Chief Complaints Flashcards
Fever
Diff: infectious, thyroid storm, drug reaction, autoimmune/gout
- What art their VS? If worried about sepsis –> blood cx, IVF, abx
- Work-up guided by PE; UA / CXR / ab US or CT
Weakness
GLOBAL v. LOCALIZED? UMN v. LMN?
Global Diff - dec perfusion (anemia, MI, dehydration, sepsis) v. electrolytes (glucose) / Vit def / rhabdo
Localized Diff - stroke, trauma, tumor, GBS, botulism, nerve entrapment, disc herniation
If non MSK - EKG, trop, lactate, CBC, CMP, CPK
If stroke - non-contrast CT head
If spinal –> possible MRI
Cyanosis
Pathophysiology: deoxy HgB > 5 or Fe+3 10-25%
CENTRAL v. PERIPHERAL?
Do they improve w/ O2? If no, shunt
Central Diff - altitude, V/Q mismatch, shunt, abnormal HgB (Fe+3 or sulfa)
Peripheral Diff - low cardiac output (CHF, shock), hypothermia, arterial or venous occlusion
Work-Up: CBC w/ smear, CXR, EKG, ABG, co-oximeter
Syncope
Hx: preceding events? witness? trauma? cardiac hx? tonic clonic movements? time to recovery?
Diff: vasovagal, dec CO, post-micturition, orthostatic, anemia, CO, hypoglycemia, sz
MUST R/O MI, stroke, PE, SAH, arrhythmia
Work-Up: CBC, BMP, glucose, EKG (consider Holter), UDS, urine preg, orthostatic vitals
+/- CT head if suspect SAH
+/- CXR and BNP if suspect CHF
Dec Consciousness
Diff:
metabolic (glucose, Na, Ca, ammonia, uremia, thiamine def, thyroid)
systemic (drugs, shock, heat stroke, hypothermia, anaphylaxis, MI, PE, dissection)
structural (concussion, CNS bleed/abscess/vasculitis/CSF/edema)
psych
NEURO EXAM - pupils, oculocephalic (eyes should not move with head)
Work-Up: CBC, CMP, glucose, ABG, UA, U tox, TSH, ammonia, CT head non-contrast
“coma cocktail” - thiamine, dextrose, naloxone
Confusion
Diff: toxin, drug withdrawal, stroke, tumor, brainstem dysfunction, infection
BMP, UA + CXR to r/o infection in elderly, bladder scan for retention
Seizure
Diff: Primary (epilepsy) v. secondary (infection, toxin, electrolytes, CNS tumor or bleed, pregnancy, dec AEDs)
Work-Up: CBC, CMP, AED levels, bedside glucose
+ CT head if focality, fever, head trauma, on A/C, age > 40 without epilepsy hx, persistent AMS
Dizziness / Vertigo
Peripheral (unilateral, horizontal ONLY nystagmus) v. Central (bilateral and can be vertical)?
Central Diff - vert stroke, TIA, migraine, anxiety
Peripheral Diff - BPPV, vestibular neuritis, Meniere’s, acoustic neuroma, fistula
Other (“malaise”) - anemia, infection, light-headed, depression
NEURO EXAM (including gait and Dix-hallpike)
Headache
Diff: SAH, CO, meningitis, temporal arteritis, shunt fail, CNS tumor/abscess/bleed, hypertensive crisis, post-LP, dental/TMJ, trigeminal neuralgia, primary (migraine, tension, cluster)
Red Flags: worst headache of life, age > 50, fever, neuro deficits, hx cx, hx HIV, different than normal headache pattern, nuchal rigidity –> CT Head
DO FUNDOSCOPIC EXAM!
Diplopia
MONOCULAR (light path) v. BINOCULAR (brainstem, misalignment or CNS)?
Mechanical v. CN problem v. neuromuscular weakness/NMJ disorder ?
Diff: aneurysm, basilar artery thrombosis, meningitis, vert dissection, botulism, MG, Wernicke, MS, thyroid, migraine, pseudotumor cerebri, tumor
- Monocular –> slit lamp / ophtho
- NMJ –> edrophonium / ice test
- CN problem - MRA, CTA, MRI or CT orbit
- Mechanical - MRI or CT orbit
- Meningitis or Miller-Fischer–> LP
Red Painful Eye
Diff: caustic injury, acute angle closure glaucoma, retrobulbar hematoma, keratitis/uveitis/scleritis/endophthalmitis, penetrating trauma, temporal arteritis, conjunctivitis
Red Flags: vision loss/ blurry vision, dec pupil reflex, corneal opacity, immune compromise, proptosis
PE: acuity, fields, pupils, EOM, slit lamp, IOP, fundoscopy, external lid exam, fluorescin
Work-Up: poss CBC, ESR, CRP, imaging of orbit
Sore Throat
Diff:
Infectious (viral, HSV, EBV, CMV, strep, candida, diphtheria, legionella, tracheitis, peritonsillar or retropharyngeal abscess, epiglossitis, tonsillitis)
Non-Infectious (Kawasaki, thyroiditis, trauma, FB, hematoma, angiogenic edema, caustic injury, tumor)
Red Flags: muffled speech, drooling, stridor, tightness, diff breathing, hx HIV
CENTOR –> strep?, mono spot, plain films if worried about epiglossitis, MANAGE AIRWAY
Hemoptysis
Diff:
- infectious (bronchitis, PNA, TB, lung abscess)
- structural (airway cx / trauma / FB, post-surg)
- vascular (PE, AVM, vasculitis, pulm HTN, aortic aneurysm)
- cardiac (congenital, valve disease - esp mitral, endocarditis)
- Coagulopathy
ABC’s - poss bronch - IVF / blood products PRN
Work-Up: CBC, coags, type and screen, CXR v. CT chest, check Cr if suspect vasculitis
Dyspnea
Diff:
- Pulm (PTX, hemothorax, acute chest, PNA, aspiration, COPD, asthma, obstruction, PE, lung cx)
- Cardiac (MI, CHF, pericarditis, cardiomyopathy, valve, effusion)
- MSK (obesity, toxin, diaphragm paralysis or rupture, ALS, polymyositis, MS, GBS, tick paralysis, rib frax)
- Other (DKA, met acidosis, panic, anemia, preg, thyroid, anaphylaxis)
Hx: exertional? orthopnea? fever/cough/sputum/chills, CP/diaphoresis/N&V?
PE: signs DVT, signs CHF, focality on lung exam, accessory muscle use or tripoding, other MSK weakness
Work-Up: CBC, CMP, EKG, trop, CXR, +/- BNP, go thru PE algorithm
Chest Pain
Diff: MI, PE, aortic dissection, tamponade, pericarditis, PTX, esophageal rupture, myocarditis, ACS, coronary spasm, PNA, rib frax/ MSK, zoster, GERD, PUD, pancreatitis, cholecystitis, biliary colic
RF: MI (family hx, HLD, DM, HTN, cocaine? last cardiac testing?
PE (surg, immob, personal hx, prior DVT, unilat leg sx, OCPs)
Diss (HTN, HLD, smoking, connective tissue disease)
PTX (smoking, chronic lung disease, Valsalva)
Myocarditis/pericarditis (recent viral illness, radiation, uremia, AI, recent cardiac surgery)
PE: Vitals, signs DVT, signs CHF, point tenderness, rash, crepitus
HEART SCORE - hx, EKG, age, RF, trop
PE algorithm
Work-Up: CBC, CMP, EKG, CXR, trop
Ab Pain
Diff by Location: Upper Quads (biliary colic, cholecystitis, pancreatitis, gastritis, GERD, PUD, acute hepatitis/ hepatic ulcer, PNA/MI/CHF, appendicitis if pregnant, splenic)
Lower Quads (appendicitis, ectopic, ovarian torsion or cyst, PID/endometriosis/TOA, hernia, psoas abscess, stone, UTI, mesenteric adenitis, menstrual, diverticulitis)
Diffuse (peritonitis, sickle cell crisis, DM/gastroparesis, AAA, intestinal obstruction, IBD, irritable bowel, mesenteric ischemia)
PE: peritoneal signs? CVA tenderness? pelvic +/- rectal exams
Jaundice
Diff:
- Hemolytic (anemia)
- Physiologic or inborn error of metabolism in newborns
- Hepatocellular Dysfunction (liver failure, hepatitis, hepatic toxin like acetaminophen, transplant rejection, Reye’s, Wilson’s, Gilbert, shock liver, CHF congestion, HELLP/Pre-E/acute fatty liver of pregnancy)
- Biliary obstruction (cholangitis, obstructing AAA, Budd-chiari, pancreatic head tumor, bile duct stone/stricture/mass)
PE: signs chronic liver disease? splenomegaly? ascites? confusion? fever?
Work-Up: CBC, coags, hepatic panel, glucose, ammonia, acetaminophen level, alcohol level, US if biliary, paracentesis if new ascites or AMS
N&V
Diff:
- Inc ICP (meningitis, CNS bleed/tumor, hydrocephalus)
- Primary GI (Boerhaave’s, ischemic bowel, GI bleed, ruptured viscous, bowel obstruction, pancreatitis, cholangitis, cholecystitis, appendicitis, peritonitis/SBP, gastritis, gastroparesis, PUD, IBD, preg, gastroentero, hepatitis)
- systemic (MI, sepsis, DKA, electrolyte prob, adrenal insuff, migraine, adrenal insuff, motion sickness)
- Meds/drugs (CO, acet toxicity, ASA toxicity, digoxin, narcotic withdrawal, chemo)
- GU (UTI, torsion, stone, pyelonephritis)
Worry about 2/2 effects - hypovolemia? metabolic alkalosis? hypokalemia? aspiration? peritonitis?
Work-Up: CBC, CMP, lipase, UA, urine preg
+/- RUQ US
+/- CT ab (suspect obstruction or if peritoneal signs)
+/- CT head if inc ICP
GI Bleed
Upper: varices, PUD, erosive gastritis, Mallory Weiss
Lower: colon cx, diverticula, AVM, hemorrhoids, colitis (ischemic, infectious, IBD), fissure
Peds: intuss or Meckel’s
Mimicks: epistaxis, dental, red food dte, pepto or iron intake, vaginal bleeding, gross hematuria, beets
ARE THEY ON A/C?
PE: signs vol loss, signs cirrhosis, ab exam, rectal exam
Work-Up: CBC, CMP, coags, ab CT, type and cross?
Diarrhea
Infectious: rotavirus, norovirus, CMV, C diff, bacterial (Shigella, salmonella, etc), Giardia, cryptosporidium, schistoma
Meds: abx, anti-dep, diuretics, ACE inhibitors, sorbitol, alcohol
Inflammatory: UC/Chron’s, IBD, CF (osmotic)
Endocrine: VIPoma, hyperthryoid, carcinoid tumor
Bloody? watery? recent travel/hosp/abx use? urine output and PO intake?
Work-up: none if suspect viral –> oral or IV hydration
CBC, CMP, stool O&P, C diff toxin, E coli toxin, giardia assay, UA, TSH
Constipation
Structural: anorectal atresia, imperforated hymen, rectal prolapse, intussussception, mechanical obstruction
Metabolic: Ca, hypothyroid, DM
Neuro: opiates, Hirschsprung, SC injury, anti-cholinergics
Other: preg, IBS, abuse, dehydration, post-op pain
Pelvic Pain
Reprod: ovarian torsion/cyst, PID/TOA, endometriosis, fibroids, dysmenorrhea, endometritis or uterine perforation, vaginitis, cervicitis, 1st trimester (ectopic, abortion), 2nd trimester (previa, abruption, round lig pain)
Urinary: pyelonephritis, UTI, stone
GI: appendicits, diverticulitis, ischemic bowel, obstruction, hernia, IBD/IBS
Other: dep, zoster, septic pelvic thrombophlebitis
-Peripheral v. central? vag d/c or bleeding? urinary sx? OB, menstrual and sex hx? N/V/diarrhea?
Work-Up: pelvic exam, (US b/f pelvic once > 20 wks pregnant), urine preg, UA, poss H&H if bleeding
Vaginal Bleeding
Ovulatory v.
Anovulatory (irregular, estrogen –> overgrowth then eventual withdrawal bleeding) v.
Non-uterine
Diff: vaginitis, atrophic vaginitis, vaginal trauma, preg, ectopic, exogenous hormone use, anovulation, thyroid dx, fibroids, cervical or endometrial polyps, cervical or endometrial cx, PCOS, coagulopathy, hemorrhagic ovarian cysts, urethral diverticula
Hx: quantify blood loss, LMP? sex and OB hx? abuse/trauma? GI/GU/vag/breast sx?
Back Pain
Diff:
aortic dissection, cauda equina, epidural abscess/hematoma, meningitis, ruptured aortic aneurysm, spinal fracture +/- impingement, vertebral OM, malignancy, herniation, spinal stenosis, transverse myelitis, muscle strain, ligament injury, ank spondylitis, zoster, seropositive arthritis
referred (GB, bliary, pancreas, esophagus, kidney, PUD, pvarion torsion, PNA, PE, pleural effusion, prostatitis)
PE: fever? neuro deficits? CVA tenderness, pulse checks, straight leg test, rectal exam for anal tone
Red Flags: neuro def, cauda equina, hc cx, suspect OM (fever, recent manipulation, pt tender)
Work-Up: UA, CBC, ESR (if infectious), MRI» CT if red flags
