CCE Flashcards
Acute MI/ Unstable Angina History
– Pain does not change with deep breath or change in position, but can increase with exertion. – Chest, jaw, arm pain/pressure can radiate or not. – Shortness of breath, dyspnea on exertion. – Nausea, vomiting, diaphoresis, ankle swelling.
Acute MI/ Unstable Angina PE
- CV exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses (radial and feet)
- check for peripheral edema
- lung exam
- abdominal exam
Acute MI/ Unstable Angina Findings
- troponin
- CXR
- ECG
- stress test
Acute MI/ Unstable Angina S&S
Chest pain travels to shoulder, arm, back, neck or jaw
- in center or L side of chest and lasts for more than a few minutes
- SOB, nausea, faint feeling, cold sweat, feel tired
- occur due to CAD -> rupture of atherosclerotic plaque
- risk factors: HTN, smoking, diabetes, lack of exercise, obesity, hypercholesterolemia, poor diet
Acute MI/ Unstable Angina Treatment
- Aspirin (immediate & long-term treatment)
- Nitroglycerin or opioids (help with chest pain)
- supplemental O2 (w/ low O2 levels and SOB)
- Angioplasty or thrombolysis
- Bypass surgery (with blockages of multiple coronary arteries & diabetes)
Aortic Dissection History
-Often complain of tearing, crushing pain shooting straight through to the back
– Long standing hypertension common.
Aortic Dissection PE
- CV exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses (radial and feet)
- check for peripheral edema
- lung exam
- abdominal exam
Aortic Dissection Findings
Widened mediastinum on CXR. Unequal peripheral pulses. S4 gallop.
Aortic Dissection S&S
- risk factors: aging, atherosclerosis, blunt trauma to chest, HTN
- sudden onset chest pain (sharp, stabbing, tearing, ripping) that can move to the back
- anxiety & feeling of doom; faint/dizzy; heavy sweating; pale skin; rapid, weak pulse; SOB & orthopnea
- weak pulse in one arm compared to other (also different BPs)
Aortic Dissection Treatment
- Surgery
- beta-blockers (treat HTN)
- strong pain relievers
Pulmonary Embolus/ DVT History
– Chest pain is usually pleuritic, shortness of breath with minimal exertion, sudden
onset, may or may not have cough/hemoptysis and low grade temperature but typically no temps over 101.
– Long air/car trip, +FHx miscarriage/CVA, Oral contraceptive use, smoker
-Dizziness/faint.
Pulmonary Embolus/ DVT PE
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
Pulmonary Embolus/ DVT Findings
CXR usually NORMAL, but can have atelectasis, pleural effusion. Lung sounds usually normal. Typically have tachycardia & tachypnea. May have hypotension or low O2 sat.
Pulmonary Embolus/ DVT S&S
- risk factors: stasis (extended travel or bed rest), hypercoagulability (estrogen, smoking, polycythemia, genetic, surgery), damage to vessel walls (prior DVT, trauma to lower leg)
- chest pain that worsens when taking a deep breath
- maybe cough/ hemoptysis
- SOB worsens w/ activity
Pulmonary Embolus/ DVT Treatment
- PREVENTION!
- anticoagulation (warfarin)
- thrombolytic therapy (tissue plasminogen activator/ tPA)
Congestive Heart Failure History
– Have shortness of breath and DOE. May or may not have cough with
pink frothy sputum (no frank hemoptysis), chest congestion, edema. Don’t usually have chest pain unless also having/recently had an MI.
– Usually have orthopnea, and feel better sitting up – ask them how many pillows they use to sleep with.
– May or may not have PND (paroxysmal nocturnal dyspnea), peripheral
edema.
Congestive Heart Failure PE
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
Congestive Heart Failure Findings
CXR with congestion and/or pleural effusion. High B natiuretic peptide. JVD, heart murmurs, peripheral edema. SOB with movement and position.
Congestive Heart Failure S&S
- risk factors: CAD, HTN, alc abuse, disorders of heart valves
- > L vent hypertrophy -> edema
- drugs/foods that cause sodium retention -> worsening of CHF (NSAIDs, diabetes meds, Ca channel blockers)
- Congested lungs
- > DOE, dyspnea at rest or lying flat
- Fluid/water retention
- > edema
- dizziness, fatigue, weakness
- rapid/irreg heartbeats
Congestive Heart Failure Treatment
- fluid restriction & decrease in salt intake
- > diuretics (furosemide/ Lasix)
- ACE inhibitors
- diet and exercise, stop smoking, control HTN/cholesterol/diabetes
COPD exacerbation History
Shortness of breath, DOE, wheezing, change in sputum color/frequency/amount.
– Smoking history, barrel chest, pursed lip breathing, prolonged expiratory phase.
Typically no fever, and diffusely decreased breath sounds with or without
wheezing. May have clubbing, cyanosis.
– Ask about occupational exposures.
COPD exacerbation PE
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
COPD exacerbation Findings
CXR: flattened diaphragms, rightward shifted heart.
- purulent exudate w/o PNA
- lung fxn test
- spirometry
COPD exacerbation S&S
-risk factors: SMOKING
COPD exacerbation Treatment
- Smoking cessation, avoid dust
- diet and exercise
- O2 therapy
- Inhaled bronchodilators
- Corticosteroids
Pneumonia History
Cough, fever (typically over 101), change in sputum color/frequency/amount.
– Pleuritic chest pain, shortness of breath, DOE, look/feel toxic.
– +/- hemoptysis
Pneumonia PE
-CV exam (including heart exam, checking JVD, carotid pulses, bruit,
peripheral pulses (radial and feet)
-check for peripheral edema
-lung exam
-abdominal exam
Add calf tenderness, Homan’s sign, fever for SOB
-Homan’s sign not commonly used
-> pain in calf on forceful and abrupt dorsiflexion of pt’s foot at the ankle while the knee is extended
Pneumonia Findings
Elevated WBC (infection). Order a CXR. Crackles on auscultation.
-mucus test
Pneumonia S&S
- cough w/ sputum (rusty, green, or tinged with blood)
- fever
- tachypnea, SOB, tachycardia
- shaking & chills
- chest pain, gets worse with cough, breathe in
- nausea/vom
- tired
Pneumonia Treatment
- antibiotics
- fever reducers
- cough meds
GERD, PUD, GI bleeding History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
GERD, PUD, GI bleeding PE
Cardiovascular exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and abdominal exams. Examine the skin for signs of liver disease (jaundice, telangiectasia, asterixis, palmar erythema, Dupuytren’s contracture.
GERD, PUD, GI bleeding Findings
GERD:
- ambulatory pH probe test
- XR of upper digestive system
- endoscopy
- manometry
GERD, PUD, GI bleeding S&S
GERD:
-risk factors: obesity, hiatal hernia, preggers, smoking, asthma, diabetes, delayed stomach emptying
- heartburn, may spread to throat
- chest pain
- dysphagia
- dry cough/ sore throat
- acid reflux (regurgitation of food/liquid)
- lump in throat sensation
PUD:
-risk factors: use of NSAIDs, excessive alcohol intake, smoking, infected with H. pylori, have other illness
- burning pain in middle or upper stomach btwn meals
- bloating, heartburn, nausea/vom
- severe: dark/black stool (bleeding), vom blood, weight loss
GERD, PUD, GI bleeding Treatment
- antacids (neutralize stomach acid)
- H2 receptor blockers (reduce acid production)
- PPIs (block acid production & heal esophagus)
- surgery to reinforce or strengthen LES
-maintain healthy weight, avoid food/drink triggers, eat smaller meals, elevate head of bed, stop smoking
PUD:
- avoid triggers
- PPI, antibiotics
Cholecystitis or symptomatic cholelithiasis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
Cholecystitis or symptomatic cholelithiasis PE
Cardiovascular exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and abdominal exams. Examine the skin for signs of liver disease (jaundice, telangiectasia, asterixis, palmar erythema, Dupuytren’s contracture.
Murphy’s
Cholecystitis or symptomatic cholelithiasis Findings
- Blood test
- abdominal ultrasound or CT
- hepatobiliary iminodiacetic acid (HIDA) scan (tracks production and flow of bile from liver to small intestine)
Cholecystitis or symptomatic cholelithiasis S&S
- severe pain in RUQ
- pain radiates to R shoulder/back
- tenderness over abdomen
- nausea/ vom/ fever
- symps occur after a meal (large or fatty)
Cholecystitis or symptomatic cholelithiasis Treatment
- fasting
- antibiotics for infection
- pain meds
- surgery: cholecystectomy
Appendicitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
Appendicitis PE
Cardiovascular exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and abdominal exams. Examine the skin for signs of liver disease (jaundice, telangiectasia, asterixis, palmar erythema, Dupuytren’s contracture. Psoas sign, heel jar, rebound tenderness, obterator test, McBurney's point.
Appendicitis Findings
- CT scan/ ultrasound
- urine test (rule out UTI)
- rectal exam
- blood test
Appendicitis S&S
- Dull pain near navel/upper abdomen that becomes sharp as it moves to RLQ
- loss of appetite
- nausea/vom
- abdominal swelling
- fever
- inability to pass gas
Appendicitis Treatment
- Appendectomy
- prevent with fiber
Diverticulitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
Diverticulitis PE
Cardiovascular exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and abdominal exams. Examine the skin for signs of liver disease (jaundice, telangiectasia, asterixis, palmar erythema, Dupuytren’s contracture. Psoas sign, heel jar, rebound tenderness, obterator test, McBurney's point.
Diverticulitis Findings
- blood test
- CT/XR
Diverticulitis S&S
- LLQ pain/tenderness, worse with movement
- fever, chills, bloating, gas
- diarrhea or constipation
- nausea, sometimes vom
- loss of appetite
Diverticulitis Treatment
- pain meds
- anti-spasmodic drugs
- antibiotics
- surgery
-liquid/low fiber foods
Pancreatitis History
Onset, location and character of pain (gradual vs sudden, colicky/constant,
diffuse vs localized quadrant pain).
– Pain affected by movement, position change, exercise, eating (any particular foods make it better or worse), defecating, urinating?
- Nausea, vomiting
(hematemesis, coffee grounds emesis), black (melena) or bloody (hematochezia) stool, diarrhea or constipation, skin color change (jaundice), sweating, fever,
weight loss, shortness of breath, chest pain, bone pain, night sweats, alcohol use
- OTC over the counter use of NSAIDs? History of any abdominal surgeries?
Any change in urine/bowel habits?
Pancreatitis PE
Cardiovascular exam (including heart exam, checking JVD, carotid pulses, bruit, peripheral pulses, and check for peripheral edema), lung, and abdominal exams. Examine the skin for signs of liver disease (jaundice, telangiectasia, asterixis, palmar erythema, Dupuytren’s contracture.
Pancreatitis Findings
- Pancreatic fxn test (measure amylase and lipase)
- glucose tolerance test
- ultrasound and CT
- biopsy
Pancreatitis S&S
- Upper abdominal pain that radiates into the back; may be aggravated by eating, esp high fat foods
- swollen and tender abdomen
- nausea, vom, fever
- tachycardia
- risk factors: gallstones and heavy alcohol drinking
Pancreatitis Treatment
- IV fluids and pain meds
- if gallstones -> cholecystectomy or bile duct surgery
- chronic: give pancreatic enzymes or insulin; low-fat diet
- surgery
- stop smoking/drinking
Migraine History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
Migraine PE
Full Neurologic exam (including ophthalmic exam looking at optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
Migraine Findings
- blood tests
- CT/ MRI
- spinal tap (underlying condition)
Migraine S&S
Migraine
- begin in childhood/early adulthood
- triggers: hormonal changes in women, foods/additives, alcohol, stress, intense physical exertion, changes in environ, meds
- 4 stages: prodrome, aura, headache, postdrome (may not experience all)
- prodrome: 1-2 days before migraine
- > constipation, depression, food cravings, hyperactivity, irritability, neck stiffness, uncontrollable yawning
- aura: before or during migraine
- > visual (flashes of light), touching, movement, speech disturbances
- headache: 4-72hrs
- > pain on 1 or both sides of head, pulsating/throbbing; sensitivity to light, sounds, smells; nausea/vom; blurred vision; lightheadedness (sometimes followed
Migraine treatment
- NSAIDS
- Triptans (constrict blood vessels and block brain pain pathways)
- Ergots
- anti-nausea meds
- opioids
- glucocorticoids
- Preventive: antidepressants, anti-seizure, Botox
Tension Headache History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
Tension headache PE
Full Neurologic exam (including ophthalmic exam looking at optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
Tension headache Findings
-CT/MRI
Tension Headache S&S
- dull, aching head pain
- sensation of tightness/pressure across forehead or on the sides/back of head
- tenderness on scalp, neck, shoulder muscles
- not associated with visual disturbances, nausea or vom
- caused by stress
Episodic: 30min – 1wk; occur less than 15 days a month for at least 3 months
Chronic: lasts hours, may be continuous; occur 15+ days a month for at least 3mo
Tension Headache Treatment
- pain relievers
- triptans (have both migraines and episodic tension headaches)
- narcotics (rarely used bc of side effects and potential for dependency)
- preventive: antidepressants
Cluster Headache History
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
Cluster headache PE
Full Neurologic exam (including ophthalmic exam looking at optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
Cluster headache Findings
-CT/MRI
Cluster headache S&S
- excruciating pain (in or around 1 eye; may radiate to other facial areas)
- sharp, penetrating, burning one-sided pain
- restless
- redness & swelling in eye on affected side
- stuffy or runny nasal passage in nostril on the affected side
- sweaty, pale face
- maybe nausea, sensitivity to light/sound, aura
-Smoking, drinking, FHx
Cluster headache treatment
- O2
- triptans
- Octreotide (synthetic somatostatin)
- local anesthetics
- Preventive: Ca channel blockers, corticosteroids, ergots, melatonin
Stroke/TIA history
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
Stroke/TIA PE
Full Neurologic exam (including ophthalmic exam looking at optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
Stroke/TIA Findings
- Blood test
- CT/MRI
- Carotid ultrasound
- Cerebral angiogram
- ECG
Stroke/TIA S&S
- Sudden numbness or weakness of face, arm, leg (esp on 1 side of body)
- Sudden confusion, trouble speaking, or understanding speech
- Sudden trouble seeing in 1 or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache w/ no known cause
Stroke/TIA Treatment
- Blood thinners
- Aspirin, tPA
- rehab
Herniated disc +/- radiculopathy history
Onset, location and character of pain. History will differentiate Migraine
vs tension vs cluster headaches.
– Pain location, aura, vision change, numbness, weakness, problems with speech, fever/chills, headache, neck stiffness, photophobia, phonophobia?
- Any nausea, vomiting, loss of urine/bowel control (incontinence), head trauma, confusion, OTC or other pain medication used chronically?
- Headache frequency, and similarity. Outdoors a lot/exposure to mosquito/ticks?
Herniated disc +/- radiculopathy PE
Full Neurologic exam (including ophthalmic exam looking at optic disc, Cranial nerves), cardiovascular (pulses in particular and BP) and lung exam.
Herniated disc +/- radiculopathy Findings
- XR (rule out other causes)
- CT/MRI
- myelogram
- nerve tests
Herniated disc +/- radiculopathy S&S
- lower back disc: pain in butt, thigh, calf, some foot
- neck disc: shoulder and arm pain
- numbness or tingling
- weakness
-risk factors: weight, occupation, genetics
Herniated disc +/- radiculopathy Treatment
- OTC pain meds
- narcotics
- nerve pain meds
- muscle relaxers
- cortisone injections
- physical therapy
- surgery
MSK History
– Onset, location, character of pain will determine additional questions
and exam.
– Tailored history and exam to the cc and where their pain is. Single or multiple joints/areas affected. Symmetric vs non-symmetric? Morning stiffness duration? Heat/cold intolerance, weight gain/loss? Symptoms of inflammation?
MSK PE
ALWAYS compare both sides (bilateral exams) and examine one joint
above and below (when possible). Directed by chief compl aint, but always examine bilaterally, and one joint up and down from affected area.
- Neuro, skin,
musculoskeletal, cardiovascular, and lung exams will be directed/focused by the patient’s history.
MSK Findings
- blood tests (rheumatoid arthritis)
- X-rays
- CT/MRI
MSK Treatment
- Physical therapy
- Splint to immobilize joint
- Use heat or cold
- Reduce workload, increase rest
- reduce stress
- acupuncture
- NSAIDs
- Strengthening and conditioning exercises
- Strengthening exercises
Diabetes History
- Age, eating patterns, exercise hx
- Hx of diabetes-related complications
- > microvascular: eye (blurry vision, visual disturbances), kidney (polyuria, urine output), nerve (tingling, numbness, pain)
- > macrovascular: cardiac (chest pain, palpitation, DOE, lower ext. swelling)
- > other: sexual dysfunction, gastroparesis
- Hx of smoking, HTN, obesity, eating, endocrine disorders
- FHx of diabetes & other endocrine disorders
Diabetes PE
- height and weight
- BP
- fundoscope
- thyroid palpation
- skin exam (acanthosis nigricans and insulin injection sites)
- foot exam (pulses, monofilament sensation)
- patellar and Achilles reflexes
- cardiovasc, lung, ab, neuro exams
Diabetes Findings
- HgA1c
- thyroid fxn test
- fasting plasma glucose and random plasma
- fasting lipid profile
- urinanalysis
- liver and pancreas fxn test
- ECG
Diabetes S&S
Polyuria, Polydipsia, Polyphagia, Weight loss
-Hyperglycemia: blurred vision, lower extremity paresthesias
Diabetes Treatment
- lifestyle: diet and exercise, weight loss
- meds: metformin, ACE inhibitors, aspirin
