Comlex-2 Pe Cases & Important Questions

Front 1

40 yo F
CC: Rt shoulder/mid-back pain
Character: burning/ stabbing, 0-9/10 - 3/10 on avg, dur 2-4 hours, aggr by eating, worse at night
ROS - pertinent POS: bloating, nausea, belching
ROS - pertinent NEG: UE weakness, CP, pain w/motion, F/C, abdo pain, vomiting
PE: POS Murphy, NEG: RUQ TTP, rebound, jaundice, icterus, shoulder special tests (empty can, etc.)

Back 1

DDx: cholecystitis, pancreatitis, angina, somatic dysfunction
Workup: CMP, abdominal U/S, lipid panel, EKG, osteo exam
Tx: consider surg cs, consider stress test/ echo, OMT for somatic dysfxn

Front 2

35 yo M
CC: Lt wrist pain, `dur: 1 week s/p fwd FOOSH, pain 3-6/10 (avg 5/10) dull throbbing, waxes/ wanes, better w/ibuprofen, worse w/mvmt, loc: lat aspect of palm at base of thenar eminence, radiates into forearm and hand
ROS - pertinent POS: pain w/mvmt, TTP, swelling
ROS - pertinent NEG: weakness, paresthesia, bruising
PE: UE strength & sensation, wrist carpal bones, forearm/ elbow/ radial head, interosseous membrane, DTRs, Tinel, (Reverse/)Phalen, Finkelstein

Back 2

DDx: de Quervain tenosynovitis, carpal tunnel, somatic dysfxn
Workup: wrist x-ray, osteo exam
Tx: consider ortho cs, bracing, ibuprofen 600 mg TID, ice 20 mins x 2-4x/day, PT, OMT (avoid HVLA & mainpulation of wrist)

Front 3

45 yo F
CC: Lt knee pain
Char.: 2 weeks ago, no inciting event, began in AM. 1-6/10 (avg.: 5/10) achy to sharp, pulling sensation (only when turning to Rt.), constant - waxes and wanes, loc: front of knee, worse w/jogging.
MHx: psoriasis
ROS - pertinent POS: pain w/mvmt, TTP
ROS - pertinent NEG: no LE weakness
PE: skin around knee (nml), knee exam, LE strength/ sensation/ DTRs (nml), gait (nml), Appley compression/ distraction (neg), patellofemoral grind (POS)
Osteo exam: TART, innominate, fibular head, tibia on talus

Back 3

DDx: patellofemoral syndrome, psoriatic arthritis, Lyme, meniscal/ lig tear, somatic dysfxn, gonococcal arthritis
Workup: x-ray of knee, CRP, ESR, Lyme titer, MRI, osteo exam, CBC, consider synovial fluid Cx
Tx: PT, ibuprofen 600 mg TID, Abx if Cx positive, consider ortho consult, OMT

Front 4

30 yo F
CC: Rt. Leg pain
Char.: Onset: few days ago, no inciting event. 3-6/10 (avg. 3/10) dull achy, constant, locn: Rt calf muscle
MHx, FHx, SurgHx, meds: NS/ND/no IVDU. Ortho-Evra.
Other: recent long flight from CA
ROS - pertinent POS: Pain w/mvmt, TTP
ROS - pertinent NEG: NO SOB/ CP/ Palps/ LE weakness
PE: cardio, pulm, Rt calf swollen, Thompson squeeze (NEG), LE strength/ sensation/ DTRs (nml)
Osteo exam: TART, fibular head, tibia on talus

Back 4

DDx: DVT, superficial thrombophlebitis, Bakers cyst, muscle/ tendon rupture, somatic dysfxn
Workup: LE Doppler U/S
Tx: heparin

Front 5

34 yo F
CC: Rt hip pain
Char.: onset: "few mos. ago" - no inciting event. 2-6/10 (avg. 3/10) achy/ stiff/ tight, Rt hip into groin, better w/rest, worse w/long periods of standing or walking. Ibuprofen minimal relief.
MHx, FHx, SurgHx: asthma, appy, tonsillectomy
ROS - pertinent POS: as above
ROS - pertinent NEG: NO paresthesias, radiation, weakness, neuro chgs
Other: computer programmer, tends to sit w/left foot tucked under her
PE: abdo, leg length (R leg short), FAIR, FABERE, impingement test, LE strength/ sensation/ DTRs (nml), NO cerebellar signs, limping gait
Osteo exam: sacrum, innominates

Back 5

DDX: piriformis, torn acetabular labrum, short leg syndrome, RA, GI/ GU, somatic dysfxn
Workup: FAIR test, MRA, X-ray of pelvis/ sacrum/ femur, abdominal CT, ESR, CRP, RF, anti-CCP, X-ray, MRI, U/S, osteo exam
Tx: PT/ stretching, consider ortho referral, heel lift, NSAIDs, steroids, DMARDs, diet change, consider GI cs, OMT for somatic dysfxn, change sitting habits at work

Front 6

14 yo F
CC: painful periods
Char.: onset "a few months ago" 0-10/10 cramping, s/t sharp pain in lower belly radiating to low back, worse w/periods, duration: ~3 days, better after periods, Tylenol = minimal relief,
MHx, FHx, SurgHx: seasonal allergies,
OBGHx: G0P0, mearche at 12 yo, 28-day cycles x 3-5 days. Not sexually active.
Social: NEG tob/ EtOH/ recreational drug use
ROS - pertinent POS: fatigue, N/V/D, HA
ROS - pertinent NEG: none
PE: abdo (nml), GU (nml)
Osteo exam: osteo (L1-L2 RSL; TART)

Back 6

DDX: dysmenorrhea, ovarian cyst, UTI, pregnancy, somatic dysfxn
Workup: pelvic/ vaginal U/S, UA, pregnancy test, osteo exam
Tx: topical heat, exercise, nutritional support, pain jnl, NSAID, OCP, IUD, Abx, cranberry juice, OMT for somatic dysfxn (e.g. sacral rocking)

Front 7

19 yo M
CC: abdominal pain
Char.: "about a year ago," 0-8/10 crampy pain, intermittent ~3 days/wk, loc'n whole abdomen, no relief from Tylenol/ Aleve/ Motrin / "grandma's percocet"
MHx, FHx, SurgHx: wisdom teeth, Father: CAD @ 59yo
Social: College student, occ'l EtOH binge on weekends, denies tobacco, tried marijuana once
ROS - pertinent POS: occasional indigestion, freq. bloating/ cramping, occ'l constipation/ straining (nml soft stools), excess flatulence. Stress.
ROS - pertinent NEG: depression, SI, HI, weight gain/ loss, dysphagia, N/V/ hematochezia, melena.
PE: abdo (nml), GU (nml)
Osteo exam: thoracic/ OA, Chapman's pts

Back 7

DDX: IBS, IBD, anxiety, constipation, depression, thyroid, somatization, abdominal mass, somatic dysfxn
Workup: C-scope, celiac panel, stool Cx, abdominal flat plate/ CT, CBC, BMP, LFTs, TSH/ T3/ T4, osteo exam
Tx: diet change (fiber), exercise, avoid laxatives, counseling, supplement thyroid if needed, consider GI referral, OMT for somatic dysfxn (eg sacral rocking)

Front 8

66 yo M
CC: epigastric abdominal pain
Char.: began ~6 mos ago, 4-10/10 intermittent deep ache in epigastrium - no radiation, occurs after eating/ EtOH, worse after eating/ drinking EtOH, ibuprofen (pt not sure), nothing makes it better. Sleeps propped on 3 pillows.
MHx, FHx, SurgHx: GERD, HTN. FHx: HLD. Surg: appy, chole
Meds: prilosec, HCTZ
ROS - pertinent POS: freq. belching, wakes w/sour taste, abdo pain
ROS - pertinent NEG: no wt loss/ gain, N/V/D/C, hematochezia / melena, hematuria
PE: abdo, GU, UE (pain raising left arm)
Osteo exam: thoracic/ OA, Chapman's pt, pre-vertebral ganglion

Back 8

DDX: GERD, PUD, compression Fx, angina, muscle spasm, somatic dysfxn
Workup: EKG/ stress test, EGD, abdo U/S, H. pylori breath/ Ab/ breath test, osteo exam
Tx:staop Prilosec, start PPI, Abx, consider ortho cs, cardio cs, muscle relaxant , OMT for somatic dysfxn

Front 9

35 yo F
CC: HA
Char.: onset: age 14, episodes last 1-2 d., has 2-3 / mo., current episode started yesterday PM, 0-9/10 (avg 6) stabbing sharp pain at base of head radiating to behind right eye, better w/medication, strong coffee (drinks 4-5 cups per day). Worse w/dehydration, stress. Ass'd Sx: photophobia, phonophobia, dry eyes, blurry vision.
MHx, FHx, SurgHx: seasonal allergies, HA. Fhx: non-contrib.
Meds; Excedrin PM, Nasonex PM
ROS - pertinent POS: see above
ROS - pertinent NEG: NO N/V, weakness, neuro signs
PE: HEENT (normal), CN, UE, cerebellar, LMN, MMSE
Osteo exam: cranial, cervical, thoracic, sacrum

Back 9

DDX: migraine HA, tension HA, intracranial aneurysm, space-occupying lesion, caffeine tox, somatic dysfxn
Workup: head/ neck MRI/CT, angiogram, osteo exam
Tx: triptan, Tylenol/ NSAID PRN, BB or TCA, stretching, stress mgmt, consider neurosurgery, counsel on caffeine reduction/ cessation, OMT for somatic dysfxn

Front 10

30 yo M
CC: chronic neck pain
Char.: onset 3 yrs ago post-MVC (rear ended), 4-8/10 (curr 7/10) dull throbbing pain w/occasional electric-like shooting & burning, waxes and eanes, loc'n: back of neck radiating into left shoulder
MHx, FHx, SurgHx: appy, Vicodin PRN (3-4x/d.)
ROS - pertinent POS: see above
ROS - pertinent NEG: NO weakness, neuro signs (incl. saddle anesthesia), no bowel/ bladder changes
PE: UE, spurling, LMN, fine motor
Osteo exam: cranial, cervical, thoracic, sacrum

Back 10

DDX: cervical HNP, stenosis of C-spine, cervical sprain/ strain, space-occupying lesion, MS, somatic dysfxn
Workup: MRI c-spine, head CT/ MRI, osteo exam
Tx: pain mgmt (gabapentin, duloxetine), long-acting opioid, PT, massage, TENS unit, cervical traction, accupuncture, trigger point, consider neurosurgery referral, OMT for somatic dysfxn

Front 11

33 yo M
CC: difficulty turning head
Char.: started 1 d. ago when woke up, no inciting event. 1-3/10 (curr.: 1) intermittent, pulling sensation on Rt. neck when turns head to right. nothing makes it better/ worse.
MHx, FHx, SurgHx: none
ROS - pertinent POS: see above
ROS - pertinent NEG: no weakness, loss of sensation, paresthesia
PE: cervical ROM, UE
Osteo exam: cranial, cervical (SCM), thoracic, sacrum

Back 11

DDX: spasmodic torticollis, cervical sprain/ strain, cervical HNP, somatic dysfxn
Workup: C-spine X-ray, osteo exam
Tx: muscle relaxant, PT, massage, accupuncture, dry needling, TENS unit, cervical traction, trigger point, , OMT for somatic dysfxn (CS)

Front 12

39 yo M
CC: frontal HA
Char.: onset 3 weeks ago (had cold prior to HA onset), 2-6/10 (current: 4/10) constant dull throbbing, loc'n above eyes, better with pressure to face, nothing makes it worse, Ass'd Sx; facial pain, thick green nasal discharge.
MHx, FHx, SurgHx: non-contrib. ALL: PCN
ROS - pertinent POS: fatigue, runny nose, congestion, HA
ROS - pertinent NEG: NO F/C, hearing/ vis chgs, cough, CP, SOB
PE: HEENT (sinuses tender, lymph nodes, ears TM mnl, pulm, cardio
Osteo exam: cranial, cervical, thoracic

Back 12

DDX: acute sinusitis, allergic rhinitis, URI, somatic dysfxn
Workup: X-ray, osteo exam
Tx:Abx (avoid PCN, ceph), sinus lavage, NSAID, OTC decongestant, antihistamine, nasal steroid, OMT for somatic dysfxn

Front 13

What is present in every DDx?

Back 13

somatic dysfunction

Front 14

Shoulder tests?

Back 14

[tbd]

Front 15

LE tests?

Back 15

[tbd]

Front 16

List Dx/ Tx options for musculoskeletal complaints

Back 16

Dx: X-ray, MRI, U/S

Tx: moist heat, ice, NSAIDs, PT, muscle relaxants (cyclobenzaprine is sedating, metaxalone is non-sedating), tramadol for pain

Front 17

Important questions for OBGHx?

Back 17

Age at menarche, regularity/ heaviness of pds., FDLMP, age at first sex, # partners, STI, last breast/ pelvic exam (& was it nml), Hx of pregnancies (TPAL)

Front 18

Important questions for depression screening?

Back 18

In last TWO WEEKS, have you felt: down depressed or hopeless? …little interest or pleasure in doing things? (0: not all all; 1: several d. , 2: > 50%; 3: nearly every d.)

Front 19

Important questions for MMSE?

Back 19

1) AAOx3.
2) Apple penny table (reg.)
3) serial 7s (att'n, calc)
4) repeat [apple, penny table]. (recall)
5) name 2 common objects (language)
6) repeat "no ifs ands or buts" (repetition)
7) complex command (draw two pentagrams).

Front 20

Important questions for GI complaints?

Back 20

abdo pain, N/ V/ D/ C, gas/ bloating, heartburn/ reflux, stool changes (color, blood, frequency)

Front 21

What does MOTHRR stand for?

Back 21

Medications, OMM, Tests, Holistic, Referral, Return

Front 22

What are the parts of a social Hx?

Back 22

TED C SED LOST

Tobacco, Ethanol, Drugs, Caffeine,

Sick contacts, Exercise, Diet, Living, Occupation, Sexual, Travel

Front 23

When do you ask ass'd Sx/ ROS?

Back 23

After HPI

Front 24

When do you wash hands?

Back 24

2 times: before shaking hands, before PE

Front 25

Important questions for stroke?

Back 25

Slurred speech, facial droop, difficulty walking, numbness/ tingling/ weakness, falls

Front 26

Tests of cerebellar fxn?

Back 26

Romberg, pronator drift, finger to nose, RAM, dysdiadocho, heel shin to toe

Front 27

Important questions for musculoskeletal injury?

Back 27

Bruising, swelling, numbness/ tingling

Front 28

Important questions for chest pain?

Back 28

Duration/ location of pain, radiation, pain at rest, sweating, N/V, SOB, dyspepsia, cough

Front 29

Important physical exam pieces for chest pain?

Back 29

JVD, carotid, reproducibility, PMI, respo, abdo (incl aorta)

Front 30

Hospital workup for chest pain?

Back 30

Admit. Cardio cs.

HB MOAN: Heparin, beta blocker, morphine, O2, ASA, nitroglycerin.

EKG, CXR, labs (CK-MB, troponins, CMP), stress test.

Front 31

Abx for appendicitis?

Back 31

ampicillin-sulbactam(unasyn), piper-taxo (zosyn), ticarcillin-clavulanate (timentin), 3Gceph+metronidazole, FQ+metronidazole, ertapenem

Front 32

Abx for sinus infection? PCN allergic?

Back 32

amoxicillin (+/ clavulanate). PCN allergic: azithromycin/ erythromycin

Front 33

Abx for skin infection?

Back 33

*cephalexin* (almost all forms).

PCN ALL: azithro/ clarithro/ clinda. TMP-SMX if MRSA suspected (purulent focus),

Front 34

How do you hold the otoscope?

Back 34

Inverted, with pinkie extended

Front 35

Hospital workup for stroke?

Back 35

Stat head CT, stroke alert / stroke team, labs (cardiac: CK-MB, trop; coags), EKG, ASA

Front 36

DDx for painful periods?

Back 36

Dysmenorrhea, ovarian cyst, UTI, pregnancy, tuboovarian cyst, tubal pregnancy

Front 37

Name three important things in the neck that you always forget

Back 37

1) carotids 2) lymph nodes 3) thyroid

Front 38

Workup for UTI

Back 38

Urine dip, UA, labs

Front 39

Workup for DVT

Back 39

ADMIT, pain relief, imaging, labs (coags, CBC, CMP), elevate leg, chest CT, hem/ onc cs

Front 40

Plan for woman who wants to get pregnant

Back 40

Folate/ prenatal vitamins ASAP, diet/ exercise, tob/ alc/ caffeine cessation, labs, OBG referral, breast & pelvic exams

Front 41

Questions for barfing baby?

Back 41

color/ texture of spitup, dribble/ shoots out, pain/ irritability, cough, turn blue, spit up blood,

Front 42

Range of diagnoses for barfing baby?

Back 42

[pyloric stenosis, malrotation, SBO, allergy, diverticulum]

Front 43

Questions for knee injury?

Back 43

how happened, bruising, swelling, ROM limited, click/ lock, numbness/ tingling

Front 44

McMurray's knee test

Back 44

[tbd]

Front 45

Questions for meningitis?

Back 45

Recent cold/ URI, fever, N/ V, confusion, stiff neck, rash, photophobia, immunizations

Front 46

Workup for meningitis?

Back 46

ADMIT, stat imaging (head CT?), labs, inform familly, ID/ neuro cs

Front 47

DDx for fever (non-infectious causes)?

Back 47

* Critical: AMI, PE/infarct, ICH, CVA, neuroleptic malignant syn, thyroid storm, acute adrenal insufficiency
* Emergenct: CHF, dehydration, recent sz, SCD, transplant rejection, pancreatitis, DVT
* Non-emergent: drug fever, malignancy, gout, sarcoid, Crohn's, postmyocardiotomy syn

Front 48

DDx for fever (infectious causes)?

Back 48

* Critical: bacterial PNA w/RF, peritonitis, meningitis, cavernous sinus, thrombosis, sepsis/ septic shock, meningococcemia
* Emergent: bact PNA, peritonsillar abscess, retropharyngeal abscess, epiglottitis, endocarditis, pericarditis, appendicitis, cholecystitis, diverticulitis, intra-abdominal abscess, pyelo, tubo-ovarian abscess, PID, encephalitis, brain abscess, cellulitis, infect decub ulcer, soft tissue abscess
* Non-emergent: otitis media, sinusitis, pharyngitis, bronchitis, influenza, TB, colitis/ enteritis, cystitis, epididymitis, prostatitis

Front 49

DDx for weakness (neuromuscular)?

Back 49

* Critical: pot'l respiratory compromise, rabies, botulism, tetanus, organophosphate, myasthenic crisis
* Emergent: Guillain-Barre, transverse myelitis, impingement syn, spinal infarct, electrolytes
* Other: Lambert-Eaton, ALS, paraneoplastic syn, diphtheria, porphyria, drug/ tox, tick paralysis, poliomyelitis

Front 50

DDx for weakness (non-neuromuscular)?

Back 50

* Critical: hemodynamic instability, MI, arrhythmia, severe infxn/ sepsis, RF, hyperK+
* Emergent: acute anemia, dehydration, metabolic d/o (eg hypothyroid, DM), electrolyte imbalance
* Other: fatigue, psych (anx/ depr), rheum (fibomyalgia, SLE), malignancy, renal/ hepatic dz, metabolic dz, alcoholism/ tox, malingering

Front 51

DDx for vertigo (central)?

Back 51

Vascular: vertebrobasilar insufficiency, cerebellar hemorrhage, occlusion of PICA (Wallenberg syn.), subclavian steal
Other: head/ neck trauma, vetebrobasilar migraine, MS, temporal lobe epilepsy, hypoglycemia

Front 52

DDx for vertigo (peripheral)?

Back 52

BPPV, labyrinthitis, Meniere's, vestibular neuronitis, acoustic neuroma

Front 53

DDx for confusion? (note: this is only a partial list)

Back 53

Critical: hypoxia (RF, CHF, MI, shock), systemic process (eg hypoglycemia), CNS infxn, HTN encephalopathy, INCR ICP
Emergent: hypoxia (eg severe anemia), systemic dz (lyte/ fluid, thyroid/ adrenal, hepatic failure, nutrition/ Wernicke's), sepsis/ infxn, tox/ withdrawal (sedatives, EtOH, antichol, others), CNS dz (trauma, infxn, stroke, SAH, epilepsy/ sz), neoplasm

Front 54

DDx for depressed consciousness / coma? (p.106)

Back 54

[tbd]

Front 55

DDx for seizure?

Back 55

Syncope (vasopressive vs dysrhythmic), hyperventilation syndrome, prolonged breath-holding, toxic/ metabolic d/o (EtOH abuse/ wd, hypogly, phencyclidine, strychnine, camphor, extrapyramidal rxn), non-ictal CNS event (TIA, transient global amnesia, hemiparetic migraine, carotid sinus hypersensitivity, narcolepsy), hemiballismus, fugue, panic attacks, pseudosz

Front 56

DDx for headache?

Back 56

* Critical: SAH, CO tox, temporal arteritis, bact mening/ encephalitis, carotid dissection
* Emergent: shunt failure, traction HA, tumor/ mass, SDH, mountain sickness, glaucoma, sinusitis, brain abscess, anoxic HA, anemia, HTN crisis
* Nonemergent: migraine, vascular HA, trigeminal neuralgia, post-traumatic, post-LP, HA, dental/ TMJ, tension HA, cervical strain, cluster/ histamine HA, febrile HA, HTN (rare), effort-dependent/ coital HA, [pseudotumor]

Front 57

Key hallmarks of emergent forms of HA: SAH, TMJ, sinus/ dental, temp arteritis, acute A-C glaucoma

Back 57

* SAH: sudden onset, syncope, "worst HA of my life"
* TMJ: jaw mvmt --> INCR pain
* Sinus/ dental: facial pain (esp forehead, maxillary sinus area)
* Temp. arteritis: forehead/ temporal/ periorbital/ retroorbital pain
* Acute AC glaucoma: periorbital/ retro-orbital pain, blurry, fixed pupil

Front 58

DDx for dyspnea?

Back 58

Critical: airway obstruction, PE, noncardiogenic edema, anaphylaxis, ventilatory failure, pulm edema, MI, tamponade, toxin, DKA, epiglottitis, tension PNX, CO tox, acute chest, CVA, intracranial insult, organophosphate tox
Emergent: spont PNX, asthma, cor pulmonale, aspiration, PNA, pericarditis, mechanical interference, hypotension, sepsis, SBO/ LBO, renal failure, lytes, metabolic acidosis, PNA (CAP score > 70), simple PNX, hemothorax, diaphragmatic rupture, anemia, MS, guillain-barre, tick paralysis
Non-emergent: pleural effusion, neoplasm, PNA (CAP < 70), COPD, congential heart dz, valvular dz, cardiomyopathy, pregnancy, ascites, obesity, hyperventilation syn, somatization, panic attack, fever, thyroid dz, rib Fx, ALS, polymyositis, porphyria

Front 59

DDx for CP?

Back 59

Critical: AMI, acute coronary ischemia, aortic dissection, tamponade, PE, tension PNX, Boerhaave
Emergent: USA, coronary spasm, Prinzmetal, cocaine (peri/myocarditis), PNX, mediastinitis, Mallory-Weiss tear, cholecystitis, pancreatitis
Non-emergent: valvular dz, AS, MVP, HOCM, PNA, pleuritis, lung tumor, pneumomediastinum, esophageal spasm/ reflux, PUD, biliary colic, muscle strain, rib fx, arthritis, tumor, chostochondritis, non-specific chest wall pain, spinal root compression, throacic outlet, zoster, postherpetic neuralgia, psych, hyperventilation

Front 60

DDx for syncope? (p. 142)

Back 60

[tbd]

Front 61

DDx for abdo pain?

Back 61

"Top to bottom:"

esophagitis

gastritis, acute gastroenteritis.

Duodenitis.

Biliary tree dz.

Acute appendicitis.

Constipation/ obstipation.

Diverticulitis.

Catch-all: non-specific/ fxnl abdo pain

Wild card: ureteral colic.

Front 62

Structures of primitive gut & pain location?

Back 62

Upper abdominal pain = foregut: stomach, duodenum, liver, pancreas
Periumbilical = midgut: small bowel, proximal colon, appendix
Lower abdominal pain = hindgut: distal colon, GU tract

Front 63

DDx for abdo pain, by quadrants (including diffuse)?

Back 63

* Diffuse: peritonitis, pancreatitis, sickle cell crisis, early appendicitis, mesenteric thrombosis, gastroenteritis, aortic aneurysm, intestinal obstruction, DM, IBD, IBS
* RUQ: biliary colic, cholecystitis, gastritis, GERD, hepatic abscess, acute hepatitis, hepatomegaly 2'/2 CHF, perf ulcer, pancreatitis, retrocecal appendicitis, MI, appendicitis in preg, RLL PNA
* LUQ: gastritis, pancreatitis, GERD, splenic pathology, MI, pericarditis, myocarditis, LLL PNA, pleural effusion
* RLQ: appendicitis, diverticuliutis (Meckel's, cecal), aortic aneurysm, ectopic preg, ovarian cyst, ovarian torsion, tubo-ovarian abscess, PID, endometriosis, UTI, ureteral calculus, psoas abscess, mesenteric adenitis, incarcerated hernia.
* LLQ: aortic aneurysm, sigmoid diverticulitis, incarcerated hernia, ectopic preg, ovarian torsion, ovarian cyst, PID, endometriosis, tubo-ovarian abscess, mittelschmerz, ureteral calculus, UTI, psoas abscess

Front 64

DDx for GI bleed? Most important distinguishing factor(s)?

Back 64

* Upper vs. lower. Adult vs. child
* Most common to least common:
--Adult lower GI bleed: diverticulosis, angiodysplasia, UPPER GI BLEED, cancer/ polyps, rectal dz, IBD

--Adult upper GI bleed: PUD, gastric erosions, varices, Mallory-Weiss, esophagitis, duodenitis (erosion --> rupture --> inflammation)
--Child upper GI bleed: esophagitis, gastritis, ulcer, varices, Mallory-Weiss (inflammation --> erosion --> rupture -->)
Child lower GI bleed: anal fissure, infectious colitis, IBD, polyps, intussusception

Front 65

DDx for diarrhea

Back 65

Infectious: 60% viral , 20% bacterial, 5% parasitic
Non-infectious:

Front 66

DDx for back pain

Back 66

1) Non-specific: 85% - no X-rays, Tx: pain ctrl

2) Vert Fx - H&P: trauma, spinal point tenderness; Dx: X-ray; Cs: ortho/ spine

3) Epidural abscess - Hx: IVDU, fever, spinal point tenderness; Dx: MRI; Tx: IV Abx, Cs neurosurg

4) Cauda Eq. - Hx: saddle anes, loss of bowel/ bladder ctrl; Dx: MRI; Tx: steroids, IMM neuroosurg cs

5) HNP - Hx: sciatica, straight-leg raise

6) AAA rupture - Hx: old male smoker; Dx: U/S, CT-; Tx: emerg surg, T&S

7) Pyelo - Hx: CVAT, urinary Sx; Dx: UA; Tx: cipro x 2 wks, f/u PCP

8) PE - w/u as PE

Front 67

DDx for cough

Back 67

* Acute:

1) PNA - Hx: fever, sputum; Dx: CXR; Tx: Abx

2) Sinusitis - Hx: purulent rhinorrhea, sinus TTPl; Dx: clin.; Tx: nasal spray/ pseudoephedrine, ABx

3) foreign body - Dx: CXR; Tx: bronchoscopy

4) URI - Hx: cong/ rhinor/ aches; Dx: clin.; Tx: reassurance

5) Asthma/ COPD - Hx: wheeze, TOB; Dx: clin.; Tx: nebs/ steroids, COPD: ABx

6) Allergic rhinitis - Dx: seasonal, swollen eyes; DX: clin; Tx: antihistamine/ loratidine

* Non-acute:

7) GERD - Hx: food, epig pain; DX: clinical; Tx: GI cocktail, f/u PCP

8) ACE cough - Tx: f/u PCP, dc ACE

Front 68

DDx for leg pain

Back 68

* Trauma: knee Fx, ACL tear, collaterals, meniscus, ankle injury

--Dx: X-ray Fx, MRI the rest

--Tx: immob, cs ortho

* Joint: Septic joint, gout, arthritis

--septic & gout are RED JOINTs; tap both

--septic: ABx, surg cs

* Other: DVT, abscess/ cellulitis

Front 69

DDx for fever

Back 69

* Real fever: meningitis/ encephalitis, AOM, strep, URI, PNA, PE, UTI/ pyelo, abdominal (app'x, GB, pancreas, SBP, PID, etc.), skin

* Hyperthermia: neuroleptic/ serotonin/ MH, heat stroke, cocaine, CNS lesion

--NMS... & heat stroke: CPK, Crn

--heat stroke & CNS: cooling

--NMS... & cocaine: benzos

Front 70

DDx for weakness

Back 70

* Tx:

1) IMMEDIATE EKG & fingerstick

2) Review VS. CHk for orthostasis.

3) Focal or Gen'l

* Focal: CVA, MS, Guillain-Barre, transverse myelitis, myashenia gravis

* Gen'l: cardiac, anemia, lytes, infxn, med change, hypothyroid, rheum, depression, dehydration

4) PE: HEENT (conjunctiva, PERRLA, EOM), lung (crackles), full neuro, rectal: good tone, guaic neg, brown stool.

5) Workups: cardiac - EKG, trops. Anemia - CBC, coags, T&S. Lytes - BMP, EKG (K+). Infxn: UA, bloodCx, CXR, LP. thyroid - TSH. Rheum - ESR, DEPR - exclude. Dehydration - clinical, BUN/Cr.

Front 71

DDx for vomiting?

Back 71

* IMMEDIATE FINGERSTICK

* 3 sources:

1) Head: ACS/ MI, ICH, mening, vertigo

2) Abdo: SBO, DKA, other (acute gastroenteritis, appy, GB, pancr, PUD, perf, etc. - workup as abdo pain)

3) Other: hyperemesis gravidarum, lytes, EtOH/ tox, post-tussive, acute gastroenteritis

* Key questions: bilious? bloody?

* Pearls/ pitfalls:

--Peritoneal signs - rebound, rigid abdomen --> IMM surgery cs

--NO REGLAN if SBO suspected; give Zofran bc it does not promote motility

--Can't tolerate PO = CAN'T GO HOME

--Diarrhea is reassuring, but make sure it's real diarrhea & not soft stool.