Retrosternal

Murmur of Aortic
Insufficiency

Radiatin
g to
Back

Pericardial Rub
Abrupt
Onset

Pericardial
Tamponade

Aortic Dissection

Loss or
Peripheral Pulses

Pleurit
ic

Side of
Embolis
m

Dyspnea /
Tachypnea /
Tachycardia /
Hypotension

Pulmonary
Embolism

Pleurit
ic

Unilater
al /
Localize
d

Dyspnea / Cough
/ Fever / Rales /
Rub

Pneumonia /
Pleuritis

Dyspnea /
Decreased
Breath Sounds

Spontaneous
Pneumothorax

Pleurit
ic

Abrupt
Onset

() Ace of Spades = "Must-not-miss"

Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
<Chest pain (6/17/10)>

*Coronary Disease (Myocardial Infarction,
Angina)

*Pulmonary Embolus

*Pneumonia, Bronchitis

*Dissecting Aortic Aneurysm

*Tumor

*Spinal Cord Compression

Aortic Stenosis

Esophageal Rupture

Pneumothorax

*Psychiatric

Chest Wall Pain

GERD

Pleurisy, Pleuritis

Herpes Zoster

Esophageal Spasm

Pericarditis, Myocarditis

*ROS Review of Systems:

() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
GEN = General & Skin: Weight Change,
Fever/Chills, Night Sweats, Skin Rash, Itching,
Mole Change, Skin Cancer, Abnormal Bleeding
or Bruising, Anemia, Pica, HIV risk factors,
Lymphadenopathy, Fatigue
Weight loss (1/20/10)
*Malignancy
*Tuberculosis
Hyperthyroidism
HIV
Depression
Adrenal insufficiency
Uremia
*Diabetes
Chronic obstructive pulmonary disease
Drugs
Dementia
Eating disorder
Anorexia of aging
Liver disease
Intestinal parasites
Malabsorption
Inflammatory bowel disease
Weakness, fatigue, malaise, vague symptoms
(3/2/10)
*Infections, infectious mononucleosis,
hepatitis, pneumonia
*Anemia
*Myocardial infarction
*Heart failure, myocarditis
Depression, anxiety
Pregnancy
Hypothyroidism, hyperthyroidism
Hypokalemia, hyponatremia
Celiac disease
Disturbance of calcium, phosphorus,
magnesium
Polymyalgia rheumatica/Temporal arteritis
Adrenal insufficiency, Addisons disease
Botulism
*Drugs (beta blocker, clonidine, alcohol)
Obstructive sleep apnea
Deconditioning
Chronic fatigue syndrome, fibromyalgia
Vitamin D deficiency
Parkinson disease

Hypogonadism
Myasthenia gravis
Pulmonary, hepatic, renal failure
Multiple sclerosis
B12 deficiency
Black widow spider bite
Fever (acute, uncertain source) (6/29/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Malignancy, tumor lysis syndrome
*Myocardial infarction
*Pulmonary embolus, deep vein thrombosis
Infections (pulmonary, gastrointestinal, urinary,
sinusitis, skin, meningitis, bone, infectious
mononucleosis, occult abscess)
Polymyalgia rheumatica
Malignant hyperthermia
Neuroleptic malignant syndrome
Transfusion reaction
Stroke, subarachnoid hemorrhage, intracranial
hemorrhage
Serotonin syndrome
Necrotizing fasciitis
Bowel ischemia, infarction
Hyperthyroidism
Endocarditis
Surgical site inflammation (seroma, hematoma)
Gout
Connective tissue disorder
Pancreatitis
Drugs (antibiotics, heparin, phenytoin)
Drug withdrawal (alcohol, opiates, barbituates,
benzodiazepines)
*PEDAL EDEMA - UNILATERAL "BIG TOES"
B - Baker Cyst Rupture, Bleed into muscle
I - Insufficient Veins
G - Groin/Pelvic Mass Obstructing Lymph Flow Gout
T - Thrombophlebitis - Trauma/Fracture/Sprain Tendon Rupture - Plantaris Longus or Achilles
tendon
O - Osteomyelitis/Cellulitis
E - Elephantiasis - Lymph obstruction
S - Sting/Allergic Reaction to contact or bite
*PEDAL EDEMA - BILATERAL: "Can Large
Legs Ruin Thin Veins"
C - Congestive Heart Failure, Constrictive
Pericarditis

L - Liver: Cirrhosis, portal hypertension, L Lymph obstruction

R - Renal: Nephrotic Syndrome
T - Thyroid: Pretibial Myxedema
V - Venous Insufficiency
Edema, leg (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Heart failure
*Pelvic Tumor
Deep vein thrombosis
Myxedema
*Drugs (NSAIDS, Ca channel blockers,
steroids)
Venous insufficiency, dependency, garments
Obstructive sleep apnea (resulting in
pulmonary hypertension)
Baker's cyst rupture
Ruptured gastrocnemius
Reflex sympathetic dystrophy
Idiopathic
Hypoalbuminemia
Cirrhosis
Lymphedema
Renal failure, nephrotic syndrome
*PRURITIS: "ITCHING"
I - Insulin Deficiency: Diabetes
T - Thyroid: Hyper or Hypo
C - Conjugated Bilirubin: Jaundice - Calcium:
Hyper or Hypo
H - Hodgkins, Leukemia, Lymphoma - Heat:
Dry skin, Hyperthyriodism - Hookworm
I - Increased RBC's: Polycythemia Vera Intrauterine Pregnancy
N - Non Organic: Neurodermatitis, Anxiety,
Drugs
G - Glomerular Disease: Uremia
Pruritus (6/17/10)
HIV
Malignancy (Hodgkins lymphoma,
polycythemia vera)
Thyroid disease
Dry skin
Atopic dermatitis
Contact dermatitis
Urticaria
Lichen simplex chronicus
Scabies

Diabetes
Drugs (narcotics, allergic reaction, cholestasis)
Pregnancy, third trimester
Psychiatric (delusional parasitosis)
Cholestasis
Lichen planus
Dermatitis herpetiformis
Renal disease
Iron deficiency anemia
*PALMAR RASH "PALM GREASE"
P - Psoriasis
A - Atopic Dermatitis
L - Lips: Hand - Foot - Mouth Disease
M - Meningococcemia
G - Gonococcemia
R - Rocky Mountain Spotted Fever
E - Erythema Multiforme
A - Allergic/Contact Dermatitis
S - Syphilis - Secondary Lues
E Eczema
Rash, generalized (7/23/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Drug Reaction
Toxic Shock Syndrome
Viral Exanthem Rocky Mountain Spotted Fever
Fifth Disease
Lyme Disease
Mycosis Fungoides
Erythema Multiforme
Scarlet Fever
Stevens-Johnson Syndrome
Kawasaki's Disease
Secondary Syphilis
Meningococcemia
Eczema, Atopic
Contact Dermatitis Rubella
Insect Bites Measles
Urticaria
Poison ivy
Folliculitis
Seborrheic Dermatitis
Psoriasis
Tinea Corporis
Guttate Psoriasis
Candida
Keratosis Pilaris
Pityriasis Rosea
Lichen Planus

Roseola
Scabies
Numular Eczema
Miliaria Rubra (Prickly Heat)
Dermatitis Herpetiformis
Id Reaction
Unilateral Lateral Thoracic Syndrome
Chicken Pox (Varicella)
HIV Acute Exanthem
Lupus (Subacute Cutaneous)
Sweet's Syndrome
CLUBBING: "CLUB"
C - Cardiac: SBE, Congenital heart disease Congenital clubbing - benign
L - Lung: Carcinoma, chronic infection (TB..)
U - Ulcerative Bowel disease
B - Biliary Cirrhosis
* ANEMIA: MACROCYTIC = "BIG FAT RED
CELLS"
B-B12 Malabsorbtion
I-Inherited
G-Gastrointestinal disease or surgery
F-Folic Acid Deficiency
A-Alcoholism
T-Thiamin responsive
R-Reticulocytes miscounted as large RBCs
E- Endocrine - hypothyroid
D-Dietary
C-Chemotherapeutic Drugs
E-Erythro Leukemia
L- Liver Disease
L- Lesch-Nyhan Syndrome
S-Splenectomy
*ANEMIA: NORMOCYTIC = "NORMAL SIZE"
N - Normal Pregnancy
O - Over hydration
R - Renal Disease
M - Myelophthistic
A - Acute Blood loss
L - Liver Disease
SI - Systemic Infection or Inflamation
Z - Zero production - Aplastic
E - Endocrine: Hypothyroid, Hypoadrenal,
Decreased androgen
ANEMIA: MICROCYTIC = "TICS"
T - Thalassemias
I - Iron Deficiency: Source: GI Bleed 56%
Menses 29% Diet 19%

C - Chronic Inflammation
S - Sideroblastic -lead toxicity
ANEMIA: HEMOLYTIC : "HEMATOLOGIST".
H - Hemoglobinopathy: Hb SS, SC, S beta Thal,
Hemoglobinuria: Paroxysmal Nocturnal
Hemoglobinuria
E - Enzyme Deficiency- Inherited Pyruvate
Kinase (PK) deficiency, pyrimidine-5'nucleotidase deficiency
M - Medication - Drug induced immune hemolytic
anemias
A - Antibodies, autoimmune
T - Trauma to the red cells. Fragmentation
(Microangiopathic)
O - Ovalocytosis - An autosomal dominant
disorder of pt from South East Asia. S&Sxs are
minimal.
L - Liver disease
O - Osmotic fragility in Hereditary spherocytosis
& Hereditary Eliptocytosis
G - G6PD: Glucose - 6 - Phosphate
Dehydrogenase Deficiency
I - Infection: Intra-erythrocytic parasites (malaria
& babesiosis)
S - Splenic destruction in hyperslenism.
Splenomegaly
T - Transfusion related - Thalassemias
*CLOTTING DISORDERS
Bleeding too much CALF DIPS
C - Cirrhosis/Liver Disease & Coumadin
A - Aspirin & other drugs NSAIDs
L - Leukemia, Lupus anticoagulant
F - Factor Deficiency Hemophilia
D - Disseminated Intravascular Coagulation
I - Idiopathic Thrombocytopenic Purpura
P - Platelet Deficiency (TTP, HUS, DIC, HeparinHIT) or Platelet Dysfunction (vWD)
S - Scurvy: Vitamin C Deficiency
Clotting Too Much 5 Ps HAD CAUSED
CLOTs
P - Pregnancy - Increased blood viscosity,
fibrinogen & factor VIII / Postpartum Hypercoaguability
P Prothrombin 20210 mutation,
P - Protien S, C, deficient Inherited
P - Polycythemia vera - increased viscosity
P Paroxysmal Nocturnal Hemoglobinuria
S- Smoking
H HIT Heparin Induced Thrombocytopenia,

*DISSEMINATED INTRAVASCULAR
COAGULATION: "D.I.C.s"
D - Disseminated Infection/Sepsis
I - Intrauterine Pregnancy: Toxemia, Abruptio,
Dead Fetus
C - Carcinomas
S - Shock / Stroke (Heat)

RETICULOENDOTHELIAL, HEMATOLOGIC
SYNDROME
BANTI'S SYNDROME: Chronic Congestive
Splenomegaly with anemia, caused by either
Portal
Hypertension or Splenic Vein Thrombosis.
BUD-CHIARI SYNDROME:
o ACUTE: Hepatic Vein Thrombosis ------>
Massive ascites and dramatic death.
o CHRONIC: Gradual hepatomegaly, portal
hypertension, nausea, vomiting, edema,
ulimately death.
DUBIN-JOHNSON SYNDROME: Defect in
excretion of conjugated bilirubin ------> recurrent
mild jaundice. Buildup of direct builirubin in blood.
CHIDIAK-HIGASHI SYNDROME:
Abnormalities
in leukocytes with large inclusions.
CRUVEILHIER-BAUMGARTEN SYNDROME:
Symptoms cluster:
o Liver cirrhosis
o Caput Medussae
o Venous hum and thrill
FELTY'S SYNDROME: Rheumatoid Arthritis
with
splenomegaly, leukopenia, anemia, and
thrombocytopenia.
LOFFLER'S SYNDROME: Eosinophilia with
transient infiltrates in lungs.

*SICKLE CELL DISEASE COMPLICATIONS:

"HBSS PAIN CRISIS"
H - Hemolysis, Hand - Foot syndrome
B - Bone Marrow Hyperplasia/Infarction
S - Skin ulcers (primarily leg)
S - Stroke: Sub Arrachnoid Bleeds/Thrombotic
P - Pain Crisis, Priapism, Psychosocial
Problems
A - Aplastic Crisis, Anemia, Avascular Necrosis
I - Infections: CNS, Bone, Joints, GU,
Pulmonary
N - Narcotic side effects/ tolerance/
dependence
C - Cholelithiasis, Cardiomegally, Congestive
Heart Failure
R - Retinopathy, Renal Failure, Renal
concentrating Defect
I - Infarction: Bone, Muscle, CNS, Bowel,
Renal, Spleen
S - Sequestration Crisis: Spleen/Liver
I - Infertility
S - Sepsis

INFECTIOUS SYNDROME
FITZ-HUGH-CURTIS SYNDROME:
Gonococcal
Periphepatitis in woman, as a complication of
Gonorrhea.
GUILLAN-BARRE SYNDROME: Infectious
Polyneuritis of unknown cause.
HUNT'S SYNDROME: Herpe's Zoster infection
of
Facial Nerve (CN VII) and Geniculate Ganglion ----> facial palsy.
o Zoster of ear
REYE'S SYNDROME: Loss of consciousness
& seizures in kids, after a viral infection treated
by aspirin.
REITER'S SYNDROME: Symptom cluster.
Etiology is thought to be Chlamydial or
postchlamydial.
o Urethritis
o Iridocyclitis (Conjunctivitis)
o Arthritis

Hyperhomocyteinemia
A Antithrombin III Deficiency
D Dysfibrinogenemia
C CHF or Congestive Heart Failure
A Antiphospholipid Syndrome
U Uremia Chronic Renal Failure
S Surgery Orthopedic is greatest risk
E Estrogen
D Diabetes
C - Cholesterol elevation, Cancer procoagulant effects,
L Leiden Factor V mutation Activated
Protein C resistance
O Obesity & Cholesterol elevation
T Trauma
 Travel (immobility) - Stasis of blood flow &
release of tissue throboplastin in trauma
 T Thyroid disease hyper or hypo
S Sepsis

o Skin lesions like karatoderma

blenorrhagicum
o Also can see fatty liver or liver necrosis.
SCALDED SKIN SYNDROME: S. Aureus
toxic
epidermal necrolysis.
STEVENS-JOHNSON SYNDROME:
Erythema
Multiforme complication.
o Large areas of skin slough, including mouth
and anogenital membranes.
o Mucous membranes: stomatitis, urethritis,
conjunctivitis.
o Headache, fever, malaise.
TOXIC SHOCK SYNDROME: Caused by
superabsorbent tampons. Infection with Staph
Aureus and subsequent toxicity of exotoxin
TSST ------> systemic anaphylaxis.
o Fever, vomiting, diarrhea
o Red rash followed by desquamation
WATERHOUSE-FRIEDRICHSON
SYNDROME: Meningeococcal Meningitis -----> DIC, hemorrhagic infarct of adrenal glands ----> fulminant adrenal failure.
o Vomiting, diarrhea.
o Shock
o Extensive purpura, cyanosis, circulatory
collapse.
NEOPLASTIC SYNDROME (Malignant or
Benign)
CARCINOID SYNDROME: Carcinoid tumor
producing Bradykinin + Serotonin ------>
secondary symptoms:
o Cyanotic flushing
o Diarrhea
o Bronchial spasm
o Edema, ascites.
CRONKHITE-CANADA SYNDROME:
GIPolyps
with diffuse alopecia (hair-loss) and nail
dystrophy.
o May see protein-losing enteropathy and
malabsorption.
GARDNER'S SYNDROME: Multiple
inherited tumors, hereditary dominant trait.
o Skull osteomas, Fibromas, Epidermoid
cysts
o Colonic polyposis (APC gene) ------>
predisposition to colonic
adenocarcinoma.

LAMBERT-EATON SYNDROME:
Progressive proximal muscle weakness
secondary to a carcinoma.
MEIGS' SYNDROME: Fibroma of ovary with
ascites and hydrothorax
PANCOAST SYNDROME: Tumor near
pulmonary apex ------>
o Neuritic pain of chest and arm
o Muscle atrophy of the arm
o Horner's Syndrome (impaired cervical
sympathetics)
PEUTZ-JEGHERS SYNDROME: Polyposis
(hamartomas) of small intestine
o Also see melanin pigmentation of buccal
mucosa and skin around mouth & lips
UNCATEGORIZED SYNDROME
YELLOW-NAIL SYNDROME: Stop growth
of nails ------> increased convexity, thickening,
and yellowing of nails.
o Found in Lymphedema, bronchitis,
chronic bronchiectasis.
COSTOCHONDRAL SYNDROME: Pain in
chest with tenderness over one or more
costochondral junctions.
o Similar to Tietze's Syndrome but no
specific inflammation.
TIETZE'S SYNDROME: Costochondritis.
Swelling and tenderness of the costal cartilege.
MIKULICZ'S SYNDROME: Salivary and
lacrimal enlargement as seen in several
diseases:
o Sarcoidosis
o Tuberculosis
o Leukemia
MUNCHAUSEN SYNDROME: Malingering - fabrication of a clinically convincing disease by
an itinerant malingerer.
PICKWICKIAN SYNDROME: Symptom
cluster
o Obesity
o Hypoventilation
o Somnolence
o Erythrocytosis
RESTLESS LEGS SYNDROME: Need to
stretch legs at night before going to sleep; twitch
in legs causing insomnia.
STRAIGHT BACK SYNDROME: Loss of
normal kyphosis of thoracic spine ------>
o Straight spine
o Ejection murmur
o Widened cardiac silouhette on x-ray

 SJGREN'S SYNDROME: Autoimmune

complex
o Keratoconjuctivitis Sicca (dry eyes and
mouth)
o Dryness of Mucous membranes
o Telangiectasias in face
o Parotid enlargement
ENVIRONMENTAL CAUSES SYNDROME
ACUTE RADIATION SYNDROME: Radiation
exposure.
o 12 hours post-exposure: Vomiting
o 24 hours post-exposure: Prostration
(extreme exhaustion), fever, diarrhea
o Later: Petechial hemorrhage,
hypotension, tachycardia, profuse bloody
diarrhea, maybe death.
CHINESE RESTAURANT SYNDROME:
MSG reaction ------> Chest Pain, burning
sensation over parts of body.
BROWN-SEQUARD SYNDROME: Damage
(injury) to half of spinal cord ------> symptoms:
o Loss of pain and temperature
sensation on contralateral side of body.
o Loss of proprioception and
discriminatory touch on ipsilateral side of body.
IATROGENIC SYNDROME (or Secondary to
Medical Treatment)
AFFERENT LOOP SYNDROME:
Gastrojejunal loop obstruction, proximal to a
gastrojejunostomy.
o Ingestion of food produces nausea,
pain,
and duodenal distension.
ASHERMAN'S SYNDROME: Adhesions
within the endometrial cavity, causing
amenorrhea & infertility.
o Adhesions probably were caused by
surgery.
ULYSSES SYNDROME: Ill effects from
follow-up diagnostic tests following a false
positive screening test.

EN = Endocrine: Hot/cold intolerance, thyroid

goiter, nodules or radiation, diabetes, increased
thirst or appetite
*SIADH "SIADH" (URINE OSMO/SODIUM
INCREASED)(SERUM OSMO/SODIUM
DECREASED)
S - Surgery Post Op
I - Infection: CNS - meningitis, Lung - TB, Fungal,
Bacterial
A - Anti - Diuretic Hormone Producing Tumor
D - Drugs: Narcotics, Diuretics...
H - Head Lesion CNS trauma, tumor, CVA
*LYMPHADENOPATHY:"LYMPHNODES"
L - Lues: secondary syphilis
Y - Yersinia Pestis (Plague)
M - Mononucleosis/CMV/Toxo
P - Procainamide (Pronestyl), Phenytoin (Dilantin)
H - Hodgkin's, Lymphomas, leukemia
N - Neoplasm metastasis
O - Obvious local infection or inflammation,
Other infections: Hep B, Rubella, Tularemia, Cat
scratch
D - Deficient Immune System AIDS or preAIDS
lymphadenopathy
E - Endocrine - Addisons, Hypothyroid
S - SLE/Rheumatoid arthritis - Serum sickness Sarcoid
Lymphadenopathy (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Tuberculosis, atypical mycobacteria
Malignancy (lymphoma, leukemia, metastases)
HIV
Tularemia
Fungal infection (histoplasmosis,
coccidiomycosis, cryptococcis)
Brucellosis
Leptospirosis
Syphilis
Lyme disease
Viral syndrome
Infectious mononucleosis
Cat scratch disease
Lupus
Medications (phenytoin, serum sickness)
Sacoidosis
Amyloidosis
Rubella

*HYPERCALCEMIA: "CALCEMIAS"
C - Carcinoma
A - Antacids containing Calcium
L - Lymphoma, Leukemia, Hodgkin's, Low
phosphate
C - Calcium Supplements
E - Endocrine: Hyperparathyroid,
Thyroid disease hyperthyroid
M - Multiple Myeloma
Metistatic Lesions to Bone
Milk-alkali syndrome
I - Iatrogenic: Thiazide Diuretics, Vitamin D
A - Addison's Disease, Acromegaly
S Sarcoid
*METABOLIC ACIDOSIS WITH A HIGH
ANION GAP "KUSSMAL"
K - Ketoacidosis, DKA
U - Uremia
S - Salicylates
S - Substance Abuse (Ethylene Glycol)
M - Methanol
A - Alcohol, AKA
L - Lactic Acidosis (Shock, Seizure, AMI,
Sepsis) Index
*NODULES, SUBCUTANEOUS: "NODULAR"
N - Neurofibromas
O - Osteoarthritic Heberden's nodules
D - Dupuyten's contracture nodules
U - Urate crystals in gouty tophi
L - Lipids in lipomas & xanthomas
A - Acute Rheumatic Fever
R - Rheumatoid nodules
ENDOCRINE, REPRODUCTIVE SYNDROME
AMENNORRHEA-GALACTORRHEA
SYNDROME: Non-physiologic lactation,
resulting from endocrinologic causes or from a
pituitary disorder.
CONN'S SYNDROME: Primary
Hyperaldosteronism ------> muscular weakness,
hypertension, hypokalemia, alkalosis.
CUSHING'S SYNDROME: Hypersecretion of
cortisol ------> secondary symptoms and
characteristics:
o Fatness of face and trunk with wasting
of extremities
o Buffalo hump
o Bone decalacification
o Corticoid diabetes
o Hypertension

PREMENSTRUAL SYNDROME: Abnormal

sensation in breasts, abdominal pain, thirst,
headache, pelvic congestion, nervous irritability.
o Ocassionally nausea and vomiting.
SHEEHAN'S SYNDROME: Post-partum
pituitary
necrosis ------> hypopituitarism.
STEIN-LEVENTHAL SYNDROME: Polycystic
ovary ------> infertility, amenorrhea, hirsutism.
Seen
in obese women.
TESTICULAR FEMINIZATION SYNDROME:
Insensitivity to Testosterone. Male
Psuedohermaphroditism
o Complete female external genatalia,
incompletely developed vagina, rudimentary
uterus.
HE = Head - pain, Ear- pain, tinnitus, hearing
loss, vertigo, Eye pain, vision change,
glaucoma, redness, excessive tearing/ discharge,
cataracts Nose - sinusitis, epistaxis, blockage,
Throat/Mouth- pharyngitis, hoarseness,
postnasal drip, Teeth cavities, abscess, GumsBleeding, lesions
Headache (4/10/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Subarachnoid hemorrhage
Temporal arteritis
Carbon monoxide poisoning
Preeclampsia
Glaucoma
Meningitis/encephalitis/brain abscess
Cerebral aneurysm
Subdural hematoma
HSV encephalitis
Brain tumor
Arterial dissections
Cerebral venous sinus thrombosis
*Drug adverse effect
Daily withdrawal headaches
Migraine
Tension type headache
Caffeine withdrawal
Sinusitis
Viral syndrome, febrile illness
Temporomandibular joint syndrome
Cervical arthritis
Spinal headache (post lumbar puncture)

Toxic exposures
Idiopathic thunderclap
Neuralgias (e.g., trigeminal neuralgia)
Pseudotumor cerebri (intracranial hypertension)
Cluster headache
Spontaneous intracranial hypotension
Pituitary apoplexy
*HEADACHE: "VINT HEENT"
V - VASCULAR: Migraine, Cluster, CVA, TIA,
AVM, Temporal Arteritis, SABleed,
hypertension
I - INFECTION: CNS - Meningitis, Abcess,
Encephalitis, SYSTEMIC- Viral syndrome
- INCREASED INTRACRANIAL PRESSURE:
Pseudotumor Cerebri
N - NEOPLASM: Tumor, Mets
T - TRAUMA: Subdural Hematoma, TENSION:
Most common HA cause, TOXIN: Carbon
Monoxide Toxicity, TAP: post lumbar puncture
H - HEAD: Neuralgia, C - Spine Disease, Scalp
Lesions
E - EYE: Acute Closed Angle Glaucoma, Strain
E - EAR: Otitis, Mastoiditis
N - NOSE: Sinusitis
T - TM JOINT: TMJ syndrome, THROAT: URI,
Viral syndrome, Bacterial Pharyngitis,
TOOTHACHE, TAP- Post LP tap
Facial pain (6/1/10)
Coronary disease
Aortic aneurysm
Sinusitis
Dental pain
TMJ syndrome
Trigeminal neuralgia
Herpes zoster
Salivary gland disorders
Migraine

Facial flushing (6/1/10)

() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Fever
Carcinoid
Serotonin syndrome
Bronchogenic carcinoma
Medullary thyroid carcinoma
Pheochromocytoma
Emotional
Menopause
Alcohol
Rosacea
Drugs (calcium-channel blockers, nicotinic acid,
others)
Heat exposure
Exercise
Foods (spicy foods, cured meats, monosodium
glutamate)
Cluster headache
Dumping syndrome
Systemic mastocytosis
*EAR ACHE: "OTITIS"
O - Other referred pain: parotid, tooth,
lymphadenitis
T - TM Joint
I - Infection: Otitis Media/Externa, Bullous
Myringitis
T - Trauma: Q-Tip, Blunt injury
I - Impaction: Cerumen, Insect, Foreign Body
S - Syndrome, Ramsey Hunt facial neuralgia
Index
Ear pain, Otalgia (6/23/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Myocardial Infarction
*Psychogenic (Depression, Anxiety)
Thyroid Tumor
Acoustic Neuroma
Nasopharyngeal Tumor
Temporal Arteritis
Cholesteotoma
Mastoiditis
Tumors (Ear, Nasopharyngeal)
Malignant External Otitis
Coronary Disease
Thoracic Aneurysm
Acute Otitis Media, Otitis Media with Effusion

TMJ Syndrome
External Otitis
Cerumen
Viral Myringitis
Dental Causes
Pharyngitis
Barotrauma
Foreign Body
Idiopathic
Cervical Adenopathy
Cellulitis, Chondritis, Perichondritis
Sinusitis
Carotidynia
Trauma
Gastroesophageal Reflux
Bell's Palsy
Wegener's Granulomatosis
Cervical Disc Disease
Ramsey Hunt syndrome
Relapsing Polychondritis
Salivary Gland Disorder
Neuralgias (Trigeminal, Glossopharyngeal)
Eagle's Syndrome
Hearing Loss (Deafness) (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Sudden Sensorineural Hearing Loss
Drugs (Aspirin, Gentamicin, Furosemide)
Stroke
Hereditary
Neoplasm
Otitis Media, Otitis Externa
Acoustic Neuroma
Presbycusis
Cerumen
Noise Exposure
Meniere's Disease
Otosclerosis
Trauma
Tinnitus (1/20/10)
Acoustic neuroma
Vascular, pulsatile (arteriovenous
malformation, bruit, fistula)
Idiopathic
Presbycusis
Noise-induced hearing loss
Menieres disease
Drugs (aspirin, antibiotics, loop diuretics,
chemotherapy)

Congenital hearing loss

Cochlear trauma
*EYE INFLAMATION - RED EYE: "IRITIS"
I - Increased Pressure: Acute closed angle
glaucoma
R - Reduced Tears:Keratoconjunctivitis Sicca
I - Iritis, Iridocyclitis
T - Trauma: Entropion, abrasion, foreign body
I - Infection: Conjunctivitis - Bacterial, viral,
allergic, irritative, chemical, autoimmune
S - Scleritis/Episcleritis, Subconjunctival
hemorrhage
Red Eye (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Episcleritis, Scleritis
Foreign Body
Bacterial Conjunctivitis
Acute Angle Closure Glaucoma
Iritis
Keratitis, Bacterial, Viral
Hyperthyroidism
Viral Conjunctivitis
Allergic Conjunctivitis
Stye (Hordeolum)
Chalazion
Blepharitis
Dry Eye Syndrome
Subconjunctival Hemorrhage
Contact Lens Over Wear
Trauma
*NASAL CONGESTION: "NOSE HAIRS"
N - Neoplasm
O - Over - reactive mucosa -vasomotor rhinitis
S - Structural: Polyps, Deviated septum
E - Estrogens: Oral contraceptives, Pregnancy
H - Hypothyroidism
A - Allergic rhinitis
I - Infection: Bacterial, Viral, Fungal
R - Rhinitis Medicamentosa: Rebound From
overuse of nasal spray
S - Substances: Reserpine, Aldomet, BetaBlockers, Aspirin

*PHARYNGITIS: "THROAT PAIN"

T - Thyroiditis
H - Herpangina ,Hodgkin's
R - Retropharyngeal abscess
O - Oral ulcers: Aphthous, Syphilis,TB, Herpes
A - Angioneurotic edema
T - Toothache/abscess
P - Peritonsillar abscess
A - Angina: Vincent's, Ludwigs
I - Infection:
 Bacterial - Streptococcus (Group B & G,),
GCH FLU
 Mycoplasma, Diptheria
 Viral-Mono, CMV, Herpes, Influenza,
HIV/AIDS...
 Fungal - Candida( Immunosupression)
 Other - Syphilis, Chlamydia, Toxic shock
N Neoplasm
*HOARSENESS (PROLONGED):
"HOARSENESS"
H - Hilar Adenopathy: TB, Sarcoid
O - Occupational: Singer...
A - Aneurysm
R - Rheumatoid Arthritis
S - SLE Ulceration
E - Edema of the Vocal Cords
N - Neoplasm of the Vocal Cords or lung
E - Endocrine: Hypothyroid
S - Sjogrens: Salivary Deficiency
S - Syphilitic/TB Ulcer on cords
Dysphagia (6/1/10)
*Stroke
Tumor (intrinsic or extrinsic)
Esophageal Spasm
Lower Esophageal Ring
Peptic Stricture
Functional Dysphagia
Nutcracker Esophagus
Achalasia
Multiple Sclerosis
Amyotrophic Lateral Sclerosis
Scleroderma
Myasthenia Gravis

LU = Lung : Dyspnea, Cough, Sputum

Production, Hemoptysis, Wheezing, TB, PPD,
CXR, Pneumonia, Asthma, Bronchitis, Smoking,
Environmental Inhalation
STRIDOR GASPER
G Glottic blockage: food or foreign body
A Angioneurotic Edema
S Sub Glottic lesion nodule or neoplasm
P Peritonsilar Abscess
E Epiglottis
R Retropharyngeal Abscess
*HICCUPS (PROLONGED): "HICCUPS"
H - Hilar Adenopathy
I - Intake of excessive Alcohol Smoke
C - Cardiac: Inferior MI
C - Carcinoma
U - Upper Motor Neuron Lesion
P - Pneumonia
S - Subdiaphragmatic Irritation Index
*WHEEZING: "ASTHMATIC"
A - Aneurysm, Asthma, Bronchospasm,
Aspiration
S - Smoke or irritant inhalation
T - Thyroid enlargement causing obstruction
H - Heart Failure - Pulmonary Edema
M - Medication (Aspirin, Beta Blocker)
A - Anaphalaxis, Angioedema
T - Tumor, Thyroid
I - Infection: Pneumonia, Bronchitis, Infarction Pulmonary Embolus, Sickle Cell Chest
Syndrome
C - Cystic Fibrosis
PULMONARY SYNDROME
KARTAGENER'S SYNDROME: Situs Inversus
(lateral transposition of lungs) resulting from
chronic
sinusitis and bronchiectasis.
HAMMAN-RICH SYNDROME: Interstitial
fibrosis
of the lung.
MIDDLE-LOBE SYNDROME: Chronic
pneumonitis and atalectasis of middle lobe of
right
lung.
CHURG-STRAUSS SYNDROME: Allergic
Granulomatous Angiitis: Asthma, fever,
eosinophilia.

BR = Breast: nodule, discharge, chest wall or

breast pain tenderness, self exam
CV = Cardiovascular : Exercise level,
orthopnea, PND paroxysmal nocturnal
dyspnea, DOE- dyspnea on exertion, chest
pain or discomfort, palpitations, syncope,
edema, claudication, CV drugs, hypertension,
DVT blood clots, past heart disease.
Rheumatic fever, family history heart
disease/clotting. leg/foot ulcers, varicose veins
*PLEURITIC CHEST PAIN: "5 Ps"
P - Pneumothorax
P - Pleurisy from Pneumonia, Infarction,
Inflammation
P - Pulmonary Embolus/Infarction
P - Pneumomediastinum
P Pericarditis
*SHOCK: "AMS" & "CRASH"
A - Acute neurologic event/trauma (brain injury)
M - Metabolic/toxic cause (brain insulted from
blood born toxin, infection, chemistry
imbalance)
S - Shock - Mnemonic "CRASH" (brain not
receiving blood)
C - Cardiogenic
R - Rapid blood or water loss
A - Anaphylaxis
S - Septic
H - Head injury (BP regulation center)
Hypotension, shock (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Myocardial infarction
*Pulmonary embolus
*Ruptured aneurysm
*Pneumothorax
*Sepsis
Hemorrhage (trauma, GI bleeding)
Pancreatitis
Cardiomyopathy
Aortic stenosis
Arrhythmias
Peritonitis
Anaphylaxis
Aortic stenosis
Hypertrophic cardiomyopathy
Hypothyroidism

Cardiac tamponade
Addison's disease/Adrenal insufficiency/
hemorrhage
Atrial myxoma
*Drugs (e.g., antihypertensives)
Hypovolemia
Vomiting, diarrhea
*HYPERTENSION "PRESSURE"
P - Pheochromocytoma; Polycythemia, Preeclampsia/Eclampsia
R - Renovascular (7%)
E - Endocrine: Hyperthyroid, Cushing,
Aldosteronism, Hyperparathyroid
S - Substances: Estrogens (BSP), Caffeine,
Cocaine, Sympathomimetics, ETOH withdrawal
S - Structural: Coarctation, AI, Arteriosclerosis
U - Upper Motor Neuron Problem: Elevated
intracranial pressure
R - Renoparenchymal (0.5%):
Glomerulonephritis, Diabetic nephropathy
E - Essential: 90% of hypertension, Error in cuff
size
*ATRIAL FIBRILLATION: "IRREGULAR P
WAVES"
I - Infarction: myocardial
Intoxication ETOH
R - Rheumatic Heart Disease
R - Recent Thoracotomy
E - Endocrine - Hyperthyroid
G - Geriatric
U - Unknown - Idipathic
L - Lung Disease - COPD
A - Atherosclerotic Heart Disease
R - Reduced Oxygen - Hypoxia
P - Pericarditis
W - Worry/Stress
A - Atrial Septal Defect
V - Valvular Lesion - Mitral
E - Embolus - Pulmonary
S - Systemic Arterial Hypertension
Sinus tachycardia (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Myocardial infarction
*Pulmonary embolus
*Pneumonia
*Anemia
Infections, fever

Hemorrhage
Hypotension, shock
Hypovolemia, dehydration
Hyperthyroidism
Hypoglycemia
Heart failure, pulmonary edema
Cardiomyopathy, myocarditis
Pericarditis
Acute mitral regurgitation
Pneumothorax
Aortic insufficiency
Hypoxia
Serotonin syndrome
Pheochromocytoma
*Drugs (alcohol, amitriptyline, amphetamines,
amyl nitrite, anticholinergics, atropine, beta
blocker withdrawal, bupropion, caffeine,
cilostazol, cocaine, ephedrine, epinephrine,
isoproterenol, nicotine, tobacco)
Anxiety, emotional stress
Pain
Recent physical exertion
COPD
Pregnancy (10 to 20 BPM at term)
Diabetic cardiovascular autonomic neuropathy
Inappropriate sinus tachycardia
Postural orthostatic tachycardia syndrome
(POTS)
Chronic nonparoxysmal sinus tachycardia
*BRADYCARDIA: "BRADYCARDIAS"
B - Beta Blockers
R - Rising intracranial pressure
A - Athlete
D - Digoxin intoxication
Y - Yellow jaundice Biliary obstruction
C - Carotid sinus sensitivity
A - Acute nephritis with hypertension
R - Reserpine
D - Decreased thyroid hypothyroid, Decreased
temperature hypothermic
I - Infections: Mycoplasma, Diphtheria,
Influenza, Infarction/myocardial usually inferior
A - A-V node dysfunction/Blocks
S - S-A node dysfunction, Sick sinus syndrome
*PERICARDITIS "PERICARDITIS"
P - Post Traumatic
E - Endocrine: Hypothyroid
R - Renal Failure
I - Infection: TB, Viral, Fungal, AIDS, Bacterial
C - Collagen Vascular Disease (SLE, RA)

A - Aneurysm
R - Rheumatic Fever- Radiation
D - Drugs: Hydralazine, Minoxidil, Procainamide
I - Infarction - AMI
TI - Tumor Invasion
S - Syphilis, Scleroderma, Serum Sickness
CARDIOVASCULAR SYNDROME
ADAMS-STOKES SYNDROME: Heart block,
with slow or absent pulse, often accompanied by
convulsions.
BARLOW SYNDROME: Floppy Mitral Valve
Syndrome; Massive Mitral Valve Prolapse ------>
Late apical systolic murmur, systolic click, or
both.
EISENMENGER'S SYNDROME: VentricularSeptal Defect ------> Pulmonary hypertension
and cyanosis.
FLOPPY-VALVE SYNDROME: Mitral
Incompetence due to myxomatous degeneration
of the leaflets.
LERICHE'S SYNDROME: Occlusion of distal
aorta ------>
o Hip, thigh, and calf fatigue.
o Impotence
BEHCET'S SYNDROME: Vasculitis ------>
secondary symptoms:
o Oral and genital ulcers
o Uveitis
o Optic atrophy
SHOULDER-HAND SYNDROME: Pain in
shoulder and swelling in hand, sometimes
occurring after Myocardial Infarction.
SICK SINUS SYNDROME: Chaotic atrial
activity; continual changes in P-Waves.
Bradycardia, alternating with recurrent ectopic
beats and runs of tachycardia.
SUPERIOR VENA CAVA SYNDROME:
Caused by a tumor. Obstruction of SVC ------>
o Edema
o Engorgement of the vessels of face, neck, and
arms.
o Nonproductive cough
o Dyspnea
TAKAYASU'S SYNDROME: Arteritis of the
Aortic Arch, resulting in no pulse. Seen in young
women.
WOLF-PARKINSON WHITE SYNDROME:
ECG pattern of Paroxysmal Tachycardia.
o Short PR interval
o Delta wave = early QRS complex.

AB = Abdominal : Nausea, Vomiting,

Hematemesis, Dysphagia, Indigestion,
Heartburn/ Dyspepsia/GERD, Abdominal Pain,
Swelling, Jaundice, Hematochezia, Melena,
Change in Stool Caliber, Diarrhea,
Constipation, Hernias, Hemorrhoids, Peptic
Ulcer Disease /PUD, Surgery, Gallbladder
Disease, Pancreatitis, Liver Disease, Hepatitis,
Alcohol Intake
Nausea, vomiting (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Appendicitis
*Pancreatic Carcinoma
*Myocardial Infarction
*Intracranial Hemorrhage
*Diabetic Ketoacidosis
*Congestive Heart Failure
Intracranial Abscess, Meningitis
Pancreatitis
Hepatitis
Glaucoma
Uremia
Thyroid Disorders
Addison's Disease, Adrenal Insufficiency
Serotonin Syndrome
Pregnancy
Bowel Obstruction
Pyelonephritis
Cholecystitis
Brain Tumor
Gastroenteritis, Gastritis
Drugs (Opioids, Iron, Chemo) Acute
Intermittent Porphyria
Migraine
Gastroparesis (Diabetes)
Eating Disorder
Irritable Bowel Syndrome
Peptic Ulcer Disease
Psychogenic Vomiting, Anxiety, Depression
Pain (esp. Visceral)
Severe Coughing
Pseudotumor Cerebri
Crohn's Disease
Mesenteric Ischemia
Inner Ear (e.g., Labyrinthitis, Meniere's)
Food Poisoning
Parathyroid Disorders
Cyclic Vomiting Syndrome

Abdominal & Pelvic Pain

() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Pregnancy Complication, Ectopic Pregnancy,
Mesenteric Adenitis
*Appendicitis
*Myocardial Infarction
*Pneumonia, Empyema
*Intraabdominal Tumor
*Diabetic Ketoacidosis
*Aortic Dissection, Ruptured Aneurysm
Fitz-Hugh-Curtis syndrome
Diverticulitis, Black Widow Spider Bite
Pancreatitis
Gallbladder Disease
Bowel obstruction, partial small bowel
obstruction
Kidney stone
Pelvic inflammatory disease
Ovarian cyst, ovarian torsion, Endometritis
Hepatitis, hepatic abscess
Mesenteric Ischemia & Infarction
Hernia
Perforated Viscus, Peritonitis
Sickle Cell Crisis
Lead Poisoning
Leukemia
Meckel's Diverticulitis
*Psychiatric (Depression, Sexual Abuse)
Porphyria
Peptic Gastritis, Esophagitis
Viral Gastroenteritis
Constipation, Familial Mediterranean Fever
Irritable Bowel Syndrome Periarteritis Nodosa
Endometriosis
Abdominal wall pain (trigger point pain)
Herpes zoster
Celiac disease
Mittleschmerz
Giardia
Food poisoning
Inflammatory bowel disease

* ACUTE ABDOMINAL PAIN: "BAD GUT PAIN"

& "ECTOPIC"
B - Bowel obstruction
A - Appendicitis, Adenitis (mesenteric)
D - Diverticulitis Diabetic Ketoacidosis
Dysentary/Diarrhea Drug withdrawal
G - Gastroenteritis Gall bladder disease/stones/

obstruction/infection
U - Urinary tract obstruction (stone) infection
(pyelo/cystitis)
T - Testicular Torsion Toxin - Lead, black
widow spider bite
P - Pneumonia/Pleurisy Pancreatitis Perforated
bowel/ulcer Porphyuria
A - Abdominal aneurysm
IN - Infarcted bowel Infarcted myocardium
(AMI), Incarcerated hernia, Inflammatory bowel
disease
S - Splenic rupture/infarction, Sickle cell pain
crisis, sequestration crisis Index
* For FEMALES with acute PELVIC pain, think
"ECTOPIC" as well as the above causes
E - Ectopic (This is your priority rule out
always), Endometriosis
C - Cyst rupture (corpus leutium cyst rupture)
T - Torsion of ovary or cyst
O - Ovulation: Mittelschmerz
P - Pelvic Inflammatory Disease, Salpingitis,
Tubo - ovarian abscess
I - Incomplete abortion
C - Cystitis/pyelonephritis
DIARRHEA: "DIARRHEAL"
D -Drugs:Laxatives, antibiotics, colchicine,
Digoxin, Diverticulitis
I - Irritable Bowel Syndrome, Infarction of
bowel,
Infection: Viral - Most common Bacterial Salmonella, Shigella, Campylobacter, Yersinia,
C. Difficle Toxin -Staph, Cholera, Botulism,
E.Coli, Vibrio, Protozoa - Giardia, amebiasis,
AIDS
A - Autoimmune - Ulcerative Colitis, Crohn's,
Appendicitis
R - Rapid Transit - Dumping Syndrome
R - Renal Failure
H - Hypersecretory -Zollinger Ellison
E - Endocrine -Hyperthyroid, Diabetes,
Addisons
A - Absorption Problem - Pancreatic
Insufficiency
L - Lesion/Neoplasm
Diarrhea (2/24/10)
Viral gastroenteritis
Irritable bowel syndrome
Salmonella
Shigella

E. coli O157 H7
Campylobacter
Clostridium difficile
Food poisoning
Lactose intolerance
Bacterial overgrowth
Diabetes
Drugs, laxatives
Lactase deficiency
Giardia
Microscopic colitis
Entamoeba histolytica
Cryptosporidium
Inflammatory bowel disease
Celiac disease
Yersinia
Bypass operations
Pancreatic insufficiency
Blastocystis hominis
Laxative abuse
*JAUNDICE: "HOT THINED SAP"
<Pre Liver>
H - Hemolytic process
O - Other - Idiopathic
T - Transport problem: Gilbert's Syndrome,
Crigler Najjar Syndrome
<Liver-Hepatic>
T - Toxin: Alcohol, Carbon Tetrachloride
H - Hereditary: Dubin Johnson, Roter Syndrome
I - Infection: Viral - A,B,C,D, E, Mono, Toxo,
CMV, Syphilis, Amoeba
N - Neoplasm: Hepatoma, Mets
E - End Stage Liver disease: Cirrhosis
D - Drugs: INH, Halothane, Estrogens, NSAIDS,
Acetaminophen, PTU, Sulfas
<Post- Liver>
S - Stones: Gall stones, Sclerosing cholangitis
A - Atresia
P - Pancreatic neoplasm/inflammation

<Hepatic Function Pearl: Liver Function Test>

 Synthetic Functions:
 Albumin
 Clotting factors Prothrombin Time
 Excretory Function
 Bilirubin
<LFT>
 AST and/or ALT
 Alkaline Phosphatase
 (GGT)
 Bilirubin
 Albumin
 Total Protein
 Abnormal LFTs not always indicate liver
disease
 Normal LFTs not always exclude liver
disease
 HCV 1:6 with persistently normal ALT will
have significant pathology on liver bx
Am J Gastro 2003;98:1588
 Clear link between ALT elevation & liver
mortality, even for values within the normal
range
Gastro 2009;136:477
 In a community setting >70% with high
Fibroscan score had normal LFTs
Harman et al BASL 2013
 Normal range is set by mean 2SD
 US study suggests ULN ALT 29 for men,
22 for women
 NHANEs data 3747 adults low risk of liver
disease
 36.4% of men and 23.8% of women have
abnormal LFTs!
Hepatology 2012;55:447
<Interpretation of LFTs>
 AST / ALT Hepatocellular Enzymes
 AST Mitochondrial
 ALT Cytosolic
 AST / ALT Ratio
 ALT > AST Hepatitis
 AST > ALT Alcohol (or in Cirrhosis)
 Alkaline Phosphatase - Biliary Enzyme
 also comes from Bone
 GGT also Biliary
 Alk P GGT => Biliary Source

Obstruction

Infiltration

Congestion









Alk Phos & GGT Normal - Think Bones

Isoenzymes rarely needed
Albumin
Globulin Fraction
PT / INR
Alpha foetoprotein (AFP)
Full blood count

*PANCREATITIS
P - Postoperative, Penetrating Peptic Ulcer,
Parathyroidism, Pregnancy
A - Alcoholism, AIDS
N - Neoplasm of Bile Duct or Ampulla
C - Cholelithiasis *common*
R - Renal failure
E - Estrogens, Elevated lipids
A - Antibiotics (TCN, Sulfonamides)
T - Trauma
I - Idiopathic, Infection: Mumps, Viral hepatitis,
Legionnaire's, Mycoplasma, Ascaris
T - Thiazides, Lasix
I - Infection: Viral mumps, mono, hepatitis
S - Scorpion bite, Shock
* AMYLASE INCREASED : "PAROTID"
P - Pancreatitis acute & chronic Pancreatic
pseudocyst Parotitis (mumps, alcohol, any
parotid inflammation) Pregnancy Perforated
bowel
A - Abdominal trauma, Acute burns
R - Ruptured ectopic pregnancy Renal failure
O - Obstructed intestines
T - Tumor of pancreas, lung, ovary, esophagus
I - Infarcted bowel
D - Diabetic ketoacidosis Drug Morphine/Demerol
GASTROINTESTINAL SYNDROME
MALLORY-WEISS SYNDROME: Laceration of
lower end of esophagus from vomiting ------>
hematemesis. Often seen in alcoholics
MALABSORPTION SYNDROME: Impaired
absorption of dietary substance ------> diarrhea,
weakness, weight loss, or symptoms from
specific deficiencies
BARRET SYNDROME: Chronic peptic ulcer of
the lower esophagus, resulting in metaplasia of
esophageal columnar epithelium ------>
squamous epithelium
ZOLLINGER-ELLISOHN SYNDROME:
Gastrinsecreting tumor in pancreas ------>
Severe peptic ulcers, gastric hyperacidity

 PLUMMER-VINSON SYNDROME:
Esophageal Webs, leading to dysphagis and
atrophy of papillae of tongue
o Also see hypochromic anemia, splenomegaly
GU = Genitourinary: urinary frequency,
urgency, dysuria, nocturia, hematuria, flow,
hesitancy, incontinence, urethral discharge,
genital lesions, STD sexually transmitted
diseases, UTIs, stones, flank pain, family
history renal disease.
 Males: prostate, testicular mass/pain,
erectile dysfunction
 Females: Age at menarche/menopause,
LMP, amount & duration of flow, pelvic pain,
vaginal discharge, abnormal bleeding,
amenorrhea, pelvic mass, pregnancies.
Both: birth control method, sexual history
Flank pain (1/20/10)
*Pneumonia
Kidney stone
Pyelonephritis
Diverticulitis
Ruptured aneurysm
Musculoskeletal
Herpes zoster
Influenza
Urinary Symptoms (Dysuria, Frequency,
Urgency) 6/17/10
Urinary tract infection
Urethritis (chlamydia, gonococcus, unknown)
Prostatitis
Vaginitis
Atrophic vaginitis
Genital herpes
Interstitial cystitis
Irritant urethritis
Daytime frequency of childhood syndrome
Reactive arthritis (Reiter's syndrome)
Hypercalciuria
Psychiatric
Genital skin lesion, genital ulcer (6/1/10)
Cancer
Syphilis
Herpes simplex
Behcet's disease
Chancroid
Lymphogranuloma venereum

Scrotal pain (1/20/10)

Testicular torsion
Fornier's gangrene
Testicular cancer
Idiopathic orchialgia
Inguinal hernia
Ureteral stone
Epididymitis, orchitis
Torsion of appendix testis
Abnormal uterine bleeding (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Ectopic pregnancy
Intrauterine pregnancy complication
Endometrial cancer, hyperplasia
Endometritis
Anovulatory bleeding, Polycystic Ovary
Syndrome
Menorrhagia
Contraceptive related abnormal bleeding (Oral,
Depo-Medroxyprogesterone, Intrauterine Device,
Progestin Implant)
Polyps
Fibroids
Hyperprolactinemia
Thyroid disease
Drugs (anticoagulants, psychotropics)
Normal variation (postmenarchal,
perimenopausal, premenstrual spotting,
postmenstrual spotting, midcycle ovulatory
bleeding)
Coagulopathy (von Willebrand)
Organ failure (late manifestation: kidney failure,
liver failure)
*HEMATURIA: "POPS GOT HEMATURIA"
P - Papillary necrosis, Polyarteritis nodosa
O - Osler-Weber-Randu
P - Prostatitis
S - Stricture, Sickle Cell Disease or Trait
G - Glomerulonephritis, Goodpasture's
Syndrome
O - Other Source such as Menstrual Blood
T - Tumor: Bladder, Kidney, Prostate
H - Hemorrhagic Cystitis
E - Exercise, Endocarditis
M - Medication - Analgesics, Malignant
Hypertension
A - Autoimmune Disease: SLE, Polyarteritis
T - Trauma to GU Tract

U - Urethritis
R - Renal Calculi
I - Infarction: SBE, Sickle Cell, ITP, TTP
A - Allergic Nephropathies: Henoch - Scholein
Purpura
Hematuria (6/1/10)
Urinary tract infection
Tumor
Tuberculosis
Transient unexplained hematuria
Stones
Menstruation (contaminated urine)
Exercise
Trauma
Benign prostatic hypertrophy
Prostatitis
Glomerular disease (IgA nephropathy,
hereditary nephritis)
Hypercalciuria
Hyperuricosuria
*URINARY FREQUENCY "VOIDED"
V - Vaginitis irritating urethra
O - Obstruction: Prostate, Bladder Stone,
Cystocele, Osmotic Particles: Protein
I - Intrauterine Pregnancy - Infection in Urethra,
Bladder, Kidney, Appendix
D - Diabetes: Mellitus or Insipidus
E - Electrolytes: Hyper K, Ca, Na
D - Drugs: Caffeine, Diuretics... - Drinking
Excessive Fluids

*VAGINITIS: "VAG ITCH"

V - Vaginal irritant: Spermicide, Douche,
Tampon, Non-Cotton Clothing
A - Atrophic Vaginitis from Estrogen Deficiency
G - Gardnerella (Clue cells) Gonococcus
I - Infection: PID, Salpingitis Infestation: Lice...
T - Trichomonas
C - Candida, Carcinoma, Chlamydia
H Herpes
RENAL SYNDROME
KEMMELSTIEL-WILSON SYNDROME:
Diabetic Glomerulosclerosis.
BARTTER'S SYNDROME: Juxtaglomerular
Cell Hyperplasia ------> secondary symptoms:
o Hyperaldosteronism, Hypokalemic
Alkalosis, elevated renin and

angiotensin
o No hypertension.
o Compare to Conn's Syndrome
FANCONI'S SYNDROME Type II: Renal
aminoaciduria, glycosuria, hypophosphaturia,
cysteine deposition, rickets.
THORN'S SYNDROME: Salt-losing nephritis.
PSY = Psychiatric: previous psych problems or
hospitalizations, interpersonal relationships,
mood swings, anxiety/nervousness, depression,
hallucinations, loss of control, vegetative
dysfunction (sleep, eating, pleasure activities),
substance abuse, suicidal thoughts & plans
Anxiety, depression (7/15/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Depression, agitated depression, bipolar
disorder
Pulmonary embolus
Hypoxemia
Pheochromocytoma
Hypoglycemia
Thyroid disorder
Anxiety (situational, generalized anxiety disorder)
Panic disorder
Alcohol
Medications
Paraneoplastic syndrome
*ANGER
A - acknowledge & apologize ("I'm sorry you feel
angry about this")
N - no negative responses
G - gather the facts - hear person out
E - empathize
R - resolve what you can
*ANXIOUS - The Patient with Fear
A. -Acknowledge fear as the emotion seen
F.- Face the object feared
R.- Real or Imagined fears
A. -Allow the patient to vent fears
I.- Infuse with knowledge
D. -Develop plan together to address fears
*DEPRESSED PATIENT-SYMPTOMS
F - Flat Affect
L - Low love life
A - Apathy

T - Tired
L - Low Self Esteem
I - Insomnia
N - No fun in life
E - Eating Disorders
*TO HELP DEPRESSION
G - good things in life
R - restore hope
A - acknowledge depression
S - suicidal thoughts & plans
P - plan for support
*DEMANDING - DEPENDANT MANIPULATIVE
R- reflect back patient responsibilities
E - empathize
F- find out any hidden agendas
L - limit personal involvement
E - expectations must be clear
C - calm yourself
T - time constraints on interview
S - staff splitting is common
*RAMBLING LOST
L Limit Time
O Observe the main reason for the visit
S- Stop the wrong direction gently
T- Take conversation back on track
*RETICENT (Quiet or Shy) PATIENT
O - Open ended questions
P - Pointed questions
E - Encourage talking
N - Notice secondary causes: Depression,
Dementia, Denial
NE = Neurologic: Headaches, Seizures,
Episodic Neuro Symptoms (talking, walking,
seeing..) Impaired Speech, Paresthesias,
Weakness, Head Trauma, Stroke, Dizziness,
Tremor, Confusion, Memory Loss, Gait
Problems
*SYNCOPE SYNCOPAL FAINT
S- Seizure
Y hYperventilation, hYsteria
N Neuropathy (Diabetic)
C Cardiac : Arrythmia, MI, IHSS, AS, Pump
Failure
O- Orthostatic Syncope
P Pedal Pooling from Venous Insufficiency

A Arterial Insufficiency
L- Low Blood Volume: Bleeding, Dehydration
F- Fainting Vasovagal
A Adrenal Insufficiency (Addisons Disease)
I Iatrogenic from Medications
N Nutritional (Not Eating, Hypoglycemia)
T Toxin: Alcohol & others
Syncope (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Anemia
*Pulmonary Embolus
*Myocardial Infarction
*Cerebrovascular (TIA, Stroke)
Arrhythmias
Hypoglycemia
Seizure, Pseudoseizure
GI Bleeding
Valvular Heart Disease, Aortic Stenosis
Hypoxia
Aortic Dissection
Adrenal Insufficiency, Addison's Disease
Hypertrophic Cardiomyopathy
Cardiac Tamponade
*Drugs
Vasovagal
Hyperventilation
Panic Attack
Orthostatic Hypotension
Autonomic Insufficiency
Valsalva
Cough Syncope
Micturition Syncope
Atrial Myxoma
*VERTIGO: "SICK SPIN"
S - Salycilates - aspirin toxicity also other NSAIA
I - Infection: Bacterial - otitis media Viral labrythitis, Herpes,
C - Cerebellar tumor, TIA, infarct, degeneration
K - Klog: cerumen impaction
S - Subclavian steal, Sea sick - motion
P - Positional vertigo
I - Infrequent: Meniere's disease
N - Neuroma (Acoustic)

Vertigo (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Brain stem stroke
Acoustic Neuroma
Otitis media
Vertebral artery dissection
Drugs (Gentamicin, Furosemide)
Benign Positional Vertigo
Meniere's Disease
Vestibular Neuronitis, Acute Labyrinthitis
Post-concussion Syndrome
Barotrauma, Ruptured Oval Window,
Perilymph Leak
Migrainous Vertigo
Otosclerosis
Psychiatric
*SEIZURES "GRAND MALS"
G - Glucose too low
R - Rising Blood Pressure, Toxemia Eclampsia, Rye's syndrome, Renal failure
A - Alcohol Withdrawal
N - Neoplasm, Primary or Mets, Neurological
Infections - meningitis
D - Drugs, Overdose or withdrawal
M - Metabolic: Hepatic/Renal Failure,
Hypothyroid
A - Arterial Disease: CVA, AVM, TIA, Aortic
Dissection, Arrhythmia
L - Lytes: Hypo Na, Ca, Mg
S - Subdural Hematoma - Subarachnoid Bleed
Seizure (6/1/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Stroke
Head trauma
Hypoglycemia
Hyponatremia
Hypoxia
Brain tumor
Intracranial infection
Drug intoxication
Hypomagnesemia
Hypocalcemia
Imitators (vasovagal syncope, pseudoseizures,

transient ischemic attack)

Epilepsy
Alcohol and drug withdrawal
*COMA - ALTERED MENTAL STATUS :
"ACUTE CLOUDING"
A - Alcohol excess/withdrawal (DTs),
Anaphylaxis, Anemia - acute blood loss
(GI,Trauma,....)
C - CVA bleed or blockage, Carbon Monoxide
U - Upper motor Neuron lesion/mass/mets
T - Trauma - subdural, concussion, contusion
Temperature problem, hyperthermia,
hypothermia
E Epilepsy - postictal state or status seizures
 Endocrine - hyper/hypo thyroid, hyper/hypo
adrenal, hyper/hypo pituitary
 Electrolytes - hyper/hypo Na, hyper/hypo Ca,
hyper/hypo Mg, hyper/hypo K
 Eclampsia
C - Cardiovascular - pump failure - MI,
Tamponade, Hypertensive crisis
L - Liver failure (Hepatic encephalopathy), Lupus
cerebritis
O - Oxygen deficiency - hypoxia from any cause
U - Uremia/Renal failure
D - Drugs excess/withdrawal (dilantin, sedatives,
opiates, salicylates)
I - Infection - CNS (meningitis, encephalitis...),
Systemic
N - Nutritional - Thiamin - Wernicke's
encephalopathy, Niacin, B12
G - Glucose -Hypoglycemia/ Hyperosmolar coma
Delirium (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Heart failure
*Drugs
*Anemia
*Glucose disturbances
*Myocardial infarction
Adrenal disease
Porphyria
Nonconvulsive status epilepticus
Serotonin syndrome
Trauma
Head injury
Alcohol
Carbon monoxide
Sepsis

Electrolyte disturbance, Na, Ca, Mg, P

Thyroid disease
Hypoxia
Hypertensive Encephalopathy
CNS infections
Brain mass
Hypothermia
Hyperthermia
B12 deficiency
Folate deficiency
Thiamine deficiency
Liver failure
Renal failure
*Psychiatric disorders
Burns
Postpartum psychosis
Mental Status, Acute Change (Coma, Lethargy)
(1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Intracranial hemorrhage
*Pneumonia
*Heart failure
Hypotension
Brain stem stroke
Disturbance of Ca, Mg, Na, K, P
Thyroid disease
Hypothermia
Liver failure
Renal failure
Brain tumor with herniation
Head trauma
Sepsis
Meningitis, encephalitis
Electrolyte abnormality
Delirium
Hypoglycemia
Urinary Retention
Hypoxia
CO2 narcosis
Alcohol
Psychosis
Drug overdose
Seizure (postictal)
Psychiatric

Dementia, memory loss (6/17/10)

() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Pseudodementia (depression)
Medications (antihistamines)
Vitamin B12 deficiency
Hypothyroidism
Delirium
Anoxia
Hypoglycemia
Head injury
Structural brain disease
Alzheimer disease
Mild cognitive impairment
Alcohol
Vascular dementia
Dementia with Lewy bodies
Parkinson disease
Transient global amnesia
Progressive supranuclear palsy
*DEMENTIA: "DEMENTIAS"
D - Drugs: Sedatives, Bromide, Narcotics,
Atropine, Dopamine decrease - Parkinson's
E - Endocrine: Hypothyroid, Hypoglycemia,
Hyperparathyroid
M - Metabolic: Renal/Hepatic failure,
hyponatremia
E - Emotional
N - Nutritional: Deficient Thiamin, Niacin, B12,
Normal Pressure Hydrocephalus
T - Tumor in CNS Trauma-subdural hematoma
Thyriod - Myxedema
I - Infections: TB, SBE, Crypto, Herpes, AIDS,
Syphilis, Creutzfeldt-Jakob, Mad Cow...
A - Atherosclerosis, CVA, ALS, Arteritis
Altzheimer's
S - Sensory Deficit: Hearing or Vision loss
Tremor (1/20/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Serotonin Syndrome
Wilson's Disease
Cerebellar Disease
Midbrain Stroke
Hyperthyroidism
Carcinoid
Tardive Dyskinesia

Pheochromocytoma
Physiologic Tremor
Essential Tremor, Familial Tremor
Parkinson s Disease
Anxiety
Medications (Bronchodilators, Caffeine,
Steroids, Lithium)
Drug Withdrawal
Orthostatic Tremor
Multiple Sclerosis
Numbness, sensory loss (4/24/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Stroke
Brain or Cord Tumor
HIV
Heavy Metal Poisoning (Lead, Mercury)
Hypocalcemia
Lyme Disease
B12 Deficiency, Vitamin B6 Deficiency
Peripheral Neuropathy, Diabetes
Compression Neuropathy
Disk Disease
Carpal Tunnel Syndrome
Meralgia Paresthetica
Herpes Zoster
Multiple Sclerosis
Alcoholism
Drugs (Vincristine, Amiodarone, Lithium,
Others)
Idiopathic
Amyloidosis
Paraneoplastic Syndrome
Chronic liver Disease
Porphyria
NEUROLOGICAL SYNDROME
CARPAL-TUNNEL SYNDROME:
Compression of Median Nerve through the
Carpal Tunnel ------> pain and parasthesia over
distribution of Median N.
FROIN'S SYNDROME: Block in CSF flow -----> xanthochromia (yellow discoloration) of
CSF.
ACUTE-BRAIN SYNDROME: Delirium,
confusion, disorientation, developing suddenly
in
a person that was previously psychologically
normal.
GERSTMANN'S SYNDROME: Lesion

between occipital area and angular gyrus ----->symptoms:

o Finger agnosia, Agraphia, acalculia
o Right-left disorientation
HORNER'S SYNDROME: Loss or lesion of
cervical sympathetic ganglion ------>
o Ptosis, miosis, anhydrosis
o Enophthalmos (caved in eyes)
KORSAKOFF SYNDROME: Loss of short-term
memory in chronic alcoholism, caused by
degeneration of mamillary bodies.
RILEY-DAY SYNDROME: Familial
dysautonomia.
MS = Musculoskeletal: joint pain/arthritis,
stiffness, swelling, muscle cramps, family history.
Muscle Cramps (1/20/10)
*Drug induced (nifedipine, beta blockers)
Idiopathic, ordinary, nocturnal
Heat-induced (volume depletion, hyponatremia)
Hemodialysis (volume and electrolyte shifts)
Lower motor neuron (injury, ALS, compression)
Writer's cramp
Hypocalcemia
Hypomagnesemia
Respiratory alkalosis
Hypokalemia
Thyroid disease
McArdle's disease (glycogen storage disease)
Myalgias, arthralgias (generalized) (6/22/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Statins
Hypothyroidism
Polymyalgia rheumatica
Rhabdomyolysis
Lyme disease
Hypophosphatemia
*Psychiatric
Influenza
Viral syndrome, infections
Fibromyalgia
Vitamin D deficiency
Polymyositis, dermatomyositis
Lupus, rheumatoid arthritis

*SHOULDER PAIN "CAPSULITIS"

C - Cuff Problem - Rotator Cuff rupture
A - Arthritis (see Differential Diagnosis) Avascular Necrosis (Sickle Cell)
P - Plexus Problems - Brachial Plexus
S - Spondylosis - DJD Cervical Spine with
Nerve Root irritation
U - Under Diaphragm Irritation: Free Air, Blood,
Pancreatitis, Spleen, Cholecystitis, Peritonitis
L - Lung Causes: Pancoast Tumor, PE,
Pulmonary Infarction
I - Ischemia - Cardiac referred. Arteritis,
Atherosclerosis
T - Tendonitis/Bursitis - Trauma - Thoracic
Outlet Syndrome
I - Inflamed Soft Tissues: Fibrositis
S - Spinal Cord Lesion/Tumor
Shoulder Pain (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Myocardial infarction
*Pneumonia
*Lung tumor
Intra-abdominal bleeding (ectopic, ruptured
ovarian cyst)
Polymyalgia rheumatica
Ruptured abdominal viscus
Ruptured spleen
Abdominal malignancy
Shoulder joint disease
Cervical radiculopathy
Biliary disease
Pericarditis
Leg Pain, Bone Pain, Extremity Pain (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Fracture, trauma
Gout
Cellulitis
Deep vein thrombosis
Compartment syndrome
Rhabdomyolysis
Osteomyelitis
Arterial occlusion
Sickle cell crisis
Leukemia
Arthritis

Varicose veins
Lumbar disc disease
Neuropathy (e.g., diabetic)
Ruptured Baker's cyst
Ruptured plantaris muscle
Vitamin D deficiency
Shin splints
RSD, complex regional pain syndrome
Gastrocnemius tear
*BACK PAIN : "DISK MASS"
D - Degeneration: DJD, Osteoporosis,
Spondylosis
I - Infection: UTI, PID, Potts, Osteo, Prostatitis Injury/Fracture, Compression Fracture
S - Spondylitis, Ankylosing Spondyloarthropathies (Rheumatoid, Reiters,
SLE.....)
K - Kidney Stones / Infarction-Infection
(Pyelonephritis / Abscess)
M - Multiple Myeloma, - Metastasis from Breast,
Prostate, Lung, Thyroid, Kidney CA
A - Aneurysm - Abdominal
S - Slipped Disk, Spondylolisthesis, Spinal
Stenosis
S - Strain, Scoliosis / Lordosis - Skin: Herpes
Zoster
Back pain (2/11/10)
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
*Abdominal or Thoracic Aortic Aneurysm
*Pulmonary Embolus
*Pneumonia
Gall Bladder Disease
Pyelonephritis, Kidney Stone
Pancreatitis, Pancreatic Carcinoma
Polymyalgia Rheumatica
Metastatic Tumor
Abdominal Tumor
Penetrating Ulcer
Infection (Diskitis, Osteomyelitis, Spinal
Abscess)
Musculoskeletal, Nonspecific
Herniated Disk
Spinal Stenosis
Compression Fracture
Psychiatric
Herpes Zoster
Vitamin D Deficiency
Prostatitis

*ARTHRITIS: "ARTHRITICS"
A - Autoimmune Arthritis, Amyloidosis
R - Rheumatic Fever
T - Trauma Acute or Chronic (DJD)
H - Hepatitis Type B, Hypertrophic Pulmonary
Osteoarthropathy
R - Reiter's Syndrome
I - Infection/Septic Joint (GC,SBE)
T - Treponema - Lyme Disease, Syphilis
I - Infarction: Sickle Cell Disease, Avascular
Necrosis, Osteochondritis Dessicans
C - Crystals: Gout (Urate) & Pseudogout
(Calcium)
S - Sarcoidosis Serum Sickness
*AUTOIMMUNE ARTHRITIS: "SUPPRESS"
S - SLE
U - Ulcerative Bowel Disease
P - Psoriasis
P - Polymyositis - Dermatomyositis
R - Rheumatoid & Juvenile RA
E - Erythema Nodosum
S - Scleroderma
S - Sjogrens, Sponylitis/Ankylosing
*CRAMPS - MUSCULAR: "CRAMPS"
C - Calcium Deficiency
R - Rupture of Tendon, Rhabdomyolysis
A - Arterial Insufficiency, Claudication
M - Magnesium Deficiency, Myotonia
P - Potassium Deficiency, Polymyalgia
Rheumatica
S - Strain / Overuse of Muscle

<Clinical Practice>
*Responding to emotional cues: NURS
Naming-That sounds like a scary experience"
Understanding or LegitimizationIt's
understandable that you feel that way"
Respecting-"You've done better than most
people would with this.
*Setting the Stage: KNOCKS PRIVATELY
K - Knock on the door - do not barge in
N - Never uses titles like "honey" or "sweetie";
use respectful sir titles like Mr., Ms....
O - Open ended questions to start with: "What
can I do for you?"
C - Comfort; ask if you can make them more
comfortable
K - Keep quiet after asking the main question.
Let them respond for at least 2 minutes.
S - Space between bodies. Maintain proper Body
Space
P - Privacy. Interview in private if possible, or a
look of privacy
R - Read the chart ahead of time. Learn about
the individual if you can.
I - Introduction - Introduce yourself & shake
hands
V - Voice tone & inflection are important
A - Ask about family, hobbies, or interests as an
ice breaker & a show of concern
T - Titles - Use the appropriate sir title for the
patient & not first name
E - Eye level, be at eye level
L - Look the part, be professional
Y - Your role on the health care team Index
*Facilitation - I CAN KEEP INTEREST GOING.
I - "I'm listening"
C - Confrontation - You say you don't know what
brings on these headaches, yet before every
episode you describe a stressful event."
A - Ask for clarification "What do you mean by
dizziness"
N - No Shopping list questions are banned, like
"do you have nausea, vomiting or diarrhea?"
K - Keep Quiet, do not interrupt, use silence to
keep the patient talking
E - Empathize: " I understand why you felt that
way".
E - Eye contact
P - Phrase repetition; repeat the last phrase back

to the patient
I - Interpretation - of pt's words / behavior, "You
say you 're not angry, but your words express
anger."
N - Nod in approval
T - "Tell me more"
E - Energize the conversation with hand
gestures & face animation.
R - Reflection. Repetition of the last statement
E - Encourage continuation with "Ah ha,
Hmmm...."
S - Summarize the conversation back to the pt
"Let me repeat your history to see if I have it
right."
T - Take notes sparingly
G - Glad you came; legitimize the visit
O - Open ended questions first
I - Involve the patient's ideas about what is
going on, "What do you think?"
N - No leading questions, "You don't have
chest pain, do you?"
G - "Go on"
*Giving Bad News: "STOP & PRAY
S. Setting the Stage
a. Privacy, schedule time, empathy &
provide for comfort.
b. Ask patient who they want to be with
them, ask permission.
c. Approach as "we've got some
decisions to make"
d. Eye contact, speak slowly, clearly, no
medical jargon.
T. Test the patient's knowledge up to that point.
O. Oppositions: Is the patient in pain, tired or
under medications?
P. Patient education tools with patient
reflection to show understanding.
A. Acknowledge & validate patient emotions &
reactions.
N. Never take HOPE away
D. Define Support Systems, D. Describe
unknown support systems: Hospice,
counselors, clergy....
P - Pray: If you are of like faith, offer to pray for
the patient. Prayer keeps hope alive
R - Referrals & follow-up.
Make close follow-up appointments.
Make consultations & referrals to
consultants who will support patient.
Let patient know how to reach you (via
service or office)

Call them at home to support them. Call if

questions
A- Alternatives for treatment, study
protocols...Medline or Internet resources (NIH,
NCI....) Warnings about alternative
treatments .Patients on study do better
Y- Your mental health, You need to be
comfortable with your mortality. Have a healthy
way to vent
Know how to recognize & prevent burn-out Have
a good life - remember what is really important.
Thanks to the "Great Physician":
J - Justifies
E - Everyone
S - Seeking
U - Undeserved
S - Salvation (Eternal life, healing, health,
deliverance, peace, & provision)

Differential Dx Checklist, Common Complaints

for Outpatient Medicine
1. Abdominal & Pelvic Pain
2. Abnormal Uterine Bleeding
3. Anxiety, Depression
4. Back Pain
5. Chest Pain
6. Cough
7. Cough, Dyspnea (infant, newborn)
8. Crying Infant (Inconsolable)
9. Delirium
10. Dementia, Memory Loss
11. Diarrhea
12. Dysphagia
13. Dyspnea, Tachypnea
14. Ear pain, Otalgia
15. Edema, Leg
16. Facial Flushing
17. Facial Pain
18. Fever (Acute, Uncertain Source)
19. Flank pain
20. Genital Skin Lesion, Genital Ulcer
21. Headache
22. Hearing Loss (Deafness)
23. Hematuria
24. Hypotension, Shock
25. Leg Pain, Bone Pain, Extremity Pain
26. Limp in Child
27. Lymphadenopathy
28. Mental status, Acute Change (Coma,
Lethargy)
29. Muscle Cramps
30. Myalgias, Arthralgias (Generalized)
31. Nausea, Vomiting
32. Numbness, Sensory Loss
33. Pruritus
34. Rash, Generalized
35. Red Eye
36. Scrotal Pain
37. Seizure
38. Shoulder Pain
39. Sinus Tachycardia
40. Syncope
41. Tinnitus
42. Tremor
43. Urinary Symptoms (Dysuria, Frequency,
Urgency)
44. Vertigo
45. Weakness, fatigue, malaise, vague
symptoms
46. Weight loss

<PEDIATRIC DDx List>

PEDIATRIC HISTORY & PHYSICAL EXAM
(CHILDREN ARE NOT JUST LITTLE
ADULTS)
-HISTORYLearning Objectives:
1. To understand the content differences in
obtaining a medical history on a pediatric patient
compared to an adult.
a. To understand how the age of the child has an
impact on obtaining an appropriate medical
history.
2. To understand all the ramifications of the
parent as historian in obtaining a medical history
in a pediatric patient.
3. To understand the appropriate wording of
open-ended and directed questions, and
appropriate use of each type of question.
4. To develop an awareness of which clinical
settings it is appropriate to obtain a complete
medical history compared to a more limited,
focused history.
Competencies:
1. To obtain an accurate and complete history of
a pediatric patient in different age groups (<1
year; 1-5 years; > 5 years).
Differences of a Pediatric History Compared to
an Adult History:
I. Content Differences
A. Prenatal and birth history
B. Developmental history
C. Social history of family - environmental risks
D. Immunization history
II. Parent as Historian
A. Parents interpretation of signs, symptoms
1. Children above the age of 4 may be able to
provide some of their own history
2. Reliability of parents observations varies
3. Adjust wording of questions - When did you
first notice Johnny was limping? instead of
When did Johnnys hip pain start?

delivery
B. Observation of parent-child interactions
1. Distractions to parents may interfere with
history taking
2. Quality of relationship
C. Parental behaviors/emotions are important
1. Parental guilt - nonjudgmental/reassurance
2. The irate parent: causes
Outline of the Pediatric History:
I. Chief Complaint
A. Brief statement of primary problem
(including duration) that caused family to seek
medical attention
II. History of Present Illness
A. Initial statement identifying the historian, that
persons relationship to patient and their
reliability
B. Age, sex, race, and other important
identifying information about patient
C. Concise chronological account of the illness,
including any previous treatment with full
description of symptoms (pertinent positives)
and pertinent negatives. It belongs here if it is
relates to the differential diagnosis for the chief
complaint.
III. Past Medical History
A. Major medical illnesses
B. Major surgical illnesses-list operations and
dates
C. Trauma-fractures, lacerations
D. Previous hospital admissions with dates and
diagnoses
E. Current medications
F. Known allergies (not just drugs)
G. Immunization status - be specific, not just
up to date
IV. Pregnancy and Birth History
A. Maternal health during pregnancy: bleeding,
trauma, hypertension, fevers, infectious
illnesses, medications, drugs, alcohol, smoking,
rupture of membranes
B. Gestational age at delivery
C. Labor and delivery - length of labor, fetal
distress, type of delivery (vaginal, cesarean
section), use of forceps, anesthesia, breech

D. Neonatal period - Apgar scores, breathing

problems, use of oxygen, need for intensive care,
hyperbilirubinemia, birth injuries, feeding
problems, length of stay, birth weight
V. Developmental History
A. Ages at which milestones were achieved and
current developmental abilities - smiling, rolling,
sitting alone, crawling, walking, running, 1st word,
toilet training, riding tricycle, etc (see
developmental charts)
B. School-present grade, specific problems,
interaction with peers
C. Behavior - enuresis, temper tantrums, thumb
sucking, pica, nightmares etc.
VI. Feeding History
A. Breast or bottle fed, types of formula,
frequency and amount, reasons for any changes
in formula
B. Solids - when introduced, problems created
by specific types
C. Fluoride use
VII. Review of Systems: (usually very
abbreviated for infants and younger children)
A. Weight - recent changes, weight at birth
B. Skin and Lymph - rashes, adenopathy, lumps,
bruising and bleeding, pigmentation changes
C. HEENT - headaches, concussions, unusual
head shape, strabismus, conjunctivitis, visual
problems, hearing, ear infections, draining ears,
cold and sore throats, tonsillitis, mouth breathing,
snoring, apnea, oral thrush, epistaxis, caries
D. Cardiac - cyanosis and dyspnea, heart
murmurs, exercise tolerance, squatting, chest
pain, palpitations
E. Respiratory - pneumonia, bronchiolitis,
wheezing, chronic cough, sputum, hemoptysis,
TB
F. GI - stool color and character, diarrhea,
constipation, vomiting, hematemesis, jaundice,
abdominal pain, colic, appetite
G. GU - frequency, dysuria, hematuria,
discharge, abdominal pains, quality of urinary
stream, polyuria, previous infections, facial
edema
H. Musculoskeletal - joint pains or swelling,
fevers, scoliosis, myalgia or weakness, injuries,
gait changes

I. Pubertal - secondary sexual characteristics,

menses and menstrual problems, pregnancies,
sexual activity
J. Allergy - urticaria, hay fever, allergic rhinitis,
asthma, eczema, drug reactions
VIII. Family History
A. Illnesses - cardiac disease, hypertension,
stroke, diabetes, cancer, abnormal bleeding,
allergy and asthma, epilepsy
B. Mental retardation, congenital anomalies,
chromosomal problems, growth problems,
consanguinity, ethnic background
IX. Social
A. Living situation and conditions - daycare,
safety issues
B. Composition of family
C. Occupation of parents
-PHYSICAL EXAMINATIONObjectives
1. To understand how the general approach to
the physical examination of the child will be
different compared to that of an adult patient,
and will vary according to the age of the patient.
2. To observe and demonstrate physical
findings unique to the pediatric population, and
to understand how these findings may change
depending upon the age of the child.
Competencies
1. To obtain accurate vital signs (Temperature,
HR, RR, BP) in a pediatric patient in different
age groups and to be able to evaluate these
vital signs compared to age-adjusted normals.
To understand the normal variation in
temperature depending on the route of
measurement.
2. To complete a thorough physical
examination on a pediatric patients in different
age groups. Two of these should be
supervised by the attending staff in Clinic 6.
Differences in Performing A Pediatric Physical
Examination Compared to an Adult:
I. General Approach
A. Gather as much data as possible by
observation first
B. Position of child: parents lap vs. exam table
C. Stay at the childs level as much as possible.
Do not tower!!

C. Order of exam: least distressing to most

distressing
D. Rapport with child
1. Include child - explain to the childs level
2. Distraction is a valuable tool
E. Examine painful area last-get general
impression of overall attitude
F. Be honest. If something is going to hurt, tell
them that in a calm fashion. Dont lie or you lose
credibility!
G. Understand developmental stages impact on
childs response. For example, stranger anxiety
is a normal stage of development, which tends to
make examining a previously cooperative child
more difficult.
II. Vital signs
A. Normals differ from adults, and vary according
to age
1. See code card for charts of age-adjusted
normals
B. Temperature
1. Tympanic vs. oral vs. axillary vs. rectal
C. Heart rate
1. Auscultate or palpate apical pulse or palpate
femoral pulse in infant
2. Palpate antecubital or radial pulse in older
child
D. Respiratory rate -Observe for a minute.
Infants normally have periodic breathing so that
observing for only 15 seconds will result in a
skewed number.
E. Blood pressure
1. Appropriate size cuff - 2/3 width of upper arm
2. Site
F. Growth parameters - must plot on appropriate
growth curve
1. Weight
2. Height/length
3. OFC: Across frontal-occipital prominence so
greatest diameter
(Occipital Frontal Circumference)
III. Unique findings in pediatric patients (See

outline below)
Outline of a Pediatric Physical Examination

B. Tympanic membranes
C. Hearing - Gross assessment only usually

I. Vitals - see above

V. Nose
A. Nasal septum
B. Mucosa (color, polyps)
C. Sinus tenderness
D. Discharge

II. General
A. Statement about striking and/or important
features. Nutritional status, level of
consciousness, toxic or distressed, cyanosis,
cooperation, hydration, dysmorphology, mental
state
B. Obtain accurate weight, height and OFC
III. Skin and Lymphatics
A. Birthmarks - nevi, hemangiomas, mongolian
spots etc
B. Rashes, petechiae, desquamation,
pigmentation, jaundice, texture, turgor
C. Lymph node enlargement, location, mobility,
consistency
D. Scars or injuries, especially in patterns
suggestive of abuse
IV. Head
A. Size and shape
B. Fontanelle(s)
1. Size
2. Tension - calm and in the sitting up position
C. Sutures - overriding
D. Scalp and hair
V. Eyes
A. General
1. Strabismus
2. Slant of palpebral fissures
3. Hypertelorism or telecanthus
B. EOM
C. Pupils
D. Conjunctiva, sclera, cornea
E. Plugging of nasolacrimal ducts
F. Red reflex
G. Visual fields - gross exam
VI. Ears
A. Position of ears
1. Observe from front and draw line from inner
canthi to occiput

VI. Mouth and Throat

A. Lips (colors, fissures)
B. Buccal mucosa (color, vesicles, moist or dry)
C. Tongue (color, papillae, position, tremors)
D. Teeth and gums (number, condition)
E. Palate (intact, arch)
F. Tonsils (size, color, exudates)
G. Posterior pharyngeal wall (color, lymph
hyperplasia, bulging)
H. Gag reflex
V. Neck
A. Thyroid
B. Trachea position
C. Masses (cysts, nodes)
D. Presence or absence of nuchal rigidity
VI. Lungs/Thorax
A. Inspection
1. Pattern of breathing
a. Abdominal breathing is normal in infants
b. Period breathing is normal in infants (pause <
15 seconds)
2. Respiratory rate
3. Use of accessory muscles: retraction location,
degree/flaring
4. Chest wall configuration
B. Auscultation
1. Equality of breath sounds
2. Rales, wheezes, rhochi
3. Upper airway noise
C. Percussion and palpation often not possible
and rarely helpful
VII. Cardiovascular
A. Auscultation
1. Rhythm
2. Murmurs
3. Quality of heart sounds
B. Pulses
1. Quality in upper and lower extremities

3. Neonatal primitive

VIII. Abdomen
A. Inspection
1. Shape
a. Infants usually have protuberant abdomens
b. Becomes more scaphoid as child matures
2. Umbilicus (infection, hernias)
3. Muscular integrity (diasthasis recti)
B. Auscultation
C. Palpation
1. Tenderness - avoid tender area until end of
exam
2. Liver, spleen, kidneys
a. May be palpable in normal newborn
3. Rebound, guarding
a. Have child blow up belly to touch your hand
IX. Musculoskeletal
A. Back
1. Sacral dimple
2. Kyphosis, lordosis or scoliosis
B. Joints (motion, stability, swelling, tenderness)
C. Muscles
D. Extremities
1. Deformity
2. Symmetry
3. Edema
4. Clubbing
E. Gait
1. In-toeing, out-toeing
2. Bow legs, knock knee
a. Physiologic bowing is frequently seen
under 2 years of age and will spontaneously
resolve
3. Limp
F. Hips
1. Ortolanis and Barlows signs
X. Neurologic - most accomplished through
observation alone
A. Cranial nerves
B. Sensation
C. Cerebellum
D. Muscle tone and strength
E. Reflexes
1. DTR
2. Superficial (abdominal and cremasteric)

XI. GU
A. External genitalia
B. Hernias and Hydrocoeles
1. Almost all hernias are indirect
2. Can gently palpate; do not poke finger into the
inguinal canal
C. Cryptorchidism
1. Distinguish from hyper-retractile testis
2. Most will spontaneously descend by several
months of life
D. Tanner staging in adolescents - See Tanner
Staging handouts
E. Rectal and pelvic exam not done routinely special indications may exist
() Ace of Spades = "Must-not-miss"
Diagnoses (*) Asterisk = Commonly Missed
Diagnoses
Crying infant (Inconsolable) (6/1/10)
Infections (otitis media, viral illness, urinary
tract infection, herpes stomatitis)
Fracture
Hair tourniquet syndrome
Colic
Corneal abrasion
Constipation
Idiopathic
Immunization reaction
Limp in child (6/1/10)
Transient synovitis
Fractures (toddlers, stress, foot, abuse)
Soft tissue trauma
Osgood-Schlatter's disease
Slipped capital femoral epiphysis
Legg-Perthes
Osteochondritis dessicans
Hip dysplasia
Tumors
Conversion disorder
Leukemia
Septic arthritis
Osteomyelitis
Diskitis
Muscular dystrophy

CONGENITAL SYNDROME
CEREBELLAR SYNDROME: Congenital
Cerebellar Ataxia
CERVICAL SYNDROME: Supernumerary C7
rib --> Pressure on brachial plexus --> pain
radiating over shoulder, arm, and forearm over
C7 distribution
DANDY-WALKER SYNDROME: Obstruction
of Foramina of Magendie & Luschka in infants -> Hydrocephalus
DIGEORGE SYNDROME: Congenital
absence of 3rd and 4th Branchial Arches
(Thymus Parathyroid Glands) --> secondary
symptoms:
o No cell-mediated immunity -->
Frequent viral & fungal infections
o Characteristic facial deformities
DOWN SYNDROME: Trisomy 21. Mental
retardation, characteristic facial features,
Simeon crease in hand
FANCONI'S SYNDROME Type I: Bonemarrow hypoplasia --> refractory anemia,
pancytopenia
EHLERS-DANLOS SYNDROME: Congenital
defect in collagen
o Hyper-elasticity and friability of the
skin
o Hyperextensibility of the joints
FETAL ALCOHOL SYNDROME: Fetal
malformations, growth deficiencies, craniofacial
anomalies, limb defects
GOODPASTURE'S SYNDROME:
Autoantibodies against basement membranes -> Glomerulonephritis (kidney) and hemoptysis
(lungs)
o Often, death by renal failure
KLINEFELTER'S SYNDROME: Trisomy XXY
--> testicular atrophy, increase in
gonadotropins in urine
KLIPPEL-FEIL SYNDROME:
o Cervical vertebrate fused
o Congenital short neck, limited neck
rotation
o Abnormalities of the brainstem &
cerebellum
o Low hairline

LESCH-NYHAN SYNDROME: Deficiency of

HGPRT (Hypoxanthine-Guanine
Phosphoribosyltransferase)-->
o Hyperuricemia, uric acid kidney stones
o Choreoathetosis
o Mental retardation, autism, spastic
cerebral palsy
o X-Linked recessive
MARFAN SYNDROME: Connective Tissue
Disorder ------>
o Arachnodactyly: Abnormally long digits
& extremities
o Subluxation of Lens
o Dissecting Aortic Aneurism
POST-RUBELLA SYNDROME: Infantile
defects resulting from maternal Rubella infection
during 1st trimester
o Microphthalmos, Cataracts
o Deafness
o Mental Retardation
o Patent Ductus Arteriosis, Pulmonary
Arterial Stenosis
PRADER-WILLI SYNDROME: Short stature,
mental retardation, polyphagia with marked
obesity, sexual infantilism
RENDU-OSLER-WEBER SYNDROME:
Hereditary hemorrhagic telangiectasia
SUDDEN INFANT DEATH SYNDROME:
Unexplained death in sleeping infants
TURNER'S SYNDROME: XO monosomy
o Dwarfism
o Webbed neck
o Valgus of elbow
o Amenorrhea
WILSON SYNDROME: Congenital defect in
Ceruloplasmin, leading to buildup of copper -->
mental retardation, cirrhosis, hepatolenticular
degeneration

<Differential Diagnosis in Paediatrics>

Global Developmental Delay
Genetic - Downs syndrome, fragile X, PraderWilli, Williams.
Metabolic - hypothyroidism, PKU.
Perinatal insult - hypoxia, intracranial
haemorrhage, teratogens
Neurological - infection (e.g. meningitis,
encephalitis), head trauma, hypoglycaemia.
40% chromosomal abnormality, 10%
developmental malformations, 4% metabolic
cause.
History:
Birth history for anoxia, prematurity.
Family history of learning disability.
Developmental history milestones.
Social history risk factors e.g. deprivation.
Distinguish delay from regression.
Examination:
Developmental assessment.
Appearance e.g. dysmorphic features of
syndromes, skin lesions of neurocutaneous
syndromes.
Head circumference.
Delayed speech
Normal variation, deafness, global
developmental delay, lack of stimulus, autism,
problem with
articulation (e.g. cleft palate, CP).
History:
Development babbling, gurgling, words.
Other areas.
PMH things affecting hearing, cleft palate.
Family history.
Distinguish delay and mechanical problems e.g.
cleft palate, CP.
Examination:
Development
Hearing

Delayed walking
Normal variation (esp bottom shuffler and
commando crawler), cerebral palsy, muscular
dystrophy, hip dysplasia, lack of stimulus.
History:
Development: Gross Motor. Any locomotion.
Other areas.
Hip problems
Examination:
Hips signs of dislocation e.g. waddling gait, leg
length uneven, limited abduction.
Tone, power and reflexes. Gowers sign for
muscular dystrophy.
Locomotion
Investigations:
Imaging of hips and spine
CKase for Duchenne muscular dystrophy
Fever
Exercise or emotion
Minor infection URTI, non-specific viral, gastroenteritis without dehydration.
Major meningitis, pneumonia, UTI,
septicaemia.]
Rarely neoplasia, thyrotoxicosis, drug reaction,
heart failure.
History:
Duration - >1wk suggests TB, malaria, typhoid,
autoimmune disorders.
Localising symptoms cough and coryza (URTI),
D and V (GI tract, vomiting alone is less
specific), painful limb, lower abdo pain (UTI,
lower lobe pneumonia), meningism (headache,
photophobia, neck pain). Probably none in
infants.
Recent foreign travel.
Examination:
Systemically unwell if well unlikely to be septic.
Local signs of infection ENT, bulging fontanelle.
Rash.
Investigations and management:
Markers of inflammation e.g. WCC, CRP.
Septic screen blood cultures, urine, throat
swab, CSF, CXR.
In infants or those looking ill, usually start
antibiotics before results. Antipyrectics prevent
against
febrile convulsions.
Rash
Infection viral, toxin related, streptococcal,
meningococcal, scabies.

Dermatitis eczema, vasculitis.

Allergy drug related, urticaria.
Scalp sebhorrhoeic dermatitis, eczema,
psoriasis, fungal.
Flexor eczema.
Extensor psoriasis, Henoch-Schonlein
purpura.
Web spaces scabies.
Trunk viral xanthems, molluscum.
Mucous membranes measles, Kawasaki
disease, SJ syndrome, herpes.
Maculopapular (viruses and drugs) measles
(prodrome, Kopliks spots in mouth), rubella
(pink
on face, lymphadenopathy), Kawasaki disease
(protracted fever, red lips, conjunctivitis,
lymphadenopathy), scarlet fever (face,
strawberry tongue).
Vesicular chicken pox, eczema herpeticum.
Haemorrhagic meningococcal septicaemia
(unwell, petechial), leukaemia (pallor,
hepatosplenomegaly), ITP (looks well, bruising,
epistaxis), Henoch-Schonlein purpura (legs
and
buttocks, arthralgia, abdo pain), NAI.
History:
HPC duration, site, spread, persistent or
comes and goes (urticaria), itch (eczema,
scabies),
drug ingestion or provative agents, other family
members affected (viral, infestations),
associated symptoms, history of skin
conditions.
Examination:
Other features fever, mucous membranes,
lymphadenopathy, splenomegaly, arthropathy.
Describe morphology, arrangement,
distribution
Short stature
Constitutional, endocrine pathology (GH
deficiency, hypopituarism, hypothyroidism,
Cushings),
bone dysplasia (achondroplasia), systemic
illness (CHD, CF, CP, chronic renal failure),
psychosocial, genetic syndromes (Turners,
Silver-Russel, Downs, Noonans), nutritional.
History:
Early childhood illness.
Parental heights midparental height is
average of parents heights +7 for boys, -7 for
girls.

Target centile range is 10cm either side in boys,

8.5cm either side in girls.
Examination:
Height and growth velocity.
Dysmorphic features Turners (neck webbing,
wide spaced nipples), Prader-Willi (obesity,
hypotonia, small testicles).
Visual fields (pituitary tumour).
Stage of puberty.
Investigations:
Bone age (early puberty with premature bone
fusion or delayed with delayed growth spurt).
Karytype (Turners).
Skeletal survery (dysplasias).
Endocrine investigations thyroid function,
growth hormone provocation test.
Skull Xray (craniopharyngoma).
Abdominal pain
Acute: medical (abdominal and systemic) colic,
constipation, mesenteric adenitis,
gastroenteritis, hepatitis, UTI, DKA, sickle cell,
lower lobe pneumonia, HSP. Surgical
appendicitis (migrate from centre to RIF),
intussusception (episodic), ovarian or testicular
torsion
(see on examination), strangulated inguinal
hernia (groin mass), volvulus.
Recurrent usually functional. Rarely, UTI,
obstructive uropathy, food intolerance IBD, ulcer,
malrotation, pancreatitis, celiac disease, CF,
porphyria, lead poisoning.
History:
Babies drawing up legs, screaming.
Duration - >4hrs usually significant.
Location further from umbilicus is usually
significant.
Nature intermittent, constant.
Other symptoms vomiting (gastroenteritis,
obstruction), bloody stools (intussusception in
infant, IBD in older child), dysuria (UTI), cough
(pneumonia).
Functional recurrent abdo pain periumbilical,
worse on waking, short-lived, no appetite loss,
family history of functional illnesses, healthy
thriving child.
Examination:
Check for fever, jaundice (hepatitis), rash (HSP),
respiratory tract (RLL pneumonia), hernial
orifices, genitalia.
Investigations:
FBC and WCC (bacterial infection), sickling test,

U&Es (electrolyte disturbances before surgery

if
vomiting), glucose.
Urinalysis glucose, ketones, infection.
AXR (constipation, renal calculi, obstruction).
USS (obstructive uropathy, appendix mass,
intussusception).

Signs of malabsorption anaemia, think, wasting,

abdominal distension.
Investigations:
Stool microscopy and culture, test for reducing
substances, tests for malabsorption (e.g. Hb),
jejunal biopsy (celiac disease), sweat test (CF).

Intestinal obstruction
Neonate congenital malformation of gut e.g.
atresia, malrotation, volvulus, exomphalos,
gastrochisis, Hirschprungs, imperforate anus,
CF, NEC.
Young child intussusception, volvulus,
strangulated hernia.
Older child strangulated hernia.
Constipation
Baby inadequate fluid intake, overstrength
formula, change to cows milk.
Infants normal, simple, lack of fibre or water,
painful anal fissure, Hirschprungs, CP,
hypothyroidism, hypercalcaemia, renal tubular
disorders.
History:
Frequency and consistency.
Pain or blood.
Soiling (overflow, simple constipation).
History of delay in passing meconium
(Hirschprungs).
Examination:
Failure to thrive and dehydration.
Abdominal distension (Hirshprungs) or
palpable colon (simple).
Anal fissure.
Rectal loading.

Vomiting
Persistent in a baby - pyloric stenosis, GORD,
overfeeding, systemic illness, lactose intolerance.
Neonate regurgitation (normal), systemic
infection, inborn errors of metabolism, bowel
obstruction (duodenal atresia, volvulus,
strangulated hernia, meconium ileus in CF,
Hirschprungs), tracheo-oesophageal fistula,
NEC, CAH.
Infant reflux, gastroenteritis, RTI, UTI,
meningitis, pyloric stenosis, intussusception.
Older children infections, appendicitis, raised
ICP, migraine, eating disorders.
Haematemesis in a neonate swallowed
maternal blood (predelivery or cracked nipple),
trauma
from a feeding tube, haemorrhagic disease of
the new born.
Haematemesis in children liver disease,
oesophagitis, gastritis.
History:
Bile or blood need to investigate urgently.
Duration.
Associated symptoms fever, abdo pain,
constipation, diarrhoea.
Last wet nappy. Feeding.
Examination:
Dehydration.
Fever, abdominal distension, hernial orifices.

Diarrhoea
Chronic - toddlers diarrhoea, malabsorption
(steatorrhoea), lactose intolerance, coeliac
disease,
cystic fibrosis, IBD, parasitic infection,
constipation with overflow.
Acute viral gastroenteritis (rotavirus, SRSV,
adenovirus), bacterial gastroenteritis,
suggested by
high fever (Ecoli, campylobacter, salmonella,
shigella), protozoo (giardia, entamoeba,
crytosporidium).
Bloody infective e.g. campylobacter, shigella,
amoeba, intussusception, haemolytic uraemic
syndrome, UC.
Examination:

Painful joints
Monoarthritis - reactive arthritis, juvenile chronic
arthiritis (chronic pain and swelling), septic
arthritis (fever, immobile), haemophilia, trauma.
Polyarthritis JIA, SLE, HSP, viral, rheumatic
fever.
History:
Acute or insidious.
One or multiple joints.
Limp
Abnormality of gait
All ages septic arthritis, osteomyelitis, trauma.
Infants congenital dislocated hip, CP. Children
- irritable hip (transient synovitis, commonest,

well child), Perthes disease, JIA. Teenagers slipped femoral epiphysis, Osgood Schlatters
disease, tumours, hysteria.
History:
Presence of pain.
Duration chronic pain is unlikely to be
infection.
Prodromal illness.
Examination:
Observe walking if possible.
Fever (infection), rashes, range of movement,
point tenderness, unequal leg length, spinal
abnormality, neurological signs (tone, power,
reflexes).
Investigations:
Xray, USS (hips), isotope bone scans, acute
phase reactants, blood cultures.
Painful limb
Growing pains, osteomyelitis, fracture or
trauma, any febrile illness, sickle cell crisis,
haemophilia, malignant deposits (worse at
night), rickets.
May present as pseudoparalysis in infants.
History:
Onset acute with trauma, osteomyeleitis,
sickle crisis.
Bleeding disorder
Can cause bleeding into skin, epistaxis,
haemarthrosis, haematuria.
Vascular defects heridatary haemorrhagic
telaniectasia, Ehler Danlos syndrome, HSP
(most
common, purpura on buttocks and lower limbs),
scurvy, meningococcal septicaemia.
Platelet defects ITP (bruising in well child),
DIC, HUS, marrow failure, drug induced e.g.
aspirin.
Coagulation defects haemophilia (male), von
Willebrand disease, vit K defiency
(haemorrhagic
disease of the newborn, malabsorption, liver
disease), anticoagulant drugs.
History:
Inherited or acquired, family history.
Age of onset.
Previous haemostatic challenges e.g.
operation.
Site and type of bleeding.
Investigations:
Blood film, liver and renal function, platelet

count, coagulation screen.

Anaemia
Decreased red cell production, increased red cell
breakdown, blood loss.
Also pallor due to vasoconstriction.
History:
Chronic disease esp renal.
GI symptoms.
Dietary history (insufficient iron is most common).
Family history e.g. of sickle cell, thalassaemia,
spherocytosis.
Examination:
Ethnicity Afro-Caribbean (sickle cell),
Mediterranean and Asian (thalassaemia).
Jaundice (haemolysis), bruising (marrow failure),
splenomegaly (haemolysis).
Hypoglycaemia
Metabolic liver disease, inborn errors of
metabolism e.g. glycogen storage diseases,
ketotic (fasting).
Hormonal hyperinsulinaemia (treated DM, islet
cell adenoma), Addison disease, CAH,
panhypopituarism, GH deficiency.
Changes in EEG at <2.6mmol/l, always send for
lab glucose as well as capillary prick test.
Management sugary drink, if unconscious
10% dextrose.
Jaundice
Neonatal in first 24 hours excess haemolysis
(rhesus or ABO incompatibility, G6PD, pyruvate
kinase deficiency, spherocytosis), congenital
infections.
Neonatal 2d-2wks physiological, breast milk
jaundice, Gilberts syndrome (common, mild
hepatic enzyme defect), infection, haemolytic
disease, resolving haematoma.
Neonatal persistent unconjugated: breast milk,
infections, continuing excess haemolysis,
hypothyroidism, galactosaemia; conjugated (dark
urine, pale stools): biliary atresia, hepatitis.
Child infectious hepatitis esp hep A (also EBV,
malaria, leptospirosis), injury due to drugs (e.g.

halothane), Gilbert syndrome (hepatic enzyme

defect), haemolysis (G6PD deficiency,
spherocytosis, HUS, malaria), biliary
obstruction (e.g. CF).
Investigations: for causes. Bilirubin levels,
conjugated or unconjugated, liver enzymes,
FBC,
urine culture, viral titres, liver USS, liver biopsy.
For neonatal conjugated screen for infection
(e.g. hepatitis) and genetic causes (e.g. A1AT
and
galactosaemia. USS of bile ducts, if dilated
then cholangiogram (choledocal cyst), if normal
or not
seen then radionucleide scan. If get excretion
then patent biliary tree (need liver biopsy), if no
excretion then suspect biliary atresia.
Hepatosplenomegaly
Hepatomegaly with jaundice: biliary atresia,
infective hepatitis.
Hepatomegaly without jaundice: cardiac failure,
hyperinflation of lungs.
Hepatosplenomegaly: advanced liver disease,
leukaemia, thalassaemia, rare storage
disorders.
Splenomegaly neonates and thin children (tip
palpaple), acute infection (e.g. CMV, EBV,
septicaemia), malignancy (lymphoma,
leukaemia), haemolytic anaemia
(spherocytosis, G6PD deficiency),
haemoglobinopathy, ITP, collagen diseases
(JCA, SLE). Also consider non-spleen e.g.
Wilms tumour, hydronephrosis, neuroblastoma.
Neck swelling
Lateral acute lymphadenitis (short history,
inflammation), TB, malignant nodes (nontender,
rubbery, other signs), branchial cyst (middle
third of SCM, transilluminates), haemangioma
(bruit, may get cardiac failure or platelet
consumption), lymphangioma (transilluminable,
rapid enlargement, soft), sternomastoid tumour
(neonate, swelling in muscle, no inflammation,
torticollis), salivary gland (pain with eating).
Midline lymph nodes (regional infection),
dermoid cyst, thryroglossal cyst, ectopic thyroid,
goitre.
Lymphadenopathy
Generalised infection (EBV, TP, CMV, HIV),

haemotological malignancy, immunological (JCA,

sarcoidosis, Kawasaki).
Cervical: acute local infection, cervical adenitis;
persistent TB adenitis, neoplasia.
History:
Duration - <4wks usually infection, >1yr unlikely
to be neoplastic.
Constitutional symptoms e.g. weight loss, fever,
rash.
Pets (cat scratch fever, TP).
Examination:
All nodal sites.
Size, mobility, tenderness (bacterial adenitis),
drainage region, abdomen.
Worrying lymph nodes rapid growth, skin
ulceration, fixation, >3cm, persist.
Investigations:
If general FBC, EBV serology, CXR, abd USS,
bone marrow aspiration, biopsy.
Collapse or coma
Infective septicaemia, meningitis.
Metabolic hypoglycaemia, DKA, inborn errors
of metabolism, liver or renal failure.
Poisoning or trauma.
Neurological - head injury, post-ictal, intracranial
tumour or haemorrhage.
Congenital heart disease.
Management:
ABC, temperature, blood glucose, AVPU/GCS,
signs of injury, fever or rash, focal neurological
signs.
Signs of coning hypertension, bradycardia,
irregular respiration (Cushings response).
Dont do lumbar puncture as raised ICP likely.
Seizures
Firstly, distinguish true seizures from others. In
infants jitteriness (doesnt have fast and slow
component), benign myoclonus (jerks when
asleep), apnoea, reflux. Toddlers - breath
holding attacks, reflex anoxic seizures, rigors.
Children syncope, tics, migraine, tantrums,
heart block, arrhythmia.
Seizures - epileptic fit (one off or recurrent),
febrile convulsion, hypoglycaemia, meningitis,
encephalitis, head injury, hyponatraemia,
cerebral tumour.
In the neonate encephalopathy (hypoxic,
bilirubin), intracranial haemorrhage, infection,
congenital abnormality, hypoglycaemia.
History:

Provoking factors when and where.

Episode loss of consciousness, abnormal
movements, altered tone, pallor or cyanosis,
eye movements, duration of episode.
Previous history birth, developmental delay,
head injury, family history.
Examination:
Usually normal in epilepsy.
Skin neurocutaneous syndromes e.g.
tuberous sclerosis, neurofibromatosis (look
with Woods
light).
Optic fundi fundal changes with congenital
infections or neurodegenerative diseases.
If actively convulsing ABC, fever, fontanelle
(raised ICP), meningism, optic fundi, focal
neurological signs, level of consciousness.
Investigations:
EEG identify a particular epilepsy syndrome
or underlying lesion. A single interictal EEG will
be
normal in 50% children with epilepsy and can
be abnormal in normal children. Can get more
from
ambulatory monitoring or recordings after sleep
deprivation.
Neuroimaging for partial seizures, intractable
seizures, focal neurological deficit, evidence of
neurocutaneous syndrome.
Investigation of underlying neurometabolic
disorder.
Epilepsy is diagnosed from a history from a
witness rather than investigations.
Recurrent headaches
Tension headache, migraine, sinusitis,
refractive errors, hypertension, raised ICP,
brain tumour.
History:
Site, intensity, duration and frequency,
provoking factors, associated symptoms (e.g.
weakness,
paraesthesia, nausea).
Examination:
Blood pressure and radiofemoral delay
(coarctation), visual acuity (refractive error),
papilloedema (raised ICP), focal neurological
deficit (tumour).
Bed wetting
Primary nocturnal enuresis, nocturnal epilepsy,
UTI, neuropathic bladder, psychological.

May be due to polyuria diabetes, UTI,

excessive drinking, chronic renal failure.
History:
Frequency, time of night.
Daytime symptoms urgency or wetting
(suggests underlying cause).
Emotional stresses.
Examination:
Any evidence of neurological problem e.g. hairy
patch. Enlarged bladder. Urinalysis.

Daytime enuresis
Psychological (acute onset, previously continent),
infection, neurological (continual since birth),
ectopic ureter (continuous dribbling since birth),
urethral obstruction, sphincter damage. If
secondary likely to be psychological or due to
UTI or polyuria e.g. diabetes.
School absence
Illness (90%).
Truancy mostly lower socio-economic class
boys with poor academic records. Parental
refusal. School-refusal pre-pubertal children,
normal intelligence, shy. Separation anxiety.
School phobia.
Hypertension
Primary becomes more common the older the
child (about 50% in teenagers).
Renal (most) chronic pyelonephritis,
hydronephrosis, tumours, chronic
glomerulonephritis, renal artery stenosis.
Other coarctation of the aorta, Cushings, CAH,
phaeochromocytoma, neuroblastoma,
thyrotoxicosis.
History:
Symptoms of renal or endocrine disease.
Symptoms of malignant hypertension.
Examination:
Malignant hypertension retinal haemorrhage,
papilloedema, heart failure. Renal masses, renal
artery bruit. Goitre. Femoral pulses.
Investigations:
Renal urinalysis, ultrasound kidneys, IVP,
kidney function tests.
Endocrine serum thyroxine, electrolytes, urine
VMA and cortisol.

Proteinuria
Mostly benign fever, exercise, orthostatic.
Nephrotic syndrome, UTI, glomerular nephritis.
Examination:
Nephrotic syndrome suggested by oedema,
ascites, pleural effusions.
Investigations:
Early morning protein:creatinine ratio, renal
function, plasma albumin, MSU, throat swab.
Haematuria
Either frank (naked eye) or on strip. Confirm by
microscopy (as strips positive in myoglobinuria
and dyes may discolour urine).
Glomerular (also white cells and protein) acute glomerular nephritis: post-streptococcal,
HSP,
IgA nephropathy, Alport syndrome.
Non-glomerular - UTI, Wilms tumour,
schistosomiasis, trauma, stones, bleeding
disorders, transient benign haematuria
(diagnosis of exclusion).
History:
Duration and recurrence.
Urinary symptoms (suggest UTI).
Loin pain (pyelonephritis).
Foreign travel (schistosomiasis).
Sore throat (post-streptococcal).
Family history (Alport syndrome).
Examination:
Fever (UTI, pyelonephritis), oedema (nephrotic
syndrome), hypertension (nephritis, scarring),
rash and joint swelling (HSP), bruises (ITP),
abdo mass (Wilms tumour).
Respiratory difficulties in neonate
Airway choanal atresia, macroglossia,
micrognathia, goitre, subglottic stenosis, cord
paralysis, laryngomalacia, tracheooesophageal
fistula.
Lung problems meconium aspiration, RDS,
penumothorax, transient tachypnoea of
newborn,
pneumonia.
Malformations diaphragmatic hernia,
pulmonary hypoplasia, CCAM.
Non-pulmonary excessive air swallowing,
septicaemia, anaemia, CHD, persistent fetal
circulation
Wheeze

Viral LRTI e.g. bronchiolitis (infants), asthma

(children over 2), reflux, foreign body,
pneumonia (fever), congestive cardiac failure,
CF (other problems), GO reflux (vomiting),
central airways disease (also stridor), postviral
wheeze.
History:
Pattern of symptoms.
Family and personal history of atopy.
Trigger factors.
Estimation of severity e.g. exercise tolerance,
sleep disturbance, school abscense.
Cough
Chronic CF (productive, other symptoms), TB,
post-viral cough receptor sensitivity, asthma
(most common, usually at night and also
wheeze), whooping cough, inhaled foreign body,
primary ciliary dyskinesia (productive), reflux.
Acute usually URTI (coryzal symptoms),
bronchiolitis (<1y, wheeze), pneumonia (fever,
dyspnoea), foreign body (acute onset). Be aware
of barking cough of croup & paroxysmal
prolonged bouts of coughing in pertussis.
History:
Duration - >3wks is chronic.
Type of cough dry, productive (may suggest
CF).
Presence of wheeze (asthma).
Trigger factors e.g. smoking, animals.
Stridor
Acute - croup, epiglottitis, inhaled foreign body,
bacterial tracheitis, angioedema.
Persistent laryngomalacia, anatomical e.g.
vascular ring lord of the ring-Aragorn son of
Arathorn.
Breathlessness
Pneumonia, bronchiolitis, asthma.
Microcephaly
Normal child, severe mental retardation,
anencephaly, craniosynostosis.
Big head
Normal child, gigantism, hydrocephalus,
megalencephaly (e.g. storage diseases),
subdural
haematoma, intracranial tumour.
Inconsolable crying infant

Colic, otitis media, incarcerated hernia, UTI,

anal fissure, intussuception.
Swollen testes
Testicular torsion, hydrocoele, torsion of
testicular appendix, epididymo-orchitis,
idiopathic scrotal
oedema, trauma kick in the balls.

<NEONATOLOGY>
<Causes of Altered Mental Status in a Neonate:
THE MISFITS>
TTrauma (nonaccidental and accidental)
HHeart disease & hypovolemia
EEndocrine (eg, congenital adrenal
hyperplasia and thyrotoxicosis)
MMetabolic (electrolyte imbalance)
IInborn errors of metabolism
SSepsis (eg, meningitis, pneumonia, and
urinary tract infection)
FFormula mishaps (eg, under- or overdilution)
IIntestinal catastrophes (eg, volvulus,
intussusception & necrotizing enterocolitis)
TToxins & poisons
SSeizures
<Causes of Seizures in Infants>
<First Day of Life>
Anoxia/hypoxia
Drugs
Hypoglycemia/hyperglycemia
Infection
Intracranial hemorrhage
Pyridoxine deficiency
Trauma
<Second Day of Life>
Benign familial neonatal seizures
Congenital anomalies or developmental brain
disorders
Drug withdrawal

Hyperphosphatemia
Hypertension
Hypocalcemia
Hypoglycemia
Hyponatremia/hypernatremia
Inborn errors of metabolism
Sepsis
Trauma
<Day 4 to 6 months of Age>
Benign Idiopathic Neonatal Seizures
Congenital anomalies or developmental brain
disorders
Drug withdrawal
Hyperphosphatemia
Hypertension
Hypocalcemia
Hyponatremia/hypernatremia
Inborn errors of metabolism
Infection
<Common Differential Diagnosis of an apparent
Life-Threatening Event>
Acid-base disturbance
Anemia
Botulism
Child abuse
Dysrhythmias
Electrolyte abnormalities
Gastroesophageal reflux
Hypoglycemia
Hypothermia seizures
Inborn errors of metabolism
Intracranial hemorrhage
Meningitis and encephalitis
Pertussis
Pneumonia
RSV
Sepsis
<Presenting Signs & Symptoms of an Inborn
Error of Metabolism>
Subtle
Abnormal Tone
Irritability
Poor feeding or feeding refusal
Poor weight gain
Somnolence
Tachycardia
Tachypnea
Vomiting
Overt
Acidosis

Altered thermoregulation
Apnea
Arrhythmia
Cardiomyopathy
Dehydration
Lethargy or Coma
Persistent hypoglycemia
Poor perfusion or hypotension
Seizures
Sudden unexplained death
<Causes of Acyanotic Heart Disease that
present with Congestive Heart Failure>
Anemia
Aortic atresia
Aortic stenosis
Arteriovenous malformation
Coarctation of the Aorta
Complete arteriovenous canal
Cor pulmonale caused by bronchopulmonary
dysplasia
Endocardial cushion defect
Hypoplastic left heart
Interrupted aortic arch
Mitral valve atresia
Patent ductus arteriosus
Truncus arteriosus
Ventricular septal defect

WARD NOTES

1) MUST KNOW FORMULAS

I. DOPAMINE DOSAGE COMPUTATION
Dopamine Drip used primarily for stabilization of the
Hypotensive Patient
Formulation of Dopamine:
o Dilute 200mg (1 Ampule) in 250cc D5W (Factor used:
13.3)
o Drip at 2.5 10mcg/kg/min
o Maximum Dose of 20mcg/kg/min (Dopa-Max)

o If Double Strength: 2 Ampules in 250cc D5W (use 26.6)

Rate (ugtt/min) = . (mcg/kg/min) x body weight . Dose
(mcg/kg/min) = . (ugtt/min) x 13.3 .
13.3 body weight
Dopamine Doses (from Harrisons p1453)
DOSE MECHANISM OF ACTION EFFECT
< 2 mcg/kg per min Stimulate DA1 and DA2 Receptors
Vasodilation of Splanchnic and Renal
Vasculature
2-4 mcg/kg per minute Stimulate B1-Receptors Increase in
Cardiac Output with little or no
change in Heart Rate or SVR
> 5 mcg/kg per minute Effects on A1-Receptors
overwhelm the
Dopaminergic Receptors
Vasoconstricion, leading to Increase in SVE,
LV Filling Pressures, and Heart Rate
**NOTE: Dopamine is generally the 1st choice for Tx in
situations where Modest Inotropy & Pressor Support are
required
o It is an Endogenous Catecholamine that stimulates B1,
A1 Receptors, and Dopaminergic Receptors (DA1, DA2) in
the heart and circulation
o Dopamine also releases Norepinephrine from nerve
terminals, which itself stimulates A1 and B1 Receptors,
thus
raising Blood Pressure
o Most useful in treatment of heart failure patients who
have Depressed Cardiac Output with Poor Tissue
Perfusion
Example) Case on Septic Shock: Patient is a 45kg / F,
given 2 amps of Dopamine in 250cc PNSS at a rate of
19uggts/min
In 1 Ampule of Dopamine = 200mg/amp
In 1 Ampule of Dobutamine = 250mg/amp
NOTE: 19ugtts/min = 19cc/hr
QUESTION: What is the Dose of Dopamine being given to
the patient at a rate of 19uggts/min?:
Dose Given (in mcg/kg/min) = Rate (in ugtt/min) x 26.6 =
19 uggt/min x 26.6 = 11.23 mcg/kg/min
45 kg 45 kg
ANSWER: 11.23mcg/kg/min is the dose given to the
Patient at a rate of 19uggts/min (or 19cc/hr)
Strength Factors:
1 amp of Dopamine = 13.3
2 amps of Dopamine = 26.6
Recall the Action of Dopamine at Different Doses (Dr.
Magno Notes):
1. At 1-5mcg = RENAL VASODILATOR
Exerts selective Renal and Mesenteric Vasodilation
Acts on Dopamine Receptors
Improve Renal Blood Flow and Urine Output
2. At 6-10mcg = INOTROPIC
Positive Inotropic Effect
Acts on Beta-1 Adrenergic Receptors
Increase Heart Rate
3. At 10-20mcg = VASOCONSTRICTOR
Peripheral Vasoconstriction
Acts on A-Adrenergic Receptors
Increase Systemic Vascular Resistance
Deleterious for CHF and Low Cardiac Output

Since we are giving 11.23mcg/kg/min, we have a

Vasoconstricting Effect. This is what we want for a
patient with Septic Shock. We can increase the ugtts/min
if patient is still Hypotensive up to
34ugtt/min (20mcg/kg/min) for a 45kg patient (Dopa
Max). If still No Response with Dopa Max, we can give
LEVOPHED
(Norepinephrine). In the computation, we used 26.6
because 2 ampules of dopamine were used for the
patient.
3
II. DOBUTAMINE DOSAGE COMPUTATION
A. Dobutamine Drip selectively stimulates Beta-1
Adrenergic Receptors
o Direct Inotropic Stimulation with Reflex Arterial
Vasodilation
o Afterload Reduction and Augmented Cardiac Output
o BP remains constant, HR increases minimally
o For patients with Chronic Refractory Heart Failure
o NOT for Heart Failure resulting from Diastolic
Dysfunction or High-Output State
B. Formulation of Dobutamine
o Dilute 250mg (1 amp) in 250cc D5W (use 16.6)
o Drip at 2.5 10mcg/kg/min
o Maximum Dose of 20mcg/kg/min
o If double strength: 2 Ampules in 250cc D5W (use 33.2)
Rate (ugtt/min) = mcg/kg/min x body weight mcg/kg/min
= . (ugtt/min) x 16.6 .
16.6 body weight
C. Action of Dobutamine at Different Doses:
o 0 10 mcg/kg/min = INOTROPIC EFFECT
o 10 20 mcg/kg/min = VASOCONSTRICTION
III. NORADRENALINE (LEVOPHED) Rounds
Each ampule has 2mg Noradrenaline per amp
Usual Starting Dose is at 2-4 mcg/min with a
maximum of 15 mcg/min
Notes from Harrisons:
Dobutamine has a Positive Inotropic Action and Minimal
Positive Chronotropic Activity at Low Doses
(2.5ug/kg/min) but moderate Chronotropic Activity at
Higher Doses
Noradrenaline (LEVOPHED) Drip:
2mg Noradrenaline in 2mL Ampule
Usual Preparation: D5W 250mL + 1 Amp (2mg)
Levophed to run at 15-60ugtts/min
Concentration = 2mg = 2,000mcg = 8mcg Noradrenaline
per cc (this is the concentration of 1 Amp + 250cc D5W)
250cc 250cc
Drip of 2-8mcg Noradrenaline/min is equivalent to 1560 ugtts/min
Example: We are using 1 Amp (2mg) in 250cc D5W. If
we mix 1 Amp with 250cc D5W, the concentration of
Levophed will be 8mcg/cc (as
computed above)
1) If Our desired dose to give patient is 2mcg/min (usual
starting dose), what is the Rate?
Step 1: Convert 2mcg/min to mcg/hour
2mcg/min x 60 mins 120mcg/hr
Step 2: If we desire a dose of 120mcg/hr given a
concentration of 8mcg Levophed per cc, compute the
rate:

120mcg/hr = 15 cc/hr or 15 ugtts/min **NOTE: cc/hr is

equal to uggts/min
8mcg/cc
2) If our desired dose is 8mcg/min 480mcg/hr
480mcg/hr = 60 ugtts/min
8mcg/cc
Example 2) We are using 4 ampules (8mg) in 250cc of
D5W. We want to give the patient a dose of 2mcg/min.
What is the rate?
Concentration = 8 mg . = 8,000 mcg = 32mcg
Noradrenaline per mL (Concentration of 4 Amps + 250cc
D5W)
250cc 250cc
Since we initially want to give a dose of 2 mcg/min
.2 mcg x 60 min = 120 mcg / hr
min hr
120 mcg/hr = 4 cc/hr or 4 uggt/min
32 mcg/cc
4
III. COMMON FORMULAS USED
A. General Formulas
BMI = kg / m2
B. Cardiac Output, Mean Arterial Pressure (MAP), Anion
Gap, Osmolality, Etc.
Cardiac Output
Heart Rate x Stroke Volume
Mean Arterial Pressure
Systolic BP + (2 x Diastolic BP) / 3
Normal Value: 70 100 mmHg
Urine Anion Gap
( Na + K ) Cl
Serum Anion Gap
Na ( HCO3 + Cl )
Urine Osmolality
( SG 1 ) x 40,000
Plasma Osmolality
[2 (Na + K)] + RBS (mmol/L) + BUN (mmol/L)
or
2 (Na in mmol/L) + (Glucose in mg/dL / 18) + (BUN / 2.8)
Normal Value is 280 300 mOsm/L
Normal Value (from Harrisons) = 275-290 mosm/kg
RBS: 1 mmol/L = 18 mg/dL

Effective Plasma
Osmolality
2 Na + RBS in mmol/L
or
2 Na + RBS in mg/dL
18
C. Adequacy of Urine Collection
o M: 20-23mL/kg
o F: 15-20mL/kg
D. 24-Hour Urine Collection Adequacy
o Creatinine is produced at a constant rate and in an
amount directly proportional to skeletal mass
o Creatinine Coefficient = 23mg/kg of IBW (men) and
18mg/kg of IB (women)

o If 24 hr urine creatinine is LESS than IBW x Creatinine

Coefficient INADEQUATE Collected Specimen
o Unpredictable when Serum Crea > 530umol/L

Rush Medical Laboratory (Rush University

Medical Center, 2012). Remember that there is
some variation in ranges based on the laboratory,
so be aware of the normal ranges for your facility.
Introduction to Electrolytes
Electrolytes
Sodium (Na+)
 The major extracellular fluid component
(ECF)
 N.V. = 137-147 mmol/L
 takes part in the regulation of
 acid-base balance
 tissue osmolality
 enzyme activity
 also essential for the retention of body water
by maintaining osmotic pressure (LeFever,
Paulanka, & Polek, 2010)
Potassium (K+)
 The major intracellular fluid component (ICF).
 N.V. = 3.4-5.3 mmol/L
 participates in
 enzyme activity
 regulation of tissue osmolality
 glycogen use
 also essential for cardiac function and
central nervous system function by
regulating muscle and nerve excitability
(LeFever, Paulanka, & Polek, 2010)

Hematology & Clinical Chem Interpretation

The most common tests include
 Chemistry panels
 Hematology (Complete Blood Count)
 Blood Bases
Lab values for this course are taken from the

Chloride (Cl-)
 another component of ECF
 N.V. = 99-108 mmol/L
 participates in tissue & cell osmolality
 passively follows sodium & water
 necessary for
 K+ retention
 transport of carbon dioxide (CO2)
 hydrochloric acid (HCL) formation in the
GI tract
 usually provided in the form of NaCl or KCl
Magnesium (Mg2+)
 Found in the bone (50%), the ICF (45%) &
the ECF (5%)
 N.V. = 1.6-2.7 mg/dL
 enzyme activity, cardiac & neuromuscular
function
 Deficits with Mg2+ usually seen with deficits
in Ca2+ and/or K+ (LeFever, Paulanka, &
Polek, 2010)

Calcium (Ca2+)
 another component of the ECF, but the
majority found in the bone
 N.V. = 8.7-10.7 mg/dL
 essential in
 blood coagulation
 endocrine functions
 neuromuscular function
 muscular contraction
 nerve excitability
 serum values may vary, depending on
total serum protein, as a relationship
exists between the two
 Abnormal total serum levels should be
verified with an ionized Ca2+ level, as this
measurement is independent of serum
protein levels
 Parathyroid & thyroid hormones as well as
vitamin D also influence Ca2+ values
(LeFever, Paulanka, & Polek, 2010)
Phosphorus (P+)
 found in the bone and the ICF. Normal
Values = 2.5-4.6 mg/dL
 plays a role in
 neuromuscular function
 bones & teeth formation
 body metabolism of nutrients
 forming & storing of energy (e.g. ATP)
 A relationship exists between P+ and Ca2+.
Therefore, if one value is abnormal, the
other should be evaluated as well (LeFever,
Paulanka, & Polek, 2010).

Review of Electrolytes
Electrolyte Imbalances:
Hypernatremia: Clinical Picture
Hypernatremia & hyperchloremia are related.
Causes include:
Dehydration
Decreased water intake
Over-administration of Na+ supplementation

Diuresis
Any process that causes a loss of free fluid
results in increased Na+ concentration
(vomiting , diarrhea, insensible water loss
through excessive perspiration)
Impaired renal function
Cushings syndrome
Congestive heart failure
Hypernatremia: Clinical Picture
Signs and symptoms include:
Anorexia, nausea, vomiting
Dry tongue and mucous membranes
Tachycardia
Hypertension
Restless & Agitated Behavior
Altered level of consciousness
Febrile
Hyperreflexia
Tremors or muscle twitching
Decreased skin turgor
Concentrated urine
Treatment of hypernatremia is focused on the
underlying cause(s) (LeFever, Paulanka, &
Polek, 2010)
Hyponatremia
Causes of hyponatremia:
Prolonged use of D5W (this dilutes the ECF,
causing water intoxication)
Impaired renal function (such as salt-wasting
renal disease)
Syndrome of inappropriate antidiuretic
hormone (SIADH)
Addisons disease
Burns
Fever
Metabolic alkalosis
Overhydration
Water retention (water retention causes a
dilution of serum Na+, but the total body
Na is within normal limits. This can be seen with
renal failure, hepatic failure,
congestive heart failure, etc.)
Diuretics
Low sodium intake
Hyponatremia: Clinical Picture
Diarrhea, nausea, vomiting
Tachycardia
Hypotension
Headaches, lethargy, confusion

 Muscle weakness
Signs and symptoms include:
Pallor
Dry skin and mucous membranes
Dilute urine
Treatment of hyponatremia is based on the
cause(s). Na+ needs to be replaced slowly
(LeFever, Paulanka, & Polek, 2010)
Hyperkalemia
Potassium levels can be falsely elevated with
hemolyzed blood samples.
Causes of hyperkalemia:
Over-administration of potassium
supplements
Metabolic acidosis
Renal failure
Potassium-sparing diuretics
ACE inhibitors, beta-blockers (both affect
potassium balance)
Trauma/bruising/bleeding (cell breakdown
causes potassium loss)
Addisons disease
Hyperkalemia: Clinical Picture
Clinical signs and symptoms of hyperkalemia:
ECG changes:
 Tachycardia
 widened QRS
 peaked T waves
 lengthening of PR interval
 P wave difficult to identify
 ventricular fibrillation
Decreased urine output
Lethargy
Decreased muscle tone, muscle cramps
Treatment is of the underlying cause(s). If the
cause is acidosis, then it must be corrected.
Diuretics may be used if renal problem.
In addition, the following are treatments for
hyperkalemia:
Kayexalate: This is a cation-exchange resin,
Na+ based (An ion-exchange resin that
has the ability to exchange positive ions in the
stationary phase with positive ions in
solution)
Calcium administration: Used to decrease the
antagonistic effect of potassium
excess on the myocardium
Insulin/glucose drip: Insulin enhances cellular
uptake of K+, forcing it back into cells

(LeFever, Paulanka, & Polek, 2010)

Electrolyte Imbalances: Hypokalemia
Causes of hypokalemia include:
Malnutrition, anorexia
Decreased K+ intake
Alcoholism
K+ losses through vomiting, diarrhea, or gastric
suctioning
Diuretics
Acute renal failure
Steroids
Stress
Insulin
Epinephrine, bronchodilators
Metabolic alkalosis
Cushings syndrome
Hypokalemia: Clinical Picture
Clinical signs and symptoms of hypokalemia:
ECG changes: Dysrhythmias, shortened ST
segment, flattened or inverted T-waves,
appearance of U wave
Intestinal ileus, gastric dilation
Anorexia, vomiting, diarrhea
Polyuria
Malaise, drowsiness, altered level of
consciousness
Muscle weakness
Treatment of hypokalemia includes underlying
cause needs to be determined and
treated. Any acid-base imbalances needs to be
corrected.
Use K+-sparing diuretics
K+ supplementation (slowly)
Identify and correct any other electrolyte
imbalances (LeFever, Paulanka, & Polek,
2010)
Electrolyte Imbalances: Hypermagnesia
Causes of hypermagnesia include:
Over-administration of magnesium products
(including antacids)
Renal insufficiency
Renal failure
Addisons disease
Severe dehydration
Ketoacidosis
Hypermagnesia: Clinical Picture
Signs and symptoms of hypermagnesia:
Drowsiness, weakness

 Lethargy
Loss of deep tendon reflexes
Paralysis
Hypotension
Third degree heart block
ECG changes: widened QRS complex,
prolonged QT interval
Flushing
Respiratory depression
Treatment includes treating underlying causes.
Use of IV Na+ or Ca2+ can decrease the
serum magnesium level. IV calcium is an
antagonist to magnesium, which can decrease
the symptoms of hypermagnesia. If renal
failure is the cause, dialysis may be necessary
(LeFever, Paulanka, & Polek, 2010).
Electrolyte Imbalances: Hypomagnesia
Causes of hypomagnesia include:
Malnutrition or inadequate Mg2+ intake
Malabsorption
Alcoholism
Increased Ca2+ intake
Chronic diarrhea
Diuretics
Ketoacidosis
Acute renal failure
Acute myocardial failure
Hypokalemia or hypocalcemia
Metabolic acidosis
Aminoglycosides, digoxin
Hypomagnesia: Clinical Picture
Clinical signs and symptoms of hypomagnesia:
Hyperirritability
Tremors
Spasticity
Hypertension
Cardiac dysrhythmias: premature ventricular
contractions, ventricular tachycardia or
fibrillation
ECG changes: flat or inverted T waves,
depressed ST
Treatment includes underlying causes and
magnesium replacement therapy (LeFever,
Paulanka, & Polek, 2010)
Electrolyte Imbalances: Hypercalcemia
Causes of hypercalcemia:
Over-administration of calcium supplements
Renal impairment

Thiazide diuretics
Bone fractures or prolonged immobility
Malignancy
Hyperparathyroidism
Steroids
Hypophosphatemia
Hypercalcemia: Clinical Picture
Clinical manifestations of hypercalcemia:
ECG changes: diminished ST segment,
shortened QT interval, third degree heart
block
Pathologic fractures
Decreased muscle tone
Depression
Flank pain and/or kidney stones
Treatment is aimed at the underlying causes.
Normal saline, loop diuretics, calcitonin,
and corticosteroids are also used (LeFever,
Paulanka, & Polek, 2010)
Electrolyte Imbalances: Hypocalcemia
Dietary deficiencies of calcium, protein, and/or
vitamin D
Chronic diarrhea
Low albumin
Renal failure
Causes of hypocalcemia include:
Hypoparathyroid
Hyperphosphatemia
Hypermagnesia or hypomagnesia
Alkalosis
Hypocalcemia: Clinical Picture
Clinical signs and symptoms of hypocalcemia:
Abnormal clotting
Tetany, muscle twitches or tremors
Muscle cramps
Numbness and tingling
Irritability, anxiety
ECG changes: Prolonged QT interval,
lengthened ST segment
Fractures with continued hypocalcemia
Treatment is aimed at the underlying cause: If
hypoparathroid or vitamin D deficits, these
needs treatment. Ca2+ supplements used for
replacement therapy (LeFever, Paulanka,
& Polek, 2010).
Electrolyte Imbalances: Hyperphosphatemia
Causes of hyperphosphatemia:
Over-administration of phophorus supplements

 Hypoparathyroidism
Renal insufficiency
Chemotherapy
Metabolic acidosis
Respiratory acidosis
Laxative over-use
Hyperphosphatemia: Clinical Picture
Signs and symptoms of hyperphosphatemia:
Tachycardia
Nausea and diarrhea
Abdominal cramps
Treatment may incorporate administration of
insulin and glucose, which can lower the
serum phosphorus level by shifting phosphorus
from the ECF into the cells (LeFever,
Paulanka, & Polek, 2010).
Hyperreflexia
Tetany
Muscle weakness
Electrolyte Imbalances: Hypophosphatemia
Hypophosphatemia may be caused by:
Ketoacidosis
Burns
Metabolic alkalosis
Respiratory alkalosis
Diuretics
Antacids containing aluminum
Malnutrition, anorexia
Alcoholism
Total parenteral nutrition (TPN)
Vomiting, diarrhea
Malabsorption
Hyperparathyroidism
Hypophosphatemia: Clinical Picture
Clinical signs and symptoms:
Muscle weakness
Tremors
Bone pain
Hyporeflexia
Seizures
Tissue hypoxia
Risk of bleeding and infection
Weak pulse
Hyperventilation
Anorexia, dysphagia
Treatment includes replacement of phosphorus
through sodium phosphate or potassium
phosphate (LeFever, Paulanka, & Polek, 2010).

Other Chemistry Tests

The combination of analytes can assist in
providing additional information about renal and
hepatic function.
Components that will be examined include
 Glucose
 Serum Albumin
 Amylase
 Serum Creatinine
 Blood Urea Nitrogen (BUN)
 Uric Acid
 Alkaline Phosphatase
 Protein
 Bilirubin
Glucose
A monosaccharide, or a simple sugar, which is a
product of cellulose, starch and glycogen. Free
glucose occurs in the blood and is the primary
source of energy for use in tissues of the body.
N.V.= 60-200 mg/dL (non-fasting). Excess
glucose is stored as glycogen in the liver or
muscle tissue (Warrell, Firth, & Cox, 2010).
Hyperglycemia
Diabetes mellitus
Hyperosmolar nonketotic syndrome (HNKS)
Cushing's syndrome
Increased epinephrine levels from extreme
stress (illness, trauma, surgery
Excess growth hormone secretion
Over-administration of glucose
Pregnancy (gestational diabetes)
Medications- particularly steroids
Hyperglycemia occurs with a blood glucose
greater than 200 mg/dL non-fasting, or a
fasting blood glucose >100 mg/dL. Causes of
hyperglycemia include:

Hyperglycemia: Clinical Picture

Signs and symptoms of hyperglycemia may be
subtle:
Polydipsia- increased thirst
Dehydration- dry mucous membranes,
decreased skin turgor
Poluria
Irritability, headaches, confusion
Decreased level of consciousness

 Changes in vision
Treatment includes increased fluids and insulin
administration (Warrell, Firth, & Cox, 2010)
Blood glucose levels should be monitored per
facility policy.
Hypoglycemia
Hypoglycemia occurs with blood glucose less
than 60 mg/dL non-fasting. Causes of
hypoglycemia include:
Imbalance between energy consumption and
use- can occur with malnutrition,
inadequate nutritional intake and exercise
Over-administration of insulin
Liver disease such as hepatitis, cirrhosis, liver
cancer
Over-production of insulin, such as insulinsecreting tumors
Medications, including beta-blockers,
sulfonylureas, and oral hypoglycemic agents
Hypoglycemia: Clinical Picture
Signs and symptoms of hypoglycemia may
also be subtle:
Altered level of consciousness
Confusion
Tremors, jitteriness
Hunger
Pallor
Diaphoresis
Treatment includes providing glucose and
carbohydrates. Depending on the patients
status and facility protocol, this may be
intravenous or orally (Warrell, Firth, & Cox,
2010).
Blood glucose levels should be monitored per
facility policy.

Serum Albumin
A large protein found in the blood plasma that
maintains the osmotic pressure between the
blood vessels and tissue. It is also used to
determine liver function, kidney
function, and nutrition (Warrell, Firth, & Cox,
2010)
N.V.= 3.5-4.8 g/dL.

Hypoalbuminemia
Hypoalbuminemia occurs with a serum albumin
<3.5 g/dL. Causes:
Poor nutrition
Liver disease
Impaired renal function
Burns
Lymphatic disease or cancer
Congestive heart failure
Inflammatory process
Hyperalbuminemia
Hyperalbuminemia occurs with a serum albumin
>4.8 g/dL. Causes may include:
Dehydration
Liver disease
Impaired renal function
Hypoalbuminemia & Hyperalbuminemia:
Clinical Picture
Clinical signs and symptoms of
hypoalbuminemia and hyperalbuminemia related
to the disease process involved. Treatment is
also focused on the underlying cause(s)(Warrell,
Firth, & Cox, 2010)
Complete Blood Count
Red blood cell count (RBC)
Hematocrit (Hct)
Hemoglobin (Hb or Hgb)
Red blood cell components
 Mean corpuscular volume (MCV)
 Mean corpuscular hemoglobin (MCH)
 Mean corpuscular hemoglobin concentration
(MCHC)
 White blood count (WBC)
 A differential white blood cell count (diff)
 Platelets
Ranges for normal laboratory values vary among
age groups, genders, and laboratories.
The laboratory references given in this course
are averages; refer to the normal ranges
provided by your facilitys laboratory.
CBC Overview
Ranges for normal laboratory values vary among
age groups, genders, and laboratories.
The laboratory references given in this course
are averages; refer to the normal ranges

provided by your facilitys laboratory.

A typical adult circulates about 5 L of blood,
which is comprised of 3 L plasma and 2 L of
blood cells. White blood cells (leukocytes), red
blood cells (erythrocytes), and platelets
(thrombocytes) are all created in the bone
marrow.
CBC results can be affected by the time of day,
hydration, medications, and other blood
values.

Pruritus
Pain in the chest or leg muscles
Ruddy complexion
Confusion
Tinnitus
Treatment is focused on the underlying cause.
Phlebotomy to remove blood or use of
medications to decrease red blood cell
production may also be used (Van Leeuwen,
Poelhuis-Leth, & Bladh, 2011)

Red Blood Cells

The primary purpose of RBCs, or erythrocytes,
is to carry oxygen from the lungs to body
tissues and to transfer carbon dioxide from the
tissues to the lungs. Oxygen transfer
occurs via the hemoglobin contained in the
RBCs, which combines with oxygen and
carbon dioxide.
Normal red blood cells values are:
Adults: (males): 4.6-6.0 million/uL
(Females): 4.2-5.0 million/uL
Pregnancy: slightly lower than normal adult
values
The average range of values for RBC is 4-5.9
million/uL

Anemia
A decrease in RBCs is known as anemia is a
decrease in RBC. Causes of anemia:
Hemorrhage
Destruction of red blood cells
Iron deficiency
Chronic disease processes
Malnutrition
Pernicious or sickle cell anemia
Thalassemia
Chemotherapy or radiation
Medications, such as anti-infectives

Polycythemia
An increase in the number of red blood cells is
known as polycythemia. Causes for
polycythemia include:
High altitudes
Strenuous physical activity
Medications, such as gentamicin and
methyldopa
Smoking
Hydration
Polycythemia vera
COPD
Chronic hypoxia

Polycythemia: Clinical Picture

Symptoms of polycythemia:
Weakness
Headache
Fatigue
Lightheadedness
Shortness of breath
Visual disturbances

Anemia: Clinical Picture

Symptoms of anemia:
Fatigue
Low energy
Weakness
Shortness of breath
Dizziness
Palpitations
Pallor
Chest pain
Tachycardia
Hypotension
Fainting
Treatment is focused on the underlying cause,
and dependent on severity. Iron and B12
supplementation is used. The patient may also
require blood transfusions (Van Leeuwen,
Poelhuis-Leth, & Bladh, 2011)

Hematocrit
The hematocrit (Hct) determines the percentage
of red blood cells in the plasma. It is calculated
when a blood sample is spun down, and the red
blood cells sink to the bottom of the sample.
Normal hematocrit values are:
Adults: (males): 40- 54%
(Females): 37 46%

 Pregnancy: decreased hematocrit, especially

in the last trimester as plasma volume
increases
The average range of values for hematocrit is
37-54%
Critical values include:
A hematocrit <15% can cause cardiac failure
A hematocrit >60% can cause spontaneous
blood clotting
Effects on Hematocrit
An increase or decrease in plasma volume
affects the hematocrit. Some conditions that
affect plasma volume and hematocrit include:
Burns
Overhydration or dehydration
Hemorrhage
Transfusions
(Van Leeuwen, Poelhuis-Leth, & Bladh, 2011)
Hemoglobin
Hemoglobin (Hgb) is a molecule comprised of
an iron-containing pigment (heme) and a
protein (globulin). The ability of blood to carry
oxygen is directly proportional to its
hemoglobin concentration. The number of
RBCs may not accurately reveal the blood's
oxygen content because some cells may
contain more hemoglobin than others.
Normal hemoglobin values are:
Adult: (males): 13.5 - 17 g/dl
(Females): 12 - 15 g/dl
Pregnancy: 11 - 12 g/dl
The average range of values for hemoglobin is
12-17.5 g/dL.
Critical values include:
A hemoglobin < 5 g/dl can cause heart failure
A hemoglobin > 20 g/dl can cause
hemoconcentration and clotting

Effects on Hemoglobin
Hemoglobin can be affected by any conditions
that affect the RBC count. Conditions that
cause polycythemia and anemia also impact
the hemoglobin levels. Levels are also
affected by disorders that cause abnormal
hemoglobin.

MCV, MCH, and MCHC

Mean corpuscular volume (MCV)
 Average size of individual red blood cells
 calculated by dividing the hematocrit (Hct) by
the total RBCs
Mean corpuscular hemoglobin (MCH)
 mass of the hemoglobin in an RBC
 calculated by dividing the hemoglobin (Hgb)
by the total RBCs
Mean corpuscular hemoglobin concentration
(MCHC)
 how much of each cell is taken up by
hemoglobin
 hemoglobin divided by the hematocrit,
multiplied by 100
The MCV, MCH, and MCHC can assist in
identification and diagnoses of disease
Processes.
White Blood Cells
White blood cells (WBC), or leukocytes, are
classified into granulocytes (which include
neutrophils, eosinophils, and basophils) and
agranulocytes (which include lymphocytes
and monocytes). WBC are released from the
bone marrow and destroyed in the lymphatic
system after 14-21 days. Leukocytes fight
infection through phagocytosis, where the cells
surround and destroy foreign organisms. White
blood cells also supply antibodies as part
of the body's immune response.
The average range of values for WBC is 4-10
thousand/uL.
WBC critical lab values include:
A WBC <500 places the patient at risk for a
fatal infection.
A WBC >30,000 indicates massive infection or
serious disease (e.g. leukemia)

WBC Differential
The differential consists of the percentage of
each of the five types of white blood cells.
Normal values for differential are:
Bands or stabs: 3 - 5 %
Neutrophils (or segs): 50 - 70% relative value
(2500-7000 absolute value)
Eosinophils: 1 - 3% relative value (100-300

absolute value)
Basophils: 0.4% - 1% relative value (40-100
absolute value)
Lymphocytes: 25 - 35% relative value (17003500 absolute value)
Monocytes: 4 - 6% relative value (200-600
absolute value)
Leukocytosis
Leukocytosis occurs with a WBC above 10,000.
Some causes of leukocytosis include:
Trauma
Inflammation
Acute infection
Dehydration
Hemoconcentration
Cancer, such as leukemia
Medications, such as corticosteroids
Treatment is focused on the underlying cause,
and dependent on severity (Van Leeuwen,
Poelhuis-Leth, & Bladh, 2011).
Leukocytosis: Clinical Picture
Signs and symptoms of leukocytosis may be
subtle or related to the disease process
occurring. Symptoms may include:
Fatigue
Hepatomegaly
Splenomegaly
Bleeding
Bruising or petechiae
Leukopenia
Leukopenia occurs when the WBC falls below
4,000. Some causes of leukopenia include:
Bone marrow disorders
Viral infections
Severe bacterial infections
Cancer
Medications, include chemotherapy,
antibiotics, anticonvulsants, cardiac
medications

Leukopenia: Clinical Picture

Signs and symptoms of leukopenia may be
subtle or related to the disease process
occurring. Symptoms may include:
Headache
Fatigue
Fever

Bleeding
Treatment is focused on the underlying cause,
and dependent on severity. Steroids,
vitamins, and cytokines can be used (Van
Leeuwen, Poelhuis-Leth, & Bladh, 2011)
Leukopenia/Neutropenia
Patients with severe leukopenia or neutropenia
should be protected from anything that
places them at risk for infection. Facilities may
have a neutropenic or leukopenic
precautions or protocol for these patients.
Considerations:
Complete isolation
No injections
No rectal temperatures or enema
Platelets
Platelets are fragments of cells that are formed
in the bone marrow, and are vital to blood
clotting. Platelets live for approximately nine to
12 days in the bloodstream.
The average range of values for platelets is
150,000 and 399,000/mm.
Thrombocytosis
Thrombocytosis is an increase in platelets
>399,000. Some causes of thrombocytosis
include:
Injury
Inflammatory process
Bone marrow disorder
Cancer
Kidney disease
Acute blood loss
Infection
Thrombocytosis: Clinical Picture
Signs and symptoms of thrombocytosis include:
Dizziness
Headache
Chest pain
Weakness
Neuropathy
Vision changes
Fainting
Treatment is focused on the underlying cause,
and dependent on severity (Van Leeuwen,
Poelhuis-Leth, & Bladh, 2011).
Thrombocytopenia
Thrombocytopenia occurs when the platelet

count is <150,000, placing the patient at a

high risk for bleeding due to injury or disease.
A platelet count <20,000 can cause
spontaneous bleeding that may result in patient
death. Some causes of thrombocytopenia:
Impaired platelet production
Disseminated intravascular coagulation (DIC),
which uses up platelets rapidly
Immune disorders
Suppression of bone marrow through
chemotherapy, radiation, or other therapy
Cancer
Thrombocytopenia: Clinical Picture
Signs and symptoms of thrombocytopenia:
Easy bruising or bleeding
Hematuria
Black, tar-like stools or frank bleeding with
bowel movements
Hematemesis
Syncope
Visual disturbances
Treatment is focused on the underlying cause,
and dependent on severity. Platelet
transfusions may be used with severe
thrombocytopenia (Van Leeuwen, PoelhuisLeth,
& Bladh, 2011).

Important Note
They are presented in good faith and every
effort has been taken to ensure their accuracy.
Nevertheless, medical practice changes over
time and it is always important to check the
information with your clinical preceptors and
with other reliable sources. Disclaimer: no
responsibility can be taken by either the author
or publisher for any loss, damage or injury
occasioned to any person acting or refraining
from action as a result of this information.