POPES Flashcards
Cardiology: Elevated BP Readings
CC: “I was told I needed to have my blood pressure
checked.”
Janelle Howard - 39 years, women, elevated BP 140/90 and 141/98 x 2 mo. Asymp. No SOB, chest pn, numbness, weakness. 20 pack hx, no hx heart dz.
BP: 148/110 P:82 Resp: 14 Temp 97.2 HT: 5'6" Wt: 167
Stage 1 HTN
2ndary dz: thyroid, kidneym sleep apnea)
Anxiety
Pregnancy (preeclampsia)
General Appearance
o Assess for body habitus, facies, fatigue
Vital Signs
o Check cuff sizes
o Assess auscultatory gap
o Recheck blood pressure in both arms
HEENT
o Perform funduscopic exam
Neck
o Inspect for JVD
o Palpate thyroid
Pulmonary
o Auscultate lungs bilaterally – A/P/L
Cardiovascular o Inspect precordium for lifts / heaves o Palpate precordium o Inspect / Palpate / Measure PMI o Auscultate 5 areas for rhythm, heart sounds o Auscultate 5 areas for murmurs o Auscultate upright and supine o Auscultate for bruits – carotid, abd aorta, renal, iliac, femoral
Abdominal
o Palpate for kidneys
PV
o Inspect for hair distribution, cyanosis
o Palpate for edema, temperature, cap
refill, distal pulses
o Palpate brachial and femoral pulses simultaneously
Cardiology Fever, chills, malaise
CC: “I’ve got a fever and I don’t feel good” x 1 day
Raymond Rhodes is a 32-year-old homeless man with a history of intravenous heroin use who was well until yesterday when he began feeling feverish and having chills. He notes accompanying fatigue and feels achy all over, especially in his knees and hips. He also complains of an aching sensation over the sternal area of his chest, and feels slightly short of breath when he exerts himself. He denies sharing needles and had a negative HIV test 6 months ago. PMH includes ETOH abuse, a 30 pack-year history of smoking and multiple abscesses at injection sites over the past 5 years.
VITALS: Temp 39.6 (103.2 F) P 104 BP 130/60 mmHg RA sitting R 18 Wt 151 lbs Ht. 5’10”
DDX: CAP Endocarditis HIV Rhematic Heart Dz Sepsis Influenza
COMMUNICATION NOTES
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for toxicity / respiratory distress
Vital Signs
o Recheck Temperature
o Recheck Heart Rate / respiratory rate
Skin, Hair, Nails o Inspect hands and feet for splinter hemorrhages, Osler nodes, Janeway lesions o Inspect skin for jaundice, abscesses, rash
HEENT
o Perform funduscopy (Roth’s spots)
Pulmonary o Inspect chest for accessory muscle use o Palpate chest wall for tenderness o Percuss lung fields A/P/L o Auscultate lungs bilaterally A/P/L
Cardiovascular
o Inspect / palpate precordium for heaves/thrills
o Auscultate heart with diaphragm for heart sounds, rubs
o Auscultate for murmurs – all positions/areas
Lymph
o Palpate nodes to locate source of possible sepsis (everywhere)
Musculoskeletal
o Inspect / palpate / ROM hips bilaterally
o Inspect / palpate / ROM knees bilaterally
CARDIOLOGY – Shortness of Breath and Swelling
CC: “I can’t seem to catch my breath and I’m pooped out” x 1 week
Cliff Harkins is a 47-year-old man with a history of mild hypertension who describes shortness of breath on exertion and generalized fatigue for the past week. He has a physically demanding job as a day laborer and has previously had no symptoms at work. He has been unable to work for the past 2 days due to swelling in both legs and ankles, progressively worsening shortness of breath and fatigue. He is having a hard time breathing while lying down and is now sleeping in a chair. His exercise tolerance has decreased to 1 block - less if on an incline. He denies chest pain or palpitations. He drinks 3-4 beers per day and
has a 25 pack year history of smoking.
Vital Signs BP 136/90 mmHg RA sitting Resp 24/minute Pulse 110 bpm Temp 98.9 F oral Wt 210 Ht 5’11”
DDx: Look for end organ damage Heart: CHF, cardiomyopathy, cor pulmonale Kidney dz Edema: liver cirrhosis Pulm: COPD Endocrine: hypothyroid
PHYSICAL EXAMINATION
General Appearance
o Assess for acute respiratory distress
Vital Signs
o Recheck Respiratory Rate
o Recheck Heart Rate
Neck
o Palpate thyroid gland
Cardiovascular o Inspect precordium o Palpate precordium o Inspect for PMI o Palpate for PMI and measures o Auscultate heart for rate, rhythm and murmurs in all locations with bell and diaphragm Auscultate for extra heart sounds (S3, S4) o Check for JVD o Measure JVP
Pulmonary o Inspect chest wall (accessory muscle use) o Palpate for tracheal deviation o Percuss lung fields A/P/L o Perform tactile fremitus o Auscultate lungs bilaterally – A/P/L o Check for post-tussive crackles
Abdomen o Auscultate for renal bruits o Palpate for hepatomegaly o Palpate for hepatojugular reflux o Palpate fluid wave for ascites
PV
o Check for cyanosis, cap refill, temp, clubbing
o Palpate for peripheral edema
CARDIOLOGY – Thigh pain on exertion
CC: “I’m here for my regular check up after my heart
attack.”
Daniel Salas is a 58-year-old man with a past medical history of myocardial infarction 3 years ago who is here for a regular blood pressure check up. He has been feeling well, has stopped smoking and has been exercising regularly since his MI. About 2 months ago, he noticed that the back of his legs and thighs began hurting when he was out for his daily walks. The pain occurs only when he walks uphill for more than a block or two, and gets better after his sits and rests for a few minutes. He denies any history of trauma.
Vital Signs BP 144/90mmHg RA sitting Resp 18/minute HR 80 bpm Temp 98.8 oral Weight 235 lbs Ht 6’1”
DDX: PAD Electrolyte difficency PVD - DVT, varicose veins Venous insufficiency Buerger's Pseudoclaudication Strain sprain Discogenic Dz Neoplasm
PHYSICAL EXAMINATION
General Appearance
o Assess for distress, pain
Vital Signs
o Recheck blood pressure
Pulmonary
o Auscultate lungs bilaterally – A/P/L
Cardiovascular / PV
o Auscultate for heart sounds
o Auscultate for murmurs
o Palpate and measure abd aorta
o Palpate pulses – femoral, popliteal, dorsalis pedis, posterior tibialis bilaterally
o Auscultate for bruits – carotid, aortic, renal, iliac, femoral
o Inspect lower legs for color changes, ulcers, hair distribution, varicosities
o Palpate legs for edema, temperature
o Check cap refill
Neurologic
o Inspect gait
o Assess DTRs (Patellar, Achilles)
o Check distal sensation
Extremities o Inspect / palpate back o Inspect / palpate hips o Inspect / palpate thighs o Inspect / palpate legs o Perform Homan’s sign o Perform straight leg raise test
PULMONOLOGY – Cough and Hemoptysis
CC: “My wife is worried about my cough.” x 3 weeks
Wesley Adams is a 64-year-old longshoreman with a 50 pack-year history of smoking who presents with cough and intermittent, scant hemoptysis for the past three weeks. He states that the cough is “not bad.” He’s not too worried as he has had similar symptoms in the past that have resolved. His wife insisted that he be evaluated today as she is concerned about him losing weight. He denies fever, chills, purulent sputum or shortness of breath.
Vital Signs BP 138/90 mmHg RA sitting Resp 18/minute Pulse 78 bpm Temp 98.4 F oral
DDX: COPD Malignacy Mesothelioma - asbethos exposure Pneumonia Acute Bronchitis
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for respiratory distress, acute
Vs. chronic illness
Vital Signs
o Recheck Respiratory Rate
o Assess weight
HEENT
o Nasoscopy and inspect oropharynx to look for bleeding source
Lymphatic
o Palpate for supra/infraclavicular LAD
o Palpate for axillary nodes
Pulmonary o Inspect chest wall for accessory muscle use, retractions, AP diameter o Palpate for tracheal deviation o Palpate for chest wall expansion o Palpate for tactile fremitus o Percuss A/P/L o Auscultate breath sounds A/P/L o Assess egophony, bronchophony, +/- whispered pectoriloquy
Cardiovascular
o Auscultate heart
o Check for cyanosis, cap refill, clubbing
Abdominal
o Palpate for liver masses/ HSM
PULMONOLOGY – Productive cough
CC: “I get this darned cough every year!”
Charlie Bender is a 51-year-old man with a 40 pack-year history of smoking who presents with a persistent recurrent cough. He has gotten this cough each year for the past 4 years and states that it lasts at least 3-4 months each time he gets
it. It seems to be lasting longer each time. The cough is wet and productive of clear mucus, but it gets thick and yellowish on occasion. He denies fever, chills, or hemoptysis. His exercise tolerance is stable, but he does note slight shortness of breath when vigorously exercising.
Vital Signs BP 140/82 mmHg RA sitting Resp 14/minute Pulse 80 bpm Temp 98.2 F oral Wt 172 lbs
DDX: COPD Lung Cancer Allergies Pneumonia Bronchiectasis Cor pulmonale
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for acute respiratory distress
Vital Signs
o Recheck Respiratory Rate
HEENT
o Inspect oropharynx
o Perform nasoscopy
Lymphatics
o Palpate for supra/infraclavicular nodes
o Palpate for axillary nodes
Pulmonary o Inspect chest wall for accessory muscle use, retractions, barrel chest o Inspect respirations for increased expiratory phase o Assess chest wall expansion o Assess diaphragmatic excursion o Palpate for tracheal deviation o Palpate for tactile fremitus o Percuss lung fields A/P/L o Auscultate for breath sounds A/P/L
Cardiovascular o Auscultate heart sounds o Inspect for JVD o Check for cyanosis, cap refill, clubbing o Inspect / palpate for edema
PULMONOLOGY – Shortness of breath
CC: “I can’t seem to catch my breath!” x 6 hours
Nena Bestel is a 32 year-old obese woman with a 20 pack-year smoking history who has had shortness of breath for the past 6 hours. The symptoms came on suddenly while she was sitting and reading. In addition to having a hard time catching her breath, she is feeling anxious and notes that her chest hurts when she takes a deep breath. She denies any recent illnesses, and is not sure what caused these symptoms. She has no cough, hemoptysis, fever, or chills. She denies any recent medication changes and takes only a daily vitamin and an oral contraceptive pill. No one in her family is ill.
Vital Signs
BP 155/94 mmHg RA sitting
Resp 26/minute
Pulse 120 bpm
DDX: Lung: PE, Pneumothorax, pluritis Psych: panic attack Imm: anaphylaxis Acute asthma Heart: MI, primetal angina MS: Costochondritis
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for acute respiratory / emotional
distress
Vital Signs
o Recheck Respiratory Rate
o Recheck Heart Rate
Skin
o Inspect skin for wheals
HEENT
• Inspect oropharynx
Pulmonary
o Inspect chest wall for accessory muscle use, retractions
o Palpate for tracheal deviation
o Palpate chest wall for tenderness
o Palpate for tactile fremitus
o Percuss lung fields A/P/L
o Auscultate A/P/L for breath sounds and pleural friction rub
Cardiovascular
o Palpate valvular areas for thrills/heaves
o Auscultate heart for rate, rhythm, and extra heart sounds
Peripheral Vascular o Inspect for JVD o Check for cyanosis, cap refill, edema o Perform Homan’s sign o Measure calf circumference
PULMONOLOGY – Shortness of breath and Cough
CC: “I can’t shake this cough.” X 3 weeks
Jennifer Nguyen is a 25-year-old nonsmoking woman who has had shortness of breath and cough for the past three weeks. She recently had a cold that resolved except for the continuing cough and shortness of breath. She can only walk about one block without stopping, and states that exertion and cold air aggravates her coughing, as does the smell of strong perfume. Once she starts coughing she has a hard time stopping. She has been otherwise healthy, although she has stopped exercising due to her symptoms. She denies sputum, chest pain, fever/chills, ear or sinus pain.
Vital Signs BP 122/76 mmHg RA sitting Resp 14/minute Pulse 76 bpm Temp 97.2 F oral Wt 118 lbs
Acute bronchitis Asthma Post viral cough Post nasal drip Atypical pneumonia
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for toxicity, respiratory distress
Vital Signs
o Recheck Respiratory Rate
HEENT o Inspect for allergic shiners o Perform nasoscopy o Palpate/percuss sinuses o Perform otoscopy o Inspect oropharynx
Skin
o Inspect for atopic changes
Lymphatic
o Palpate for cervical LAD
o Palpate for supra/infraclavicular LAD
Pulmonary
o Inspect chest accessory muscle use,
retractions
o Inspect during normal and deep resp, A/P/L
o Palpate for tracheal deviation
o Palpate for tactile fremitus A/P/L
o Percuss A/P/L
o Auscultate breath sounds A/P/L
o Auscultate for wheezes on forced exp
o Perform at least one – egophony (E-E-E),
bronchophony (99-99), whispered pectoriloquy (1-2-3)
Cardiovascular
o Auscultate heart sounds
o Check for cyanosis, cap refill
NEPHROLOGY / UROLOGY - Dysuria
CC: “There is blood in my pee!” x 1 day
Desiree Baker is a 16-year-old girl who has had urinary urgency, frequency and dysuria for the past 24 hours. She states it hurts the most at the end of her urination, and she has noticed blood and a bad odor to her urine. She needs to use the restroom every 2-3 hours, and urinates a tiny amount each time. She admits to becoming sexually active recently and is very concerned because she does not want her parents to find out. She states she has reliably used condoms each time she has had intercourse. She denies fever or chills, and has not had any back pain or vaginal discharge.
Vital Signs
BP 114/68 mmHg RA sitting
Resp 14/minute
Pulse 68 bpm
DDX: Cystitis Vaginitis, herpes Interstitial cystitis Contact irritant
COMMUNICATION NOTES
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for toxicity
Vital Signs
o Check temperature
Abdominal
o Palpate suprapubic area for tenderness
o Percuss for CVA tenderness
NEPHROLOGY / UROLOGY – Fatigue and Swelling
CC: “I’m too tired to go to school or work.” x 3 days
Anjuli Imani is a 17-year-old girl who is brought in by her father for a 3 day history of swelling. She has also been feeling extremely fatigued, has noticed a
decrease in her urination and states there is occasionally some blood in the urine. She has not had urgency, frequency or dysuria. She denies nausea, vomiting, diarrhea, fever or chills, but has gained 7 pounds in the last few days. She denies any significant past medical history, but was ill about 2-3 weeks ago with a cold and sore throat that resolved without treatment.
Vital Signs BP 148/90 mmHg RA sitting Resp 18/minute Pulse 84 bpm Temp 98.8 F oral
DDX: Glomerular nephritis Wegners - lung/sinus issue Good pasture ATN Minimal change disease
COMMUNICATION NOTES
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for distress / body habitus
Vital Signs
o Recheck blood pressure
o Check weight
HEENT
o Inspect periorbital area for edema
Pulmonary
o Auscultate lungs bilaterally – A/P/L
Cardiovascular
o Auscultate heart for rate, rhythm
Abdominal o Inspect abdomen o Palpate for tenderness / masses o Palpate for ascites o Palpate for kidneys o Percuss for CVA tenderness
Genitourinary
o Inspect external genitalia for edema
Skin
o Inspect for petechiae and purpura
Extremities
o Inspect / palpate for edema
NEPHROLOGY / UROLOGY – Back Pain
CC: My side is killing me and I’m throwing up!” x 6 hours
Aaron Finklestein is a 32-year-old man with a 6 hour history of constant back pain that awakened him from sleep in the middle of the night. The pain radiates from the right side of his back into his groin, and is rated at an 8/10. He has had nausea and vomited once. He thinks he might have seen some blood in his urine, but states that it was nighttime and dark in the bathroom so he is unsure.
He denies penile discharge, testicular or scrotal pain. He has had no history of trauma and has no past medical history. He is not taking any medications.
Vital Signs BP 138/88 mmHg RA sitting Resp 18/minute Pulse 96 bpm Temp 99.0 F oral
DDX: Urinary stone Pyelonephritis Testicular torsion AAA Apendicitis Herpes Zoster
COMMUNICATION NOTES
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for acute distress, pain level
Vital Signs
o Recheck temperature
Skin
o Inspect skin and sclera for jaundice
Pulmonary
o Auscultate lungs bilaterally – A/P/L
Cardiovascular
o Auscultate heart for rate, rhythm
o Auscultate for abdominal bruits
Abdominal
o Inspect for shape, distension, ecchymosis, scars
o Auscultate for bowel sounds
o Palpate for tenderness / masses (including
suprapubic area)
o Check for peritoneal signs (rebound, etc.)
o Blunt percuss for CVA tenderness
Musculoskeletal
o Inspect / palpate back
Genitourinary
o Inspect external genitalia
o Palpate for hernias
o Palpate for testicular pain / torsion
NEPHROLOGY / UROLOGY – Incontinence
CC: “I’m so embarrassed – I’m leaking!” x 6 months
Beverly Angelo is a 58-year-old G4P3 nonsmoking woman who has been having trouble with urinary leakage for the past 6 months. It occurs primarily
when she coughs or strains to have a bowel movement, but she has also notices leakage at other times as well. She denies problems with leakage when she lies down, but notices it starting once she is upright. She has had to wear a pad in her undergarments to protect her clothes. She occasionally feels a very strong urge to go to the bathroom, and has had a couple of occasions where she has not made it to a toilet in time. She denies dysuria, polyuria, fever or chills, has no back pain and has not had loss of sensation in the perineal area. Her bowel movements are normal.
Vital Signs BP 134/84 mmHg RA sitting Resp 16/minute Pulse 80 bpm Temp 98.4 F oral
DDX: Stress incontinence Urge incontinence Cystocele Atrophic Vaginitis Cauda Equina syndrome
COMMUNICATION NOTES
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for body habitus
Abdominal o Inspect abdomen o Palpate for masses / tenderness o Palpate suprapubic area for distension o Percuss for CVA tenderness
Genitourinary
o Inspect external genitalia for erythema / skin breakdown (from chronic wetness /pad use), atrophy
o Inspect external genitalia with valsalva for
urethrocele, cystocele, rectocele
o Perform speculum exam to detect uterine prolapsed / loss of rugation / atrophy
o Perform rectal exam for sphincter tone and sensation (anal wink)
ORTHOPEDICS / RHEUMATOLOGY – Low Back Pain
CC: “I screwed up my back” x 3 days
Lamar Jensen is a 34-year-old accountant who is seen for low back pain that has persisted for the past 3 days. His back initially began hurting while he was helping a friend move over the weekend, and the next day he had a lot of difficulty in moving around and tying his shoes. The pain is increased when he twists to the left, and he has felt pain down into his left buttock and the back of his left thigh. He has a hard time sitting for his job and is most comfortable standing. He denies urinary incontinence or numbness in the perineal area and does not have a past history of back problems. He has no cardiovascular or lipid abnormalities. Both parents have osteoarthritis.
Vital Signs:
Pulse 90bpm,
RR 19/minute,
BP 134/82mmHg RA sitting
DDX: Impingement Rotator Cuff tear Frozen Shoulder Bicipidal tendonitis SLAP Tear Should subluxation Cancer Referred pain (gallbladder, diaphragm)
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for pain, posture
MS – Neck
o Inspect neck
o Palpate neck for tenderness
o Perform active ROM
MS – Back o Inspect for scoliosis, posture, swelling o Palpate for focal tenderness o Palpate sciatic notch o Perform active ROM o Perform straight leg raise test
MS – Hip
o Inspect hips
o Palpate hips
o Perform active ROM of hips
Neurological o Inspect gait o Observe gait on toes and heels o Perform distal DTRs in LE bilaterally o Assess distal sensation to sharp, soft, and dull at correct dermatomes bilat o Assess distal strength at foot
Peripheral Vascular
o Assess arterial pulses bilaterally – dorsalis pedis, posterior tibialis
ORTHOPEDICS / RHEUMATOLOGY – Knee Pain
CC: “I hurt my knee skiing and it isn’t getting better” x 6 weeks
Brandy Pierotti is a 22-year-old woman who fell while skiing 6 weeks ago. Her bindings failed to release, and her left knee was twisted during a fall resulting in a “popping” sensation. The pain was immediate and severe, and she had difficulty bearing weight. Her knee began to swell over the course of several hours. She was treated by the ski patrol medics on duty, and was sent home with a knee immobilizer and crutches. Since that time the swelling in her knee has diminished and she has been able to discontinue the crutches, but she complains of an intermittent locking sensation and a feeling that her knee is going to “give way”. She denies any history of arthritis or prior knee injuries.
Vital Signs:
Pulse 66bpm,
RR 12/minute,
BP 122/72 mmHg RA sitting
ACL/PCL MCL/LCL Meniscus M/L Patellar dislocation/subluxation Fracture - tibia, patella Skier's Triad
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for pain, posture
MS – Hip
o Inspect hip
o Palpate Hip
o Perform active ROM of hip
MS – Knee o Inspect for swelling/deformity o Palpate soft tissue and bony prominences - anterior/posterior o Perform active/passive ROM of knee o Check LE strength against resistance bilaterally o Assess for varus/valgus laxity o Check for joint effusion – patellar tap, patellar bulge o Check for patellar apprehension test o Perform Lachman test o Perform McMurray test o Perform Apley grinding/distraction o Examine contralateral joint
MS – Ankle
o Inspect ankle
o Palpate ankle
o Perform active ROM of ankle
Neurovascular
o Assess distal DTRs bilaterally
o Assess distal sensation of the LE bilaterally
o Assess distal pulses of the LE bilaterally
ORTHOPEDICS / RHEUMATOLOGY – Painful Shoulder
CC: “I did something to my shoulder while painting” x 3 weeks ago
Gus Kinyon is a 47-year-old house painter who is seen for right shoulder pain for the past 3 weeks. He recalls it beginning to hurt as he was reaching overhead to paint, and the pain worsened later when he carried cans of paint to his truck. In addition to pain that he rates at a 4/10, he now notes that he is no longer able to lift his arm above his head, and he feels a catching sensation. It hurts to lie on it at night and his sleep has been disrupted. His past medical history includes hyperlipidemia for which he is taking a statin drug, but is otherwise healthy.
Vital Signs:
Pulse 80bpm,
RR 18/minute,
BP 138/84 mmHg RA sitting
DDX: Psoriatic arthritis (unilateral joint) -(RA - can be asymmetric, usually doesn't affect DIP) Reactive arthritis Ankylosing Spondylitis Septic Joint (gono, non gono, staph) SLE - 90% have joint probs Irrital bowel dz
COMMUNICATION
o Greet patient
o Introduce yourself
o Wash hands
PHYSICAL EXAMINATION
General Appearance
o Assess for posture, pain
MS – Neck o Inspect for symmetry o Palpate for tenderness of muscle and bony prominences o Perform active ROM
MS – Shoulder o Inspect shoulder A/P/L o Palpate soft tissue structures o Palpate bony structures o Perform active ROM of shoulder o Perform passive ROM of shoulder o Perform ROM of shoulder against resistance o Examine contralateral side o Perform Yergason’s test o Perform Drop Arm test o Perform Apprehension test o Perform Neer / Hawkins test
MS – Elbow
o Inspect elbow
o Palpate elbow
o Perform active ROM
Neurovascular
o Assess UE distal pulses bilat
o Asses UE distal sensation bilat
o Assess UE DTRs bilat
