Medicine cases: Overall approach

Question 1

Chest pain

Answer 1

Can you tell me anything more about your chest pain?

1. OCD
2. PQRST
3. AA (aggravates or alleviates)
   * breathing/meals/position/exercise/stress
   * how you came? Ambulance? Any medications?
4. Associated/IMPACT
   * General: N/V; sweating; feeling tired
   * Brain: light headedness/LOC/dizziness
   * Heart: feel heart racing?
   * CHF: pillows to sleep? Wake up gasping for air?/eye puffiness/liver pain.
   * Lungs: SOB?/wheezing/pain with respiration/ chest tightness/cough of phlegm(blood?)/recent fever/flu like symptoms?
   * Chest wall: any trauma/blisters or skin rash
   * GIT: difficulty swallowing/ heart burn or acidic taste/hx of PUD or GERD
   * Lower limbs: swelling in ankles, calfs or legs/pain/hx of recent long travel
5. Constitutional sx
6. Risk factors
   * CAD:
   - High blood pressure
   - High blood sugar
   - High cholesterol
   - Family hx of heart attack at male <55; female <65
   - SAD

     - Obesity; exercise; fast food; stress
       * Pericarditis
     - Recent flu sxs
     - Medications (Isoniazide/Rifampicine)
     - Hx of surgery
     - Hx of heart attack
     - Hx of kidney disease/puffy face/frothy urine
     - Hx of TB
     - Hx of autoimmune disease
       * PE
     - Recent long flight
     - Hx of malignancy
     - Family hx of blood clots
     - Female: pregnancy/OCPs/HRT

7. PMH
8. FH
9. SH

Question 2

Fall

Answer 2

1. Analysis of CC:
   * First time? Or happened before?
   * Related to emotions? Coughing? Urination?
2. Associated symptoms:
   * During:
   - Lose conscious? Hit your head?
   - Alone? WIth someone? Did he/she describe it?
   * Is she/he with you? Is it ok with you, after we finish, can I talk to him/her?
   - Were you shaking? Part of your body or all?
   - Were you breathing? Turn blue?
   - Did you bite your tongue? Roll your eyes? Wet yourself?
   * Before:
   - Did you take a few steps or fall all of a sudden (orthostatic hypotension)?
   - Before you lose consciousness, did you feel:
   * CARDIAC: Dizzy, lightheaded, N/V, chest pain, heart racing?
   * NEURO: Things spinning around (vertigo); weakness, numbness, vision changes (stroke); any flashing light, strange smells (epilepsy).
   * METABOLIC: Sweaty, shaky, hungry (hypoglycemia)
   * After:
   - How long it last?
   - How you regain consciousness? were you able to recognize the surroundings? Able to talk? Able to move?
   - Did you feel any weakness, numbness?
3. Impact:
   - Did you hurt yourself? How do you feel now?
4. Risk Factors
   * Constitutional sx
   * Risk factors for IHD
   * ALWAYS ASK to geriatric:
   - Balance
   - Vision
   - Hearing
   - Urination
5. DDx:
   * Diseases: Arrhythmia / CAD, CVA, seizure, hypoglycemia
   * Environment:
   - room well lit? You tripped?
   * Meds:
   - Do you take meds? Do you have a list?
   - Go one by one.
   - Which one was added / changed recently?
   - Any OCT?
   * Fluids: Enough fluids?
6. PMH
7. FH
8. SH: OCCUPATION (School bus driver, pilots, etc.)!!!!!!

Question 3

Back Pain

Answer 3

Can you tell me anything more about your back pain?

1. OCD: First time?
2. PQRST
3. AA (aggravates or alleviates)
   * breathing/meals/position/exercise/stress
   * how you came? Ambulance? Any medications?
4. Associated/IMPACT
   * General: N/V; sweating; feeling tired
   * Brain: light headedness/dizziness
   * Eyes: Red/painful?
   * Lungs: SOB?/pain with respiration/ chest tightness
   * Lower limbs: numbness or tingling?/calfs or legs/hx of recent long travel
   * GIT: R/O celiac or Chron for ankylosis spondylitis
   * GU: Pain with urination/changes in urine? for renal colic
5. Constitutional sx!!!
6. Risk factors depending on the dif dx!!
7. PMH
8. FH
9. SH: OCCUPATION (School bus driver, pilots, etc.)!!!!!!

Question 4

Dysphagia

Answer 4

What do you mean with “difficulty swallowing”? Initiating vs moving food down the esophagus

1. OCD: First time? Gradual? to solids then fluids?
2. PQRST
3. AA (aggravates or alleviates)
   * breathing/meals/position/exercise/stress
4. Associated/IMPACT
   * General: N/V; undigested food
   * GIT: Change in bowel movements? Change in size of abdomen? Abdominal pain or blood in stools?
   * Liver: Yellowish decoloration/itching/dark urine/pale stools
   * Chest pain/tightness?
   * Cough/change in voice/neck swelling (thyroid lump)?
5. Constitutional sx!!!
6. Risk factors depending on the dif dx!!
   * GERD/PUD
7. PMH
8. FH
9. SH: Alcohol/smoking

Question 5

SOB due to CHF

Answer 5

What do you mean with “difficulty breathing”?

• Breathing in and out (cardiac/anemia) vs Breathing out (COPD/asthma)
• Do you have any history of heart disease?
  - No -> newly dx
  - Yes -> acute on top of CHF
  - Heart racing? Dizziness? LOC? HTN?
• Do you have any history of asthma?
  - Wheezes?
  - Cough?
  1. OCD: First time? If before, when, treatment, how?
  2. PQRST
  3. AA (aggravates or alleviates)
• activity (how many blocks) at rest? at night?
  4. Associated/IMPACT
• Left ventricle
  - SOB? # of pillows?/wake up gasping for air?
  - Cough?/crackles?
• Right ventricle
  - Swelling in your LL? Related to position? Weight gain?
  - Eye puffiness? pain on liver?
• Other cardiac sx
  - Chest pain; N/V; sweating
  - LOC/dizziness

5. Constitutional sx!!!
6. Risk factors depending on the dif dx!!
   * Compliance
   * Diet
   * Medical
7. PMH
8. FH
9. SH: Alcohol/smoking

Question 6

Abdominal pain

Answer 6

Can you tell me anything more about your abdominal pain?

1. OCD
2. PQRST
3. AA (aggravates or alleviates)
   * eating/antiacids/defecation/position/medications
   * how you came? Ambulance? Any medications?
4. Associated/IMPACT
   * Nausea/vomiting:
   - Which started first, pain or N/V? Does it relieve pain? (1st pain, 2nd N/V-> surgical)
   - If vomiting: COCCA +-B
   - Screen for dehydration: Dizziness, lightheadedness
   * Bowel movements:
   - Any blood? Still passing gas?
   - Did you notice swelling in your ankles/legs?
5. Constitutional sx
6. Risk factors
   * Intestinal obstruction:
   - Previous surgery? Type? When?
   - Hx of gallstones?
   - Hx of IBD?
   * Gastroenteritis
   - What did you eat yesterday? New place? Diarrhea?
   - Anyone else who ate with you has the same symptoms?
   * Mesenteric infarction:
   - AFib?
   - Anticoagulants?
   - Previous MI?
   * Renal:
   - Flank pain? Going more frequently to bathroom?
   * Liver:
   - Yellowish decoloration? Itching? Dark urine?
7. PMH
8. FH
9. SH

Question 7

Diarrhea

Answer 7

Can you tell me anything more about it?

1. OCD-How many times?
2. What about during nights? How does it affect your sleep?
   - Yes -> organic
   - No -> irritable bowel syndrome (IBS) - day only
3. COCCA +- B/Mucous
   - If blood: Before the bowel movement? Mixed? On the surface?
4. Associated symptoms/Impact
   * Pain? If yes -> OCD/ PQRST AA
   - If improves with bowel movement -> IBS
   * Vomiting?
   * Alteration with constipation?
5. Red flags/impact:
   * Acute/dehydration: thirsty/dizziness/light headedness/LOC
   * Constitutional symptoms
6. DDx
   - Hyperthyroidism: “Do you feel abnormally hot/cold when others don’t?”
   - Stress: What do you do for live?/Any stress?
   - Infections: Travels?/camping?/Any other person in household with diarrhea?
   - HIV: If risk factors?
   - Diet: Celiac / lactose intolerance / sugars
   - Medications: ATB (C. diff), stool softeners
   - Rheumatic disease: red eyes/mouth ulcers/skin changes/hx of psoriasis/morning stiffness
7. PMH
8. FH
9. SH

Question 8

Fever

Answer 8

Can you tell me anything more about it?

1. OCD:
   - Did you measure it? How often? What is the highest? Diurnal variation?
2. AA (aggravates or alleviates)
   * Any medications?
3. Constitutional sx
4. Associated/IMPACT
   * General: N/V; sweating; feeling tired
   * CNS: headache/neck stiffness/light headedness/ LOC/ dizziness /vision changes
   * ENT
   * Heart: chest pain/feel heart racing (pericarditis)?
   * Lungs (pneumonia, PE, TB, cancer): SOB?/wheezing/pain with respiration/ chest tightness/cough of phlegm(blood?)/recent fever/flu like symptoms?
   * GIT: abdominal pain/distension/difficulty swallowing/ change in bowel movements
   * Urinary: burning/frequency/flank pain/blood in urine/discharge/ulcers
   * MSK: swelling in ankles, calfs or legs/pain/joint pain/red eyes/ skin rash/
   * Liver: yellow/itching/dark urine/pale stools
5. PMH
6. FH
7. SH

Question 9

Fatigue

Answer 9

Can you tell me anything more about it?/”What do you mean with feeling tired”? -> No energy or feeling weak?

1. OCD:
   - Anything happened at the time it started?
   - Diurnal variation?
   - How is your sleep? Do you wake up refreshed? Has your partner ever told you that you snore?
2. AA (aggravates or alleviates)
3. Constitutional sx
4. Associated / IMPACT (able to function?)
   * Hypothyroidism: Weight changes?/Skin changes?/Do you feel abnormally hot/cold when others don’t?/Constipation?
   * DM: Thirsty/Go to pee more frequently? Appetite?
   * Sleep disorders: Snoring?/Movement of legs or discomfort?
   * Menstrual: LMP? How is your period?
   * Diet: How is your diet? Any strict diet?
   * PMR: Any difficulty getting out of bed/couch/chair?
   * Mononucleosis: Young male practicing contact sports?
   * CNS: headache/neck stiffness/light headedness/ LOC/ dizziness /vision changes
   * Heart: chest pain/feel heart racing (anemia)?
   * Lungs (pneumonia, PE, TB, cancer): SOB?/wheezing/pain with respiration/ chest tightness/cough of phlegm(blood?)/recent fever/flu like symptoms?
   * GIT: abdominal pain/distension/difficulty swallowing/ change in bowel movements
   * Urinary: burning/frequency/flank pain/blood in urine/discharge/ulcers
   * MSK: swelling in ankles, calfs or legs/pain/joint pain/red eyes/ skin rash/
5. PMH
6. FH
7. SH