Diseases for Clinical Skills

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					Chest pain:

                        Nature of                                                                                                    Precipitating/Aggravating              Ameliorating
                                                        Nature of Symptoms                             Associated Symptoms
                         Patient                                                                                                               Factors                        factors

                                                                                                                                     •   Exertion (including sexual
                                                                                                                                                                        •   Nitroglycerine
                                       •   Achy, dull, tight, severe, pressing                     •   Women more likely to              activity)
                                                                                                                                                                        •   Rest
 Angina Pectoris    •   Adult          •   Not usually sharp or sticking                               have atypical symptoms        •   Cold exposure
                                                                                                                                                                        •   Valsalva's
                                       •   Substernal                                                  (back pain, nausea, fatigue   •   Emotional stress
                                                                                                                                                                            Maneuver
                                                                                                                                     •   Recumbency often

                                                                                                                                     •   Overeating
                                                                                                                                     •   Recumbency (may                •   Antacids
 Gastroesophageal                      •   Burning, tightness                                      •   Water brash
                    •   Any age                                                                                                          awaken from sleep)             •   Proton pump
 reflux                                •   May be identical to symptoms of angina                  •   "Heartburn"
                                                                                                                                     •   Occasionally precipitated by       inhibitors
                                                                                                                                         exertion

                                       •   Sharp or dull                                           •   Fever
 Pericarditis       •   Any age
                                       •   Protracted duration                                     •   Recent viral infection

                                                                                                   •   Fever
                    •   Classical                                                                  •   Cough that produces
                        presentation   •   Classic presentation: rapid onset with fever, chills,       sputum; may contain blood     •   Risk factors include
                        less               cough and pain in the side / chest, often so            •   Physical exam: egophony,          smoking, alcohol abuse,
 Pneumonia
                        common in          severe as to limit respiratory movements                    dullness on percussion,           asthma,
                        infants and    •   May also have shortness of breath                           rales                             immunocompromised pt
                        elderly                                                                    •   Symptoms vary with extent
                                                                                                       of disease

                                                                                                                                     •   Prolonged immobilization
                                                                                                   •   Tachypnea (rapid                  (DVT)
 Pulmonary          •   Usually        •   Sharp, severe, often pleuritic                              breathing)                    •   Oral contraceptives (esp.
 Embolism               adult          •   Often heavy & steady                                    •   Hemoptysis (blood in              in smokers)
                                                                                                       sputum)                       •   Worse with changes in
                                                                                                                                         position


Questions to ask:
• OPQRST
• Worse with eating? Eating certain types of food? (GERD)
• Worse with exercise or exertion? Climbing stairs? (Angina, maybe GERD)
• Any long periods of sitting still recently? Plane trips, car rides? (DVT --> PE)
• Any fever, cough, recent illness? (pericarditis or pneumonia with cough). Any blood in your sputum? (PE)




                                                                                                                                                                                           1
Abdominal pain:

                                                                                                                                   Precipitating /
                                                                                                                                                      Ameliorating       Associated
                        Location                           Presentation                                 Timing                      aggravating
                                                                                                                                                        Factors          Symptoms
                                                                                                                                      factors

                                           •   Classical presentation (appear in <50%
                                               patients):
                                               ◦ epigastric/periumbilical pain
                                               ◦ followed by brief nausea, vomiting,
Appendicitis                                                                                                                                                         •   Low-grade
                 •   Pain epigastric or           anorexia                                •   Acute onset
(acute                                                                                                                                                                   fever common
                     periumbilical             ◦ pain shifts to RLQ after a few hours     •   Changing symptoms over time
inflammation                                                                                                                                                             (100-101 F)
                 •   Shifts to RLQ after       ◦ RLQ direct and rebound tenderness            (see Presentation)
of veriform                                                                                                                                                          •   Nausea,
                     a few hours                  at McBurney's point
appendix)                                                                                                                                                                vomiting
                                           •   Non-classical: variations are common;
                                               pain may not be localized (infants &
                                               children), tenderness may be diffuse or
                                               absent

                                                                                          •   Episodic: episodes begin
                                           •   80% asymptomatic (biliary colic findings
                 •   RUQ (or elsewhere                                                        suddenly,                                                              •   Nausea,
Cholelithiasis                                 described here)
                     in abdomen)                                                          •   intensify within 15m-1h,                                                   vomiting
(presence of                               •   Pain usually severe enough to send pt to
                 •   Often poorly                                                         •   remain at steady intensity for                                         •   Fever and
1+ calculi /                                   ED
                     localized                                                                6-12h,                                                                     chills only if
gallstones in                              •   RUQ or epigastric tenderness may be
                 •   May radiate into                                                     •   gradually disappear over                                                   cholecystitis
gallbladder)                                   present; peritoneal findings absent (no
                     back or arm                                                              30-90m, leaving dull ache                                                  has developed
                                               rebound tenderness)
                                                                                          •   Pts feel well between episodes

                                                                                                                               •   May be worse a
                                                                                                                                   couple of hours
                                                                                                                                   before or after    •   Drinking   •   Nausea
                                                                                          •   Heals & recurs
                                                                                                                                   meals                  milk /     •   Loss of
                                           •   Indigestion, heartburn-type symptoms       •   Pain may occur for days/
                                                                                                                               •   NSAID use (esp.        eating         appeitite
                                           •   Pain or discomfort                             weeks then wane/disappear
Gastric ulcer    •   Middle of upper                                                                                               aspirin), high     •   Antacids   •   Weight loss
                                           •   Bloating, early sense of fullness with         (symptom free for weeks or
(peptic ulcer)       abdomen                                                                                                       caffeine intake,       (not       •   GI bleeding
                                               eating                                         months)
                                                                                                                                   alcohol/tobacco        always)        (vomit blood
                                           •   30% of pts awakened at night               •   Pain typically soon after
                                                                                                                                   use, stress can    •   Pain           or blood in
                                                                                              eating
                                                                                                                                   contribute to          returns        stool)
                                                                                                                                   gastric ulcer
                                                                                                                                   formation

Intestinal       •   Often described as    •   Abdominal pain (crampy)                    •   Paroxysms of pain every 4-5      •   Surgery (post-
                                                                                                                                                                     •   Nausea /
obstruction          periumbilical         •   Abdominal distension                           minutes                              operative
                                                                                                                                                                         vomiting



                                                                                                                                                                                        2
                                                                                       •   Colon requires 12-24 hrs to
                                                                                           empty after onset of bowel
                                       •   Obstipation (severe & obstinate                                                                                •   Fever and
(small bowel                                                                               obstruction, so flatus &           adhesions /
                                           constipation)                                                                                                      tachycardia
obstruction)                                                                               passage of feces may               hernias)
                                       •   Inability to pass flatus                                                                                           if strangulating
                                                                                           continue after onset of
                                                                                           symptoms

                                                                                       •   Unlike cholelithiasis, can last
               •   Acute upper
                                                                                           for days                                                       •   Nausea /
                   abdominal pain
                                                                                       •   Acute, rapid onset (max                                            vomiting
                   (mid-epigastrum,
                                       •   Usually severe enough to elicit ED visit,       intensity in 10-20m)                             •   Bending   •   Restlessness,
Pancreatitis       RUQ, or diffuse)
                                           admission to hospital                       •   If related to alcohol, may occur                     forward       agitation
               •   Band-like
                                                                                           1-3 days after binge or                                        •   Fever,
                   radiation to back
                                                                                           cessation of drinking                                              tachycardia
                   (50% pts)
                                                                                       •   May be recurrent


Questions to ask:
• OPQRST
• Nausea / vomiting / fever? (common to all conditions here but probably still important)
• Location of pain & any movement / radiation especially important
• Timing also especially important (episodic / first time, how often).
• Does the pain wake you up at night?
• What medicines do you take regularly? How much (esp. NSAIDs - aspirin, ibuprofen, naproxen)? (gastric ulcer)
• Alcohol / tobacco use? (gastric ulcer)
• Recent surgeries? (small bowel obstruction)
• Any blood (brown or red) in vomitus or stool? (gastric ulcer)
• Rebound tenderness? (appendicitis)




                                                                                                                                                                             3
Shortness of breath:

                 Nature of                                                                                                              Precipitating/Aggravating         Ameliorating
                                                   Nature of Symptoms                                Associated Symptoms
                  Patient                                                                                                                         Factors                   factors

                                                                                                                                    •   Allergens
             •   Most
                                •   Acute dyspnea                                                                                   •   Exercise
                 common
                                •   Episodic                                                                                        •   Noxious fumes
                 cause of                                                                       •   Cough (indicates asthmatic
Asthma                          •   May rarely be dyspneic only at night                                                            •   Respiratory tract infections
                 recurrent                                                                          bronchitis)
                                •   Physical findings: bilateral wheezing; sibilant,                                                •   Recumbency
                 dyspnea in
                                    whistling sounds; prolonged expiration                                                          •   Exposure to cold
                 children
                                                                                                                                    •   Beta-blockers

                                •   Chronic dyspnea with gradual onset                                                              •   Exercise
                                                                                                                                                                          •   Nocturnal
                                •   Paroxysmal nocturnal dyspnea                                                                    •   Beta-blockers or Ca-
Congestive                                                                                                                                                                    dyspnea
             •   Older          •   Dyspnea remains long after stopping exercise                                                        channel blockers
Heart                                                                                           •   Edema                                                                     may be
                 patients       •   Physical findings: edema, shallow respirations,                                                 •   Recumbency
Failure                                                                                                                                                                       relieved by
                                    hepatomegaly, elevated JVP, 3rd heart sound, basilar                                            •   Trauma, shock, hemmorhage,
                                                                                                                                                                              sitting
                                    rales                                                                                               anesthesia

             •   Older
                 patients                                                                                                           •   Smoking                           •   Leaning
                                •   Chronic dyspnea                                             •   Fast recovery to normal
                 (rarely <                                                                                                          •   Exertion                              forward
COPD                            •   Dyspnea with exertion                                           respiration after stopping
                 30yo)                                                                                                              •   Postural changes have little or       while
                                •   Physical findings: rapid, shallow respirations                  exercise
             •   Most often                                                                                                             no effect                             seated
                 smokers

                                •   Progressive dyspnea precedes onset of cough
                                •   Usually no dyspnea at rest
Emphysema
                                •   Physical findings: "pink puffers"; hyperventilated lungs,
(a type of                                                                                                                          •   Smoking
                                    hyperresonance, decreased breath sounds &
COPD)
                                    diaphragmatic movement, increased anteroposterior
                                    chest diameter

                                                                                                •   Fever
             •   Classical                                                                      •   Cough that produces sputum;
                                •   Classic presentation: rapid onset with fever, chills,
                 presentation                                                                       may contain blood               •   Risk factors include smoking,
                                    cough and pain in the side / chest, often so severe
Pneumonia        less common                                                                    •   Physical exam: egophony,            alcohol abuse, asthma,
                                    as to limit respiratory movements
                 in infants                                                                         dullness on percussion, rales       immunocompromised pt
                                •   May also have shortness of breath
                 and elderly                                                                    •   Symptoms vary with extent of
                                                                                                    disease



Acute dyspnea after exercise: think: is it pulmonary or cardiac? Pulmonary: fast rate of recovery to normal respiration; cardiac: remain
dyspneic much longer after cessation of exercise. Heart range changes with exercise last longer, too, in a pt with cardiac dyspnea.

                                                                                                                                                                                        4
Questions to ask:
• OPQRST
• Smoking history?
• Cardiac history?
• Does it get worse with exertion? What kind of exertion? How quickly does it pass afterwards? (CHF = takes long time to recover)
• Coughing? (pneumonia, COPD, asthmatic bronchitis) Blood in sputum? (pneumonia)
• Any fever? Signs of infection? (pneumonia)
• Worse at any particular times of the year? Worse in certain places (environmental exposures --> asthma)?
• Does sitting up (CHF) or leaning forward (COPD) make it better? Does laying down make it worse (asthma, CHF)?




                                                                                                                                    5
Headache:

                   Nature of                                                                                                         Precipitating/Aggravating     Ameliorating
                                                      Nature of Symptoms                           Associated Symptoms
                    Patient                                                                                                                    Factors               factors

                                    •   Recurrent or chronic
                                                                                                                                 •   Emotional / physical stress
                                    •   Usually or psychogenic origin
                                                                                                                                 •   Abnormal neck position
                                        ◦ Children: stress, anxiety, depression
                                                                                                                                     (esp. extension)
                                    •   Adults: usually dull, non-throbbing, persistent low
                                                                                                                                 •   Prolonged mental
               •   Most                 intensity
                                                                                                                                     concentration
                   common           •   Timing varies with cause of tension
Tension                                                                                                                          •   Withdrawal of analgesics or
                   cause of         •   May awaken with headache in morning but rarely at
(muscle                                                                                                                              tranquilizers                 •   Stress
                   headache at          night                                                 •   Fatigue
contraction)                                                                                                                     •   Dental malocclusion or            reduction
                   any age          •   May last a few days
headaches                                                                                                                            poorly fitting dentures
               •   More common      •   Severity may increase as day progresses and then
                                                                                                                                 •   Bruxism (nighttime grinding
                   in females           decrease towards evening
                                                                                                                                     of teeth)
                                    •   Usually occipital, suboccipital, bilateral
                                                                                                                                 •   Withdrawal of analgesics
                                    •   Described as constrictive band around head or
                                                                                                                                     used chronicallly to treat
                                        tightness of scalp
                                                                                                                                     headaches
                                    •   Rarely awakens pt from sleep

               •   More common
                   in women                                                                   •   Visual auras (scotomata,
               •   Incidence:       •   Recurrent or chronic                                      transient blindness, blurred
                   1.4% < 7 yr,     •   Prominent aura                                            vision, hemianopsia            •   Menstruation
                   5% @ 17 yr,      •   Prodrome: has abrupt onset                            •   Nonvisual auras (weakness,     •   Emotional stress
                   17%                  ◦ Lasts 15-20 min                                         aphasia, mood disturbances,    •   Fatigue
                   postpubescent        ◦ Precedes headache by 15-30 minutes                      photophobia)                   •   Bright lights
Classic            males, 20%           ◦ Often contralateral to headache                     •   Nausea and vomiting            •   High altitude                 •   Sleep
Migraine           postpubescent    •   Headache                                              •   Anorexia                       •   Weather changes               •   Triptans
                   females; 50%         ◦ Severe, throbbing, unilateral                       •   Sonophobia, photophobia        •   Exercise
                   of adults with       ◦ Supraorbital / frontal region                       •   Irritability                   •   Certain foods
                   migraines            ◦ Gradual onset                                       •   Dizziness                      •   Fasting
                   have onset of        ◦ Intensity increases steadily & rapidly              •   Fluid retention                •   Hypoglycemia
                   symptoms             ◦ Lasts 2-8 days                                      •   Abdominal pain
                   earlier than                                                               •   Sleepiness
                   age 20

                                    •   Recurrent or chronic                                  •   Those of classic migraine
Common                              •   Vague or absent aura and prodrome                     •   General malaise, fatigue
Migraine       •   More frequent    •   Gradual onset                                         •   Chills                                                           •   Sleep
(without           in children      •   Lasts up to 72 hours                                  •   Diarrhea                                                         •   Triptans
aura)                               •   Not always unilateral                                 •   Urticaria
                                    •   Usually in frontotemporal or supraorbital region      •   Motion sickness


                                                                                                                                                                                   6
                                                                                 • Neurologic dysfunction
                                                                                 • Projectile vomiting without
Tumor                     •   Progressive, chronic headache (becoming more and     nausea
                                                                                                                  •   Coughing
(increased                    more severe)                                       • Localized pain prevents
                                                                                                                  •   Sneezing
intercranial              •   Change from usual headache pattern                   sleep
                                                                                                                  •   Straining at stool
pressure)                 •   Onset of severe headaches > 50 yo                  • Headache worse in the
                                                                                   morning
                                                                                 Physical findings: papilledema


Questions to ask:
• OPQRST
• Sensitivity to light? Sound?
• Any changes in your vision along with the headache? Any changes in speech?
• Nausea or vomiting?
• Has it been getting worse recently or staying about the same?
• Is it worse when you cough, sneeze, or have a bowel movement?
• Does it wake you up at night?




                                                                                                                                           7
Musculoskeletal:

                                                                                                                                                                         Associated
                                  Location                                               Presentation                                       Timing
                                                                                                                                                                         Symptoms

                                                                 •   Superficial inflammation (tendon sheaths & bursae) &
                                                                     soft tissue swelling
               •   Fingers: DIP                                  •   Single joint with erythema (redness) of the joint,
                                                                                                                                 •   Intermittent pattern
               •   Classic: pain, edema, inflammation in             warmth, tenderness, or combination of symptoms
                                                                                                                                 •   Episodic; intervening
Gout               metatarsal-phalangeal joint of                •   Asymmetric edema
                                                                                                                                     periods free of joint
                   great toe                                     •   May see tophi (extra-articular deposits of monosodium
                                                                                                                                     symptoms
               •   Also ankle, wrist, knee                           urate crystals) along Achilles tendon, ear helix,
                                                                     oleacranon bursa, prepatellar bursa
                                                                 •   May see degenerative changes in joint

                                                                                                                                 •   Insidious onset (may         •   Malaise, fatigue
                                                                                                                                     begin with systemic          •   Fever
               •   Typically symmetrical (at least               •   Inflammatory arthritis - inflammation with swelling,
                                                                                                                                     features, then overt         •   Arthralgia (joint
                   bilateral; may lack absolute symmetry)            tenderness, warmth, decreased range of motion
                                                                                                                                     joint inflammation)              pain)
               •   Target: synovial membrane                     •   Atrophy of interosseous muscles
                                                                                                                                 •   About 10% have abrupt        •   Weakness
Rheumatoid     •   Usually polyarthritis (3+ joint areas         •   Ulnar deviation, boutonnier and swan-neck
                                                                                                                                     onset                        •   Lack of ability to do
Arthritis          out of MCPs, wrist, PIPs, knee, MTP,              deformities, hammer toes can result from joint /
                                                                                                                                 •   Spontaneous remission            normal ADLs
                   shoulder, ankle, cervical spine, hip,             tendon destruction
                                                                                                                                     uncommon                         (activities of daily
                   elbow, TMJ in order of frequency)             •   Pain with motion, especially at extremes of motion
                                                                                                                                 •   Often have morning               living)
               •   DIP joints usually spared                     •   Doughy or boggy synovial membrane
                                                                                                                                     stiffness (around joints,    •   Episcleritis and
                                                                                                                                     ~1 hr of especially stiff)       scleritis occasionally

                                                                                                                                 •   May describe shoulder
                                                                                                                                     pain when sleeping on
                                                                 •   Pain worse with overhead motion of arm                          affected side
                                                                 •   Tenderness in subacromial region                            •   May occur as result of
Rotator Cuff
               •   Pain in deltoid region of shoulder            •   Pain in mid-arc of active abduction                             recognizable injury
Tendonitis
                                                                 •   Range of passive shoulder abduction exceeds active              (throwing) or
                                                                     shoulder abduction                                              insidiously (repeated
                                                                                                                                     impingement on
                                                                                                                                     overlying bones)

               •   Classic presentation: point tenderness        •   Most common cause of hip region pain                        •   Most commonly follows
                   in greater trochanteric region of             •   May be associated with a limp                                   repetitive /
                   lateral hip                                   •   Pain may awaken pt at night                                     cumulative trauma
Trochanteric
               •   Pain may radiate down into lateral            •   Increases with walking, squatting, climbing stairs, lying       (repetitive contraction
Burstitis
                   aspect of ipsilateral thigh but not all the       on ipsilateral side, increased activity or exercise             of gluteus medius
                   way into foot                                 •   Decreases at rest                                               during walking,
                                                                 •   Pain may limit pt strength, make legs feel week                 running)



                                                                                                                                                                                           8
                                                                                                        •   May also follow acute
                                                                                                            trauma (fall, tackle) or
                                                                                                            develop spontaneously
                                                                                                        •   Onset can be insidious
                                                                                                            or acute



Questions to ask:

•   OPQRST
•   Any recent trauma?
•   Does the pain wake you up at night?
•   Any fever? Weakness? Feeling more tired than usual?
•   Affecting your daily activities?
•   Both sides or just one?



Counseling for behavior change:

                                                    Features                                                  How to counsel

                    •   Thinking about change but ambivalence is core feature
                                                                                •   Listen for words of ambivalence
                    •   Patient aware of pros, cons, both have value
                                                                                •   Respond with reflection (one one hand it seems like... but on the
    Contemplation   •   Can get stuck in this stage
                                                                                    other...is that right?) & empathy (distress of dilemma)
                    •   Discussion leads to emotional arousal, resistance
                                                                                •   Offer support & partnership
                    •   Gap between value and behavior

                                                                                •   Reflective listening
                    •   Tried to quit but failed                                •   Try to elicit things learned from this attempt: what worked, what didn't
       Relapse
                    •   May be discouraged, demoralized                         •   Show empathy
                                                                                •   Arrange follow-up for support & encouragement to try again




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