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A review of systems (ros) provides which of the following information?

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Hi everyone:

One of my first projects as Program Director was to codify the “Yale Way,” our system for note writing and presenting on rounds. The Yale Way isn’t unique to Yale, of course; other institutions use the same method, more or less. But codification works. It ensures we all speak the same language and tell stories that are thorough, concise, efficient, lucid, and easy to follow.

This is the time of year to establish good habits, so with that in mind, I offer these notes on notes:

  1. Make the Chief Concern (CC) a full sentence. Fragments (e.g., “abdominal pain”) lack context. Tell us the patient’s name, age, gender, and relevant background information. For example:
    1. CC: Mr. Jones is an otherwise healthy 21-year-old man presenting with one day of worsening right lower quadrant abdominal pain.
    2. CC: Ms. Smith is a 45-year-old woman with a history of ulcerative colitis, presenting with 5 days of crampy abdominal pain and bloody diarrhea.
    3. CC: Mr. Washington is a 68-year-old man with atrial fibrillation and severe peripheral vascular disease, presenting with sudden, excruciating abdominal pain.
  2. Put the Past* Medical History (PMH) in the PMH section. Sometimes, I feel like I’m at the beach, drowning in a tidal wave of saltwater, seaweed, sand, shell fragments and fish parts:
    1. An atrocious CC: Ms. Thompson is a 57-year-old woman with obesity s/p gastric bypass in 2014, Type 2 DM on metformin, poorly controlled hypertension, hyperlipidemia on atorvastatin, Vitamin B12 deficiency, asthma, migraines, gout, DJD, anxiety, past IVDU, presenting with a sudden severe headache. If you can focus when you read this, more power to you. I can’t.
    2. A better CC: Ms. Thompson is a 57-year-old woman with a history of multiple medical problems, including poorly controlled hypertension, presenting with a sudden severe headache. Relegate the miscellaneous details to the PMH.
  3. State where you got your information. Patient, family members, prior records, etc. Tell us if information is missing. Review old records, including the Epic Media Section and Care Everywhere. We found old PFTs on a Fitkin patient yesterday, which transformed how we viewed her illness.
  4. Tell the HPI in order. Your goal isn’t to write a modernist novel that no one can follow. Start at the beginning:
    1. This works: “The patient was in her usual state of health until...”
    2. Create a timeline referring to the day of admission: “5 days prior to admission, this happened; 2 days prior to admission, this happened; on the day of admission, this happened, etc.”
    3. For patients admitted through the ED, highlight the main events: “The patient had a fever of 102 and a chest x-ray showing a right upper lobe infiltrate. She was started on ceftriaxone and doxycycline, and admitted to the floor”
    4. For patients transferred from other services, highlight the prior hospital course: “The patient spent two weeks on the ventilator, completed two weeks of vancomycin for MRSA pneumonia, had two left-sided chest tubes placed to drain an empyema, was extubated yesterday, and transferred to the floor today.”
  5. Don’t put the Review of Systems (ROS) in the HPI. It’s common to confuse the ROS with pertinent positives and negatives. The ROS is a screening tool, a top to bottom survey, which we should ask of everyone. In your note, it goes just before the physical exam. In contrast, pertinent positives and negatives are targeted descriptions of relevant symptoms, essential to a thorough history. For example, in a patient with a fever, pertinent positives point to the diagnosis (“The patient described chills, cough, rusty sputum, and right-sided chest pain that worsened with inhalation”). Pertinent negatives point away from associated complications (“He denied shortness of breath”) and rule out other diagnoses (“He denied headache, neck stiffness, nausea, vomiting, diarrhea, dysuria, and rash”).
  6. Humanize your patients. Use “woman,” not “female.” Use “man,” not “male.” Without being gratuitous, enrich your story with special information (a guitar player, an avid gardener, a retired teacher, a standup comic, etc.).
  7. Elaborate on the key parts of the physical exam. If a patient has lymphadenopathy, supply the details: Where? How many? Mobile? Size? Tender? Consistency (firm, rubber, hard, matted, etc.)? Do the same for the heart exam in a patient with endocarditis, the neuro exam in a patient with altered mental status, and the lung exam in a patient with asthma.
  8. Provide context for test abnormalities. New abnormalities demand immediate attention; old abnormalities may not (unless they’ve been overlooked):
    1. “The creatinine is 2.4 today, up from 1.2 yesterday.
    2. “The chest x-ray shows a 2 cm speculated right upper lobe nodule, new from a year ago.”
    3. “The hemoglobin is 8.1, unchanged from her baseline.”
  9. Start your assessment with a summary. Patients can be really complicated. Highlight the relevant details and filter out the rest. For example: “In summary, this is an elderly woman with longstanding dementia and dysphagia who resides in an ECF, presenting with fever, hypoxemia, and a new right lower lobe infiltrate, one day after aspirating tube feeds.”
  10. Create a complete problem list. If you mentioned it in your note, you own it. Go back to your CC. If the patient presented with fatigue, that’s a problem. If you found a goiter, that’s a problem. If the ultrasound showed a renal mass, that’s a problem. Some problems can and should be grouped, like thyromegaly, tachycardia, tremulousness, and a low TSH. You need to decide what to group and what to separate. Above all, don’t identify a problem in the first part of your note, just to let it drop at the end.
  11. Think before you plan. Assess. Show your work. What’s your differential diagnosis? What’s most likely (“minor neck trauma”)? What’s less likely but still a “can’t miss" (“cervical spine fracture")? Why do you think the patient has SIADH? How do you know she isn’t volume depleted? Do you think HCTZ is contributing? Tell us.
  12. List action plans. Create a list, and don’t use the plan section to repeat data or share observations (e.g., “s/p 14 days of ceftazidime”). Use bullets, first workup, then treatment:
    • Check blood cultures
    • Obtain an echocardiogram
    • Start vancomycin and pip-tazo
    • Consult ID

Baker’s dozen. Seniors- remember to attach a succinct addendum to all Intern H&Ps. You contributed to the patient’s workup. We need to see your thoughts.

This list is incomplete, of course, and I’d love to hear your ideas. Remember, we can’t take great care of our patients if we don’t communicate well. Look over your notes. Make them memorable. Things of beauty. And think before you sign.

With that, I’m off to join my Fitkin team.

Mark

*Why do we call it the “past” medical history? Is there a “future” medical history?

PS Wriggling by me yesterday on a climb up East Rock:

A review of systems (ros) provides which of the following information?

MDS

Submitted by Mark David Siegel on July 12, 2020

  1. Review of Systems includes 14 systems (per CMS)

  1. Bone pain
  2. Joint Pain or Joint Swelling
  3. Muscle pain

  • History
  • Skin (integument, includes Breast)

  1. Anxiety
  2. Sadness
  3. Irritability
  4. Insomnia
  5. Suicidality

  1. Heat intolerance or cold intolerance
  2. Excessive thirst (polydipsia)
  3. Excessive hunger (polyphagia)

  • History
  • Hematologic or Lymphatic

  • History
  • Allergic or immunologic

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:

  1. As a screening tool asked of every patient that the clinician encounters.
  2. 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:

  1. The questions asked reflect an array of common and important clinical conditions
  2. These disorders would go unrecognized if the patient was not specifically prompted
  3. 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:

  1. Clicking on the main questions reveals a list of common disorders that might be at the root cause of the particular symptom.
  2. Comments in parentheses that follow include other symptoms and/or historical features commonly linked to that particular disorder.
  3. "Red flag" indicates symptoms that are particularly worrisome for a serious illness.
  4. 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:

  1. The list of possible diagnoses that follows a question is not exhaustive. In addition please realize that no patient responses are pathognomonic.
  2. 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.
  3. 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.

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
    • 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
      • 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
      • 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


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
  • 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
    • 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

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


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


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
    • 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


More Info About Pulmonary Disorders: National Heart, Lung and Blood Institute

Comprehensive pulmonary exam

Chronic or past pulmonary disorders?

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
    • Effusions- 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


    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

    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


    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→ https://medpics.ucsd.edu/index.cfm?page=skin_sclerodactyly.htm, 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.


    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


    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?


    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
        • chronic
    • 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


    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?

    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
    • Discharge
      • benign
      • 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


    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).


    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

    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


    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)


    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)


    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


    Known disease?

    • cancer, psoriasis, alopecia, etc


    Skin eruptions/rashes?

    • Infection, inflammatory, other


    Growths?

    • Benign
      • skin tags
    • 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
    • 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
    • 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.

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    How do you play Roblox on a Chromebook without downloading it
    How do you play Roblox on a Chromebook without downloading it

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