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
