Chest Pain and Myocardial Infarction

Chief Compliant The patient is a 50 year old white male with hypertension who complains of chest pain for 4 hours. History of the Present Illness Duration of chest pain. Location, radiation (to arm, jaw, back), character (squeezing, sharp, dull), intensity, rate of onset (gradual or sudden) relationship of pain to activity (at rest, during sleep, during exercise) relief by nitroglycerine increase in frequency or severity of baseline anginal pattern. Improvement or worsening of pain. Past...

Physical Examination

General Appearance Signs of dehydration, pallor. Note whether the patient appears ill, well, or malnourished. Vital Signs BP, pulse (orthostatic hypotension), respiratory rate, temperature (tachycardia), oliguria. Skin Cold, clammy skin delayed capillary refill, pallor, jaundice. Stigmata of liver disease Umbilical venous collaterals (Caput medusae), jaundice, spider angiomata, parotid gland hypertrophy, gynecomastia. Rashes, purpura, buccal mucosa discolorations or pigmentation...

Chronic Obstructive Pulmonary Disease

Chief Compliant The patient is a 50 year old white male with chronic obstructive pulmonary disease who complains of wheezing for one day. History of the Present Illness Duration of wheezing, dyspnea, cough, fever, chills increased sputum production sputum quantity, consistency, color smoking (pack-years) severity of attack compared to previous episodes chest pain, pleurisy. Current and baseline peak flow rate. Frequency of bronchodilator use, relief of symptoms by bronchodila-tors. Frequency of...

Alcohol Withdrawal

Chief Compliant The patient is a 50 year old white male with alcoholism who presents with tremor and agitation after discontinuing alcohol 12 hours prior to admission. History of the Present Illness Determine the amount and frequency of alcohol use and other drug use in the past month, week, and day. Time of last alcohol consumption tremors, anxiety, nausea, vomiting diaphoresis, agitation, fever, abdominal pain, headaches hematemesis, melena, past withdrawal reactions history of delirium...

Delirium Coma and Confusion

Chief Compliant The patient is a 50 year old male with coronary heart disease who presents with confusion for 6 hours. History of the Present Illness Level of consciousness, obtundation (awake but not alert), stupor (unconscious but awakable with vigorous stimulation), coma (cannot be awakened). Confusion, hallucination, formification (sensation that insects are crawling under skin) poor concentration, agitation. Activity and symptoms prior to onset. Fever, headache, epilepsy (post-ictal...

Hyperthyroidism and Thyrotoxicosis

Chief Compliant The patient is a 50 year old white male who presents with tremor and restlessness for 4 days. History of the Present Illness Tremor, nervousness, hyperkinesis (restlessness), fever, heat intolerance, palpitations, diaphoresis, irritability, insomnia thyroid enlargement, masses, thyroid pain, amenorrhea. Weight loss with increased appetite dyspnea and fatigue after slight exertion softening of the skin fine, silky hair texture proximal muscle weakness (especially thighs when...

Headache

Chief Compliant The patient is a 50 year old female with hypertension who complains of chest pain for 4 hours. History of the Present Illness Quality of pain (dull, band-like, sharp, throbbing), location (retro-orbital, temporal, suboccipital, bilateral or unilateral), time course of typical headache episode onset (gradual or sudden) exacerbating or relieving factors time of day, effect of supine position. Age at onset of headaches change in severity, frequency awakening from sleep analgesic or...

Attempted Suicide and Drug Overdose

Chief Compliant The patient is a 50 year old white male with depression who presents after overdosing on antidepressants 3 hours prior to admission. History of the Present Illness Time suicide was attempted and method. Quantity of pills motive for attempt. Alcohol intake, other medications place where medication was obtained last menstrual period. Symptoms of Tricyclic Antidepressant Overdose Dry mouth, hallucinations, seizures, agitation, visual changes. Psychiatric History Previous suicide...

Intestinal Obstruction

Chief Compliant The patient is a 50 year old white male with colon cancer who complains of abdominal pain for 6 hours. History of the Present Illness Vomiting (bilious, feculent, bloody), nausea, obstipation, distention, crampy abdominal pain. Initially crampy or colicky pain with exacerbations every 5-10 minutes. Pain becomes diffuse with fever. Hernias, previous abdominal surgery, use of opiates, anticholinergics, antipsychotics, gallstones colon cancer history of constipation, recent weight...

Oliguria and Acute Renal Failure

Chief Compliant The patient is a 50 year old white male with diabetes who presents with decreased urine output for 8 hours. History of the Present Illness Oliguria (< 20 mL h, 400500 mL urine day) anuria (< 100 mL urine day) hemorrhage, heart failure, sepsis, vomiting, nasogastric suction diarrhea, fever, chills measured fluid input and output by Foley catheter prostate enlargement, kidney stones Dysuria, flank pain. Abdominal pain, hematuria, passing of tissue fragments, foamy urine...

Specific Signs on Palpation

Murphy's sign Inspiratory arrest with right upper quadrant palpation, cholecystitis. Charcot's sign Right upper quadrant pain, jaundice, fever gallstones. Courvoisier's sign Palpable, nontender gallbladder with jaundice pancreatic malignancy. McBurney's point tenderness Located two thirds of the way between umbilicus and anterior superior iliac spine appendicitis. Iliopsoas sign Elevation of legs against examiner's hand causes pain, retrocecal appendicitis. Obturator sign Flexion of right thigh...

Commonly Used Formulas

A-a gradient (PB-PH2O) FiO2 - PCO2 R - PO2 arterial (713 x FiO2 - pCO2 0.8 ) -pO2 arterial PB 760 mmHg PH2O 47 mmHg R . 0.8 normal Aa gradient < 10-15 mmHg (room air) Arterial oxygen capacity (Hgb(gm) 100 mL) x 1.36 mL O2 gm Hgb Arterial O2 content 1.36(Hgb)(SaO2)+0.003(PaO2) NL 20 vol O2 delivery CO x arterial O2 content NL 640-1000 mL O2 min Cardiac output HR x stroke volume Normal CO 4-6 L min SVR MAP - CVP x 80 NL 800-1200 dyne sec cm2 GFR mL min (140 - age) x wt in Kg_ 72 (males) x serum...

Abdomen

Inspection Scars, ecchymosis, visible peristalsis (small bowel obstruction), distension. Scaphoid, flat. Auscultation Absent bowel sounds (paralytic ileus or late obstruction), high-pitched rushes (obstruction), bruits (ischemic colitis). Palpation Begin palpation in quadrant diagonally opposite to point of maximal pain with patient's legs flexed and relaxed. Bimanual palpation of flank (renal disease). Rebound tenderness hepatomegaly, splenomegaly, masses hernias (incisional, inguinal,...

Abdominal Pain and the Acute Abdomen

Chief Compliant The patient is a 50 year old white male with diabetes who complains of right lower quadrant abdominal pain for 4 hours. History of the Present Illness Duration of pain, pattern of progression exact location at onset and at present diffuse or localized location and character at onset and at present (burning, crampy, sharp, dull) constant or intermittent (colicky) radiation of pain (to shoulder, back, groin) sudden or gradual onset. Effect of eating, vomiting, defecation, flatus,...

Congestive Heart Failure

Chief Compliant The patient is a 50 year old white male with hypertension who complains of shortness of breath for 1 day. History of the Present Illness Duration of dyspnea rate of onset (gradual, sudden) paroxysmal nocturnal dyspnea (PND), orthopnea number of pillows needed under back when supine to prevent dyspnea dyspnea on exertion (DOE) edema of lower extremities. Exercise tolerance (past and present), weight gain. Severity of dyspnea compared with past episodes. Associated Symptoms...

Cirrhosis

Chief Compliant The patient is a 50 year old white male with alcoholism who complains of jaundice for one week. History of the Present Illness Jaundice, anorexia, nausea abdominal distension, abdominal pain, increased abdominal girth (ascites) vomiting, diarrhea, fatigue. Somnolence, confusion (encephalopathy). Alcohol use, viral hepatitis, blood transfusion, IV drug use. Precipitating Factors of Encephalopathy Gastrointestinal bleeding, high protein intake, constipation, azotemia, CNS...

Cough and Pneumonia

Chief Compliant The patient is a 50 year old white male with hypertension who complains of cough for 12 hours. History of the Present Illness Duration of cough, chills, rigors, fever rate of onset of symptoms. Sputum color, quantity, consistency, blood living situation (nursing home, homelessness). Recent antibiotic use. Associated Symptoms Pleuritic chest pain, dyspnea, sore throat, rhinorrhea, headache, stiff neck, ear pain nausea, vomiting, diarrhea, myalgias, arthralgias. Past Medical...

Dyspnea

Chief Compliant The patient is a 50 year old white male with hypertension who complains of shortness of breath for 4 hours. History of the Present Illness Rate of onset of shortness of breath (gradual, sudden), orthopnea (dyspnea when supine), paroxysmal nocturnal dyspnea (PND), chest pain, palpitations. Dyspnea with physical exertion history of myocardial infarction, syncope. Past episodes aggravating or relieving factors (noncompliance with medications, salt overindulgence). Edema, weight...

Findings Suggesting Secondary Hypertension

Primary Aldosteronism Serum potassium < 3.5 mEq L while not taking medication. B. Aortic Coarctation Femoral pulse delayed later than radial pulse posterior systolic bruits below ribs. C. Pheochromocytoma Tachycardia, tremor, pallor. D. Renovascular Stenosis Paraumbilical abdominal bruits. E. Polycystic Kidneys Flank or abdominal mass. F. Pyelonephritis Urinary tract infections, costovertebral angle tenderness. G. Renal Parenchymal Disease Increased serum creatinine 1.5 mg dL, proteinuria....

Jaundice and Hepatitis

Chief Compliant The patient is a 50 year old white male with alcoholism who complains of jaundice for 3 days. History of the Present Illness Dull right upper quadrant pain, anorexia, jaundice, nausea, vomiting, fever, dark urine, increased abdominal girth (ascites), pruritus, arthralgias, urticarial rash somnolence (hepatic encephalopathy). Weight loss, melena, hematochezia, hematemesis. IV drug abuse, alcoholism, exposure to hepatitis or jaundiced persons, blood transfusion, day care centers,...

Hypothyroidism and Myxedema Coma

Chief Compliant The patient is a 50 year old white female with hypothyroidism who presents with weakness for 5 days. History of the Present Illness Fatigue, cold intolerance, constipation, weight gain or inability to lose weight, muscle weakness thyroid swelling or mass dyspnea on exertion mental slowing, dry hair and skin, deepening of voice carpal tunnel syndrome, amenorrhea. Somnolence, apathy, depression, paresthesias. Myxedema madness Agitation, disorientation, delusions, hallucinations,...

Intrarenal Insult

Insult to the renal parenchyma (tubular necrosis) causes 20 of acute renal failure. B. Prolonged hypoperfusion is the most common cause of tubular necrosis. Nephrotoxins (radiographic contrast, aminoglycosides) are the second most common cause of tubular necrosis. C. Pigmenturia induced renal injury can be caused by intravascular hemolysis or rhabdomyolysis. D. Acute glomerulonephritis or acute interstitial nephritis (usually from allergic reactions to beta-lactam antibiotics, sulfonamides,...

Mesenteric Ischemia and Infarction

Chief Compliant The patient is a 50 year old white male with coronary heart disease who complains of abdominal pain for 6 hours. History of the Present Illness Sudden onset of severe, poorly localized, periumbilical pain pain is postprandial and may be relieved by nitroglycerine episodes of bloody diarrhea, nausea, vomiting, food aversion, weight loss. Pain out of proportion to the physical findings may be the only presenting symptom. Past Medical History Peripheral arterial occlusive disease,...

Medications Associated with Hypernatremia

Amphotericin, phenytoin, lithium, aminoglycosides. General Appearance Lethargy, obtundation, stupor. Note whether the patient appears ill, well, or malnourished. Vital Signs BP (orthostatic hypotension), pulse (tachycardia), temperature (fever), respiratory rate decreased urine output. Skin Decreased skin turgor (doughy consistency), delayed capillary refill, hyperpigmentation (Conn's syndrome), moon-face, truncal obesity, stria (hypoadrenal crisis, steroid withdrawal). HEENT Decreased eye...

Pancreatitis

Chief Compliant The patient is a 50 year old white male with alcoholism who complains of abdominal pain for 4 hours. History of the Present Illness Constant, dull, boring, mid-epigastric or left upper quadrant pain radiation to the mid-back exacerbated by supine position, relieved by sitting with knees drawn up nausea, vomiting, low-grade fever, rigors, jaundice, anorexia, dyspnea elevated amylase. Precipitating Factors Alcohol, gallstones, trauma, postoperative pancreatitis, retrograde...

Wheezing and Asthma

Chief Compliant The patient is a 50 year old white male with hypertension who complains of wheezing for one day. History of the Present Illness Onset, duration, and progression of wheezing severity of attack compared to previous episodes cough, fever, chills, purulent sputum current and baseline peak flow rate. Frequency of bronchodilator use, relief of symptoms by bronchodila-tors. Frequency of exacerbations and hospitalizations or emergency department visits duration of past exacerbations,...

Differential Diagnosis of Atrial Fibrillation

Lone Atrial Fibrillation No underlying disease state. Cardiac Causes Hypertensive heart disease with left ventricular hypertrophy, heart failure, mitral valve stenosis or regurgitation, pericarditis, hypertrophic cardiomyopathy, coronary artery disease, myocardial infarction, aortic stenosis, amyloidosis. Noncardiac Causes Hypoglycemia, theophylline intoxication, pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary embolism, heavy alcohol intake or alcohol withdrawal,...

Seizure

Chief Compliant The patient is a 50 year old white male with epilepsy who presents with a seizure 4 hours prior to admission. History of the Present Illness Time of onset of seizure, duration of seizure, tonic-clonic movements, description of seizure. Past seizures, noncompliance with anticonvulsant medication (recent blood level). Aura (irritability, behavioral change, lethargy), pallor, incontinence of urine or feces, vomiting, post-ictal weakness or paralysis. Biting of tongue, past episodes...

Differential Diagnosis

Generalized Pain Intestinal infarction, peritonitis, obstruction, diabetic ketoacidosis, sickle crisis, acute porphyria, penetrating posterior duodenal ulcer, psychogenic pain. Right Upper Quadrant Cholecystitis, cholangitis, hepatitis, gastritis, pancreatitis, hepatic metastases, gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome), retrocecal appendicitis, pneumonia, peptic ulcer. Epigastrium Gastritis, peptic ulcer, gastroesophageal reflux disease, esophagitis, gastroenteritis, pancreatitis,...

Cholecystitis

Chief Compliant The patient is a 50 year old white male with obesity who complains of right upper quadrant pain for 6 hours. History of the Present Illness Biliary colic (constant right upper quadrant pain, 30-90 minutes after meals, lasting several hours). Radiation to epigastrium, scapula or back nausea, vomiting, anorexia, low-grade fever fatty food intolerance, dark urine, clay colored stools bloating, jaundice, early satiety, flatulence, obesity. Previous epigastric pain, gallstones,...

Pelvic Pain and Ectopic Pregnancy

Chief Compliant The patient is a 50 year old female with hypertension who complains of chest pain for 4 hours. History of the Present Illness Positive pregnancy test, missed menstrual period, pelvic or abdominal pain (bilateral or unilateral), symptoms of pregnancy (nausea, breast tenderness) abnormal vaginal bleeding (quantify). Last menstrual period, menstrual interval, duration, age of menarche, obstetrical history. Characteristics of pelvic pain onset, duration shoulder pain. Rupture of...

Anorexia and Weight Loss

Chief Compliant The patient is a 50 year old white male with diabetes who complains of loss of appetite and weight loss for one week. History of the Present Illness Time of onset, amount and rate of weight loss (sudden, gradual) change in appetite, nausea, vomiting, dysphagia, abdominal pain exacerbation of pain with eating (intestinal angina) diarrhea, fever, chills, night sweats dental problems restricted access to food. Polyuria, polydipsia skin or hair changes 24-hour diet recall dyspepsia,...

Conditions That Mimic or Provoke Heart Failure

Coronary artery disease and myocardial infarction C. Aortic or mitral valve disease D. Cardiomyopathies Hypertrophic, idiopathic dilated, postpartum, genetic, toxic, nutritional, metabolic E. Myocarditis Infectious, toxic, immune G. Tachyarrhythmias or bradyarrhythmias J. High output states Anemia, hyperthyroidism, arteriovenous fistulas, Paget's disease, fibrous dysplasia, multiple myeloma K. Renal failure, nephrotic syndrome Factors Associated with Heart Failure A. Increase Demand Anemia,...

Pyelonephritis and Urinary Tract Infection

Chief Compliant The patient is a 50 year old female with diabetes who complains of flank pain for 8 hours. History of the Present Illness Dysuria, frequency repeated voiding of small amounts , urgency suprapubic discomfort or pain, hematuria, fever, chills, pyelonephritis back pain, nausea, vomiting. History of urinary infections, renal stones or colicky pain. Recent antibiotic use, prostate enlargement. Diaphragm use. Risk factors Diaphragm or spermicide use, sexual intercourse, elderly,...