Review of Systems – Practical Guide to Clinical Medicine

Review of Systems – Practical Guide to Clinical Medicine
UC San Diego’s Practical Guide to Clinical Medicine
Contents
Adult Review of Systems (ROS)
1.1
Overview
1.1.0.0.1
General
1.1.0.0.2
Head and Neck (H&N)
1.1.0.0.3
Pulmonary
1.1.0.0.4
Cardiovascular (C/V)
1.1.0.0.5
Gastrointestinal
1.1.0.0.6
Genito-Urinary
1.1.0.0.7
Hematology/Oncology
1.1.0.0.8
Ob/Gyn/Breast
1.1.0.0.9
Neurological
1.1.0.0.10
Endocrine
1.1.0.0.11
Infectious Diseases
1.1.0.0.12
Mental Health
1.1.0.0.13
Skin and Hair
Adult Review of Systems (ROS)
Overview
The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to
uncover dysfunction and disease within that area. It can be applied in several ways:
As a screening tool asked of every patient that the clinician encounters.
Asked only of patients who fall into particular risk categories (e.g. reserving questions
designed to uncover occult disease of the prostate to men over 50; or using a cardiovascular
ROS in patients who have cardiovascular risk factors).
So, what’s the best way to use the ROS? I have always been dubious of its utility as a broadly
applied screening tool. Using it in this fashion makes sense if the following hold true:
The questions asked reflect an array of common and important clinical conditions
These disorders would go unrecognized if the patient was not specifically prompted
The identification of these conditions then has a positive impact on morbidity/mortality
Unfortunately, aside from a few specific screening tools (e.g. depression), there is little
evidence to support these assumptions. In fact, positive responses to a screening ROS are often
of unclear significance, and may even create problems by generating a wave of additional
questions (and testing) that can be of low yield. For these reasons, many clinicians (myself
included) favor a more targeted/thoughtful application of ROS questions, based on patient
specific characteristics (e.g. age, sex) and risk factors (e.g. history of diabetes → perform
cardiovascular ROS). This strategy, I think, is both more efficient and revealing. As you gain
experience, you can make an informed decision about how you’d like to incorporate the ROS into
your overall patient care strategy.
It’s important to recognize that positive responses will require follow-up questioning. For
example, if a patient responds “yes” to an ROS question about chest pain, you would then need to
ask additional questions to further define the core dimensions of this symptom. The
OLD CARTS
mnemonic (or other similar frameworks) provide
structure for these follow-up questions. In addition, for a patient with chest pain, an
assessment of cardiac risk factors and an organized search for exam findings indicative of
vascular disease (e.g. elevated BP, diminished peripheral pulses, etc.) would be relevant. In
addition to also consider non-cardiac etiologies (e.g. pulmonary, GI, MSK, etc.). On the basis
of the sum of this data, the clinician can come to an informed conclusion about the
importance/cause of this patient’s chest pain (e.g. angina, heartburn, pulmonary embolism), and
use this to guide their subsequent decision making.
Guide To Using This ROS
There is no ROS gold standard. The breadth of questions included is somewhat arbitrary, based on
the author’s sense of the most commonly occurring illnesses and their symptoms. There is planned
redundancy, as the same symptoms often apply to multiple organ systems. Feel free to edit/adapt
to fit your clinical needs. Realize that exotic or regional illnesses might require other ROS
questions. In addition, some sub-specialty areas use an expanded ROS, specific to the conditions
that they evaluate and treat.
I’ve added a few novel features, designed to clarify why an ROS question is asked and in what
direction the response should lead. These include:
Clicking on the main questions reveals a list of common disorders that might be at the root
cause of the particular symptom.
Comments in parentheses that follow include other symptoms and/or historical features
commonly linked to that particular disorder.
“Red flag” indicates symptoms that are particularly worrisome for a serious illness.
Where possible, I’ve bundled the diagnostic possibilities into clinically logical groupings
(e.g. acute/chronic, painful/painless, upper/lower, etc.).
I would like to highlight several important limitations:
The list of possible diagnoses that follows a question is not exhaustive. In addition please
realize that no patient responses are pathognomonic.
Common associated symptoms, risk factors, exam findings, and selected links to additional
info are provided in
(parentheses)
after most items on the
differential. This is only meant to point you in the right direction in terms of possible
diagnoses – it is not meant to be inclusive.
The disease categorizations reflect rough groupings. There are many exceptions. For example,
disorders listed in the “acute” section may have chronic presentations, those described as
“upper abdominal” may present w/thoracic symptoms, etc.
Clicking on the main categories reveals a list of broad questions.
Clicking on any of these symptoms questions reveals a list of common disorders that might be at
the root cause of the particular symptom.
General
More Info About General Symptoms:
National Library of
Medicine/Medline Plus
Comprehensive HPI
and
the rest of the
history
Weight Loss? (confirm with objective
measurement and other indicators: e.g. pants and other clothes no longer fit)
Intentional
Appropriate → dieting
Inappropriate → anorexia
(chronic/progressive, hyper-concern about
weight and body image, women>men, binge/purge cycles, hide eating
habits)
Unintentional
increased metabolic rate
COPD
(high work breathing, too sob to
eat)
CHF
(high work breathing and activity, too
sob to eat)
Hyperthyroidism
Malignancies → calories diverted to grown cancer, decreased
appetite → cancer site defined by localizing symptoms
Chronic infections – in particular TB and HIV
Illicit drug use – in particular methamphetamines – focus of life and money
soley on drug use
Medications which affect appetite → chronic nausea, abdominal pain,
diarrhea → chemo for cancer, HIV rx
Neurological disorders
stroke
(other vascular risk factors,
problems w/initiating swallowing, other focal findings, hx
aspiration)
parkinsons disease
resting tremor
, bradykinesia,
shuffling gait, cogwheel rigidity on exam)
Oral pathology
mechanical problems with chewing → dental problems
(prevent chewing and/or cause pain)
Sores/ulcers
cancer
chronic inflammatory processes- HIV
Bechets
mucositis from chemotherapy
Esophageal disorders
Cancer
(Progressive swallowing problems
→ food gets stuck, worse w/solids then liquids, pain,> 50,
chronic GERD, smoking, ETOH abuse)
Obstruction from benign causes
Zenker’s diverticulum
(chronic
symptoms, bad breath, sensation food stuck in
throat/upper esoph, regurgitation undigested
food)
esophageal web or ring
(chronic,
non-or slowly progressive, sensation of food getting
stuck → occurring more w/larger solids
esophageal stricture
(long hx gerd
or hx caustic ingestion; sensation of food getting stuck
→ occurring more w/larger solids, can be
progressive if related to chronic inflammatory
process)
Inflammatory
GERD
Infection
candidiasis
(often compromised
host → cancer/chemo/hiv, evidence candida in
mouth)
HSV
(oral hsv, often compromised
host → cancer, chemo, hiv)
malignancy
pills
(symptoms occur soon after
incomplete swallowing of pill, patient can often point to spot
along esophagus where pain is focused)
Dysmotility
achalasia
(progressive dysphagia,
solids and liquids, regurgitation, GERD, food sticks
lower area esophagus)
esophageal spasm
(acute,
intermittent pain and difficulty w/swallowing)
eosinophilic esophagitis
(allergies, asthma, no pain, no
response to PPI)
Chaga’s disease
(from central or
south America, low socio-economic class,
progressive)
Scleroderma
skin tightening
, women > men,
< 50, GERD, known disease)
Stomach disorders
Cancer
(feel full when eating ever small
quantities of food., pain, > 50, smoking, ETOH abuse)
Obstruction from benign causes
pyloric stricture
(history ulcer
disease, hx past gastric surgery)
extrinsic gastric compression for other abdominal mass e.g.
profound splenomegaly
Peptic ulcer disease → pain with eating
NSAID use
H Pylori
Dysmotility
gastroparesis from autonomic dysfxn
(Hx DM w/poor control, early
satiety, decreased sensation feet/other evidence DM
induced neuropathy)
Abdominal disorders that cause pain or other symptoms w.eating
chronic pancreatitis
(hx multiple episodes
prior pancreatitis from any etiology)
IBD – Chron’s Disease or UC
(sub-acute,
recurrent or chronic; wt loss, bloody stools, mucous, cramps,
constipation, nocturnal diarrhea; systemic Sx; presentation can
also be fulminant)
mesenteric ischemia
(known
atherosclerosis or risk factors, known risk factors for embolic
disease → a fib, ventricular thrombus, acute low BP
superimposed on atherosclerosis, persistent/progressive
generalized pain w/few exam findings)
Chronic GI Infections
parasites
(sub-acute or chronic, watery
→ Giardia; bloody → Ameobiasis; camping/drinking
unfiltered water)
HIV
(chronic and progressive, atypical
infxns → parasite, fungal)
bacterial overgrowth s/p gastric bypass
Other malabsorptive d/o
IBD
(sub-acute, recurrent or chronic; wt
loss, bloody stools, mucous, cramps, constipation, nocturnal
diarrhea; systemic Sx; presentation can also be
fulminant)
celiac disease
(bloating, gas, wt
loss/inability to gain weight, chronic symptoms)
chronic pancreatitis
(multiple past
episodes pancreatitis, ETOH abuse or other chronic exposure to
pancreatitis inducing toxins/process, chronic upper abdominal
pain, back pain, nausea, vomiting, bloating, stools difficult to
flush)
lactose intolerance
(n, bloating, gas, abd
discomfort → within few hours eating milk/milk
products)
Whipple’s disease
(rare d/o, chronic
diarrhea, wt loss, abd pain, male>female, fatigue, joint
pain)
hyperthyroidism
(irritability, inability
to sleep, weight loss, palpitations, tremor, heat intolerance,
diarrhea)
laxative, sorbitol, use/abuse; excessive caffeine intake
Other causes chronic diarrhea
Diarrhea or other change
in bowel habits
Other medical disorders that decrease appetite/cause nausea
anosmia (can’t smell normally), which affects taste
Chronic or acute kidney disease
Chronic or acute liver disease
Other chronic medical conditions
Other – depression, psychiatric illness
Weight gain?
decreased metabolic rate
inactivity
(no regular walking or exercise)
hypothyroidism
(wt gain, edema, dry skin,
constipation, cold intolerance, depression)
excessive caloric intake
fluid retention
advanced kidney disease
edema for other reasons
CHF
(C/V RFs, orthopnea, PND, exam
findings: lower extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
Ascites →
GI
Abdominal swelling or distention?
Fatigue?
sleep disorders
obstructive sleep apnea
(snoring, obese, observed
apnea, poorly rested in AM, daytime fatigue)
Travel/jet lag, work with odd hours/shifts
endocrine
Hypothyroidism
(wt gain, edema, dry skin,
constipation, cold intolerance, depression)
Hypercalcemia
(polyuria, constipation, confusion,
Bone pain, known/suscepted squamous cell ca)
Diabetes
(known dz → poor control, polyuria,
polydypsia)
Low Testosterone
(decreased libido, erectile
dysfxn)
Adrenal Insufficiency
(poorly in general, n, v,
orthostatic sx)
Heme/Onc
Anemia
Cancer – type identified based on detailed review major organ systems
mental health
depression
(little interest or pleasure in doing
things; feeling down depressed or hopeless)
substance abuse
Musculo-skeletal/Rheumatologic
DJD
(chronic pain, difficulty moving)
Chronic or sub-acute inflammatory disorders – Rheumatoid Arthritis, Lupus,
polymyalgia, other
Infection
Chronic
HIV (generalized sx → wt loss, fatigue; HIV RFs: men having sex
w/men, sex w/prostitutes, IVDU, transfusion w/o screening, sexually
active, past STI, TB, sex w/anyone w/HIV RFs, sex for money)
TB (cough x weeks, hemoptysis, wt loss; immunocompromised →
malnourished, chronic steroids, known HIV or HIV RFs, malnutrition;
endemic area)
Sub-acute: endocarditis
Pulmonary
COPD
(SOB, DOE, sputum, acute or chronic, cough,
smoking, wheezing)
Other chronic pulmonary disorders
Cardio/Vascular
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
S3
elevated jvp
displaced pmi
rales on lung exam
Bradycardia
(fatigue, decrease exercise tolerance,
CHF Sx)
Neuro
Neuromuscular disease
(progressive, muscle
weakness, no numbness)
polymyositis
myopathy
myasthenia gravis
(subacute, progressive,
worse w/repetitive movement)
central nervous system d/o
stroke
(acute, focal deficits, vascular dz
risk factors)
multiple sclerosis
(relapsing/remitting,
patchy symptoms: numbness, visual changes,
balance/coordination)
peripheral nervous system
guillain barre
(acute, progressive,
ascending pattern of involvement)
CIDP
(pain, tingling, numbness, focal
weakness)
mixed CNS & PNS
ALS
(progressive weakness, twitching,
breathing problems)
Stroke
Parkinson’s disease
(older, progressive, rigidity,
difficulty starting/stopping movement, balance problems, gait
problems)
Other/Metabolic
Chronic liver disease
chronic kidney disease
profound hypokalemia
hypercalcemia
hyponatremia
Difficulty sleeping?
Often assoc w/problems in other organ systems:
obstructive sleep apnea
(snoring, obese, observed
apnea, poorly rested in AM, daytime fatigue)
central sleep apnea
hyperthyroidism
(irritability, diarrhea,
palpitations, tremor, heat intolerance)
nocturia
BPH —
See:
GU — Urination at Night?
meds
(nocturnal diuretics,
caffeine)
excessive intake PM liquids, ETOH
diabetes
(poorly controlled sugars)
mental illness – depression, anxiety
Travel/jet lag, work with odd hours/shifts
Feeling well (or poorly) in general?
A possible non-specific indicator of problems
Recent medical evaluations or
treatments?
Patients sometimes neglect to mention evaln/rx by other MDs/Clinics, ERs, hospitals,
etc
Chronic pain?
often underappreciated and under addressed
Fevers, chills, sweats, weight loss?
Infection
Localize sx to specific organs on basis of other ROS questions & exam → identify
site of infection – e.g. urinary burning, frequency, urgency → simple UTI; other
key hx to define likelihood of specific infxn: age, co-morbid predisposing illness (e.g.
cancer, DM, substance abuse), past hx (hospitalizations, operations), travel/geographic
exposures, season, status of immune system (acquired or congenital immunodeficiency),
meds that affect immune system (steroids, chemotherapy, tnf-inhibitors, etc), indwelling
devices/hardware, valvular heart disease.
More info from:
CDC
Infectious Disease Soc
America
Bacteria
Gram Negative Organisms
e coli
(GNR, cause uti, also
abdominal/pelvic abscesses; HO157 causes enteritis and
HUS)
klebsiella, enterobacter, serratia
(GNRs, cause of urinary tract infection,
also abdominal/pelvic abscesses; hospitalized patients
→ pneumonia, wound infection, uti)
proteus
(common cause of urinary tract
infection, can contribute to stone formation; wound
infection hospitalized patients)
pseudomonas
(lung infections in
patients with bonchiectasis → CF, COPD, compromised
pts; bacteremia in patients w/neutropenia, also
abdominal/pelvic abscesses, wound infection in patients
w/DM; wound and urinary infections hospitalized/compromised
pts; osteomyeliitis; otitis externa in patients w/DM)
neisseria meningitidis
(GNC,
meningitis; f, c, ha, n, v, sepsis)
neisseria gonorrhea
(GNC, urethritis;
cervicitis/PID; if
disseminated
infectious
arthritis)
moraxella
(GNC, otitis media;
bronchitis in copd exacerbation; pneumonia in COPD)
legionella
(community acquired
pneumonia, cough, sputum, f, c)
haemophilus influenza
(pneumonia,
otitis media, epiglottitis, meningitis; much less common
since widespread use of vaccine)
HACEK organisms
(endocarditis →
typically sub-acute → f, c, malaise x weeks)
salmonella
typhi
(relapsing daily fever x
weeks, malaise, ha, chills, relative brady, related
to poor sanitation → outbreaks, travel to
endemic areas, gall bladder can act as
reservoir)
non-tyhoidal
(diarrhea, n, v,
cramps, often w/bloody stools)
shigella
(diarrhea, n, v, cramps,
often w/bloody stools, typically self limited)
campylobacter
(diarrhea, n, v, cramps,
often w/bloody stools, typically self limited)
yersinia
enterocolitica
(diarrhea, f,
c, cramps; typically self limited)
pestis → plague
(passed
from rodents to humans by fleas or direct contact
w/feces, rapid onset f, c, sepsis, pneumonia)
helicobacter
(stomach ulcers)
pertussis
(characteristic whooping
cough; kids can have airway compromise; adults presents as
persistent cough x weeks easily spread; vax of kids and
re-vax of adults preventive)
Other less common gram negatives
vibrio
cholera
(toxin mediated
profound watery diarrhea, related to exposure to
unclean water sources, often s/p natural disasters
→ presents as epidemics)
vulnificus
(causes sepsis in
hosts w/cirrhosis or otherwise compromised hosts,
exposure via raw/under cooked shellfish; also skin
infection if same hosts exposed via
inoculation)
francisella tularensis → tularemia
(passed from dying wild animals to
humans via ticks/insects, US Southeast and Rocky Mtns,
causes skin ulcers, lymphangitis, f, c)
brucella
(ingestion of raw/uncooked
dairy, not present in all countries, causes recurrent f, c,
systemic sx, arthritis, other organ involvement)
batonella
henslae
(caused by cat
scratch, regional adenopathy w/in few weeks,
fatigue)
bacillary angiomatosis
nodules on skin
, resemble
Kaposis Sarcoma
, occurs in
HIV infected or otherwise compromised pts)
Gram positive organisms
Cocci
Staph aureus
coag +
cellulitis
skin abscess
wounds; osteomyelitis via direct extension;
arthritis; bacteremia with seeding of
abnormal or artificial valves, joints or
devices; virulent w/rapid destruction
valves/death w/in hours/days; toxic shock;
pneumonia following viral infection; toxin
based food poisoning → n/v hours after
exposure, others affected who ate
same)
coag –
cellulitis
skin abscess
bacteremia with seeding of abnormal or
artificial valves, joints or devices, less
virulent than coag +)
mrsa
cellulitis
skin abscess
bacteremia with seeding of abnormal or
artificial valves, joints or devices, can be
hospital or community acquired; healthcare
assoc pna)
Streptococcus
Group A
(cellulitis/lymphangitis;
skin abscess; erysipelas; throat infections
→ acute pain, f, adenopathy:
pharyngeal erythema
and d/c; impetigo; contribues to
necrotizing
fasciitis
; scarlet fever → high
temp, rash, palatal petchiae, throat sx)
Group B
(endometritis,
meningitis, bacteremia, neonatal
infection)
Group D → enterococcus
(urinary tract
infection, pelvic/abd abscess, wound/other
infxn in chronically ill/hospitalized
patients)
Viridans
(endocarditis
→ subacute w/sx f, c, malaise x
weeks)
pneumoniae
(pneumonia,
upper respiratory infections, meningitis;
bacteremia if severe; increased risk if s/p
splenectomy)
Rods
listeria
(meningitis in old
and young patients)
diptheria
(upper respiratory
infection w/cough, f, sore throat, pseudo-membrane
w/airway obstruction; uncommon now w/vax)
anthrax
(acquired from animal
exposure or biological weapon; inhalation: cough, f,
c,pneuonia sepsis; cuteaneous: ulcer to eshcar
w/surrounding edema)
Anaerobes (GN or GP)
often associated with mixed/complex infections/abscesses of abdomen,
pelvis, lung, mouth
clostridium: GPR
perfringes
(most common cause
food born diarrhea → undercooked meat, cramps,
diarrhea, 6-18h after ingestion, resolves in 24h,
other who ate same ill simultaneously; deep tissue
infection contibuting to
necrotizing faciitis
contribute to abd/pv abscess; NEC in
neonates)
difficile
(antibiotic
associated colitis, can occur after any abx, cramps,
diarrhea)
tetani
(exposure via
contaminated wounds if unvax, 1w
incubation,increased tone in jaw muscles, dysphagia,
diffuse musle pain/spasams, airway compromise;
uncommon w/widespread use vax)
botulinum
(food/wound born
toxin, incubation 1-2d, rapid descending symetric
paralysis staring w/cranial nerves, dizziness, dry
mouth, visual sx, no sensory deficitis, aggitation,
resp failure, death)
bacteroides fragilis
(GNR, contributes
to abdominal/pelvic abscesses)
peptostreptococus
(GPC, lives in
mouth, contributes to mixed oral/lung infxns/abscess)
Other bacteria
chlamydia
trachomatis
(urethritis,
cervicitis/PID)
pneumoniae
(fever, upper resp
sx, non-productive cough)
psittacosis
(spread by
exposure to parrots & sometmes other birds, 1-2 week
incubation; fever, cough, severe HA; other organ
systems as well)
mycoplasma pneumoniae
(common cause
CAP; acute f, c, cough, upper resp sx; not usually
severe)
nocardia
(lives in soil, causes
sub-acute pneumonia, also abscess/cellulitis/lymphangitis if
direct inoculation)
actinomyces
(oral/neck/face slow
growing abscess, often w/sinus tract development, can
affectother organ systems as well)
Viruses
rhino, adeno
(common cause of upper
respiratory infxn, cough, nasal congetsion, sore throat, ear
pain)
influenza
(common cause upper and lower
respiratory infection, seasonal in North America oct to april,
increase risk if no vaccination; abrupt onset of myalgias,
arthralgias, fever, chills) more from
CDC
rotavirus, norovirus
(common cause of
acute enteritis: abrupt onset n, v, d, diarrhea; rota in partic
kids < 5; noro adults/daycare/hospitals/nursing homes)
enteroviruses
(non-specific sx of f, c,
aches; meningitis)
coxsackievirus
(myocarditis,
pericarditis,
hand/foot/mouth
in kids f,
malaise)
polio – eradicated in US w/vaccine
EBV → mononucleosis
(incubation 4-6w,
pro-drome 1-2w of fatigue and myalgias; then f, head/neck
adenopathy, pharyngitis, hepatomegaly, splenomegaly)
herpes simplex
(past by sexual or oral
contact; genital or oral herpes, encephalitis; fever or pain
prior to appears
vesicles
; resolves spont; can recur,
can be congenitally acquired)
varicella zoster
chicken pox
, shingles →
dermatomal vesicles
, pneumonia in
setting severe chicken pox)
Hepatitis
(acute liver infection, spread
fecal/oral/ingestion contaminated food, can be epidemic;
incubation 2-4w, n, v, abd pain, f,
jaundice
icterus
; generally self
limited)
(acute liver infection,
incubation 3m; spread via sexual contact, vertical,
shared needles, needle sticks in health care workers,
unscreened blood transfusion: acute may cause f, c,
jaundice
icterus
; may be sub-acute; 95%
adults resolve, 5% go on to chronic hepatitis →
risk cirrhosis, HCC)
(chronic hepatitis, acute
infection generally not recognized, spread via needles,
unscreened blood transfusion, cocaine inhaling tools,
needle sticks in health care workers, vertical, sexual –
rel difficult; 10-20% resolve; long term risk cirrhosis
and HCC)
HPV
genital warts
peri-anal warts
, years later causes
cervical cancer, head/neck scc, penile scc)
RSV
(winter mos, cough, fever, typically
affects infants and children)
para-influenza
(upper resp
infection/croup, tracheobronchitis)
parvo
(most common ages 5-19, slapped
cheek rash, also rash on arms, soles, palms; acute
arthralgias/arthritis that can mimic RA; can cause acute
hypoprolif anemia)
CMV
(retinitis/colitis/disseminated dz in
patients w/HIV; systemic infection in patients 1-4m s/p
transplant; normal hosts get mono-like symptoms: incubation 3-8
w, then f, c, malaise hepatomegaly, splenomegaly, fatigue x
4-6w; head/neck adenopathy & pharyngitis are rare)
rabies
(bite from infected animal →
skunk, bat, squirrel, dog; incubation can be days to mos, f, ha,
myalgias, arthralgias, hydrophobia, intermitent
confusion/aggitation, sensitivity to sound/light; sx onset to
death avg 4d)
Hanta
(rodent exposure; 3-4d f, myalgias,
HA, n, v, abd pain; then rapidly progressive resp sx)
West Nile
(incubation 2d-2w; summer/fall
in North America, fever, muscle aches, confusion, ha, stiff
neck, rash, confusion → meningo-encephalitis)
measels
(uncommon w/vaccination,
winter/spring in US, cough, f, malaise, conjunctivitis, runny
nose, then rash, white spots on oral mucosa; complications
include encephalitis, pneumonia)
mumps
(uncommon w/vaccination, f, myalgia,
malaise, affects B parotids and testicles)
rubella
(uncommon w/vaccination, rash
starts on face, fever, adenopathy; can be congenitally
acquired)
Fungi
candida
(common cause of fungal skin
infection:
tinea cruris
tinea pedis
, vaginitis;
worse/recurrent if immune-compromised)
Coccidioidomycosis
(south west US,
higher risk if immune-compromised, sub-acute
pneumonia/effusions, also arthritis,
skin
, seeding of other
sites)
aspergillus
(pneumonia in compromised
host, tissue invasive or fungal ball, invasive sinusitis in
patients w/DM or otherwise compromised, can infect any
organ; recurrent wheezing in normal hosts →
ABPA)
histoplasmosis
(can be asx/mild and
resolve spont; often see x-ray evidence prior infection
lung, spleen w/o known past infxn; exposure to Mississippi &
Ohio river valley; cough, fever; can cause resp/systemic
illness in HIV+)
mucor
(invasive sinusitis, pneumonia
in patients w/DM or otherwise compromised; cough, fever, HA,
sinus pain)
pneumocystis jerovecii
(pneumonia in
patients w/HIV; also in those compromised by long term
steroid use)
Mycobacteria
tuberculosis
(sub-acute, cough,
hemoptysis, weight loss, sweats; can also infect GI/GU
tracts, bone; increased risk if immune-compromised/hiv
+)
more from
CDC
MAC
(HIV + cause of diarrhea;
indolent lung infection in patients with
bronchiectasis)
MAI
(diarrhea in patients
w/HIV)
M Marinum
sub-acute skin infection
, after
exposure via fish tanks)
M Leprae
(slow, anesthetic macule,
area of involvement spreads, direct nerve involvement,
neuropathic pain and enlargement of involved nerve,
Southeast Asia)
Retrovirus (HIV)
HIV
(hiv risk factors →
men who have sex w/men, unprotected intercourse, sex
w/prostitutes, sex w/somone known hiv +, ivdu,
transfusion w/unscreened blood, drug/etoh abuse, hx
other sti’s, health care worker’s w/needle stick
injury; risks of unusual infection increase as CD4
declines – see organ specific sx)
more from CDC
Spirochetes
borrelia burgdorferi → lyme
(endemic area north east,
upper mid west, tick contact x 24-48h;
inoculation days to weeks, then–>rash, f, c,
aches; then arthralgias, heart block, CNS
involvement; later still arthritis)
more from
CDC
syphillis
(sexual exposure,
initially painless genital
ulcer
→ heals 4-6w; weeks later
non-specific rash
w/predilection for palms
, and
soles
, condyloma around
genital areas, mucous involvement, adenopathy;
late manifestations yrs later affecting CNS,
large blood vessels → aortitis,
aneurysm)
more from
CDC
leptospirosis
(contract
via exposure to rodent/wild animal feces;
inoculation period several weeks; mild dz is
self limited f, c, ha, n, v, musle aches,
conjunctival injection; severe dz with hepatic
and renal involvement,
icterus
Rickettsiae
Rock Mtn Spotted Fever
(exposure to tick,
incubation 2d to 2w; can occur in most
states in US, f, c, ha, arthralgias, then
generalized rash – though not always, can be
severe/fatal)
human ehrlichiosis
(often co-infection
w/lyme, tick born, incubation ˜1w, f,
ha, n, v, myalgias; often causes BM
suppression)
Parasites
malaria
(passed
via mosquitoes, live in tropical
climates: Southeast Asia, Africa;
susceptibility increase if don’t use
proph abx; incubation 1-4w; recurrent
high fevers, c, HA)
toxoplasmosis
(protozoa, carried
in cat feces, healthy hosts not
affected, in HIV + causes brain
infection dc4 < 200 → headache,
f, delirium, szr; pregnant women can
pass in utero → congenital
abnl)
giardia
(protozoa,
spread via poor hygiene, contaminated
water, drinking from ponds/streams, anal
intercourse; many infected are asx;
incubation 1-3w; non-bloody diarrhea,
gas, burping)
entamoeba hystolytica → amebiasis
(protozoa, acquired
via unclean water/poor sanitation, also
anal intercourse; only 10-20% develop
sx; incubation 2-4w; abd pain, bloody
diarreha; occas liver abscess)
trichinosis
(roundworm, rare in
US; from eating infected meat; abd pain,
n, v, diarrhea; after 1-2w, muscle pain
when migrate to muscles, rash, ha, n,
v)
ascariasis
(roundworm,
tropics/sub-tropics/SE US, eggs
swallowed if contaminated soil ingested
→ eggs hatch in intestines →
larvae enter blood stream → migrate
lungs → mature & coughed up →
swallowed → mature in intestines;
cough, fever, sob, n, v, abd pain,
impaired growth of children, sbo)
hook worm
(common
world-wide, enter thru feet/skin if walk
barefoot in soil w/infected feces →
bloodstream → lungs →
swallowed → intestines → blood
loss → anemia, d)
enterobiasis
(pin
worm, fecal oral, common in kids, cause
nocturnal peri-anal itching)
w bancrofti
(tropics/sub-tropics,
spread by mosquitoes, filaria invade
lymphatis, after years → lymphedema
from obstruction of channels)
onchocerciass
(causes river
blindness, Africa/central-south America;
spread by black fly;
conjunctivits/keratitis, skin
nodules)
schistomiasis
(south america,
middle east, caribbean, africa: flukes,
invade skin of swimmers, enter blood
stream → live in portal/mesenteric
veins; can cause cirrhosis after years;
can live in bladder → SCC after
years)
cysticercosis
(tapeworm, ingest
eggs via infected beef that’s
undercooked; Mexico, Africa, Southeast
Asia; eggs cross intestines, migrate to
host muscles and brain, can cause
seizures)
echinococcus
(worm; from cattle
and dogs; in US and many other areas;
eggs ingested by humans → travel to
liver, lungs, other organs → cysts
form: in liver → can cause RUQ pain
→ compress biliary tract → if
rupture can cause anaphylaxis); in lung-
→ can cause cough, SOB,
sputum)
Non-Infectious
Malignancy – many cancers (e.g. renal, leukemia, lymphoma), with specific dx
guided by localizing sx, careful exam and identification of risk factors
Auto-immune – specific disorder based on other symptoms and findings –
relatively uncommon (compared w/above)
RA
(sub-acute, persistent/progressive joint
pain, tendency for bilateral involvement →
MCPs
hands
, knees; warmth; redness; worse in am; women > men;
fatigue)
Lupus
(sub-acute, female > male,
black>white, sub-acute, fever and feeling poorly in general, rash
on face, other system involvement → kidneys, brain)
Familial Med Fevers
(uncommon, associated
w/cryptic abdominal pain, rash, arthritis, arthralgias, myalgias,
recurrent fever)
Still’s disease
(subacute, uncommon,
rash
, sore throat, arthralgias)
Polymyalgia Rheumatica – PMR
(sub-acute, age
> 50, morning shoulder and hip aches, no findings on exam of
joint inflammation)
Giant Cell Arteritis
(age > 50, often prior
hx PMR, fatigue, headache, joint aches, visual loss)
Other vasculitides
Inflammatory bowel disease
(sub-acute,
recurrent or chronic diarrhea; wt loss, bloody stools, mucous,
cramps, constipation, nocturnal diarrhea; systemic sx; presentation
can also be fulminant)
Serum sickness
(acute, symetric,
additive/migratory, polyarthritis; myalgias, fever, rash; typically
from rx to abx, or secondary to viral infxn → e.g. acute hep b;
onset days to weeks after exposure)
Endocrine
Low testosterone
(sweats but no fever,
decreased libido, fatigue, errectile dysfunction)
Menopause
(sweats but no fever, age ˜
50, irregular menstruation)
hyperthyroidism
(irritability, inability to
sleep, diarrhea, palpitations, tremor, heat intolerance)
adrenal insufficiency
(weakness, n, v, skin
darkening if central etiology)
Meds: Dx based on r/o other causes and temporal link between initiation med and
fever onset
malignant hyperthermia → e.g. inhalational anesthetics – typically
in OR or soon thereafter
neuroleptic malignant syndrome → e.g. haldol, chlorpromazine
(high fever, cramps, delirium, autonomic
instability)
many other meds – including broad range of abx
Other
DVT/PE
(acute, cough, SOB, pleuritic,
hemoptysis, unexplained unilateral leg swelling, RFs for DVT;
Well’s
Criteria for DVT
Well’s
Criteria for PE
Vision
More Info About Eye Disorders:
NIH National Eye Institute
Comprehensive eye exam
Chronic or past eye disorders?
glaucoma, macular degeneration, DM retinal disease, other
Decrease/change in vision or blurriness? With or
without pain?
Acute
Painless
Retinal artery occlusion
(unilateral, like
a “curtain dropping,” other Cardio-Vascular Risk Factors)
Retinal vein occlusion
(unilateral, other
C/V RFs)
Retinal detachment
(unilateral, floaters,
flashes)
Vitreous hemorrhage
(unilateral, diabetes,
trauma)
Stroke
(acute, loss of specific visual
field, other C/V RFs)
Painful
Acute angle glaucoma
(unilateral,
red)
Infection
– any eye/peri-orbital structure
aside from conjunctiva
(unilateral,
discharge, red, trauma, foreign body)
trauma
optic neuritis
(acute, sometimes painful,
known MS, waxing and waning symptoms of sensory or motor loss,
non-specific dizziness)
Slow & painless
Macular degeneration
(initially vague, ultimately
central field loss, uni or bilateral)
Refractive errors: near or far sighted
(bilateral)
Cataract
(uni or bilateral)
Glaucoma
(uni or bilateral)
Retinal disease
(history poorly controlled
diabetes, htn)
Double vision?
Monocular – present with even one eye closed → refractive error or other
localeye problem
Binocular – resolves when one eye closed;
exam to assess
for dysfunction →
of nerves and/or muscles that move eye → loss of
coordinated bilateral movement
Stroke
(acute, other neuro Sx, C/V RFs)
Tumor
(known central nervous system tumor
affecting cranial
nerves, loss of other discrete neuro fxns)
myasthenia gravis
(slowly progressive, generalized
muscle weakness, worse w/use, improves w/rest)
nerve entrapment → e.g. following trauma, orbital fracture
Eye discharge (D/C)?
Conjunctivitis
(conunctival
redness, itching, painless, no visual change, uni- or bilateral)
other infectious, allergic
Red Eye?
Painless
conjunctivitis
Viral →
(redness of conjunctiva, URI sx, watery
discharge, no visual change, uni- or bilateral, gritty
sensation)
Bacterial →
(redness of conjunctiva, pus, no visual
change, uni- or bilateral)
Allergic
(itchy, watery d/c, chronic, no
visual change)
Blepharitis
(redness along eye-lid margins, itchy,
no visual loss)
Episcleritis
(redness of superficial layer of
sclera, uni- or bilateral, assoc w/auto-immune d/o, often remits
spontaneously)
sub-conjunctival hemorrhage
(no
d/c, no pain, no visual sx, unilateral)
Ectropion →
(inside of lower lid chronically exposed, chronic
conjunctival redness, dryness, no pain or visual loss)
Dacrocystitis
(acute pain and redness over medial
lower lid where tears drain, acute, no visual loss, unilateral)
Dry eyes
(chronic, mild redness, bilateral,
itchy)
Painful
Conjunctivitis
Bacterial (some hyperacute bacterial infections are painful and
cause visual los- e.g. gc)
Herpes- conjunctivitis, keratitits, scleritis (pain prior to
erruption, vessicles, visual loss, unilateral)
Scleritis →
(redness of deeper layer of sclera, darker
discoloration compared w/episcleritis, assoc w/auto-immune d/o, no
visual loss)
Keratitis →
(acute, painful, visual loss, inflammation in
cornea, unilateral)
Corneal abrasion (acute, painful, related to local trauma or foreign body,
visual loss, unilateral)
Acute angle closure glaucoma (unilateral, visual loss, acute, globe feels
hard)
Other infection/inflammation: iritis, anterior chamber infection
Other discoloration of eye/peri-orbital structures
icterus – yellowing of conjunctiva – painless, no visual
symptoms
hyperbilirubinemia from liver dz
hemolysis
lid
Chalazion/hordeolum
(acute/sub-acute,
discomfort, red bump, preserved vision, focal redness)
skin around eye:
pre-septal cellulitis
(acute, red, painful, preserved vision)
orbital cellulitis
(acute, decreased vision, pain
w/eye movement, head ache, peri-orbital redness)
fleshy growth on sclera:
pterygium
Head and Neck (H&N)
More Info About Head and Neck Disorders:
National Library of Medicine/Medline Plus
Comprehensive head and neck exam
Chronic or past head and neck
disorders?
Pain?
infection
, inflammation, trauma, other
Sores or non-healing ulcers in/around
mouth?
Malignancy
Squamous
cell CA
(RFs for CA:
smoking, drinking, chewing tobacco)
Infection
Viral
Herpes Simplex Virus
Fungal
(white discharge, bleeds,
immune-suppressed)
Syphilis
HIV related
Inflammatory/autoimmune
apthous
ulcer
IBD related
Bechets Dz
(eye & genital lesions)
Medication related
Masses or growths?
Lymph nodes
malignancy
Squamous cell
CA
(RFs for
CA: smoking, drinking, chewing tobacco)
Lymphoma
(diffuse LN enlargement, sweats, fever,
wt loss)
Infection
(w/in lymph nodes
themselves or assoc w/infection in/around mouth)
Thyroid
(near mid-line
anterior)
Parotid
(either side of face in
cheek area; inflammatory → acute, painful; non-inflammatory/malignant
→slowly progressive, painless)
Change in hearing acuity?
Conductive – outside → in to level of CN 8
external canal obstruction:
wax
(slow, uni- or bilateral,
painless)
bony growth
(slow,
uni- or bilateral, painless, hx extensive swimming)
Otitis externa
(cute, painful, discharge)
middle ear:
tympanic membrane perforation
(acute,
trauma, discharge, pain)
effusion → following Sx otitis media
(ear pain, acute, cough, nasal
congestion)
Sensori-Neural – level of CN8 to brain
age and noise related
(slow, bilateral,
older)
acoustic neuritis
(abrupt, unilateral)
ototoxic meds → aminoglycosides, cisplatin
Menierres
(hearing loss accompanied by dizziness,
tinnitus)
trauma
Mixed sensori-neural and conductive
Ear pain or discharge?
middle ear infection → otitis media
(acute, cough,
nasal congestion)
outer ear →
otitis externa
Nasal discharge, post nasal drip?
Infection – e.g. rhinosinusitis
Viral
(acute, cough, colored D/C, self
limited)
Bacterial
(acute, cough, persistent, colored D/C,
fever, tooth or facial pain)
Allergic rhinitis
(chronic, cough, clear D/C)
Change in voice/hoarseness?
Vocal cord pathology
Cancer
(red flags: progressive, cough, hemoptysis,
smoking, SOB)
Nodules/polyps
(slow, worse w/talking, improves
w/rest)
Infection
(acute, pain w/talking, cough)
GERD
(epigastric discomfort, radiates upward under
sternum, worse lying down, bad taste in mouth, chronic/recurrent)
Neurologic disorder
Weakness in phonation
Parkinson’s disease
(age > 50,
bradykinesia, tremor)
Vocal cord paralysis from recurrent laryngeal nerve dysfunction – typically
causes a breathy voice
Cancer of: thyroid, larynx, mediastinum, other head/neck
Stroke
Other cause of cord paralysis
Overuse – hx persistent speaking, loud voice (work related shouting, singing, no
red flags)
Tooth pain or problems?
Dental infection
, poor chronic care, lack of access to
dentists
Sense of lump/mass (globus) in throat
w/swallowing?
GERD
(heartburn, bad taste in mouth when lie down)
Cancer
(hx smoking, etoh, slowly progressive sx)
Psychogenic
Pulmonary
More Info About Pulmonary Disorders:
National
Heart, Lung and Blood Institute
Comprehensive pulmonary exam
Chronic or past pulmonary
disorders?
COPD, asthma, other
Shortness of breath – @ rest or
w/exertion?
Pulmonary parenchymal disease
Pneumonia
(acute, cough, sputum production, fever,
chest pain,
lung
findings on exam
, cxr w/infiltrate –
specific
infectious etiologies
bacterial
community acquired: pneumoccous, h influenza, legionella, chlamydia,
mycoplasma
health care associated: hospitalized x2d within last 3m; also
consider patients on HD, in NH, on recent IV abx; many of these
patients w/sig underlying medical conditions; flora changes to
gnr’s, mrsa, other resistant organsisms – though could still be CAP
organisms
viral
(influenza: acute, Sept →
March, fever, chills, muscles aches, no hx vaccine)
fungal
cocci
(acute or sub-acute, live in
southwest)
histoplasmosis
mycobacterial
TB can occur at any CD4, if > 350, similar sx to non-hiv +
→ cough, fever, sweats, sob, hemoptysis; CD4 < 350,
extra-pulmonary TB increases)
MAC
(subacute, hx bronchietasis
→ copd, prior lung infections w/parenchymal
destruction)
immuno-compromised host
Chemotherapy w/neurtopenia
(increased risk pseudomonas, TB,
fungal – though also can be typical bacterial
pathogens)
HIV – see below
Cancer
(sub-acute, cough, wt loss, hemoptysis,
smoking and/or asbestos exposure, chest pain)
COPD
(sputum, acute or chronic, cough, smoking,
wheezing or other exam
findings
Asthma
(acute or chronic, cough, wheezing, or
other exam findings
Pneumothorax
(acute, SOB, pleuritic, trauma,
smoker,
absent
breath sounds
other inflammatory/infiltrative processes
Pulmonary vascular disease
Pulmonary emboli
(acute, cough, SOB, pleuritic,
hemoptysis, RFs for
DVT
Well’s Criteria
for DVT
Well’s
Criteria for PE
Pulmonary HTN
Primary: (women > men, vague chest pain, subacute sob worse
w/activity, dizziness with activity;
elevated
jvp, edema, right ventricular heave, loud p2, rapid heart
rate
Secondary from: sleep apnea, chf, chronic pulmonary emboli, HIV,
connective tissue d/o if hx scleroderma or rheum arthritis;
congenital heart disease
Pleural disorders
Effu
sions
– distinguish between exudate and
transudate by sampling pleural fluid and applying
Lights
Criteria
cancer
(SOB, sub-acute, cough, wt
loss)
infection
(acute, F, cough, sputum,
SOB)
para-pneumonic
(secondary to
adjacent infection, but fluid not infected – aspiration
to dx)
empyema
(fluid infected –
complication of pneumonia, lung surgery, trauma –
persistent f, c, sob – aspiration to dx)
CHF
(C/V RFs, orthopnea, PND, exam
findings: lower extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
cirrhosis associated
(portal hypertension,
ascites
Pulmonary emboli
(acute, cough, SOB,
pleuritic, hemoptysis, RFs for
DVT
Well’s
Criteria for DVT
Well’s
Criteria for PE
Inflammatory/autoimmune
Lupus
Rheumatoid arthritis
other
Chylous
Injury to thoracic duct
Trauma
Surgery – with manipulation in are near apex of lung
Cancer – occluding lymphatics
Pneumothorax
(acute, SOB, pleuritic cp, absent
breath sounds)
Primary
(tall thin male, smoker)
Secondary
(trauma, chronic
infection–>hiv, severe copd)
Chest wall/diaphragm
Neuromuscular disease
(generalized weakness, other
neuro Sx)
phrenic nerve injury
(post thoracic surgery,
absence of diaphragmatic excursion
on
percussion
Cardio-vascular
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
S3
elevated jvp
displaced pmi
rales on lung exam
Systolic heart failure
(Known CAD/MI, HTN,
hx cardiomyopathy, chronic SVT)
Diastolic heart failure
(chronic poorly
controlled htn; age > 50; infiltrative processes that decrease
compliance → amyloid, etc)
Pericardial disease
(hx open heart
surgery, hx pericardial inflammatory process)
High output
A-V fistula
(trauma, inflamation
or surgery induced)
hyperthyroidism
(weight loss,
tachycardia, diarrhea, tremor)
anemia
thiamine deficiency
(ETOH abuse,
confusion, extremity numbness/difficulty walking)
Paget’s disease
(> 50, slowly
progressive multi-site bone pain, leg bowing)
CAD
(other C/V RFs, pressure w/walking, radiation
to L arm/neck/back, sweating, N)
Valvular heart disease – in particular: aortic, mitral with
characteristic murmurs
, often
associated with Sx of CHF
rhythm associated
SVT
(rapid heart rate,
palpatations)
bradycardia
(fatigue, decreased exercise
tolerance, CHF symptoms)
Many other causes
anemia
(see under
fatigue
known blood loss, known problem with blood production, hemolysis)
deconditioning
(inactivity)
, etc
renal failure
volume overload for any reason
panic attacks/anxiety disorder
Chest pain?
Primary pulmonary disorders
Pneumonia
(acute, cough, SOB, sputum
production, fever)
Cancer
(sub-acute, SOB, cough, wt loss,
hemoptysis, smoking and/or asbestos exposure)
Pulmonary emboli
(acute, cough, SOB,
pleuritic, hemoptysis, RFs for
DVT
Well’s
Criteria for DVT
Well’s
Criteria for PE
Pneumothorax
(acute, SOB, pleuritic, trauma,
smoker)
C/V disorders- Increased likelihood if + C/V RFs: Smoking, diabetes, early
family history, male, age >~ 50, HTN, Hyperlipidemia
angina
(central chest pressure secondary to
coronary artery insufficiency; associated w/CRFs, sometimes radiates
to l arm, l neck, back; can be related to combination of intrinsic
atherosclerosis + decreased O2 carrying capacity → aneamia,
hypoxemia + increased demand → catechol surges, extremes of
BP)
Stable angina
(known cad, sx occur
after a predictable amount of work, never at rest, not
progressive, resolve when stops activity)
Unstable angina
(known cad, sx at
rest, progression of symptoms such that occurring with less
and less activity)
Myocardial infarction
(chest pressure from
acute ischemia, n, v, sob, diaphoresis, hx known cad or vascular
disease elsewhere)
Aortic dissection
(C/V RFs, tearing type CP,
radiation to back)
Pericarditis
(chest pain, worse lying down,
better sitting up/leaning forward)
Viral
(antecedent respiratory viral sx
→ fever, cough, sweats)
Post MI
(known recent heart
attack)
Post cardiac surgery
Advanced kidney disease
Hypothyroidism
Rheumatologic illness
Lupus
(arthralgias/arthritis,
fever, fatigue, facial rash, female>male,
black/asian/hispanic>white, age 15-30s)
Scleroderma
(GERD,
raynauds → fingers
blanch/hurt when exposed to cold temp
skin thickening/tightness
Mixed connective tissue d/o
(fatigue, muscle and joint
aches,
raynauds → fingers
blanch/hurt when exposed to cold temp
finger swelling)
GI Disorders
GERD
(sub-sternal pain radiating upwards, bad
taste in mouth, worse lying down)
Esophageal spasm
Esophagitis
Infection
(viral, fungal → acute,
immuncompromised)
Pill induced
(pain after ingesting pill→ not
fully swallowed)
Musculoskeletal
(worse w/movement, Hx
overuse/injury)
Trauma
Neuropathic pain from
Zoster
(burning, localized to
dermatome, vesicular rash several days after pain onset)
Cough?
Intrinsic lung pathology
Infection
Pneumonia
(fever, colored sputum, SOB,
acute, systemic Sx)
Sinusitis
(acute sense of sinus/facial
fullness, anterior nasal discharge, post nasal drip, sore
throat)
Bronchitis
(acute, sputum production,
symptoms of infection in any contiguous space in the upper
respiratory tract, not seriously ill)
Pertussis
(persistent cough x weeks,
coughing so hard that vomit, not seriously ill
otherwise)
Acute Exacerbation Chronic bronchitis – AECB
(Hx COPD, Sob, colored sputum, wheezing,
acute)
Asthma
(acute or chronic, wheezing,
SOB)
COPD
(acute or chronic, sputum, wheezing, SOB,
smoking)
Cancer
(SOB, known cancer, wt loss, smoking,
asbestos, chest pain, hemoptysis, sputum)
Other parenchymal process
Pulmonary emboli
(acute, cough, chest pain
w/breathing, hemoptysis, RFs for Deep Vein Thrombosis (
DVT
))
Non-pulmonary
GERD
(heartburn, chronic)
Rhinitis
(post nasal drip, chronic or
acute)
Meds – ace-inhibitors
(ACE-I)
angiotensin receptor blockers
(ARBs)
Hemoptysis (coughing up
blood)?
Upper airway
(Sense of blood dripping down back of
throat; source: nose, mouth, pharynx)
Trauma
Tumor
(hx smoking, age > 50, progressive
sx)
Infection
(acute, purulent sputum,
fever)
Lower airways/lung parenchyma
Cancer
(persistent, smoking and/or asbestos
exposure, SOB, cough)
Infection
Bronchitis or pneumonia
(acute,
sputum, fever, SOB)
Tuberculosis
(sub-acute, fever,
sweats, SOB, weight loss, HIV/otherwise
immune-compromised)
Bronchiectasis
(fever, cough, sputum,
SOB, Hx COPD)
Other
Pulmonary embolism
(acute, cough, SOB,
pleuritic, hemoptysis, RFs for
DVT
Other parenchymal or vascular inflammatory process
Contribution from primary bleeding disorder &rarr see under
Hematology/Oncology
– Abnormal bleeding/bruising
Bleeding from GI source →esophagus, stomach w/aspirated blood coughed up
and/or vomiting mistaken as hemoptysis
Wheezing?
Asthma
(intermitent, known Hx, response to
precipitant)
COPD
(SOB, DOE, sputum, intermitent or constant,
smoking Hx)
pulmonary
edema
aka – "cardiac asthma" – Sx CHF
(C/V RFs, orthopnea, PND, exam findings: lower extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
stridor → upper airway obstruction
lower airway obstruction from foriegn body
(young
child, Hx aspiration, altered mental status)
other pulmonary parenchymal inflammatory process
Pulmonary embolism
(acute, cough, SOB, pleuritic,
hemoptysis, RFs for
DVT
Cancer w/airway obstruction
(smoking, asbestos, cough,
hemoptysis, weight loss, SOB)
Allergic reaction
(acute, temporally related to med,
hx med reaction, hives)
Snoring or stop breathing?
obstructive sleep apnea
(obesity, snoring, witnessed
apnea, not rested when awaken, day time fatigue)
central sleep apnea
Cardiovascular (C/V)
More Info About Cardiovascular Disorders:
National
Heart, Lung and Blood Institute
Comprehensive cardiovascular exam
Chronic cardiovascular
disorders?
Hypertenion, hyperlipidemia, congestive heart failure, valvular heart disease,
coronary artery disease, peripheral vascular disease, stroke, etc
Chest pain (CP) or
pressure?
C/V disorders- Increased likelihood if + C/V RFs: Smoking, diabetes, early family
history, male, age >~ 50, HTN, Hyperlipidemia
angina
(central chest pressure secondary to
coronary artery insufficiency; associated w/CRFs, sometimes radiates to
l arm, l neck, back; can be related to combination of intrinsic
atherosclerosis + decreased O2 carrying capacity → aneamia,
hypoxemia + increased demand → catechol surges, extremes of
BP)
Stable angina
(known cad, sx occur after a
predictable amount of work, never at rest, not progressive,
resolve when stops activity)
Unstable angina
(known cad, sx at rest,
progression of symptoms such that occurring with less and less
activity)
Myocardial infarction
(chest pressure from acute
ischemia, n, v, sob, diaphoresis, hx known cad or vascular disease
elsewhere)
Aortic dissection
(C/V RFs, tearing type CP,
radiation to back)
Pericarditis
(chest pain, worse lying down, better
sitting up/leaning forward)
Viral
(antecedent respiratory viral sx
→ fever, cough, sweats)
Post MI
(known recent heart attack)
Post cardiac surgery
Advanced kidney disease
Hypothyroidism
Rheumatologic illness
Lupus
(arthralgias/arthritis,
fever, fatigue, facial rash, female>male,
black/asian/hispanic>white, age 15-30s)
Scleroderma
(GERD,
raynauds → fingers blanch/hurt
when exposed to cold temp
skin thickening/tightness
Mixed connective tissue d/o
(fatigue, muscle and joint aches,
raynauds → fingers blanch/hurt
when exposed to cold temp
, finger
swelling)
Primary pulmonary disorders
Pneumonia
(acute, cough, SOB, sputum production,
fever)
Cancer
(sub-acute, SOB, cough, wt loss, hemoptysis,
smoking and/or asbestos exposure)
Pulmonary emboli
(acute, cough, SOB, pleuritic,
hemoptysis, RFs for
DVT
Well’s Criteria for
DVT
Well’s
Criteria for PE
Pneumothorax
(acute, SOB, pleuritic, trauma,
smoker)
GI Disorders
GERD
(sub-sternal pain radiating upwards, bad taste in
mouth, worse lying down)
Esophagitis
Infection
(viral, fungal → acute,
immuncompromised)
Pill induced
(pain after ingesting pill→ not
fully swallowed)
Esophageal spasm
(acute, intermittent, swallowing
problems)
Anxiety/panic disorder
Musculoskeletal
(worse w/movement, Hx overuse/injury)
Trauma
Neuropathic →
Zoster
(burning, localized to
dermatome, vesicular rash)
Shortness of breath – @ rest or
w/exertion?
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
Systolic heart failure
(Known CAD/MI, HTN, hx
cardiomyopathy, chronic SVT)
Diastolic heart failure
(chronic poorly controlled
htn; age > 50; infiltrative processes that decrease compliance →
amyloid, etc)
Pericardial disease
(hx open heart surgery, hx
pericardial inflammatory process)
High output
A-V fistula
(trauma, inflamation or
surgery induced)
hyperthyroidism
(weight loss, tachycardia,
diarrhea, tremor)
anemia
thiamine deficiency
(ETOH abuse,
confusion, extremity numbness/difficulty walking)
Paget’s disease
(> 50, slowly progressive
multi-site bone pain, leg bowing)
CAD
(other C/V RFs, pressure w/walking, radiation to L
arm/neck/back, sweating, N)
rhythm related
SVT
(rapid heart rate, palpatations)
bradycardia
(fatigue, decreased exercise
tolerance, CHF symptoms)
Valvular heart disease – in particular: aortic, mitral – often w/Sx CHF
Pulmonary parenchymal disease
Pneumonia
(acute, cough, sputum production, fever,
chest pain)
Cancer
(sub-acute, cough, wt loss, hemoptysis,
smoking and/or asbestos exposure, chest pain)
COPD
(acute or chronic, cough, smoking,
wheezing)
Asthma
(acute or chronic, wheezing, cough)
other inflammatory/infiltrative processes
Pulmonary vascular disease
Pulmonary emboli
(acute, cough, chest pain
w/breathing, hemoptysis, RFs for Deep Vein Thrombosis (
DVT
))
Pulmonary HTN
(slowly progressive, Hx HIV, Hx
IVDU)
Pleural disorders
Effusions
cancer
(SOB, sub-acute, cough, wt
loss)
infection
(acute, F, cough, sputum,
SOB)
CHF
(C/V RFs, orthopnea, PND, exam
findings: lower extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
Pulmonary emboli
(acute, cough, SOB,
pleuritic, hemoptysis, RFs for
DVT
Well’s
Criteria for DVT
Well’s
Criteria for PE
Pneumothorax
(acute, SOB, pleuritic, trauma,
smoker)
Chest wall/diaphragm
Neuromuscular
disease
(generalized weakness, other neuro
Sx)
phrenic nerve injury
(post thoracic
surgery)
Many other
anemia
fatigue
known blood loss, known problem with blood production, hemolysis)
deconditioning
(inactivity)
, etc
renal failure
volume overload for any reason
panic attacks/anxiety disorder
Orthopnea (short of breath lying
down)?
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
COPD
(acute or chronic, cough, smoking, wheezing)
Paroxysmal Nocturnal Dyspnea (PND)? –
sudden shortness of breath that awakens pt from sleep
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
Lower extremity edema?
Bilateral
Hydrostatic:
L sided CHF → systolic and diastolic dysfxn CHF
(C/V RFs, orthopnea, PND, exam findings:
lower extremity
edema
+ S3
elevated jvp
displaced pmi
rales on lung exam
R sided CHF → pulmonary htn, L sided CHF
Portal htn → cirrhosis
(known liver
disease from viral/etoh/other chronic hepatitis,
ascites
jaundice
icterus
Venous insufficiency
(chronic, worse after
standing, dark skin discoloration)
Low oncotic pressure
Advanced liver disease
(known liver
disease from viral/etoh/other chronic hepatitis,
ascites
jaundice
icterus
Malnutrition
(lack of access to calories,
disadvantaged Socio-economic status,
temporal wasting
Loss of protein in urine → nephrotic syndrome
General volume overload:
cirrhosis
(chronic liver dz →
hep C, ETOH)
renal failure
Unilateral edema → local problem
Infection
(redness, pain,
fever)
DVT
(acute, localized discomfort, RFs:
hypercoaguable state, immobility, trauma;
Well’s Criteria
Lymphatic obstruction
lymphatic injury
(lymph node dissection,
trauma)
obstructing cancer
Venous insufficiency
(chronic, Hx saphenous vein harvest w/CABG, worse
after standing, dark skin discoloration)
Sudden loss of consciousness
(syncope)?
Cerebral hypo-perfusion from sudden drop in blood pressure, noting that BP is a
function of: Cardiac output x systemic vascular resistance; and CO is a function of
heart rate x stroke volume; and stroke volume is a function of inotropy and
pre-load.
Ventricular dysrhythmia
(red flags: abrupt,
resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx
CHF
Bradycardia
fatigue
decrease exercise tolerance,
CHF
Sx)
SVT
(rapid/irreg heart beat, palpatations)
Aortic stenosis →
characteristic murmur
hypovolemia
(bleeding,
diarrhea
Sx provoked by standing,
+orthostatic vital
sign changes
orthostatic blood pressure changes
from autonomic dysfunction
(Hx diabetes, other
neuropathy)
cerebral vascular disease affecting vertebral-basilar system
(vascular risk factors; symptoms/findings in
territory supplied by v-b system: sudden dizziness, double vision,
swallowing/speech problems, nausea, vomiting)
Non-cardiac
Seizure
d/o
intracranial process → blood, tumor, trauma
hypoglycemia
(known DM & Rx w/meds)
drug overdose, e.g. heroin
Sense of rapid or irregular heart beat,
palpatations?
Supraventricular tachycardia (SVT): atrial fibrillation, atrial flutter, a-v nodal
re-entrant tachycardia
Ventric tachycardia
(red flags:
syncope/presyncope
abrupt, resultant fall w/injury, Hx CAD, Hx
CHF
Premature ventricular contraction, atrial premature contraction
(awareness of extra beat, early beat, strong beat; No SOB,
CP,
CHF
Sx,
presyncope/syncope)
Acute physiologic response
(fever, pain, hypovolemia,
stress)
Panic/anxiety d/o
(anxiety, panic, depression, terror,
multi-system concerns w/o organic disease)
Meds/toxins
(cocaine, caffeine) cigarettes,
sympathomimetics)
Calf/leg pain/cramps
w/ambulation?
Peripheral Arterial Disease: associated with typical vascular dz risk factors
subacute/chronic
(from progressive athero, calf
cramps/pain, worse w/activity, better w/rest, feet progressively cool,
hairless,
diminished cap refill, ulcers
acute
(sudden pain from abrupt artherial
occulsion; embolit from a fib w/o coumadin, or ventricular thrombus if
severe lv dysfxn; recent catheterization where plaque disrupted from
aorta;
blue/hypoperfused
toes
Spinal stenosis
(radiates down back both legs, worse
w/walking, better leaning forward)
electrolyte abnormalities, other
Cramps – often non-specific
(hypokalemia, dehydration,
hypocalcemia, idiopathic)
Wounds/ulcers in feet? Difficult/slow
to heal?
Peripheral Arterial Disease – PAD
(progressive, C/V RFs,
better w/rest, better w/dangling legs, worse w/leg elevation; exam findings:
lost of pulses,
decreased cap
refill
diabetes
(PAD, neuropathy)
venous insufficiency
(chronic
swelling, worse at end of day)
peripheral neuropathy
trauma
skin cancer
Gastrointestinal
More Info About Gastrointestinal Disorders:
National Digestive Diseases Clearinghouse
Comprehensive GI exam
Chronic or past GI
disorders?
ulcers, hepatitis, inflammatory bowel disease, cancer, irritable bowel syndrome, etc
Heart burn/sub-sternal
burning?
Gastroesophageal Reflux Disease
(worse after meals, worse
if lie down after eating, bad taste in mouth, obesity, ETOH, smoking, caffine,
chocolate)
Esophageal spasm
(acute, intermittent, swallowing
problems)
Esophagitis
Infection
(viral, fungal → acute,
immuncompromised)
Pill induced
(pain after ingesting pill → not
fully swallowed)
C/V
disorders
Musculoskeletal
(worse w/movement, Hx
overuse/injury)
Trauma
Neuropathic → Zoster
(burning, localized to
dermatome, vesicular rash)
Primary pulmonary
disorders
Abdominal pain?
Acute Upper Abd
GI
Gastroenteritis
(self limited, N, V, D, others
similarly ill)
Peptic ulcer Dz
(epigastric, better or worse
w/food, nsaid use, black stools, hematemesis)
Pancreatitis
(epigastric, constant, radiates
to back, N, V, ETOH abuse)
Cholecystits
(constant, right/upper abd,
fever, nausea)
Biliary colic
(episodic, after meals, right
upper quadrant)
Non-Gi
MI
(acute, N, V, SOB, CP, C/V RFs)
Pneumonia
(acute, sob, cough, sputum, fever,
CP)
Chronic Abdominal Pain
GERD
(epigastric, radiates upward under sternum,
worse lying down, bad taste in mouth)
Non-ulcer dyspepsia
(epigastric, better or worse
w/food; no red flags)
Mesenteric/small bowel ischemia
(generalized abd
pian, known atherosclerosis or RFs, pain after meals →angina of the
gut, weight loss, food avoidance)
Functional constipation
(no red flags)
Inflammatory Bowel Disease – upper or lower abd
(sub-acute, recurrent or chronic; wt loss, diarrhea,
bloody stools, cramps, constipation; presentation can also be
fulminant)
Abdominal Cancer – primary or metastatic to abdomen
Gastric
(red flag Sx: anorexia, weight
loss, epigastric, persistent/progressive, N, V, early
satiety)
Pancreatic
(red flag Sx: anorexia, weight
loss, epigastric pain radiating to back,
persistent/progressive)
Liver
(red flag Sx: anorexia, weight loss,
right upper quadrant, persistent/progressive, Hx chronic
Hepatitis)
Biliary
(red flag Sx: anorexia, weight
loss, epigastric/right upper quadrant, persistent/progressive,
jaundice, ictreus, white stools)
Colon
(red flag Sx: anorexia, weight loss,
vague pain, persistent/progressive, bloody stools, change in
bowel habits, pain w/defecation)
Lymphoma
(red flags: wt loss, sweats,
adenopathy elsewhere)
Metastatic disease to abdomen e.g. &rarr Lung
Acute generalized or Lower abd
GI
Bowel obstruction
(comes in waves,
generalized, N, V, decreased flatus, abd distention)
Diverticulitis
(left/lower abdomen, fever,
nausea)
Appendicits
(starts umbilicus → R lower
queadrant, fever, nausea, anorexia)
Abdominal aortic aneurysm
(vague umbilical Sx,
radiating to back, C/V RFs)
Hernia – incarcerated or strangulated
(inguinal area, severe)
Mesenteric/small bowel ischemia
(known
atherosclerosis or risk factors, known risk factors for embolic
disease →a fib, ventricular thrombus, acute low BP superimposed
on atherosclerosis, persistent/progressive generalized pain w/few
exam findings)
Colonic Ischemia
(mild generalized abdominal
pain, known atherosclerosis or RFs, small amounts of bright red
blood w/stool, diarrhea, hypotension from other process superimposed
on atherosclerosis, RFs for embolic events → a fib, ventricular
thrombus)
GU
Renal stones
(colicky, radiates from flank
towards pelvis, N, V, hematuria)
simple UTI
(acute, frequency, urgency, no
vaginal d/c if female, no other Sx)
complex infection/pyelonephritis
(fever,
chills, lower abd/low back pain)
Testicular torsion
(acute, unilateral, n,
v)
Testicular/epididymal infection
(acute, unilateral, dysuria, frequency,
fever, sexual activity)
GYN
Ectopic pregnancy
(sharp, vaginal
bleeding, sexually active)
Pelvic inflammatory disease
(vaginal D/C,
fever, sexually active)
Ovarian etiology
cyst rupture
(mid-menstrual cycle,
gradual onset)
torsion
(severe, N, V)
Difficulty swallowing?
neuro-muscular disorders
stroke
(acute, other vascular risk factors,
problems w/initiating, other focal findings)
Neuro-muscular
(botulism, guillain barre,
myasthenia → acute, progressive, other neuro findings)
mechanical problems with chewing and/or swallowing
dental problems
(prevent chewing and/or cause
pain)
esophageal or stomach obstruction
cancer
esophageal
(Progressive swallowing
problems→ food gets stuck, worse w/solids then
liquids, pain, >50, chronic GERD, smoking, ETOH
abuse)
gastric
(feel full when eating
ever small quantities of food., pain, >50, smoking, ETOH
abuse)
benign
esophageal dysmotility
achalasia
(progressive dysphagia,
solids and liquids, regurgitation, GERD, food sticks
lower area esophagus)
esophageal spasm
(acute,
intermittent)
eosinophilic esophagitis
(allergies, asthma, no pain,
no response to PPI)
Chaga’s disease
(from
central or south America, low socio-economic
class, progressive)
Scleroderma
(skin
tightening→
women > men, < 50, GERD, known disease)
gastric stricture
(history ulcer
disease, surgery)
esophageal web or ring
esophageal stricture
(long hx
gerd)
Zenker’s diverticulum
(chronic
symptoms, bad breath, sensation food stuck in throat,
regurgitation undigested food)
dysmotility
achalasia
(progressive dysphagia, solids and
liquids, regurgitation, lower area esophagus)
esophageal spasm
eosinophilic esophagitis
(allergies, asthma, no pain, no
response to PPI)
Pain upon swallowing?
Esophageal inflammation
viral/fungal infection
(acute, often immune
compromised)
pills
(acute, occurs after a pill stuck)
GERD
esophageal cancer
(hx GERD, progressive symptoms,
dysphagia)
Nausea or Vomiting?
impaired gastric emptying
malignancy
(red flags: age > 50, wt loss,
smoking, after each meal, progressive)
autonomic nerve dysfunction – e.g. w/DM
(neuropathic Sx elsewhere)
benign stricture
(Hx ulcers, chronic
GERD
gastroenteritis
(acute, w/diarrhea)
small or large bowel obstruction
(abd pain, distention, Hx
surgery → adhesions, decreased flatus, decreased bowel movements)
many non-GI etiologies
increased intracranial pressure
(HA, trauma,
cancer)
meds
toxins, etc
generalized systemic infections
generalized acute illness
infections
myocardial
ischemia
increased vagal tone
chronic systemic illness
liver failure
renal failure
Abdominal swelling or
distention?
Fluid within peritoneum →
ascites
(known cancer, advanced
liver disease, TB/chornic infxn)
Gas → bowel distention or obstruction
Organomegaly → liver, spleen, kidney, uterus
(pregnant v other)
, bladder
ventral hernia
(past surgery,
bulge thru scar line, increases w/straining)
Jaundice (yellowish coloration of
skin)?
hepato-biliary disease
→ failure to excrete conjugated
bilirubin
Stone in common bile duct
(acute, if also infxn:
RUQ pain, F, N, systemic illness)
Common duct or pancreatic cancer
(sub-acute,
painless, age > 50, wt loss)
Chronic liver dz – Hep C, Etoh, Hep B
(long
duration illness)
Hemolysis
beta carotene overdose
Vomiting blood
(hematemasis)?
Bleeding in upper GI tract
Ulcer
(epigastric, better or worse w/food, nsaid
use, black stools, ETOH)
varices
(chronic liver disease → portal
hypertension)
gastritis
(stress, ETOH)
esophagitis
(GERD Sx)
Swallowed blood from upper respiratory source → nose bleed
Swallowed blood from mouth source
Contribution from primary bleeding disorder → see under
Hematology/Oncology
– Abnormal bleeding/bruising
Black/tarry stools?
Bleeding in upper GI tract
Ulcer
(epigastric, better or worse w/food, nsaid
use, black stools, ETOH)
varices
(chronic liver disease → portal
hypertension)
gastritis
(stress, ETOH)
esophagitis
(GERD Sx)
Swallowed blood from upper respiratory source
Contribution from primary bleeding disorder → see under
Hematology/Oncology
– Abnormal bleeding/bruising
Unrelated to bleeding
Iron supplementation
Pepto Bismol
Bloody stools?
Structural
AVM
polyp
diverticulum
(acute, bright red blood)
cancer
hemorrhoid
(painless if
internal
; painful if external and
thrombosed
Fissue
(acute, painful)
Contribution from primary bleeding disorder → see under
Hematology/Oncology
– Abnormal bleeding/bruising
Inflammatory
inflamatory bowel disease
(sub-acute, recurrent or
chronic diarrhea; wt loss, bloody stools, mucous,
cramps, constipation, nocturnal diarrhea; systemic Sx)
Infectious
bacterial
(acute, F, bloody stool, abd pain; prior abx
use &rarr c dif)
parasites →Ameobiasis
(camping/drinking
unfiltered water)
HIV
(chronic, atypical infxns → parasite,
fungal)
Colonic ischemia
(acute, pain, hx vascular disease and
RFs, hx hypoperfusion → hypotension for any reason)
Constipation?
Functional
low fiber diet
Irritable Bowel Syndrome
(chronic, crampy pain, no wt
loss, no blood in stool; no systemic Sx; occasional diarrhea)
Obstruction
distal cancer
(red flags: sig pain, blood, wt loss,
progressive)
stricture
(prior surgery, IBD or other inflammatory
process)
Fecal impaction
(low liquid intake, impaired
awareness/cognition, chronic Low motility)
Metabolic/Endocrine
Hypo-thyroid
(wt gain, edema, dry skin, constipation,
cold intolerance, depression, hair loss)
Hypcercalcemia
(polyuria, constipation, confusion,
Bone pain, known/suspected squamous cell ca)
Hypo/hyperkalemia
(older, diuretic use, risk for low
or high k)
Diabetes
(known dz, poor control→polyuria,
polydypsia, neuopathy)
Neurologic
Spinal cord problems
(trauma, urinary incontinence,
lower extremity weakness, numbness, other RFs for cord problems→cancer,
infection)
Peripheral neuropathy
Poorly controlled dm
Other
Meds →narcotics, anti-cholinergics
Diarrhea or other change in bowel
habits?
structural problems
distal colon malignancy
(red flags: progressive,
wt loss, pain, blood in stool, nocturnal diarrhea)
benign stricture
(prior surgery, IBD or other
inflammatory process)
inflammatory disorders:
Inflammatory Bowel Disease
(sub-acute, recurrent
or chronic; wt loss, bloody stools, mucous, cramps, constipation,
nocturnal diarrhea; systemic Sx; presentation can also be
fulminant)
Infections
bacterial
(acute, F, bloody stool, abd
pain, prior abx use → c dif)
viral
(acute, fever, abd pain)
parasites
(sub-acute or chronic, watery
→ Giardia; bloody → Ameobiasis; camping/drinking
unfiltered water)
Diarrhea in HIV +:
Can still be any of the processes that affect normal hosts
as above; other etiologies that increase as cd4 levels
decline:
Infection
Parasite
Isosporiasis
(associated
with drinking untreated water,
CD4 < 100 or untreated
HIV)
giardia
Fungal
Cryptosporidium
(acute or
subacute profound diarrhea,
abdominal cramps, fever, n, v,
CD4 < 100 or untreated HIV
Microsporidiosis
(associated
with drinking untreated water,
CD4 < 100 or untreated HIV, in
addn to diarrhea, can affect
other systems, causing-->
keratitis, encephalitis,
other)
Histoplasmosis
(CD4 < 150,
f, c, wt loss, abd pain;
liver, spleen and lymph node
involvement)
mycobacteria
MAI
(CD4 <
50, diarrhea, n, v,
abdominal pain, f, c,
fatigue; can infect liver,
spleen, lymph nodes, bone
marrow, lung, pericardium-->
causing adenopathy or
organomegaly, anemia)
Viral
CMV
(CD 4
< 50, cramps, abd pain
persistent diarrhea -
sometimes w/blood, anorexia,
wt loss, fatigue, cmv
elsewhere-->
retinitis)
Malignancy
Kaposis
(CD4 <
150, KS elsewhere on body)
Lymphoma
(sub-actue, f,
sweats, wt loss, adenopathy elsewhere,
unexplained organogmegaly)
Staph toxin assoc diarrhea
(sx of abrupt
onset n, v, cramps, d; secondary to eating contaminated food,
occurs hours after consumption, other affected who ate similar,
self limited)
Traveler’s diarrhea
(n, v, cramps,
diarrhea after travel to another country – central/south
America, asia, africa; secondary to variety of enteric
pathogens, from consuming undercooked food/poor hygiene in
restaurants/untreated water)
malabsorptive d/o
celiac disease
(bloating, gas, wt loss/inability
to gain weight, chronic symptoms)
chronic pancreatitis
(multiple past episodes
pancreatitis, ETOH abuse or other chronic exposure to pancreatitis
inducing toxins/process, chronic upper abdominal pain, back pain,
nausea, vomiting)
lactose intolerance
(n, bloating, gas, abd
discomfort → within 2 hours eating milk/milk products)
Whipple’s disease
(rare d/o, chronic diarrhea, wt
loss, abd pain, male>female, fatigue, joint pain)
Irritable Bowel Syndrome/Functional
(chronic, no wt loss,
crampy pain, no systemic Sx, no blood, sometimes constipation)
other non GI
hyperthyroidism
(irritability, inability to sleep,
weight loss, palpitations, tremor, heat intolerance)
laxative, sorbitol, other meds abuse
excessive caffeine intake, etc.
Genito-Urinary
More Info About GU and Renal Disorders:
National Kidney and Urologic Diseases
Clearinghouse
Comprehensive male genital/rectal exam
Chronic or past GU disorders?
BPH, cancer, stones, intrinsic renal disease, etc
Blood in urine?
Malignancy of GU tract
(red flags: persistent gross blood,
age > 50, male, hx smoking)
Stones
(pain, frequency, urgency, nausea, vomiting)
Infection
(acute, pain, frequency, urgency, fever)
Other causes red or dark urine not from blood:
myoglobin
rhabdomyolysis
muscle breakdown → extreme muscle activity
meds → statins
bilirubin
(jaundice,
chronic liver
disease
dehydration → concentrated urine
Beet ingestion
meds → e.g. rifampin, pyridium
Contribution from primary bleeding d/o → see under
Hematology/Oncology
– Abnormal bleeding/bruising
Beeturia -urine colored red from eating beets
Burning with urination?
simple UTI
(acute, frequency, urgency, no vaginal d/c if
female, no other Sx)
complex infection/pyelonephritis
(fever, chills, lower
abd/low back pain)
other e.g. stones, malignancy
Sexually Transmitted infxn
(+ sexual active, urethral d/c,
hx past STI)
Urination at night?
Benign Prostatic Hypertophy – BPH
(chronic, progressive,
urgency, frequency, hesitancy, difficulty starting/stopping stream, incomplete
emptying, decrease force, voiding again soon after urinate)
AUA BPH Symptom Index – AUASS/IPSS – page 277
Over production of urine e.g. diabetes
Meds/drugs: diuretics, ETOH
CHF → redistribution of volume w/lying down
Incontinence (unintentional loss of
urine)?
Disorders of urine storage
Detrussor over activity
(sudden urgency)
Detrussor under activity → overflow
Disorders of bladder outlet resistance
Increased resistance
BPH
(see above – urination @ night)
urethral stricture
(hx STI, trauma)
Decreased resistance
stress incontinence
(women > 50,
childbirth, worse w/cough/sneeze/sudden movement)
complication of prostatectomy
Non-GU based
excess urine production → poorly controlled DM, diuretic use
among older patients
infection, delirium, immobility, etc
Urgency?
BPH
(chronic, progressive, urgency, frequency, hesitancy,
difficulty starting/stopping stream, incomplete emptying, decrease force,
voiding again soon after urinate)
infection
(acute, pain, frequency, urgency, fever)
cancer
(red flags: persistent gross blood, age > 50,
male, hx smoking)
stone
(pain, frequency, urgency, nausea, vomiting)
strong and sudden → detrussor over activity
Frequency?
primary GU
BPH
(chronic, progressive, urgency, frequency,
hesitancy, difficulty starting/stopping stream, incomplete emptying,
decrease force, voiding again soon after urinate)
infection
(acute, pain, frequency, urgency,
fever)
cancer
(red flags: persistent gross blood, age
> 50, male, hx smoking)
stone
(pain, frequency, urgency, nausea,
vomiting)
strong and sudden → detrussor over activity
non-GU
DM
diuretic use
CHF
(C/V RFs, orthopnea, PND, exam findings: lower
extremity
edema
S3
elevated jvp
displaced pmi
rales on lung exam
excessive ETOH and/or PM oral liquid intake
Incomplete emptying? Hesitancy? Decreased
force of stream? Need to void soon after urinating?
BPH
AUA BPH Symptom Index (ACP)
decreased bladder contraction
(peripheral neuropathy –
sensory or motor)
urethral stricture
(men: Hx urethral trauma, Hx gonorrhea,
Hx pelvic xrt, Hx prostate surgery)
spinal cord problem
(injury, infection, tumor, other
→ multiple sclerosis, etc)
For Men:
Erectile Dysfunction (ED)?
problem with libido/lack of interest
(+ morning
erections, + erections w/some partners)
decreased testosterone
(fatigue, weakness)
depression
meds
(many – in particular
anti-depressants)
chronic medical conditions
renal & liver disease, anemia
problem getting &/ or maintaining erection
(no AM
erections, occurs w/all partners, + libido)
In-flow probs → Arterial disease
(C/V RFs,
known vasc dz)
Nerve dsyfxn
(hx CNS or PNS d/o, dm)
Outflow problems → inapprop drainage
(idiopathic)
Structural probs w/cavernosa
Past trauma
Inappropriate curvature from fibrosis
(Peironies)
Penile d/c or pain?
Sexually Transmitted Infection (STI) – Gonorrhea or Chlamydia
Trauma
UTI
Testicular pain?
Infection
(pain w/urination,
penile D/C)
torsion
(acute, unilateral, severe)
Testicular swelling,
mass?
Cancer
(progressive, painless)
hydrocele
(painless)
Penile Ulcers or Growths?
Syphiliis
(hx STIs, acute
ulcer, painless, resolves spontaneously)
Herpes Simplex Virus
(hx STIs,
acute, painful, vesicles, recurrent, resolve spontaneously)
Human Papillomavirus
(hx STIs,
persistent, painless)
Donavanosis → granualoma inguinale
(tropics & not
in US unless travel, spread by direct sexual contact, incubation 1-3m,
papule to painless ulcer in genital area, beefy red/bleeds, develops over
weeks, can be hard to distinguish from chancroid, RF for HIV)
lymphogranula venereum
(caused by chlamydia
trachomastis, spread by sexual contact, rare in US, incubation 1-3 weeks,
painless papule or ulcer on penis/vagina/rectal area, then painful
adenopathy, RF for HIV)
h ducreyi → chancroid
(Africa/Caribean & not in
US unless travel, spread by direct sexual contact, incuabtion 1d-2w, papule
to painless ulcer in genital area, adenopathy; RF for HIV)
cancer
SCC
(non-healing progressive,
ulcer
;hx HPV)
BCC, melanoma
Fertility problems?
Hx STIs?
Increased risk for: HPV, HIV, Hepatitis B, Syphilis, other
# Sexual partners & type of
sexual activity?
Risks as per STIs
Hematology/Oncology
More Info About Oncology and Hematology Related Disorders:
National Hematologic Diseases
and
National Cancer Institute/
Chronic or past Heme/Onc
disease?
solid or liquid malignancies; benign hematological diseases, etc
employ multi-system ROS to define
Fevers, chills, sweats, weight
loss?
Infection
Acute – bacterial
Localize site by Sx – e.g.:
UTI
(urinary frequency, urgency, burning,
lower abd pain)
Pneuomnia
(cough, colored sputum,
SOB)
Acute-Viral
Influenza
(cough, muscle aches, fatigue)
Other viral →Localize site by sx
Acute retroviral
HIV
(Sore throat, adenopathy, rash, fatigue, HIV
RFs: men having sex w/men, sex w/prostitutes, IVDU, transfusion w/o
screening, sexually active, past STI)
Sub-acute or Chronic
HIV
(generalized sx→wt loss, fatigue; HIV
RFs: men having sex w/men, sex w/prostitutes, IVDU, transfusion w/o
screening, sexually active, past STI, TB, sex w/anyone w/HIV RFs, sex
for money)
TB
(cough x weeks, hemoptysis, wt loss;
immunocompromised→malnourished, chronic steroids, known HIV or HIV
RFs, malnutrition; endemic area)
Sub-acute bacterial endocarditis
(known valvular
heart dz, recent bacteremia→de novo infection or procedure
induced)
Non-Infectious
Malignancy – localize by symptoms
Solid tumor
Lung
(sob, smoker, cough)
Colon
(BRBPR, change in bowel habits)
Pancreas
(upper abd pain, wt loss,
jaundice)
Liver
(upper abd pain, jaudice, chronic
hepatitis)
etc.
Lymphoma
(adenopathy)
Leukemias
Auto-immune/Rheumatologic – localize by sx
Lupus
(facial rash, joint pain, joint swelling,
fatigue)
PMR
(age > 50, fatigue, hip and shoulder pain,
worse in am)
Giant Cell Arteritis
(age > 50, hip/shoulder pain,
worse in am, fatigue, headaches, scalp tenderness, visual loss)
RA
(persistent/progressive; bilateral: MCPs hands,
knees; warmth; redness; worse in am; women > men; fatigue)
Other
Abnormal
bleeding/brusing?
Defect in clotting system
Acquired – no history of chronic bleeding problems → implying
development later in life
(ie no excessive
bleeding during/after: surgical procedures, trauma, dental extraction,
menstruation etc).
Platelets → problems w/hemostasis
mucocutanous bleeding → gums, nosebleeds, menorrhagia,
immediate & prolonged bleeding after trauma
low quantity
impaired function from: aspirin, clopidogrel, renal
failure, von Willebrand’s disease, other
Impaired coagulation pathways
spontaneous or minimally provoked hemarthroses, hematomas,
delayed hemorrhage after trauma
e.g. coumadin use, heparin
Hereditary – bleeding problems noted from birth or early life
(e.g. hemophilia)
New/growing lumps or
bumps?
Adenopathy
lymphoma, metastatic disease
infection
acute
bacterial or viral
chronic
TB, HIV
masses
primary CA in an organ v metastatic disease v other
benign → lipoma, cyst, etc
Hypercoaguability?
Hx
DVTs
, Pulmonary Emboli
Acquired states
Malignancy, immoblility, trauma, smoking, Meds
Hereditary states
Protein s, protein c, AT3 deficiency, factor 5 leiden abnormality
hx early/unexplained arterial thrombo-embolic events (young, no risk
factors)
anti-phospholipid anti-body syndrome
Ob/Gyn/Breast
More Info About Ob/Gyn/Breast Disorders:
National Library of Medicine/Medline Plus
Comprehensive breast exam
Chronic or past disease?
Infertility, endometriosis, infection, cancer, etc
Menstrual Hx?
Cessation or irregularity of menstruation
Pregnancy
(sexually active, morning sickness,
abdominal swelling, planned pregnancy)
Cancer – uterine or cervical –
(hx uterine or cervical ca,
age > 50, bleeding after menopause)
Fibroids
(known fibroids, abdominal pain or
pressure)
Menopause
(age > 40, sweats, hot flushes, vaginal
dryness)
Dysfunctional Uterine Bleeding
(excessive bleeding,
bleeding between periods, no exam/lab/hx to suggest other)
Ectopic pregnancy
(known pregnancy, past STI, lower
abdominal pain)
Cervicitis → gc or chlamydia
(sexually active,
vaginal d/c)
Primary bleeding d/o
hematology
Sweats?
peri-menopause
(hot flashes, vaginal dryness, age near
~50)
infection
auto-immune/inflammatory
malignacy
Past pregnancies?
# went to term? complications? infertility?
Vaginal Discharge?
Vagniniitis: fungal, bacterial
(acute, odor, itch,
irritation)
Cervicitis: STI
(discharge, lower abd/pv pain, sexually
active)
tubo-ovarian abcess
(pain, fever, acute, discharge)
bacteremia
# Sexual partners & type of sexual
activity?
Risks as per STIs
Breast mass, pain or discharge?
Mass
malignancy
(increase w/time, firm)
benign → cysts, fibrous tissues
(size varies
w/menstrual cycle)
changes in appearance of nipple or skin
nipple inversion →
(malignancy)
skin puckering/retraction/chronic inflammatory
(malignancy)
Discharge
benign
milk, cyst fluid
malignancy
(bloody)
milk when not post partum or male → increased prolactin
(HA, visual Sx, infertility)
pain suggests inflammation
mastitis
(post partum)
cancer
cyclic
(partic time of menstrual cycle)
Therapeutic or spontaneous
abortions?
Hx STIs?
spectrum
cervicitis
(discharge, lower abd/pv pain, sexually
active)
tubo-ovarian abcess
(pain, fever, acute,
discharge)
bacteremia
STIs increases risk for:
infertility → tubal scarring via PID
cervical CA via HPV
HIV, Hepatitis B, syphilis, other
Neurological
More Info About Neurologic Disorders:
National Institute of Neurological Disorders and
Stroke
Comprehensive neuro exam
Known disease?
Stroke, seizure, neurodegenerative – Multiple sclerosis, ALS, etc
Sudden loss of neurological
function?
acute weakness and/or numbness suggests vascular event:
stroke if loss is persistent; TIA if transient
(known cardiovascular disease; C/V RFs: Smoking,
diabetes, early family history, male, age > ˜ 50, HTN,
Hyperlipidemia, Hx atrial fibrillation)
CNS or PNS trauma
Non-neuro
Intoxication/drug overdose
Abrupt loss/change in level of
consciousness?
Seizure d/o
intracranial process → blood, tumor, trauma
hypoglycemia
(known DM & Rx w/meds)
drug overdose, e.g. heroin
Cerebral hypoperfusion
Ventricular dysrhythmia
(red flags: abrupt,
resultant fall w/injury, known depressed LV fxn, Hx CAD, Hx CHF)
Bradycardia
(fatigue, decrease exercise tolerance,
CHF Sx)
, SVT
(rapid/irreg heart beat,
palpatations)
hypovolemia
(bleeding, diarrhea, Sx provoked by
standing)
Aortic stenosis
(progressive, known valvular heart
disase, SOB/DOE)
Orthostatic blood pressure change from autonomic dysfunction
(Hx diabetes, other neuropathy)
Cerebral vascular disease affecting vertebral�basilar system
((vascular risk factors; symptoms/findings in
territory supplied by v-b system: sudden dizziness, double vision,
swallowing/speech problems, nausea, vomiting)
drug use/overdose/toxin
hypoglycemia
delirium, etc
Witnessed seizure activity?
Primary Seizure d/o
Secondary szr
Cerebral hypoperfusion
Ventricular dysrhythmia
(red flags:
abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD,
Hx CHF)
Bradycardia
(fatigue, decrease exercise
tolerance, CHF Sx)
SVT
(rapid/irreg heart beat,
palpatations)
hypovolemia
(bleeding, diarrhea, Sx
provoked by standing)
Aortic stenosis
(progressive, known
valvular heart disase, SOB/DOE)
Orthostatic blood pressure change from autonomic dysfunction
(Hx diabetes, other neuropathy)
Stroke
(abrupt loss of function, known
vascular RFs: age > 50, atherosclerosis elsewhere, htn, dm,
hyperlimidemia, atrial fibrillation, smoking)
CNS tumor
CNS infection
Hypoglycemia
Meds, drug use/overdose/toxins
trauma
Numbness?
Suggests sensory abnormality – e.g. central or peripheral nerve dysfunction
Other metabolic: thyroid, hypocalcemia, other
Weakness?
generalized etiology – e.g. deconditioning, poor nutrition, anemia, chronic advanced
medical conditions, combinations etc
Neuromuscular disease
(progressive, muscle weakness, no
numbness, weakness usually is proximal)
polymyositis
myopathy
myasthenia gravis
(subacute, progressive, worse
w/repetitive movement, ocular sx → double vision)
central nervous system d/o – with UMN findings (rigidity,
hyper-reflexia
Brain
tumor
(progressive, focal deficits)
bleeding
(trauma, use of
anti-coagulants)
infection/abscess
stroke
(acute, focal deficits, vascular
dz risk factors)
multiple sclerosis
(relapsing/remitting,
patchy symptoms: numbness, visual changes, balance/coordination)
Spinal cord level
Trauma
Tumor
(known malignancy, progressive,
pain)
Bleeding
(acute, use of anti-coagulants,
trauma)
Compression from boney encroachment
(progressive, chronic pain)
ischemia
peripheral nervous system
(weakness is usually
distal)
compression neuropathy
Cervical
(arms, pain radiates along nerve
distribution)
Lumbar
(legs, pain radiates along nerve
distribution)
Median nerve –
carpal tunnel
(pins/needles, thumb/index/middle/1/2 ring,
worse in AM)
other nerves – with sx consistent with nerves affected
metabolic disorders
(diabetes → distal
findings first, longstanding, poor control)
toxic exposures
guillain barre
(acute, progressive, ascending
pattern of involvement)
CIDP
(pain, tingling, numbness, focal
weakness)
mixed CNS & PNS
ALS
(progressive weakness, twitching, breathing
problems)
Parkinson’s disease
(older, progressive, rigidity, difficulty starting/stopping
movement, balance problems, gait problems)
see
fatigue
Dizziness?
Vertigo – sensation of movement when none occurring
Central:
stroke
(other C/V RFs, acute, other focal
neurological complaints)
tumor
Peripheral
labrythitis
(abrupt, worse w/movement,
self limited, URI Sx prior)
benign positional vertigo
(acute, worse
w/movement, no other neuro Sx, prior trauma, usually self
limited)
Meniere’s Disease
(tinnitus, waxes and
wanes, unilateral, hearing loss)
Syncope or presyncope
Cerebral hypoperfusion
Ventricular dysrhythmia
(red flags:
abrupt, resultant fall w/injury, known depressed LV fxn, Hx CAD,
Hx CHF)
Bradycardia
(fatigue, decrease exercise
tolerance, CHF Sx)
SVT
(rapid/irreg heart beat,
palpatations)
hypovolemia
(bleeding, diarrhea, volume
loss for any other reason, Sx provoked by standing, +
orthostatic vital signs →
vital.html#Blood
Aortic stenosis
(progressive, known
valvular heart disase, SOB/DOE)
Orthostatic blood pressure change from autonomic dysfunction
(Hx diabetes, other neuropathy)
Non-cardiac
meds or toxins
hypoglycemia
(known DM & Rx
w/meds)
Disequilibrium
impaired sensory inputs when walking/standing
(vision, hearing, peripheral neuropathy,
muculoskeletal, other)
Balance problems?
Primary Neuro
link to
weakness
peripheral neuropathy →
numbness
cerebellar d/o
(ataxic gait, impaired fine motor fxn,
difficult to understand speech)
neuro muscular dz
movement d/o
Non-Neuro
visual problems
generalized weakness
deconditioning
chronic illness
link to fatigue
MSK Disease (e.g. arthritis)
cognitive disorders
(dementia, delirium)
medication side effects
combinations of any
Headache
red flags: severe, acute, age<55, trauma, immunocompromised, loss of function, fever,
delirium/behavioral change, awakens from sleep, unremitting, hx cancer w/met potential
Chronic/recurrent (though even these have a “first time”)
migraine
(recurrent, last many hours, severe,
throbbing/pulsating, sometimes aura, assoc w/ N, V, light & sound
sensitivity, unilateral; often seek quiet & dark places to lie down ’til
resolves)
tension
(recurrent, bi or uni-lateral, dull, no
migraine/other sx)
cluster
(recurrent, brief, severe, focused around
eye/temporal area, assoc w/tearing/rhinorrhea)
post concussive
(hx discrete traumatic event, or
hx recurrent events)
chronic daily headache
(headache 15d/m for 3m,
represents transformation of a primary headache syndrome →
typically migraine or medication overuse)
Acute
Trauma – can cause concussion, bleeding, or swelling
Blood in/around brain
Subdural
(older → assoc w/brain
atrophy, mild (deceleration) to severe trauma, change in
behavior/level of consciousness, acute to
sub-acute)
Epidural
(assoc w/significant blunt
trauma, rapid decline in level of consciousness – which can wax
and wane)
sub-arachnoid
(acute and severe head ache,
rapid decline in consciousness, “worst headache of life”)
Parenchymal
(acute, loss of function
→ based on location)
Infection
Meningitis
viral
(acute, fever, head ache,
neck pain, n, v, delirium)
bacterial
(acute, fever, head
ache, neck pain, n, v, delirium)
fungal
(sub-acute, often assoc
w/compromised states → hiv, cancer, fever, feeling
poorly in general, sub-acute headache & neck pain,
delirium)
encephalitis
(acute, headache, fever,
systemically ill, deliirium)
abscess
(acute/subacute, headache, fever,
loss of function based on location, progressive, delirium;
reason for abscess → spread from adjacent site, AVM, PFO,
neurosurgery)
Mass
tumor
benign
(sub-acute, loss of
function based on location, confusion/change in
personality, headache)
malignant
primary
(sub-acute, loss
of function based on location, confusion/change
in personality, headache; abrupt worsening if
bleeding superimposed)
metastatic lesion
(sub-acute, loss of function
based on location, confusion/change in
personality, headache; abrupt worsening if
bleeding superimposed, known primary w/tendency
to met to brain → renal cell, breast,
melanoma, lung)
Vascular
Aneurysm
(acute headache if leaking, other
localizing sx if pushes on a nearby structure, when
leaks/ruptures → sub-acrachnoid bleed)
AVM
(acute or sub-acute, loss of function
based on location, can have abrupt change if superimposed
bleeding)
vasculitis
temporal arteritis
(older, acute,
jaw pain w/chewing, Hx Polymyalgia, neck/shoulder aches,
decreased vision, tender over temporal artery)
Other vasculitides – suggested by hx/specific organ
involvement: lupus, PAN, Wegeners, Takayasus, Churg-Strauss
dural sinus thrombosis
(acute, assoc
w/hypercoaguable state or inflammation, can cause seizures and
focal deficits, delirium)
Special considerations in HIV + patient
Infection
Bacterial
Meningitis
(acute, neck
pain, delirium, fever)
Abscess
(fever, head ache,
delirium, focal neuro deficits)
Parasites
Toxoplasmosis
(sub-acute,
headache, confusion, fever, CD4 < 200 or
untreated HIV, focal neruo deficits)
Virus
HSV
(similar to non-HIV +,
causes encephalitis &rarr fever,
confusion)
Fungal
Cryptococcus
(CD4 < 50
or untreated HIV, sub-acute headache, fever,
confusion)
Cocci
(CD4 < 250,
headache, neck pain, lethargy, living in endemic
area &rarr Southwest)
Mycobacterial
TB
(fever, sweats, weight
loss, confusion, TB elsewhere, CD4 < 350)
Syphilis
(can occur at any CD4
level, primary:
genital ulcers
, and secondary
(rash, other systemic findings:
generalized skin
hands
feet
; other sx and findings
similar to non-hiv +, neurosyphillis &rarr gait
problems, confusion, sensory deficits)
Malignancy
Lymphoma
(sub-actue, f, sweats, wt
loss, adenopathy elsewhere, unexplained
organogmegaly)
Non-neuro
Depression
(recognizing that HA will not
be the sole manifestation of depression)
Eye related
Strain
(slowly progressive, worse with
reading, glasses working less well, no red flags)
Glaucoma
(acute, eye pain, visual changes,
eye redness, firm globe on palpation)
Sinusitis
(acute, post nasal drip, facial
pain, nasal d/c, cough)
Generalized viral or bacterial infections
Systemic Hypertension
(severe, though
chronic htn is typcially well tolerated and asx; acute increases
in BP beyond a threshold; or very very high values)
carbon monoxide
(winter months w/exposure
to heaters in closed spaces/poorventilation, worse when in that
environment → better outside, others w/similar sx who
live/work in same place).
Endocrine
More Info About Endocrine Disorders:
National Endocrine and Metabolic Diseases
Clearinghouse
Known Endocrine disorder?
Diabetes, hypo/hyperthyroidism, etc
Polyuria, polydypsia, polyphagia?
Poorly controlled dm
see under
Genito-Urinary –
Frequency
Fatigue?
see under
General – Fatigue
Weight loss?
See under
General – Weight loss
Weight gain?
See under
General – Weight gain
Infectious Diseases
More Info About Infectious Diseases:
National Institute for Allergy and
Infectious Diseases
and
Centers for Disease
Control
Known disease?
TB, HIV, endocarditis, chronic hepatitis B or C, immune compromised state, other
acute or chronic infections, etc
Fevers, Chills, Sweats?
Infection
Localize sx to specific organs on basis of other ROS questions & exam → identify
site of infection – e.g. urinary burning, frequency, urgency → simple UTI; other
key hx to define likelihood of specific infxn: age, co-morbid predisposing illness (e.g.
cancer, DM, substance abuse), past hx (hospitalizations, operations), travel/geographic
exposures, season, status of immune system (acquired or congenital immunodeficiency),
meds that affect immune system (steroids, chemotherapy, tnf-inhibitors, etc), indwelling
devices/hardware, valvular heart disease.
More info from:
CDC
Infectious Disease Soc
America
Bacteria
Gram Negative Organisms
e coli
(GNR, cause uti, also
abdominal/pelvic abscesses; HO157 causes enteritis and
HUS)
klebsiella, enterobacter, serratia
(GNRs, cause of urinary tract infection,
also abdominal/pelvic abscesses; hospitalized patients
→ pneumonia, wound infection, uti)
proteus
(common cause of urinary tract
infection, can contribute to stone formation; wound
infection hospitalized patients)
pseudomonas
(lung infections in
patients with bonchiectasis → CF, COPD, compromised
pts; bacteremia in patients w/neutropenia, also
abdominal/pelvic abscesses, wound infection in patients
w/DM; wound and urinary infections hospitalized/compromised
pts; osteomyeliitis; otitis externa in patients w/DM)
neisseria meningitidis
(GNC,
meningitis; f, c, ha, n, v, sepsis)
neisseria gonorrhea
(GNC, urethritis;
cervicitis/PID; if
disseminated
infectious
arthritis)
moraxella
(GNC, otitis media;
bronchitis in copd exacerbation; pneumonia in COPD)
legionella
(community acquired
pneumonia, cough, sputum, f, c)
haemophilus influenza
(pneumonia,
otitis media, epiglottitis, meningitis; much less common
since widespread use of vaccine)
HACEK organisms
(endocarditis →
typically sub-acute → f, c, malaise x weeks)
salmonella
typhi
(relapsing daily fever x
weeks, malaise, ha, chills, relative brady, related
to poor sanitation → outbreaks, travel to
endemic areas, gall bladder can act as
reservoir)
non-tyhoidal
(diarrhea, n, v,
cramps, often w/bloody stools)
shigella
(diarrhea, n, v, cramps,
often w/bloody stools, typically self limited)
campylobacter
(diarrhea, n, v, cramps,
often w/bloody stools, typically self limited)
yersinia
enterocolitica
(diarrhea, f,
c, cramps; typically self limited)
pestis → plague
(passed
from rodents to humans by fleas or direct contact
w/feces, rapid onset f, c, sepsis, pneumonia)
helicobacter
(stomach ulcers)
pertussis
(characteristic whooping
cough; kids can have airway compromise; adults presents as
persistent cough x weeks easily spread; vax of kids and
re-vax of adults preventive)
Other less common gram negatives
vibrio
cholera
(toxin mediated
profound watery diarrhea, related to exposure to
unclean water sources, often s/p natural disasters
→ presents as epidemics)
vulnificus
(causes sepsis in
hosts w/cirrhosis or otherwise compromised hosts,
exposure via raw/under cooked shellfish; also skin
infection if same hosts exposed via
inoculation)
francisella tularensis → tularemia
(passed from dying wild animals to
humans via ticks/insects, US Southeast and Rocky Mtns,
causes skin ulcers, lymphangitis, f, c)
brucella
(ingestion of raw/uncooked
dairy, not present in all countries, causes recurrent f, c,
systemic sx, arthritis, other organ involvement)
batonella
henslae
(caused by cat
scratch, regional adenopathy w/in few weeks,
fatigue)
bacillary angiomatosis
nodules on skin
, resemble
Kaposis Sarcoma
, occurs in
HIV infected or otherwise compromised pts)
Gram positive organisms
Cocci
Staph aureus
coag +
cellulitis
skin abscess
wounds; osteomyelitis via direct extension;
arthritis; bacteremia with seeding of
abnormal or artificial valves, joints or
devices; virulent w/rapid destruction
valves/death w/in hours/days; toxic shock;
pneumonia following viral infection; toxin
based food poisoning → n/v hours after
exposure, others affected who ate
same)
coag –
cellulitis
skin abscess
bacteremia with seeding of abnormal or
artificial valves, joints or devices, less
virulent than coag +)
mrsa
cellulitis
skin abscess
bacteremia with seeding of abnormal or
artificial valves, joints or devices, can be
hospital or community acquired; healthcare
assoc pna)
Streptococcus
Group A
(cellulitis/lymphangitis;
skin abscess; erysipelas; throat infections
→ acute pain, f, adenopathy:
pharyngeal erythema
and d/c; impetigo; contribues to
necrotizing
fasciitis
; scarlet fever → high
temp, rash, palatal petchiae, throat sx)
Group B
(endometritis,
meningitis, bacteremia, neonatal
infection)
Group D → enterococcus
(urinary tract
infection, pelvic/abd abscess, wound/other
infxn in chronically ill/hospitalized
patients)
Viridans
(endocarditis
→ subacute w/sx f, c, malaise x
weeks)
pneumoniae
(pneumonia,
upper respiratory infections, meningitis;
bacteremia if severe; increased risk if s/p
splenectomy)
Rods
listeria
(meningitis in old
and young patients)
diptheria
(upper respiratory
infection w/cough, f, sore throat, pseudo-membrane
w/airway obstruction; uncommon now w/vax)
anthrax
(acquired from animal
exposure or biological weapon; inhalation: cough, f,
c,pneuonia sepsis; cuteaneous: ulcer to eshcar
w/surrounding edema)
Anaerobes (GN or GP)
often associated with mixed/complex infections/abscesses of abdomen,
pelvis, lung, mouth
clostridium: GPR
perfringes
(most common cause
food born diarrhea → undercooked meat, cramps,
diarrhea, 6-18h after ingestion, resolves in 24h,
other who ate same ill simultaneously; deep tissue
infection contibuting to
necrotizing faciitis
contribute to abd/pv abscess; NEC in
neonates)
difficile
(antibiotic
associated colitis, can occur after any abx, cramps,
diarrhea)
tetani
(exposure via
contaminated wounds if unvax, 1w
incubation,increased tone in jaw muscles, dysphagia,
diffuse musle pain/spasams, airway compromise;
uncommon w/widespread use vax)
botulinum
(food/wound born
toxin, incubation 1-2d, rapid descending symetric
paralysis staring w/cranial nerves, dizziness, dry
mouth, visual sx, no sensory deficitis, aggitation,
resp failure, death)
bacteroides fragilis
(GNR, contributes
to abdominal/pelvic abscesses)
peptostreptococus
(GPC, lives in
mouth, contributes to mixed oral/lung infxns/abscess)
Other bacteria
chlamydia
trachomatis
(urethritis,
cervicitis/PID)
pneumoniae
(fever, upper resp
sx, non-productive cough)
psittacosis
(spread by
exposure to parrots & sometmes other birds, 1-2 week
incubation; fever, cough, severe HA; other organ
systems as well)
mycoplasma pneumoniae
(common cause
CAP; acute f, c, cough, upper resp sx; not usually
severe)
nocardia
(lives in soil, causes
sub-acute pneumonia, also abscess/cellulitis/lymphangitis if
direct inoculation)
actinomyces
(oral/neck/face slow
growing abscess, often w/sinus tract development, can
affectother organ systems as well)
Viruses
rhino, adeno
(common cause of upper
respiratory infxn, cough, nasal congetsion, sore throat, ear
pain)
influenza
(common cause upper and lower
respiratory infection, seasonal in North America oct to april,
increase risk if no vaccination; abrupt onset of myalgias,
arthralgias, fever, chills) more from
CDC
rotavirus, norovirus
(common cause of
acute enteritis: abrupt onset n, v, d, diarrhea; rota in partic
kids < 5; noro adults/daycare/hospitals/nursing homes)
enteroviruses
(non-specific sx of f, c,
aches; meningitis)
coxsackievirus
(myocarditis,
pericarditis,
hand/foot/mouth
in kids f,
malaise)
polio – eradicated in US w/vaccine
EBV → mononucleosis
(incubation 4-6w,
pro-drome 1-2w of fatigue and myalgias; then f, head/neck
adenopathy, pharyngitis, hepatomegaly, splenomegaly)
herpes simplex
(past by sexual or oral
contact; genital or oral herpes, encephalitis; fever or pain
prior to appears
vesicles
; resolves spont; can recur,
can be congenitally acquired)
varicella zoster
chicken pox
, shingles →
dermatomal vesicles
, pneumonia in
setting severe chicken pox)
Hepatitis
(acute liver infection, spread
fecal/oral/ingestion contaminated food, can be epidemic;
incubation 2-4w, n, v, abd pain, f,
jaundice
icterus
; generally self
limited)
(acute liver infection,
incubation 3m; spread via sexual contact, vertical,
shared needles, needle sticks in health care workers,
unscreened blood transfusion: acute may cause f, c,
jaundice
icterus
; may be sub-acute; 95%
adults resolve, 5% go on to chronic hepatitis →
risk cirrhosis, HCC)
(chronic hepatitis, acute
infection generally not recognized, spread via needles,
unscreened blood transfusion, cocaine inhaling tools,
needle sticks in health care workers, vertical, sexual –
rel difficult; 10-20% resolve; long term risk cirrhosis
and HCC)
HPV
genital warts
peri-anal warts
, years later causes
cervical cancer, head/neck scc, penile scc)
RSV
(winter mos, cough, fever, typically
affects infants and children)
para-influenza
(upper resp
infection/croup, tracheobronchitis)
parvo
(most common ages 5-19, slapped
cheek rash, also rash on arms, soles, palms; acute
arthralgias/arthritis that can mimic RA; can cause acute
hypoprolif anemia)
CMV
(retinitis/colitis/disseminated dz in
patients w/HIV; systemic infection in patients 1-4m s/p
transplant; normal hosts get mono-like symptoms: incubation 3-8
w, then f, c, malaise hepatomegaly, splenomegaly, fatigue x
4-6w; head/neck adenopathy & pharyngitis are rare)
rabies
(bite from infected animal →
skunk, bat, squirrel, dog; incubation can be days to mos, f, ha,
myalgias, arthralgias, hydrophobia, intermitent
confusion/aggitation, sensitivity to sound/light; sx onset to
death avg 4d)
Hanta
(rodent exposure; 3-4d f, myalgias,
HA, n, v, abd pain; then rapidly progressive resp sx)
West Nile
(incubation 2d-2w; summer/fall
in North America, fever, muscle aches, confusion, ha, stiff
neck, rash, confusion → meningo-encephalitis)
measels
(uncommon w/vaccination,
winter/spring in US, cough, f, malaise, conjunctivitis, runny
nose, then rash, white spots on oral mucosa; complications
include encephalitis, pneumonia)
mumps
(uncommon w/vaccination, f, myalgia,
malaise, affects B parotids and testicles)
rubella
(uncommon w/vaccination, rash
starts on face, fever, adenopathy; can be congenitally
acquired)
Fungi
candida
(common cause of fungal skin
infection:
tinea cruris
tinea pedis
, vaginitis;
worse/recurrent if immune-compromised)
Coccidioidomycosis
(south west US,
higher risk if immune-compromised, sub-acute
pneumonia/effusions, also arthritis,
skin
, seeding of other
sites)
aspergillus
(pneumonia in compromised
host, tissue invasive or fungal ball, invasive sinusitis in
patients w/DM or otherwise compromised, can infect any
organ; recurrent wheezing in normal hosts →
ABPA)
histoplasmosis
(can be asx/mild and
resolve spont; often see x-ray evidence prior infection
lung, spleen w/o known past infxn; exposure to Mississippi &
Ohio river valley; cough, fever; can cause resp/systemic
illness in HIV+)
mucor
(invasive sinusitis, pneumonia
in patients w/DM or otherwise compromised; cough, fever, HA,
sinus pain)
pneumocystis jerovecii
(pneumonia in
patients w/HIV; also in those compromised by long term
steroid use)
Mycobacteria
tuberculosis
(sub-acute, cough,
hemoptysis, weight loss, sweats; can also infect GI/GU
tracts, bone; increased risk if immune-compromised/hiv
+)
more from
CDC
MAC
(HIV + cause of diarrhea;
indolent lung infection in patients with
bronchiectasis)
MAI
(diarrhea in patients
w/HIV)
M Marinum
sub-acute skin infection
, after
exposure via fish tanks)
M Leprae
(slow, anesthetic macule,
area of involvement spreads, direct nerve involvement,
neuropathic pain and enlargement of involved nerve,
Southeast Asia)
Retrovirus
(HIV)
HIV
(hiv risk factors →
men who have sex w/men, unprotected intercourse, sex
w/prostitutes, sex w/somone known hiv +, ivdu,
transfusion w/unscreened blood, drug/etoh abuse, hx
other sti’s, health care worker’s w/needle stick
injury; risks of unusual infection increase as CD4
declines – see organ specific sx)
more from CDC
Spirochetes
borrelia burgdorferi → lyme
(endemic area north east,
upper mid west, tick contact x 24-48h;
inoculation days to weeks, then–>rash, f, c,
aches; then arthralgias, heart block, CNS
involvement; later still arthritis)
more from
CDC
syphillis
(sexual exposure,
initially painless genital
ulcer
→ heals 4-6w; weeks later
non-specific rash
w/predilection for palms
, and
soles
, condyloma around
genital areas, mucous involvement, adenopathy;
late manifestations yrs later affecting CNS,
large blood vessels → aortitis,
aneurysm)
more from
CDC
leptospirosis
(contract
via exposure to rodent/wild animal feces;
inoculation period several weeks; mild dz is
self limited f, c, ha, n, v, musle aches,
conjunctival injection; severe dz with hepatic
and renal involvement,
icterus
Rickettsiae
Rock Mtn Spotted Fever
(exposure to tick,
incubation 2d to 2w; can occur in most
states in US, f, c, ha, arthralgias, then
generalized rash – though not always, can be
severe/fatal)
human ehrlichiosis
(often co-infection
w/lyme, tick born, incubation ˜1w, f,
ha, n, v, myalgias; often causes BM
suppression)
Parasites
malaria
(passed
via mosquitoes, live in tropical
climates: Southeast Asia, Africa;
susceptibility increase if don’t use
proph abx; incubation 1-4w; recurrent
high fevers, c, HA)
toxoplasmosis
(protozoa, carried
in cat feces, healthy hosts not
affected, in HIV + causes brain
infection dc4 < 200 → headache,
f, delirium, szr; pregnant women can
pass in utero → congenital
abnl)
giardia
(protozoa,
spread via poor hygiene, contaminated
water, drinking from ponds/streams, anal
intercourse; many infected are asx;
incubation 1-3w; non-bloody diarrhea,
gas, burping)
entamoeba hystolytica → amebiasis
(protozoa, acquired
via unclean water/poor sanitation, also
anal intercourse; only 10-20% develop
sx; incubation 2-4w; abd pain, bloody
diarreha; occas liver abscess)
trichinosis
(roundworm, rare in
US; from eating infected meat; abd pain,
n, v, diarrhea; after 1-2w, muscle pain
when migrate to muscles, rash, ha, n,
v)
ascariasis
(roundworm,
tropics/sub-tropics/SE US, eggs
swallowed if contaminated soil ingested
→ eggs hatch in intestines →
larvae enter blood stream → migrate
lungs → mature & coughed up →
swallowed → mature in intestines;
cough, fever, sob, n, v, abd pain,
impaired growth of children, sbo)
hook worm
(common
world-wide, enter thru feet/skin if walk
barefoot in soil w/infected feces →
bloodstream → lungs →
swallowed → intestines → blood
loss → anemia, d)
enterobiasis
(pin
worm, fecal oral, common in kids, cause
nocturnal peri-anal itching)
w bancrofti
(tropics/sub-tropics,
spread by mosquitoes, filaria invade
lymphatis, after years → lymphedema
from obstruction of channels)
onchocerciass
(causes river
blindness, Africa/central-south America;
spread by black fly;
conjunctivits/keratitis, skin
nodules)
schistomiasis
(south america,
middle east, caribbean, africa: flukes,
invade skin of swimmers, enter blood
stream → live in portal/mesenteric
veins; can cause cirrhosis after years;
can live in bladder → SCC after
years)
cysticercosis
(tapeworm, ingest
eggs via infected beef that’s
undercooked; Mexico, Africa, Southeast
Asia; eggs cross intestines, migrate to
host muscles and brain, can cause
seizures)
echinococcus
(worm; from cattle
and dogs; in US and many other areas;
eggs ingested by humans → travel to
liver → cysts form & can cause RUQ
pain → compress biliary tract
→ if rupture can cause
anaphylaxis)
Non-Infectious
Malignancy – many cancers (e.g. renal, leukemia, lymphoma), with specific dx
guided by localizing sx, careful exam and identification of risk factors
Auto-immune – specific disorder based on other symptoms and findings –
relatively uncommon (compared w/above)
RA
(sub-acute, persistent/progressive joint
pain, tendency for bilateral involvement →
MCPs
hands
, knees; warmth; redness; worse in am; women > men;
fatigue)
Lupus
(sub-acute, female > male,
black>white, sub-acute, fever and feeling poorly in general, rash
on face, other system involvement → kidneys, brain)
Familial Med Fevers
(uncommon, associated
w/cryptic abdominal pain, rash, arthritis, arthralgias, myalgias,
recurrent fever)
Still’s disease
(subacute, uncommon,
rash
, sore throat, arthralgias)
Polymyalgia Rheumatica – PMR
(sub-acute, age
> 50, morning shoulder and hip aches, no findings on exam of
joint inflammation)
Giant Cell Arteritis
(age > 50, often prior
hx PMR, fatigue, headache, joint aches, visual loss)
Other vasculitides
Inflammatory bowel disease
(sub-acute,
recurrent or chronic diarrhea; wt loss, bloody stools, mucous,
cramps, constipation, nocturnal diarrhea; systemic sx; presentation
can also be fulminant)
Serum sickness
(acute, symetric,
additive/migratory, polyarthritis; myalgias, fever, rash; typically
from rx to abx, or secondary to viral infxn → e.g. acute hep b;
onset days to weeks after exposure)
Endocrine
Low testosterone
(sweats but no fever,
decreased libido, fatigue, errectile dysfunction)
Menopause
(sweats but no fever, age ˜
50, irregular menstruation)
hyperthyroidism
(irritability, inability to
sleep, diarrhea, palpitations, tremor, heat intolerance)
adrenal insufficiency
(weakness, n, v, skin
darkening if central etiology)
Meds: Dx based on r/o other causes and temporal link between initiation med and
fever onset
malignant hyperthermia → e.g. inhalational anesthetics – typically
in OR or soon thereafter
neuroleptic malignant syndrome → e.g. haldol, chlorpromazine
(high fever, cramps, delirium, autonomic
instability)
many other meds – including broad range of abx
Other
DVT/PE
(acute, cough, SOB, pleuritic,
hemoptysis, unexplained unilateral leg swelling, RFs for DVT;
Well’s
Criteria for DVT
Well’s
Criteria for PE
Musculoskeletal
More Info About Musculoskeletal Disorders:
National Institute of Arthritis and Musculoskeletal and
Skin Disorders
Comprehensive Muscuoskeletal Exam
Known disease?
Degenerative joint disease/Osteoarthritis, Rheumatoid Arthritis, Lupus, gout, etc.
Joint pain and/or Swelling (general
comments)
Generalized joint pain or swelling?
Intra-articular prcess
Inflammatory
Single joint (typically)- with associated effusion
Infection
Bacterial
(acute,
red, warm worse w/passive or active
movement, one or few joints, fever,
chills)
Gonorrhea
(hx sti, hx
sexual activity, hx penile or
cervical d/c)
Staph or Strep
(hx direct
trauma w/inoculation of bacteria
into joint, actue symptoms after
joint surgery/aspiration, spread
from systemic bacteremia, or
spontaneous)
Fungal
(relatively
uncommon, sub-acute, hx coccidiomycosis,
exposure to endemic areas for cocci
→ Southwest)
Spirochete
(hx
living in area endemic w/lyme, bull’s
eye type rash prior to joint
pain)
Crystal Induced
Gout
(acute, worse
w/movement, one or few joints –
commonly great
toe
, male >> female, hx
prior gout, evidence of
tophi
Pseduogout
(presentation
similar to gout)
More than one joint
Infectious
Bacterial- secondary to bacteremia →
very ill
Viral
Parvo
(symetric
moderate joint inflammation,
exposure to kids who harbor
illness, self limited)
Gout, psedogout – can affect a few joints
simultaneously, though more commonly
mono-articular
Autoimmune
RA
(persistent/progressive;
bilateral:
MCPs hands
knees; warmth; redness; worse in am;
women > men; fatigue; systemic
Sx)
Lupus
(female
>male, black>white, sub-acute, fever
and feeling poorly in general, rash on
face, other system involvement
→kidneys, brain)
Psoriatic
(hx
psoriasis,
findings of
psoriasis on exam
Serum sickness
(acute, symmetric,
additive/migratory, polyarthritis;
myalgias, fever, rash; typically a rxn
to abx, or secondary to viral infxn
→ e.g. acute hep b; onset days to
weeks after exposure)
Reactive arthritis
(acute
pain and swelling following infection elsewhere:
GI (campylobacter, yersinia, salmonella,
shiegella), STI (chlamydia); if eye and urethral
sx →consider Reiters, most common in
knees/feet/ankles, acute/sub-acute, age
typically 20-40)
Less inflammatory
Osteoarthritis
(subacute/chronic,
worse w/activity, slowly progressive, prior injury, wt
bearing joints (knees, hips))
Trauma
Structure around/near the joint
Bursitis
(exam reveals absence of effusion,
area of inflammation is over anatomic bursa
, focal
redness, warth, pain on touch)
Cellulitis
local redness
, induration, pain, not restricted to a
joint or anatomic bursa, not clearly worse w/movement)
Teno-synovitis
(worse w/active motion, over tendon)
Muscle pain
Other/non-joint related pathology – e.g. arthralgias from systemic illness, in which
case exam of the joint is normal
Muscle ache?
Myopathy/myositis
statin use
primary disorder
extreme exercise
Polymyalgia Rheumatica
(age > 50, subacute, hips and
shoulders, worse in AM)
Fibromyagia
(chronic, pain at multiple trigger sites, no
other explanation found on exam and labs, fatigue, head aches)
Meds/drugs → cocaine
Referred from joint pathology
Polymyostitis
(associated with weakness)
Systemic infection
Local infection
Cramps – often non-specific
(hypokalemia, dehydration,
hypocalcemia, idiopathic)
Low back pain?
Detailed exam
Pain radiating from back down legs
Nerve root irritation from disc or DJD → “sciatica”
(waxes/wanes, radiates down leg)
spinal stenosis (older, slowly progressive, worse standing, radiates down B
legs w/walking)
Para-spinal muscles/Muscle spasm
(acute, wax/wane,
para-spinal area; pain on palpation)
Osteoarthritis/non-specific musculo-skeleatal
(waxes/wanes, no red flags or other Sx, no findings on
exam)
Spondylolisthesis
(progressive, pain is focal w/o
radiation, sometimes preceded by antecedent increase in activity, worse
w/activity and better w/rest; pain sometimes worse on palpation over
affected area)
Sacro-iliac joint problems
(pain over SI areas,
sometimes assoc w/trauma, can be linked to inflammatory
arthritides→Ank Spond)
Spondyloarthroathies
(onset 20s, better with
activity, very limited range of motion)
Conditions with high morbidity, associated with red flags: onset sx > 50,
unremitting pain, neuro deficits, doesn’t improve w/rest, fever, trauma,cancer, wt
loss, > 6 weeks duration, in particular if progressive
Fracture
(trauma/mechanism of injury that could
cause fx, osteoporosis, age > 50, pain on palpation)
Cancer
(known cancer with prediection for mets to
spine → prostate, lung, breast; if not known cancer then symptoms
suggestive of primary somewhere)
Infection: Osteomyelitis/discitis
(unremitting,
known systemic infection → endocarditis, fever, chills,
acute/sub-acute; pain on palpation over infected area;extension from
skin/trauma; associated with foley catherization; spontaneous )
Cauda equina
(acute/sub-acute, bowel and/or
bladder incontinence; weakness and numbness of legs)
Multiple myeloma
(fatigue, anemia, shortness of
breath, fever, bleeding)
Distant disorders
Retroperitoneal:
Abdominal Aneurysm
(age > 50, C/V RFs,
abd sx w/radiation to back, if obese → non-specific abd
pain on palpation; if thin, might be able to feel the aneurysm;
severe VS abnormality from bleeding and hypovolemia if
rupture)
Renal stone
(acute, severe, colicky,
radiates towards abd/pv)
Renal infection
(acute, F, C, N, dysuria,
urinary frequency)
Posterior duodenal ulcer
(severe, acute,
boring/gnawing pain that radiates from epigastrium to back,
n)
pancreatitis
(acute, N, V, ETOH abuse,
gall stones)
Systemic infection sometimes cause non-specific lbp
endocarditis
(F, sweats, abnormal/prosthetic
valves, systemic Hx, Hx bacteremia)
viral syndromes
Knee pain/swelling?
Detailed Exam
Acute
Trauma – mechanism of injury important
Fracture
(direct fall on knee or impact w/hard
structure → dashboard))
Patella dislocation
(acute, prior hx
dislocation, appears displaced lateral/medial on exam)
ACL disruption
(twisting injury, often
non-contact, acute pain, audible pop, acute swelling from
blood)
Meniscal injury
(twisting or contact,
acute/sub-acute pain, hx meniscal injury, swelling hours to days
later → slower accumulation blood)
Inflammatory
Intra-articular
Infection
(acute, worse w/movement,
one or few joints, fever,\ chills)
Non-infectious
Gout
(acute, worse w/movement,
one or few joints – commonly great toe, male
>> female,
red/inflamed joint
tophi
pseudo-gout
(acute, worse
w/movement, one or few joints – commonly great toe,
male >> female)
RA
(persistent/progressive;
bilateral:
MCPs hands
, knees; warmth;
redness; worse in am; women > men; fatigue;
systemic Sx)
Lupus
(female > male,
black>white, sub-acute, fever and feeling poorly in
general, rash on face, other system involvement
→ kidneys, brain)
Structures around the joint
Bursitis
Prepatellar
(redness & swelling limited
to directly over patella, hx chronic
kneeling)
Anserine
(redness and swelling
inferio-medial to knee)
Cellulitis
redness in skin
, sometime pain to
touch of skin but less w/range of motion joint, not
anatomically limited to over knee)
Chronic
Osteoarthritis
(subacute/chronic, worse w/activity,
slowly progressive, prior injury, wt bearing joint, obesity)
Meniscal injury
(sesnse of instability/giveway,
decrease ROM, locking, swelling)
Ligamentous insufficiency
(hx ligament injury, sense
of give-way and pain when stress applied in direction that ligament
typically check – eg. twisting)
Hand Symptoms?
Detailed Hand Exam
Trauma, with attention paid to the mechanism of injury
Metacarpal fracture
(striking closed fist against
solid surface,
pain over 4th/5th metacarpal
Fall on outstretched hand
Navicular fracture
(pain over anatomic
snuff box, persists despite negative xrays)
Distal radial fracture
(pain over distal
radius)
Fall with thumb abducted – Ulnar collateral ligament disruption
(pain and swelling over MCP area, pain and weakness
with grasping,
laxity on exam
Extensor tendon disruption of finger
(caused by
sudden direct force jamming extended finger, pain, finger distal to dip
rests in flexion, unable to extend)
Sub-ungual hematoma finger
(related to direct
trauma distal aspect finger, pain, swelling, dark discoloration under
nail from blood)
Pins and needles type pain radiating into hand
Median nerve compression
(chronic sx, affects
thumb/2nd/3rd and 1/2 4th fingers, worse in AM, patient feels need to
“shake out hands” to improve blood flow,
weakness and atrophy late findings
Ulnar nerve compression
(chronic, sx radiate down
to 1/2 ring and index finger, often worse at night/in AM)
Radial nerve compression
(typically associated
w/trauma at proximal humerus or prolonged compression in that area
→ intoxication and passed out x hours, unable to extend at wrist,
numbness back of hand
Cervical nerve root irritation
(pain radiates to
fingers from neck, can be provoked by maneuvers that compress nerve
roots at neck)
Inflammatory processes within the joint:
Wrist, fingers
RA
(sub-acute, symmetric, worse
w/movement,
predilection for MCPs
, worse in am due
to gelling phenomenon → better w/use, pain if squeeze
involved joints, feels spongy if palpate around joints from
synovial inflammation, female > male, other joints as
well)
Infection
(acute, symptoms localized to
area that’s infected, worse w/movement,
red, warm, painful, local trauma as portal or systemic seeding;
DIP infection
Gout
(acute, red, warm, pain w/movement,
hx gout elsewhere;
MCPs
wrist
Inflammation of skin/soft tissue
Infection
Nail area infection (paronychia)
(acute,
localized redness and swelling,
pain at margin of nail
Soft tissue distal finger (felon)
(acute,
pain, warmth, redness, swelling most prominent on pulpy aspect
of distal phalynx)
Sub-ungual infection (beneath nail)
(acute
swelling, pain beneath nail, symptoms worse with nail pressure
then with pressing on pulp)
Tenosynovitis
(extensor or flexor surface;
pain with active extension or flexion of wrist or affected
fingers, passive motion hurts less, sometimes associated
w/penetrating trauma if secondary to infection → e.g. cat
bite; redness, warmth and swelling over affected tendon)
Cellulitis
(acute pain, swelling,
redness,
warmth of the skin
Bumps/lumps
Ganglion cyst
(painless bump over dorsal or
ventral aspect of wrist, not warm or colored, transilluminates as it’s
fluid filled,
doesn’t interfere with function
Nodules at PIP or DIP
(firm, boney, non-tender,
associated with OA
Other cysts or lipomas
(slowly progressive,
non-tender,
not associated w/an underlying structure
Skin cancer
(non healing, slow growing:
Basal cell
squamous cell
melanoma
Benign processes interfering w/function
Dupuytrens contracture
(focal thickening of palmar
fascia, can interfere w/ability to extend fingers, non-tender, no
inflammation, associated with diabetes, ETOH, and
idiopathic
Trigger finger
(finger stuck in flexed position
w/inability to extend smoothly, then sudden give-way and able to move,
slowly progressive to point where cant extend, sometimes tender, no
redness or swelling)
Osteoarthritis
(slowly progressive pain at any
joint, related to chronic wear and tear, can also have antecedent injury
that damages joint, worse w/use, better w/rest, no redness or warmth,
common at base of thumb → interferes with gripping/twisting)
Extensor tendonitis of thumb (Dequervains)
(sub-acute, pain at base of thumb’s metarcarpal,
worse with thumb extension, interferes with pinching/grasping, no warmth
or redness,
pain on palpation or provocative
maneuvers
Elbow symptoms?
Exam
Trauma – with assessment for fracture based on mechanism of injury, site of pain
Swelling within the joint – associated with intra-articular inflammation
(acute, pain with range of motion, redness, warmth,
swelling
Gout or pseudogout
(acute, hx gout or pseudogout
elsewhere)
Infection
(fever or systemic sx, trauma w/direct
path of infection into joint, or systemic seeding)
RA
(sub-acute, persistent, symmetric, hx RA
elsewhere,
can be associated with nodules
, worse in am due
to gelling phenomenon → better w/use)
Swelling around joint
Olecranon bursitis – non-infected
(sub-acute,
swelling at point of elbow, non-tender, no warmth or redness,
doesnt interfere w/joint movement or
function
Oelcranon bursitis – infected or otherwise inflamed
(swelling at point of elbow, red, warm, tender to
touch,
able to still move elbow joint with minimal
pain
Cellulitis
(redness, swelling, tenderness in skin,
not restricted to anatomic bursa, no evidence bursal fluid
collection)
Non-inflammatory pain
Osteoarthritis
(not common probably because not a
load bearing joint and not prone to injury, worse with activity,
chronic/slowly progressive, no warmth, redness or swelling)
Lateral epicondylitis
(chronic, pain over lateral
aspect of elbow, associated with chronic/repetitive motion, no warmth or
redness, worse w/wrist extension)
Medial epicondylitis
(chronic, pain over medial
aspect of elbow, associated with chronic/repetitive motion, no warmth or
redness, preserve range of motion of elbow, worse w/wrist
flexion)
Hip area symptoms?
Exam
Groin/inguinal crease, which is the typical location for pain secondary to
intra-articular pathology
Osteoarthritis
(chronic, progressive, associated
with obesity, worse with weight bearing and increased use, sometimes
prior trauma)
Fracture
(hx fall or other high force
injury)
avascular Necrosis
(sub-acute, progressive, pain
w/weight bearing, hx underlying predisposing condition: ETOH, lupus,
trauma, steroid use)
labral injury
(pain in front of hip/groin, worse
w/flexing/rotating, sensation of catching/clicking, can be sports
related)
vascular
(hx atherosclerosis, dull ache, worse
w/activity, better w/rest)
Infection
(acute, pain w/any range of motion,
warmth and redness, fever; direct extension from truama/surgery or
spread from systemic infection)
Non-infectious inflammatory
RA
(known disease elsewhere, sub-acute,
warmth/redness, pain w/ROM, symmetric, worse in morning)
Lateral hip
Trochanteric bursitis
Non-infected
(sub-acute, worse w/movement,
pain on palpation of trochanter, pain w/resisted abduction of
hip, limited warm/redness/swelling, preserved range of motion of
hip)
Infected
(uncommon, pain over trochanter,
redness, warmth and swelling over trochanter)
Referred pain from back
(patients will also
typically have back pain, with radiating/electric shock type symptoms
that travel from back area towards and below hip)
Shoulder pain or symptoms?
Detailed exam
Trauma
Fracture
(acute pain over affected bone(s)→
scapula, clavicle, humerus; sometimes obvious deformity, loss of
function)
A-C separation
(fall directly on shoulder, pain
over A-C,
A-C deformity
Dislocation
(most are anterior w/humeral head
displaced forward out of gleno-humeral joint, significant force from
behind that pushes humerus forward; combination of arm extended,
abducted and externally rotated; deformity and extreme pain, no range of
motion; person will often be holding arm (w/opposite hand) in slight
abduction and ext rotation; can be recurrent, in which case hx prior
dislocation)
Rotator cuff tear
(acute from fall or throwing
injury; often chronic pain prior indicating partial tear)
Mechanical shoulder problems (most common) –
exam
Osteoarthritis
(slowly progressive process, hx
trauma/injury to shoulder that set up the development of OA, loss of
range of motion)
Impingement/sub-acromial bursitis
(sub-acute/chronic, worse w/arm overhead, pain at
night, associated w/repetitive overhead activity like swimming)
Labral tear
(pain w/throwing, decreased velocity
w/throwing of ball)
Instability
(sense that arm will pop out of joint
when move in certain ways, hx prior dislocation)
Biceps tendonitis
(sub-acute/chroicanterior
shoulder pain, worse w/flexion and supination,
biceps rupture
Acrom-clavicular arthritis
(chronic, pain over a-c
joint)
Adhesive capsulitis
(sub-acute to chronic;
exam remarkable for decreased range of motion in all directions,
sometimes antecedent injury that leads to cycle of decreased use
→ decreased ROM → decreased use; no warmth or
redness)
Rotator cuff tear and/or tendonitis
(typically of supraspinatus, results from
chronic overhead motion, resultant pain w/anterior movement,
weakness; if complete tear, cant lift arm from side)
Intra-articular Inflammation
Infection
(acute, pain with any ROM,
red
, fever, hx prior procedure/injection that
introduced infection
Rheumatoid Arthritis
(subacute/chronic, hx RA, B
shoulder sx, worse in AM and better later in day w/use, other symmetric
joint involvement–>MCPs hands, warmth, redness, decreased ROM)
Inflammation around shoulder
PMR
(sub-acute, pain around shoulders and hips,
age > 50, fever w/o other source, worse in AM, fatigue; non-specific
pain around shoulder during exam,)
Referred from processes elsewhere:
intra-abdominal process
R shoulder → subphrenic abscess around liver
(detailed shoulder exam normal, abdominal
symtpoms and pain on palaption)
L shoulder → splenic infarct or abscess
(LUQ pain, reason for embolic event to
spleen → endocarditis)
Cervical nerve root irritation
(pain radiates from
neck to shoulder and down arm; exam w/o evidence intrinsic shoulder
pathology)
Intra-thoracic pathology
(heart attack →
pain can radiate to L shoulder; aortic dissection → pain to L
shoulder, PE → can radiate to either shoulder; in any of these
situation, shoulder exam would be normal and patient should have other
suggestive sx)
Mental Health
More Info About Mental Health:
National Institute of Mental Health
Comprehensive mental status exam
Known mental health disorder?
depression, anxiety, schizophrenia, etc
Do you feel sad or depressed much of the
time?
depression
(PHQ2 screen: little interest or pleasure in
doing things; feeling down depressed or hopeless)
PHQ-9
Depression Screen
Alcohol, other substance abuse?
depression, substance abuse d/o
Anxious much of the time?
Anxiety d/o, substance abuse, depression
Memory problems?
Assoc w/dementia, other – define with
Mini Mental
Status Exam (MMSE)
Confusion?
Delirium
(acute change from prior behavior →
disorganized thinking, confusion; waxes/wanes, spectrum from somnolent to very
agitated, more likely in elderly & those w/underlying cognitive problems like
dementia, easier to identify those who are agitated then those who are
somnolent)
Always secondary to something:
Infection anywhere — the greater magnitude infection, the more likely
delirium
(site of infection identified by
localizing sx and findings)
Meds – in particular psychoactive (benzos, anti-psychotics, narcotics) –
though could be any – often a result of combination of agents
Toxins/over dose – cocaine, crystal, etc
Severe metabolic derangements – hyponatremia, hypercalcemia, hypoglycemia,
etc
Severe organ dysfxn – liver, renal, cardiac, anemia, hypoxemia
Severe pain, in particular if coupled w/any of above
Primary neuro process – trauma, bleeding, infection
Often combinations of the above
Dementia
(older, progressive, memory deficits, slowly
progressive – define w/ comprehensive exam,
SLUMS
Primary thought disorder – assoc w/agitation and disorientation – hx known disease
which is untreated or initial presentation
bipolar
(cycling between periods of depression and
mania → euphoria, risky behavior, racing thoughts, easily
distracted, poor performance school/work, not sleeping,
delusions)
schizophrenia
(age onset teens-30s,delusions,
halucinations, hearing voices, disordered thought, disorganized
behavior, social withdrawal)
Skin and Hair
More Info About Skin Disorders:
National Institute of Arthritis and Musculoskeletal and Skin
Disorders
Hair Loss
Without Scarring
Andro-genetic
Men
(bi-temporal & /or posterior)
Female → diffuse
Hereditary
(family hx)
Alopecia areata
(male or female, 20-50, circumscribed
patches or generalized, spontaneously re-grows)
Telogen effluvium → diffuse loss
(w/severe
systemic, chemo or other meds, hiv, pregnancy; generally regrows after
insult)
Local trauma → chronic pullin
Local fungal infection
(patches, flaking)
Malnutrition
With Scarring
Hereditary or developmental d/o
Necrotizing Infection – bacterial, fungal
Cancer of the skin or mets
Exposures
Burns, XRT, Caustic agents, severe trauma
Dermatoses
Sarcoid, lupus, lichen
Known disease?
cancer, psoriasis, alopecia, etc
Skin eruptions/rashes?
Infection, inflammatory, other
Growths?
Benign
skin tags
lipoma
epidermal cyst
malignant
basal cell cancer
(telangiectasias, pearly w/rolled edges, growing,
non-healing, central depression, sun exposed areas)
squamous cell cancer
(non-healing, growing, crusted, firm, sun exposed
areas)
melanoma
(asymmetry,
bleeds, irregular borders, non-homogeneous pigment, grows, doesn’t
heal)
Sores that grow and/or don’t heal?
malignant
basal cell cancer
(telangiectasias, pearly w/rolled edges, growing,
non-healing, central depression, sun exposed areas)
squamous cell cancer
(non-healing, growing, crusted, firm, sun exposed
areas)
melanoma
(asymmetry,
bleeds, irregular borders, non-homogeneous pigment, grows, doesn’t
heal)
benign
compromised healing from: peripheral arterial disease, poor nutiritional
state,
chronic advanced illness (kidney, liver, hiv), meds (prednisone,
chemotherapy), chronic skin infection
Lesions changing in size, shape, or
color?
Benign
skin tags
lipoma
epidermal cyst
malignant
basal cell cancer
(telangiectasias, pearly w/rolled edges, growing,
non-healing, central depression, sun exposed areas)
squamous cell cancer
(non-healing, growing, crusted, firm, sun exposed
areas)
melanoma
(asymmetry,
bleeds, irregular borders, non-homogeneous pigment, grows, doesn’t
heal)
Itching?
local skin problems
eczema
(chronic,
waxes/wanes, hands/arms/face)
contact dermatitis
(acute,
following contact w/something)
systemic illness:
elevated bilirubin →
jaundice
(advanced liver
disease)
chronic renal dz, other
Finally, we’ve developed the on-line Web App
Digital DDx
, which provides a much more extensive diagnostic support tool. ROS questions are provided, along with a clickable tree of diagnoses to aid in the interpretation of responses. It also contains many other features that highlight the connections between organ based symptoms and specific disorders.
Clinical Images
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