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USA Differential Diagnosis Practical
Terms in this set (129)
Observe the Hands for:
-Pallor or palmar creases (anemia, GI malabsorption)
-Palmar xanthomas (lipid deposits on palms of hands; hyperlipidemia, diabetes)
-Turgor (lift skin on back of hands; hydration status)
Observe/Screen the Fingers and Toenails for:
-Color (transparent=normal, darkness, whiteness)
-Capillary refill time (should be 2-3 sec)
-Clubbing (Crohn's or cardiac/, lung (cancer, hypoxia, cystic fibrosis, ulcerative colitis, biliary cirrhosis, present at birth, neoplasm, GI involvement)
-Splinter hemorrhages - sign of heart disease
-Leukonychia (white dots; malnutrition from eating disorders, alcoholism, cancer, MI, renal failure, poison, anxiety)
-Koilonychia (spoon nails; congenital or hereditary, iron-deficiency anemia, thyroid problem, syphilis, rheumatic fever)
-Beau's lines (white horizontal lines - decreased production of nail by matrix; acute illness, chemo for cancer, MI, chronic alcohol abuse, eating disorders, local trauma to nail bed)
-Adhesions to nail bed
-Onycholysis (loosening of nail plate from distal edge forward; Grave's disease, psoriasis, reactive arthritis, obsessive compulsive behavior e.g. "nail pickers")
-Pitting - due to inflammation (RA, psoriasis, eczema, alopecia areata)
-Thinning/Thickening (circulation issue, fungus)
Examining a skin lesions or mass:
(5 [S]tudents and 5 [T]eachers around the CAMPFIRE)
Appearance of client
Mobility of lump (see upcoming slide)
Pulsation (see upcoming slide)
Fluctuation (see upcoming slide)
Regional lymph nodes
Edge (clearly defined, symmetric, etc.)
How to examine Pulsation of a mass:
Place 2 fingers on mass:
are fingers pushed in same direction or apart from each other?
How to examine Fluctuation of a mass:
Does it contain fluid?
Place 2 fingers in V-shape on either side of mass. Tap in center of lump with index finger of opposite hand. If your fingers move, the lump is fluid filled.
Mobility characteristics of Lump:
-muscle: contraction decreases mobility of lump
-skin: skin moves over lump
If a lesion is present, assess for:
(bleeding, jt pain, fever)
-when did it first appear?
-is it changing over time?
how? (bigger, smaller, etc.)
-were there known triggers?
(e.g. perfume, cosmetics, soaps, ticks, sunlight, medication, diet, emotional/psychologic factors)
-a military history may be important
When describing s kin lesion (ABCDE):
Asymmetry, Border, Color, Diameter, Elevation and evolution
The sequence in examination of the abdomen:
Inspection, auscultation, percussion, and palpation
Landmarks in RLQ
Lower pole of right kidney
Cecum and appendix
Portion of ascending colon
Bladder (if distended)
Ovary and salpinx
Uterus (if enlarged)
Right spermatic cord
Landmarks in RUQ
Liver and gallbladder
Head of pancreas
Right adrenal gland
Portion of right kidney
Hepatic flexure of colon
Portions of ascending & transverse colon
Landmarks in LUQ
Left lobe of liver
Body of pancreas
Left adrenal gland
Portion of left kidney
Splenic flexure of colon
Portions of transverse and descending colon
Landmarks in LLQ
Lower pole of left kidney
Portion of descending colon
Bladder (if distended)
Ovary and salpinx
Uterus (if enlarged)
Left spermatic cord
Scars, lesions, rashes, stretch marks
(may indicate hepatic cirrhosis or obstruction of inferior vena cava)
(inverted, everted and any signs of hernia or inflammation)
Inspect from an overhead and side view
General contour of abdomen and any bulging
Observe for peristaltic movements
Observe for pulsations of the aorta
Skin-colored or silver striae are typical when...
A history of obesity or pregnancy
Purple-pink striae may indicate...
An Umbilicus displaced to the R. or L. might indicate...
an underlying mass
Suprapubic bulging may be due to...
pregnancy or a distended bladder
Lower quadrant masses in a woman may be an...
ovarian or uterine tumor
Pulsations of the aorta are present with...
aortic aneurysm or with increase pulse pressure
How to palpate abdominal aortic aneurysm
- Put two index finger 4 inches part, slightly above umbilicus on both sides.
- Press 2.5-5 cm deep and move medially to feel aorta pulse.
- If pulsation is felt more than 3 cm apart, then aneurysm is a concern
When are peristaltic movements seen?
In a very thin person or if there is an intestinal obstruction
What is abdominal auscultation used for?
Used to assess bowel motility and abdominal complaints, to search for renal artery stenosis as a potential cause of hypertension, and in examining for other vascular obstructions
-warm diaphragm side of the stethoscope
-listen in all 4 quadrants
-normal: gurgles every 10-15 sec.
-increased in diarrhea or early intestinal obstruction
-decreased and then absent in ileus and peritonitis
-if appears to be absent, listen for 3-5 min. in RUQ
-listen for bruit (murmur in BV; blowing/swishing in aortic, iliac, renal, or femoral arteries)
Listen for bruit in Renal arteries
Located in the epigastric area lateral to midline
*Esp. listen if the patient has HTN
A bruit in the central epigastric area may indicate...
an aortic aneurysm
Listen for bruits over the iliac and femoral arteries if the patient is suspected to have...
peripheral vascular disease
Sites to listen for bruits:
What is Friction rub and what does it indicate?
It is a grating sound that indicates inflammation of the peritoneal surface of an organ. This may indicate an infection, infarct, or cancer in an organ. They are usually auscultated over the liver and spleen.
- resonant at level of umbilicus
- dull at inferior border of last rib
- resonant over rib cage
long, high pitched, & loud noise; air filled viscera
Tympani represents gas or air in the intestinal tract
The predominate percussion note in the abdomen is tympany, with scattered areas of dullness typically present
Note the gastric bubble in the LUQ
short, low pitched, quiet noise; liver or spleen
Dullness indicates fluid or solid matter (feces or a mass). Masses include: pregnant uterus, ovarian tumor, distended bladder (above pubic symphysis), or enlarged liver or spleen
Note dullness over the liver in the RUQ
solid, dense tissue; like anterior thigh
sustained note of mod pitch; i.e., lungs
Pitch between tympany and resonance; base of L lung; pneumothorax; sounds like flicking puffed cheeks.
Tap ___ to ___ times in each area to determine the percussion note.
Dullness in both flanks calls for further evaluation for __________
Where does the upper border of the liver begin?
begins about the 5th and 7th intercostal space
To find lower border: locate where the tympany of the abdomen becomes dullness of the liver
The normal span of the liver in the midclavicular line is 6 to 12 centimeters
If the liver is displace downward may indicate...
a lung mass or low diaphragm of chronic obstructive pulmonary disease (COPD)
How to preform Percussion of kidneys:
Place one hand flat against the patient's costovertebral angle.
Hit the hand with the ulnar side of the other hand with enough force to create a painless thud
Ask the patient about pain with percussion—pain may indicate a kidney infection
How to preform Light palpation:
Performed with one hand, with 4 fingers flat on the abdominal surface
Use a light dipping motion with 4 fingers and depress gently approx 1 cm deep
- Used to assess texture, moisture, temp, pulse, vibration, superficial lesions.
*Palpate the painful quadrant last
How to preform Deep palpation:
Use the top hand to apply the force; use the bottom hand to sense your palpation findings
Depress firmly up to 1 inch deep in all 4 quadrants.
- Used to assess abdominal structures
What to note during palpation:
-is the pain with the push down or rebound
-if theres a mass note the mobility, size, shape, tenderness, location
-if there's muscle guarding (if there is, try to reposition to put the abdominal wall on slack)
Does it hurt with the push down or release in a "+" Blumberg sign for peritoneal inflammation
Pain with release (withdrawal)
Does it hurt with the push down or release in a "+" McBurney sign
Pain with release (withdrawal)
McBurney's: line between the ASIS and the umbilicus in RLQ
Indicates: acute appendicitis
How to palpate the aorta:
-do in persons over 50 years
-use 2 index fingers side by side, press firmly and deeply in the epigastric area, slightly to the left of midline
-identify the pulsations of the aorta
-gradually widen your fingers until you feel the rounding of the vessel
-normal width of the aorta in this area is 2.5-3.0 cm
: aortic width larger than 3 centimeters should be referred for further medical examination
Test for ventral hernia
Ask the patient to raise the head and shoulders off the table
Test is positive if a bulge appears when the patient lifts up the head
4 Types of hernias:
1. Umbilical hernia: protrudes through defective umbilical ring; more common in infants
2. Incisional hernia: protrudes through operative scar
3. Epigastric hernia: small protrusion in midline through a defect in the linea alba between xiphoid and umbilicus
4. Diastasis recti: (ventral hernia) separation of the 2 rectus abdominis muscles through which abdominal contents bulge; repeated pregnancies
How to differentiate an abdominal mass versus a mass in abdominal wall:
-Palpate the mass at rest
-Ask patient to raise head and shoulders
-Feel for the mass again
-If the mass goes away, it is likely located in deeper abdominal tissue
Method 1: Resist hip flexion of the right leg in supine or side-lying
Method 2: With patient in side-lying, passively stretch the right hip into extension
+ if elicits hypogastric pain
Tests for appendicitis or peritonitis
-place the patient's right leg in 90° hip and knee flexion
-externally rotate, then internally rotate the hip passively
+ if produces right hypogastric pain
Tests for appendicitis or peritonitis
-Hook your left thumb or fingers of your right hand under the right costal margin or rib cage at the point where the lateral border of the rectus muscle intersects with the costal margin
-ask the patient to take a deep breath
+ if the patient has a sharp increase in tenderness with a sudden stop in inspiratory effort
A positive Murphy sign is highly suggestive of acute cholecystitis (inflamed gallbladder).
Test for shifting dullness (abdominal ascites)
This test is based on principles of gravity.
Fluid in the abdomen will sink to the dependent areas while gas will float to the top.
-Percuss the abdomen in supine
-Percuss outward from the center of tympany
-Now have patient turn onto one side (note areas of tympany and dullness while the patient is in sidelying)
-In ascites, the fluid should shift to the dependent areas of the abdomen, so the dullness will now be located on the dependent side (the down side), while tympany will be present at the top (the up side)
Test for fluid wave (abdominal ascites)
-Based upon the premise that fluid will transmit forces more easily than fat
-Have patient lie supine, placing the ulnar borders of his hands or a third persons hands longitudinally across the midline of the abdomen.
-This pressure should limit mobility of fat or helps stop the transmission of a wave through adipose tissue
-Tap one flank sharply with your fingertips, while palpating on the opposite side
-If the impulse is easily felt on the opposite side, this suggests ascites
-Visible or palpable pulsatile mass in epigastric area
-Positive rebound sign or other signs of peritoneal inflammation
Abdomen NOT emergency but still need to refer
-Abdominal aorta > 3 cms wide
-Mass in Abdomen
-Absence of bowel sounds
-Signs of ascites
-Signs of jaundice
-Pt. reports blood in stool or in vomit
Causes of pain in RLQ
-Ruptured ectopic pregnancy
Causes of pain in RUQ
Causes of pain in Periumbilical
Causes of pain in LUQ
Causes of pain in LLQ
-Ruptured ectopic pregnancy
LQ Screening Abdomen Supine:
a. Listen for bowel sounds in all 4 quadrants
b. Listen for bruits over renal artery, aorta, iliac artery, femoral artery
c. Percuss in all 4 quadrants
d. Percussion of the liver—determine the span and the upper and lower borders
e. Perform light and deep Palpation in all 4 quadrants
f. McBurney point
g. Palpate aorta
h. Psoas Sign
i. Obturator Sign
j. Murphy Sign
k. Rebound/Blumberg Sign
l. Abdominal Reflex
Rebound tenderness for peritonitis (GI special test)
Rebound tenderness = pressing a hand on the abdomen deeply elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place
Also called Blumberg's sign
Used for peritonitis or appendicitis
Jar Sign (GI special test)
Shake table; a + test is pain
Psoas Sign for Abscess (GI special test)
Lift RIGHT leg against resistance OR in side-lying extend hip
Obturator Sign for Abscess (GI special test)
Flex RIGHT hip and flex knee - then rotate in IR and ER
+ if pain on passive IR (knee in, foot out)
Carnet's sign intra vs extra abdominal problems (GI special test)
Abdominal pain better/no change w/ sit-up = (+) → Intra-abdominal problem
Abdominal pain worse w/ sit-up = (+) → Abdominal wall problem
Murphy's percussion for kidney disorder (GU special test)
Rebound tenderness for peritonitis (ectopic pregnancy) (GU special test)
Pain upon removal of pressure
Percussion for ascites (Hepatic and Biliary System Special Tests)
Then done sidelying
If any fluid is there it should move
In SL there should be tympani on top and dullness on bottom
Palpation and percussion for hepatomegaly (Hepatic and Biliary System Special Tests)
- apply pressure under last rib
- when patient exhales, sink deeper
- when patient inhales, remain pressure
- Positive = pain felt with palpation
- Patient lying supine
- Right side, along mid-clavicular line, begin percussing at level of umbilicus.
- Should hear tympani/resonance, then become dull when on top of liver; inferior border of liver.
- Continue toward head and resonant again over lung; superior border of liver.
- liver span should not be more than 10 cm.
Palpation and percussion for splenomegaly (Hepatic and Biliary System Special Tests)
- sink in deep under left lower rib
- Positive = palpable spleen (normally not)
- patient is supine
- find lowest intercostal space in anterior axillary line.
- percuss at rest (normal=resonant)
- percuss at full inspiration (normal=dullness); spleen descends
- enlarged spleen = dullness with both conditions
Murphy's Percussion / Punch test for kidney infection (Hepatic and Biliary System Special Tests)
- Patient is seated or prone with back exposed.
- place flat hand over costovertebral angle of 12th rib.
- Make fist with other hand and apply a firm thud to back of palpating hand.
- Positive = pain in back, flank, lateral abdomen
Physical Inspection of the Head and Neck
-thyroid enlargement (goiter)
-signs of facial asymmetry
-abnormal bony enlargements of the face, jaw, hands and feet (acromegaly)
-round "moon" face appearance, buffalo hump (fatty deposits) at the neck (Cushing syndrome)
-check for bluish discoloration of the conjunctiva (anemia)
-check the color of the sclera: yellow for jaundice, hepatitis, liver disease; redness for ciliary flush
-check for inflammation or infection of eyes
-check for eye drainage
-check for ptosis, nystagmus, abnormal gaze (strabismus )
-check for absent teeth, chipped, discoloration
- low red blood cell count
- conjunctiva calor (pale inner eyelid)
- pale palms
- spoon nail
Red blood cell disorder S/S:
- red complexion, easy bruising, dizziness, peripheral neuropathy, hypoxia (tissues have low oxygen supply)
- polycythemia - increased RBCs
- sickle cell disease
Platelet disorder s/s:
- bleeding, bruising, effusion, petechiae
- thrombocytopenia (low platelet count)
- thrombosis - clot
- thrombocytosis (high platelet count)
When screening for cancer:
- prior history
- family history
- Changes in bowel/bladder
• A sore does not heal (6 weeks)
• Unusual bleeding/discharge
• Thickening/lump soft tissue
• Indigestion or difficulty swallowing
• Obvious change in wart or mole
• Nagging Cough or hoarseness
Physical Examination (vitals, neuro)
- can palpate lymph nodes
- skin inspection
- lung auscultation
Palpate Lymph nodes:
-preauricular (front of ears)
-posterior auricular (behind ears)
-occipital (base of occiput)
-tonsilar (lower jaw)
-submandibular (lower mandible)
-submental (below chin)
-superficial cervical (superficial SCOM)
-deep cervical (under SCOM)
-posterior cervical (in front of upper trap)
-supraclavicular (on top of clavicle)
~Epitrochlear lymph nodes (along the inside of the upper arm)
~Axillary lymph nodes
Apply a steady, gentle pressure and circular motion
How to palpate the LE Horizontal group of lymph nodes:
-lies just below the inguinal ligament high in the anterior thigh
-drains the superficial portions of the lower abdomen and buttock, the external genitalia (except for the testes), the anal canal, perianal area, and the lower vagina
How to palpate the LE Vertical group of lymph nodes:
-near the upper part of the saphenous vein
-palpated vertically in the anterior thigh below the inguinal ligament and medial to the femoral artery
Palpate Thyroid gland:
- begin at tip of chin, slide down midline, first prominence is thyroid cartilage.
-first palpate and identify the thyroid cartilage
-move your fingers down until you can palpate a small indentation, the crico-thyroid membrane
-move downward until you palpate the next well-defined tracheal ring
-gently displace the trachea laterally with the left thumb or fingers and palpate the left thyroid gland with the right thumb or fingers
-you might ask the pt to swallow as you palpate (thyroid gland should slide beneath your finger while it moves upward)
-repeat for R. side
- check for asymmetry, size, lobe position, and presence of nodules.
*Avoid applying pressure in the carotid sinus area
Normal size of thyroid gland:
The normal size of the thyroid gland is approximately 4 centimeters in diameter, with the right lobe often being 25% larger than the left
An enlarged thyroid that is
acute infections, hemorrhage, thyroiditis or Graves disease
and stony thyroid gland may indicate:
carcinoma or scarring
Capillary refill test (hands & toes):
- test for peripheral arterial disease (PAD)
-Press nail bed or tip of any finger for about 3 seconds, causing the underlying skin to blanche
-After releasing the pressure, normal pink color should return in 3 to 4 seconds in toes or less than 2 seconds in fingernails
-A delay indicates lack of perfusion, poor arterial circulation, shock, dehydration
When assessing Skin temperature:
use the back of the hands for assessment of temperature and moisture
Most common pulse locations:
- dorsalis pedis
0 Absent, not palpable
1+ Weak or diminished
2+ Normal, easily palpable
3+ Slightly increased strength (abnormal)
4+ Bounding (abnormal)
- pulse should increase slightly with inspiration and decrease with expiration. Opposite = paradoxic; common with COPD, percarditis, pericardial effusion, tension pneumothorax
- Body temp: avg=98.6 (96.8 - 99.5); Fever > 100.4
- Pulse: 60-100 bpm
- Respiration: 12-20 bpm
- oxygen saturation: 95-100% (referral below
- Blood pressure: >120/80 mmHg
- walking speed (6th vital sign)
What can mimic sciatica?
Arterial insufficiency of the distal aorta, iliac, or femoral arteries is commonly associated with LE aching, cramping, numbness, tightness, or fatigue, and may therefore mimic sciatica
How to palpate the Femoral pulse:
-below the inguinal ligament, halfway between the ASIS and the symphysis pubis
-position hip in slight flexion
-press deeply (2 hands may be necessary)
decreased or absent
pulse suggests disease at the aorta or the iliac arteries
pulse suggests a femoral aneurysm
How to palpate the Popliteal pulse:
-palpated behind the knee centrally with the patient supine, the knee flexed, and the leg relaxed
-place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply in to the popliteal fossa
-is deeper and feels more diffuse than other pulses
popliteal pulse suggests an aneurysm of the popliteal artery
absent or diminished
pulse may indicate an arterial obstruction proximal to this site
How to palpate the Dorsalis Pedia pulse:
-on the dorsum of the foot approx. where the 2nd MT meets the middle cuneiform
-can be congenitally absent
How to palpate the Post. Tibialis pulse:
-felt as it passes behind the medial malleolus
-curve your fingers behind and lightly below the medial malleolus of the ankle
decreased or absent
foot pulses with normal femoral and popliteal pulses suggests occlusive disease in the lower popliteal artery or its branches. This pattern is often associated with
Sudden arterial occlusion, as by embolism of thrombosis, causes pain and numbness or tingling and the limb presents as cold, pale, and pulseless—which
requires emergency treatment.
How to check for pitting edema:
-press firmly but gently for 5 seconds in 3 areas:
(1) over the dorsum of each foot
(2) behind each malleolus
(3) over the bony portion of the anterior shins
-Normally, there is no edema present.
-If present, grade on a 4-point scale (next slide)
GRADING PITTING EDEMA
1+ No pitting,; mild indentation of skin (2 mm)
2+ Moderate pitting that indents 4 mm; disappears within 10-15 seconds
3+ Deep pitting that indents 6 mm; remains indented >1 minute; dependent extremity is visibly swollen
4+ Very deep pitting that indents 8 mm; remains 2-5 minutes; dependent leg is grossly distorted
Causes of pitting edema:
systemic cardiovascular disease, heart failure, DVT, chronic venous insufficiency, incompetence of venous valves, or lymphedema. Venous distention suggests a venous cause of edema
-equal leg circumference should be a
clinical red flag for medical evaluation
- breathing pattern should be deep & regular
- no use of accessory muscles (SCOM,scalenes)
- no blue/pale lips, nails, or skin.
Percussion: can do back and/or front
- from T1-T12 intercostal spaces between scapula and spinous processes.
Clinical Decision Rule Developed by Wells
-Active cancer (within 6 months of diagnosis or palliative care)
-Paralysis, paresis, or recent plaster
-immobilization of lower extremity
-Recently bedridden >3 days or major surgery within 4 weeks of application of CDR
-Localized tenderness along distribution of the deep venous system
-Entire lower-extremity swelling
-Calf swelling by >3 cm compared with asymptomatic lower extremity
-Pitting edema (greater in the symptomatic lower extremity)
-Collateral superficial veins (nonvaricose)
-Alternative diagnosis as likely or greater than that of deep vein thrombosis
Case: Differentiate between arterial and venous problem in the lower extremity.
- Check for swelling/pitting edema. Swelling would indicate a venous problem. Although, swelling could also be CHF.
- Venous: skin may be rusty colored (iron breakdown in pooling blood)
- Check for DVT. At risk for DVT- use Well's clinical prediction rules (name some of the criteria).
- For arterial: check pulse. Look for paleness in limb. Elevation will cause more paleness. Check capillary refill test
Case: 3 weeks post total knee. What would you expect if infection?
- Swelling, inflammation around knee locally
- Systemic: fever, fatigue, GI
- Cellulitis - soft tissue infection
- *Blood tests - call PCP, found signs of infection.
Case: Suspect anemia. How would you determine?
Look for S&S of anemia:
- paleness in eyelids (conjuctiva palor)
- pale palms
- blood test - low red blood cell count
- spoon nail
Case: Mole on back, concerned about Melanoma. What would you do?
Case: R lower quadrant & hip pain.
- Non-tender hard lymph nodes are more concerning.
- Tender soft lymph nodes are more likely infection
Case: Bilateral hip, knee, and wrist pain.
Look for swelling at joints. Check nails and skin (pitting in nails) for psoriatic arthritis.
Know cardiac pain patterns for male vs female
female is interscapular
Case: What would make you suspicious of lyme disease?
- Swollen joints
- Spends a lot of time outdoors (exposure to ticks)
- Lives in northeast or midwest
Has a rash that looks like a bulls eye.
Case: Tell me everything you know about psoriatic arthritis:
- It's an autoimmune disease
- Usually has bilateral symmetrical joint involvement
- Enthesitis - site of tendon attachment to bone is inflamed.
- Psoriasis of the skin - over extensor muscles.
Early onset (age 20-30)
case: What would make you suspicious of ankylosing spondylitis?
- Young male
- Insidious onset of low back pain
- Stiffness in the spine
- Bilateral symmetrical joints
- Look at hands
○ Fingers drift ulnarly
- Need blood work
- Imaging: erosion of joint lines
- Women more affected
- Multi-system inflammation
○ Less appetite
- Non-inflammatory disease
- Central sensitization
- Allodynia: non-harmful stimuli becomes painful
- Hyperalgesia: elevated pain response
- Multi-point tissue involvement
- Cognitive involvement
- Sleep disturbances
Case: Refer out for suspected cancer (colon):
- Changes in bowel/bladder
- Bloody stool
- Digestion problems
- Family history
- Environment exposure
- Know how to palpate lymph nodes
Case: What are constitutional symptoms associated with chronic renal disease?
- Increase in blood pressure
- Cardiac involvement
Pt has back and abdominal pain. Differentiate between a urogenital source and a GI source.
- Ask pt questions about bowel movements.
- Examine abdomen: auscultate, percuss, palpate.
- Ask about changes in urinary function: incontinence, pain, blood
- Urogenital will typically be lower abdomen
Case: What would make you suspicious of kidney involvement?
- Don't do kidney percussion first, do history first.
- Ask about changes in urinary frequency or pain; blood in urine
- If no red flag in history, don't need to percuss kidneys
Know different types of urinary incontinence:
Case: If you suspect acute bronchitis, what finding would urge you to make a referral?
- If fever above 100.4
- Symptoms persist longer than 3 weeks.
- Repeated episodes throughout year
- Auscultate lungs for wheezing & fluid
- Percuss lungs
Ask pt about color of mucus & dyspnea
Case: Who is at greatest risk for hospital-acquired pneumonia?
- Over age of 70
- Prior pulmonary diagnosis (COPD)
- Prolonged hospitalization
Case: What are the red flags for lung cancer?
- Shoulder/thoracic/neck pain
- Worse with inhaling
- Blood with coughing
- Unexplained weight loss
- History of smoking
- Prior cancer
- Family history
Left vs right-sided heart failure:
Left-sided heart failure:
- Pulmonary involvement.
- worse in supine
Right-sided heart failure
- System backup (jugular vein distention)
- Upper quadrant pain
Case: - If pt complains of chest pain and they have a stent, need medical care ASAP.
- Composite score chest pain:
○ Male over age 55
○ Known vascular disease
○ Worse with exercise
○ Worse with palpation
Pt hypothesizes cardiac involvement
- Fluid retention
- Swelling in abdomen
Can be from many different pathologies (liver backup, hypertension, heart disease)
Case: For suspected psoas abcess, peritonitis, appendicitis (make referral for all 3):
- Obturator test
- Psoas sign
- Deep psoas palpation
- Heel jar test
- Rebound tenderness
Know what to look for with blood/platelet disorders:
- Infection (elevated WBCs)
Differentiate between hyper and hypothyroidism:
○ Weight loss
○ Warm skin
○ Palpate thyroid for inflammation
○ Weight gain
○ Cold intolerance
○ Swelling in extremities due to heart failure
If concerned about atherosclerosis of peripheral vascular disease:
- Auscultate carotid artery (bruits)
Auscultate aorta, renal aa, iliac & femoral aa (bruits)
Know blood pressure cutoffs
THIS SET IS OFTEN IN FOLDERS WITH...
Exam 1: Differential Diagnosis
DD final- google drive questions
E1 Wrist and Hand Final
E1 Exam 1
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