MINIMAL MEDICAL HISTORY

Abdominal Pain:
1. Are your abominal muscles hard and does it hurts to move? (acute abdomen)
2. How long has it been going on? ( 12 hours or more till risk of appendix rupture)
3. Did the pain start with mild vauge pain in the epigastric, periumbilical, entire abdomen, or RLQ, and then 3 hours or more later was followed by acute loss of appetite? (Appendicitis)
4. Are you passing gas or having BMs? (if no, risk of obstruction)
5. Any black tarry stools? (GI bleed)
6. Does the pain radiate to the back? (AAA)
7. Is there more pain upon exertion? MI
8. Location? Almost every part of the abdomen has some high risk (if not appendicitis, then pancratitis, or cholelithiasis, or diverticulits, MI, AAA--all CAN be life threating--even the left lower quadrant can be appendicitis or ruptured diverticuli; however, many time they are not; therefore refer out)

Back Pain
1. Have you ever used IV drugs?
2. Do you have numbness where you sit or between your legs or urinary retention or difficulty controlling bowels?
3. Trauma


Chest Pain:
1. Location: Above trachea only? (usually a cold); Substernal: (MI, Angina, or Cold)
2. Do you or any family members have a history of heart disease? (MI, Angina)
3. Is the pain in the chest effected by walking? (MI, angina)
4. Does your discomfort radiate to arms, jaw, or back? (Viral Myocardis, MI, aneurysm)
5. Is the chest discomfort worse with exertion? (Viral Myocarditis, MI)
5. Does it hurts more when taking a deep breath? (PE or Pleuritis) - needs xray, ask PERC questions
(< 50 yr, pulse >100, O2<95, leg edema, HX or PE or DVT, Surgery <1 mo), hemoptysis, Exogenous Estrogen)
6. When does the chest pain occur? only when coughing? (bronchitis, or muscular)

Cough:

1. Is there any swelling in the feet or lower legs (PE, CHF)
2. Is there sharp pain on deep inspiration (PE)
3. Is there REAL difficulty breathing? (Asthma, COPD, CHF, PE, Bronchitis)--SEE SOB

Headache:
1.Was it most painful at the beginning? (Sabarachnoid hemorrhage)
2. Does It continues to worsen? (subdural bleed, tumor, or intracraneal bleed)
3. Location? temple (Temporal arteritis)
4. Is there any change in ability to move arms, legs or walk or feel? (CVA, TIA)

5. Any Heart disease? Rare

Dizzy:
1. Do you feel light headed, as if you are going to faint? (Cardiac involvemnt, dehydration)
2. Is there vertigo that is vertical or gyrational? Central lesion ( neuro consult or ER)
3. Is there Unresolving (not brief) disquilibrium with walking? central lesion (neuro consult or ER)
4. Is the dizziness last minutes to hours? could be Central Lesion -or- Vestibular Neuritis or Meneirres


Nausea:

1. Is there also abdominal pain? SEE ABDOMINAL PAIN
2. Is the nausea increased with exertion? (MI)

3. Is there REAL difficulty breathing (not nasal congestion) happening at the same time? (MI)
4. Is there diphoresis happening at the same time? (MI)


Shortness of Breath "Difficulty breathing":
1. Do you think you have pneumonia? (Pneumonia, Asthma)
2. Does it occur when walking up stairs -or walking? (MI, PE, Asthma, COPD, Pneumonia)
3. Is there a fever? (pneumonia)
4. Is there swelling in the calves or the feet? (CHF, PE)



Neurological Disorders
Headache Vertigo/Dizziness Facial Droop

Respiratory Urgencies Cough Dyspnea/SOB

Cardiac Urgencies
Chest Pain Hypertensive Emergency

Gastrointestinal Urgencies

Diarrhea Nausea Nausea & Vomiting Nausea, Vomiting & Diarrhea Abdominal Pain

Orthopedic, Environmental, and Traumatic Urgencies Back Pain Ankle & Foot Pain Knee Pain Shoulder Pain Neck Pain Or Swelling

Dermatolgical Urgencies
Various Skin Problems







Black Line
Pediatric Vital Signs



Anatomy


skull 3. neck-vertebrae. external eye

back ribs. back chart .
. chest lines
foot ligamentsfeet bones. .  
. hand phalanges. hand anatomy

Finger Joints

toe phalanx


This website is designed for nurse practitioners and any other health care worker who would liek to use it. It is mostly a reminder of different diseases and illnesses.

WARNING: Some parts of this website are incomplete. It is also possible that there are small errors on this site (there are certainly many spelling errors). Other medical websites may be more comprehensive.

Use the web site at your own risk. This website should not and will not replace a visit to your physcian. You can not totally rely on the information in this website. All individual will have indivual variables that must be taken into consideration when making a diagnosis and treatment





Headache



Absolute Minumum History to Ask to rule these our are:

1. On a scale of 1 to 10, what number would you give to your pain?
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |

If the patient reports only a 1, 2, or 3 and has a viral syndrome only a few more questions need to be asked.
2. Did the headache come on suddenly - or gradually? |yes |

3. Does the headache seems typical or in some way unusual? |yes |
------ If yes, in what way is it unusual?
4. Is there accompanying neck pain or stiffness? |yes |
------ If yes, is the patient able to touch there chin to there chest? |yes |
------ Is there any type of immune suppression due to HIV, alcholism, chronic steroid use, or homelessness?
|yes |
5. Has there been any noticeable decrease in strength-or other neurolgical deficits? |yes |
6. Was there any truama (severe or mild)? |yes |
7. Is the patient pregant or recently gave birth? |yes |
8. Does exercising or coughing make the headache worse? |yes |
9. Is there obvious conjunctivitis with tearing (may be bilateral)? |yes |
If Patient reports that pain is greater than 5 or answer "yes" answer to any of these questions means you must do a complete PHYSICAL NEURGOLICAL ASSESSMENT and might very well have to refer the patient to Emergency Room for a CT Scan on the neck or head, or MRI/MRA, or Lumbar puncture

The Fifth Step is to take the Appropriate and Necessary History.

General Information:
Onset:
Location:
Duration:
Character:


1. What part of the head is effected: frontal | temporal | parietal | occipital | behind the eyes
2. Is the headache on: the right | the left | both side
3. On a scale of 1 to 10, what number would you give to your pain?
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
4. Have you been able to work and do household chores while you have this headache?|yes |
5. Does this headache feel unusual? | yes | no |

6. Did the headache start within a few minutes? | yes | no |
7. Does this headache come and go? |yes

Specific Information
R/O subarachnoid Hemorrhage:
1. Is this the worse headache ever? |yes |
2. Did the headache start out very bad and then gradually decrease? |yes |

R/O Stroke and TIA:
1. Are you able to move both arms and both sides of your face equally? |yes |
2. Was there recently a time where you could not move your arms or your face equally? |yes |

R/O Trauma that causes increased Intracranial Pressure:
1. Was there trauma? |yes |

R/O Meningitis:
1. Is there neck pain or stiffness?|yes |
2. Is there a fever? |yes |
3. Can you touch you touch your chin to your chest (you can open your mouth to do this)? |yes |

R/O Tension Headache
1. Does it feel as if there is a band around your head? |yes |
2. Does it feel as if your neck and back of your head muscles are tight? |yes |
3. Do you feel your work, school, or home life is very stressful? |yes |

R/O Migraine
1. Are you very sensitive to light? |yes |
2. Are you very sensitive to sound? |yes |
3. Is there an aura that precedes this headache? |yes | "

FURTHER SPECIFIC: OPTIONAL QUESTIONS

R/O Menstrual Cycle Headache
1. Are you currently on your menstrual cycle? |yes |

R/O Carbon Monoxide Posioning:
1. Use of heater in home (carbon monoxide poisoning)? yes |
2. Does anyone else in your family have the same symptoms? |yes |

R/O Pre Eclampsia
1. Could you be pregant? |yes |
2. What is the date of your last menstrual cycle?

R/O Headache to to drugs or drug withdrawal:

1. Did you recently stop using Alcohol? |yes |
2. Did you recently stop using Caffeine? |yes |

R/O other medical conditions causing the headache like a cold, sinus infection, or the flu:
1. Other Medical problems not previously stated? |yes |
2. Other's Symptoms of illness not previously stated? |yes |

R/O Pre Herpes Zoster Syndrome:
1. Is there a history of chicken pox? |yes |
2. Is there a feeling of numbness, tingling or burning? | yes |

R/O Rare disease from other countries:
1. Have you traveled internationally or spent time in forested areas? | yes . |

R/0 Lyme Disease?
1. In the past have you spent much time camping or hunting in forested areas? | yes |

R/O carotid disection leading to clots in the brain:
1. Is there neck pain? | yes |

R/O brain Aneurysm:
16. Is there increase pain with exercise? | yes |

R/O Tumor:
17. Is the Headache worse in the morning? | yes |
18. Is there weight loss?| yes |

The Sixth Step is to to the Appropriate and Necessary Physical

Genernal Information:
1. Is there guarding of the head? | yes |
2. Is there facial grimances? | yes |
3. Is patient walking normanlly? |yes

R/O Menigitis:
1. Is there Fever? |yes
2. Are Kernig and Brudzinski test positive? |yes
3. Are Cranial Nerves III_XII grossly intact? |yes
4. Finger to eye coordination wnl? |yes
5. Patella DTN Is wnl? | yes
6. Is grip strength equal 5/5? |yes

R/O Glaucoma
|yes |yes

R/O Temporal Ateritis:
1. It there any tenderness or imflammation in the temporal area? . |yes

R/O Pre Herpes Zoster Syndrome:
1. Are there any vesicles in the ear or on the face or in the eye? |yes

R/O Rare disease from other countries:
1. Have you traveled internationally or spent time in forested areas? |yes

R/0 Lyme Disease:

1. Lyme titer is needed

R/O carotid disection leading to clots in the brain (CVA/TIA):
1. Is there a carotid murmur? |yes

R/O brain Aneurysm:
1. Need CTA or MRI

R/O Tumor:
1. Need MRI

For MORE Severe Headaches:
R/0 Increased intracranial pressure:
1. Is the pupil dialted? |yes |
2. Optic Disc and cup could be clearly visualized? |yes |
3. The right and left optic cup to disc ratio are the same? |yes | Unable to determine |
4. The optic cup to disc ratio is >60% |yes | Unable to determine |
5. There is hemorrhages seen in the retina? |yes | Unable to determine |

FURTHER OPTIONAL TEST that may indicate EMERGENCY conditions
1. Balance (toe to heel walk) is wnl? yes
2. Babinskin is negative (one directional flaring)? yes
3. Rhomberg is negative? yes
4. Pronator drift is negative? yes Seventh: if labs or test are needed and available order them consider:
UA, Strep, rapid flu test, gluocse

Eighth
:
if uncertain of the diagnosis or treatment call MD for consult .

Ninth
:
make diagonosis based on available information: "Headache or Cephalagia"

Tenth
:
refer out, or send home with apppropirate meds, and follow up instruction

Eleventh:
Possible Treatments: Immetrex, Motrin, Zogran 8 mg, Tylenol, ASA for suspected TIA, Thorazine, Compazine (with Cogentin)


The First Step is to take the blood pressure to make certain that the blood pressure is not too high .

The Second Step is to tell the patient that the clinic is designed to treat to minor illness and injuries (a headache can be either a minor problem or a major problem). You are happy to try to help them, but there is diagnostic equipment that you do not have and therefore it is doubtfull that you will be able to give them a definite diagnosis. In addition if is more than a minor problem, you will probable NOT be able to give them the treatment they need. Instead, you will have to send them somewhere to get the treatment they need.

The Third Step is to think of and try to rule out the most dangerous causes [otherwise know as cant miss diagnosis]:

In this case the most dangerous Medical Problems are: CVA (secondary to Caroti or Vertebral Artery Disection), TIA (secondary to Cerebral Venous Thrombosis), Meningitis, and Subarachnoid Hemorrhage, Aneurysm
The Fourth Step is to think of and try to rule out as many possible causes as is reasonably possible. . .

HEADACHE DIFFERENTIAL:

Most Dangerous:
1. Meningitis: ........................................:Fever, Neck Stiffness, Headache .
2. Sabarachnoid Hemorrhage: ..............: Thunderclap HA- Then Decreased HA
3. Cerebral Vascular Accident-or TIA...: Usually will one side weak-
4. Post-Tramatic Headache: .................: Hx of trauma .
5. Pre-Eclampsia Headache: ................: also pregnant, Inc. BP, proteinuria . .
6. Acute Glaucoma - Papiledema: ..................: pupil size, Decresed visual field.
7. Vertebral Artery Disection: ..............: Usually neck pain, no fever .
8. Carotid Artery Dissection: ...............:Usually neck pain, no fever .
9. Carbon Monoxide Poisoning: ..........: HX of space heater, or car .
10. Cerebral Venous Thrombosis: .........: (usually occurs in pregnant women, or women who just gave birth) Rare, Varity of poss. SX, HA, N, V, Aphasia, seizure, coma, hemianopia, tinnitus, facial weakness, vision changes, hemiparesis .
11. Structural Lesion (Aneurysm): ...:........ Increased with Activity .
12. Temporal Arteritis: ...............................:Usually palpable temporal artery .
13. Optic Neuritis: .....................................: HA + decreased vision, demyelinated, MS
14. A Cranial Mass (Tumor or Cancer): ....: slow Inc. pain, Inc. pain in AM

Less Dangerous
1. Chronic Paroxysmal Hemicrania:...~ mild cluster HA, (TX Indocin) .
2. Migraines: ... Photosensitivity, Phonosensitivity, Debilitating .
3. Tension Headache: Not-Debilitating, Follow Muscle Pattern .
4. Cluster Headache:...Severe pain behind the eyes .
5. Sinusitis: ...: Fever, Sinus Tenderness or behind bridge of nose .
6. Influenza: ...: Fever, usually also Influenza Symptoms .
7. Dehydration: ...: follows vomiting, diarrhea; decreased BP .
8. Streptococcal Pharyngitis: ...: Usually will have sore throat .






Facial Droop



Fifth step is to take the Appropriate and Necessary History.

General Information:
Onset:
Location:
Duration:
Character:


R/O Lyme Disease:
Recent Travel History (forest)? |yes
R/O SubArachnoid Hemorrhage:
Is this start with in seconds (thunderclap) and then slowly get a little better? |yes

R/O Herpes Zoster:
History of having Chicken Pox? |yes

R/O Stroke or TIA:
1. Family history of strokes or Carotid Artery Problems? |yes
2. Does the patient have a history of high blood pressure? |yes

R/O Bell' Palsy:
Is there a Recent history of a cold? |yes

R/O stroke:
Is there a decrease in the ability to move one side of the face? |yes

R/O Bells Palsy:
Is there a decrease in the ability to raise the eyebrows (consistent with Bell's-but not stroke)? |yes

The Sixth Step is to to the Appropriate and Necessary Physical

The extent of the neurolgical exam depends on the History Findings: The greater the pain and the more unsual, the more the neurological exam that is required.

Does the person look well in general {Gestalt}? |yes

Is systemic health WNL
1. Heart WNL? |yes
2. Lungs WNL? |yes

R/O Herpes Zoster:
1. Is there Skin (vessicles in or around the ear){if present may indicate Ramsey Hunt disease}? |yes

R/O stroke:
1. Muscle strength of extremeties 5/5? |yes
2. Sensation WNL? |yes
3. Patella DTR WNL ? |yes R/O increased incranail pressure and hemorrhage:
1. Is the Fundoscopic exam WNL? |yes

R/O Cerebellum Brain Damage

1. Is finger to eye coordination nomral? |yes
2. Is Proprioception wnl? |yes
3. Is Pronator Drift WNL? |yes
4. Is heel to toe walk WNL? |yes

Seventh: if labs or test are needed and available order them consider:
UA, Strep, rapid flu test, gluocse (consider the need for CBD, CT, CTA (head and neck if TIA is suspected), MRA,Lyme tiiter)

Eighth
: if uncertain of the diagnosis or treatment call MD for consult

Ninth: make diagonosis based on available information: "facial weakness"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Treatment: Acyclovir, Prednisone, Daily aspirin for Suspected TIA, Also, inform the patient that you can not give them a definite answer for their headache, if symptoms persist or get worse be reevaluated

The first step is to see if the person can lift both eyebrows, if they can they may have had a stroke. They have three hours or less to qualify for TPA.

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis and you might not be able to give them treatment.


That a fcaial droop can be a symptom of a moderate illness or an indication of serious and dangerous problem.
That you will be evaluate their facial droop but the evaluation may not be enough to determine the cause of the facial droop.
Sometime other test such as CT scan may be necessary to determine the cause of a headache.
If you feel you can not identify the cause of the nausea, you will refer them to higher level of care.

The third step is to think of and try to rule out the most dangerous causes:

In this case the most dangerous problems are CVA (Stroke) and TI
A. Cerebral Vascular Accident(Stroke)-able to raise both eyebrows, but has motor and sensory defecits, usually on one side
B. Transient Ischemic Attack (TIA) - able to raise both eyebrows, the symptoms may go away before being seen. Must be referred for workup. .
The fourth step is to think of and try to rule out as many possible causes as is reasonably possible.

C. Bell's Palsy - Partial paralysis on one side of the face. Unable to raise affected side eyebrow.
D. Ramsy Hunt Syndrome - Partial paralysis and will have vesicle around one ear
E. Lyme Disease - HX of contact with Tick, may have had a bullseye rash at some time . .  




Vertigo/Dizziness

The fifth step is to the appropriate history Open Note Writer

General Information:
Onset:
Location:
Duration:
Character:


Important Edulcational Notes:
Central Vertigo: is the LEAST COMMON, BUT the MOST EMMERGENT
Central Vertigo: is caused by a problem in the brain and when found usually requires a referral to ED visit for immediate CT or MRI.
Central Vertigo: is a constant vertigo that get waxes and wained but it always present.
Central Vertigo: may be Vertical (up and down) Vertigo, or rotary vertigo, or it may be horizontal (side to side).
Central Vertigo: Usually has a greater degree of eye nysstagmus.
Central Vertigo: Vertical Nystagmus and Horizontal Nystagmus (that occurs bi-directionally) supports central Vertigo.

Peripheral Vertigo: More Common and less Dangerous Central Vertigo
Peripheral Vertigo: is usually Horizontal Nystagmus that occurs in one direction and is fatigueable.
Peripheral Vertigo: only occurs with certain head movements, and is fatigueable, unidirection nystagmus, and last for seconds

Fifth step is to take the Appropriate and Necessary History.

R/O Dizziness due to arrythmia or hypovolemia
1. Is there dizziness due to hypovolemia [most immediate danger]? |yes
2. Do the dizzy speells occur when you going from a lying to stand, or sitting to standing Position?
|yes
3. When you have the episodes does it seem like you are about to faint? |yes
Is this a central vertigo, which is caused by CNS problems?
1. Is this type of dizziness constant? |yes
2. Do the dizzy spells last for more than a few minutes? |yes
3. If you have a spinning sensation is the sensation up and down or gyrating configuration? |yes
4. When you have the episodes is it hard to walk in a straight line for more than 5 minutes? |yes

Is this a peripharal vertigo:
1. Do the dizzy spells occur when you change the position of your head? |yes
2. When you have the episodes does it seem as thought the room is spinning ? |yes
3. If you have a spinning sensation, is it horizontal? |yes
4. When you have the episodes is it hard to walk in a straight line for more than 5 minutes? |yes

R/O Tumor:
1. Is there a headache which is worse in the morning? |yes
2. Is ther weight loss?

R/O Crebella infarction and hemorrhage (stroke):

1. Is there ataxi or poor coordination? yes

R/O Migrainous vertigo
1. Is there vertigo? + phonophobia? + Photophobia? and a HX of Migrain? |yes

R/O Brainstem ischemia (CVA)
1. Is there Constant Decrease Balance, or Vision, or Hearing, or weakness? |yes

R/O Chiari Malformation (CX excess CNS in brainstem; therefore increase pressure)
1. Is there a variety of problems with coordiantion and balance, sometime since birth? |yes

R/O Demyelination of nerves:
1. Is there constant Vertigo, or visual changes, or weakness or fatigue: |yes

R/O Psychogenic: Is the dizziness ill-defined and/or unrelated to posture

R/O Ototoxic:
1. Were any the following drugs taken: aminoglycosides, antimalarials, erythromycin, Furosemide? . .
|yes

R/O Temporal Lobe Epilepsy:
Is there a History of seizures? |yes

R/O Drug or Alcohol Abuse
Is there a History of using alsochol or illicit drugs? |yes
R/O Presyncopal faintness
Does it occurs when arising, or cause lightheaded? Is there low BP? Increased capillary refill time?
|yes

R/O Disequilibrium

Is there a problem balacing when walking? When stading still? (if positive CT scan) |yes

R/O Psychogenic Dizziness
Do the same feelings occur when the person breaths rapidly? |yes

R/O Benign Paroxysmal Position Vertigo
Does it last seconds and occur with head movement?|yes

R/O Vestibular Neuritis
1. Was there recently a cold? Is there N&V? Does it last longer than BPPH but has similar episodes?
|yes
2. Is there no decrease in hearing, [Treatement can be Cortisone]? |yes

R/O Herpes Zoster Oticus (Ramsay Hunt Syndrome)
Are there vessicles present close to or in the ear canal? |yes

R/O Meniere Disease
Does is last longer than BPPH? And have tinnitus and decreased hearing?
|yes

R/O Labyrinthine Concussion
Was there a recent concussion or whiplash & have N&V and effects hearing also?
|yes

R/O Perilymphatic Fistula (middle ear to inner fistula)
1. Is there nausea, vomiting, and tinnitus? |yes
2. Do the symptoms increase with a sneeze, cough, strain, altitude, elavation (including decreased hearing)?
|yes [the cause is barotrauma]

R/O Semicircular Canal Dehiscence (Rare, the cause is a thin temporal bone)
1. Is there hyperacusis? (hear eye balls move? |yes
2. Is there decrease low pitch hearing? |yes
3. Is there pulsatile tinnitus? |yes
4. Is there HA? |yes
5. Is there Migraine? |yes
6. Is there sound induced vertigo? |yes
7. Is there decrease vision? |yes
8. Is there nystagmus? |yes

R/O Cogan Syndrome [This can lead to blindness. It is a rare autoimmune disease.]
Is there Vertigo, keratitis, fever, fatigue, and hearing loss?, |yes

R/O Acoustic Neuroma
Did it develop slowly? |yes
Is there vertigo? |yes
Is there N&V? |yes
Is there a Decreased balance? |yes
Is there one-side tinnitus? |yes
Is there a one-side decrease in hearing? |yes
R/O Aminoglycoside Toxicity
Is there vertigo + bouncy vision? |yes an ability to hear one's own speech? |yes
2. Is vertigo activated with hearing sounds? |yes
3. Does vision that seems to jerk or jump? |yes
4. Is there pulsatile ringing in the ear? |yes
5. Is there mental clouding (brain fog)? |yes

R/O Cervicogenic Dizziness
1. Was there any recent trauma such as whiplash? |yes
2. Is there stiffness of pain in the neck? |yes

R/O Heart Attack
Is there also REAL shortness of breath? |yes
Is there diphoresis? |yes
Is there any pain in the chest, jaw, or arms?|yes

R/O Otoxicity
Is there any medication being used or recenly used especially medicaitons such as Gentamycin?

R/O Paraneoplastic Neurologic Syndrome
Is there know previous cancer?
Is there weight loss without trying?

R/O Multiple Sclerosis
Is there any known Multiple Sclerosis?

R/O Other possible causes that are even more rare:
R/O Diabetic Neuropathy: .......................................Is there known Diabetes?
R/O Lymphoma: ........................................Is there any swollen lymph nodes?
R/O Pernicious Anemia: .............................................Is there known anemia?
R/O Ramsey Hunt Syndrome Type 2: ............................Is there facial Droop?
R/O Panic Attack: ......................................................Is there known anxiety?
R/O Dumping Syndrome: .........................................Is there a lot of diarrhea?
R/O Drop Attac: ...................Is there a sudden fall and loss of consciousness?
R/O Peripheral Artery Disease: ..........................Is there coldness of the feet?
R/O Traumatic Brain Injury: .....................Has there been recent head injury?
R/O Lyme Disease: Has there been recent camping or known Lyme Disease?
R/O Von-Hippel-Lindau Disease (brain tumor): .....Is there history of cancer?
R/O Heart Cancer: ...Is there a history of weight loss and cardiac symptoms?
R/O Type 1 Diabetes: ..........................Is there excessive there and urination?
R/O Carbon Monoxide Toxicity: ............................Is there use of gas heater?


The Sixth Step is to to the Appropriate and Necessary Physical

R/O Cardiac Arrythmia or any other cause of LOW Blood pressure such as AAA
1. Is standing blood pressure low for height and weight and age? |yes
2. Is the pulse rate irregular? |yes
|yes

R/O Abdominal or Thoracic Aneursym that could cause a low blood pressure

1. Is there a abdominal murmur?
2. Is there pulsatile abdominal mass?


R/O Most Major Neurological problems (Brain Tumors, Intracranial Bleeding, Stroke)
1. Is patient able walk in a normal way? |yes
2. CNIII to XII WNL? |yes
3. Is there any obvious nystagmus? |yes
4. Is patella reflex WNL? |yes
5. Is grip strength WNL? |yes
6. Is finger to eye coordination WNL? |yes
7. Head impulse test is WNL? |yes
8. Test of skew test is wNL? |yes
9. Is Nystagmus present with a primary gaze to the right gaze or to the left? |yes
10. Toe-heal-walk test is WNL? |yes
11. Rhomberg test is negative? |yes
12. Pronator drift wNL? |yes

13. Dix Hall-Pike test WNL? |yes
R/O Otitis Media

1. Is the TM immovable & bulging & malleus obscured? |yes
2. Throat WNL? |yes

R/O Otitis Externa

Is Ear canal WNL? |yes


Edcuation Note:
HINT tests: Head-Impulse and Nystagmus and Test-of-Skew ):

Gaze Test: Easiest: Observation for nystagmus in right, and left gaze Nystagmus when gazing to the far right or far left.

Test of Skew: Patient looks at your nose and you cover and uncover each of his eyes one after the other, and look for an eye that has to refocus.

Head Impulse Test (pt. focus on your nose) turn his head quickly--slow response indicate peripheral vertigo (good)

Educational Note

Near syncope causes are the following: (irregular heart rate, PVCs, Afib, valve problems (murmurs), Aneurysm (listen and palpate- even over the eyes with the lids down)

SYNCOPE; RULE OF 15:
15% Seizure
15% Brugada Syndrome [EKG will show elevated ST segments in V1, V2, And V3]
15% aortic anerusym
15% Arrythmia: AV block, sick sinus syndrome, Mechanical Heart Problems [usually get worse with exertion: aortic stenosis, pulmonaray stenosis, hypertrophic cardiac myopathy, myxoma obstructing the mitral valve, (usually a reason-->faint due to vasovagal, Medications: legal and illegal

[SYNCOPE ALWAYS IS A REFERAL: AT A MINIMUM REQUIRES AND EKG] .

Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse, (Consider need to for CT or CTA or MRI/MRA)

Eigth:
if uncertain of the diagnosis or treatment call MD for consult .

Ninth:
make diagonosis based on available information: "Dizziness and Giddiness"

Tenth:
refer out, or send home with apppropirate meds, and follow up instruction .

Eleventh: Possible TREATMENT
:


Epply Manuver: If the problem is thought to be BPPV Benign Paroxsymol Position Vertigo

May also give meclazine (Antivert) a try. meclizine : 12.5 to 25 mg orally every 4-8 hours when required, maximum 150 mg/day; or 12.5 to 25 mg orally as a single dose approximately 60 minutes prior to repositioning maneuver

Asprin (daily) can be considered if TIA is suspected, Carotid Endarterectomy is also a possible treatment if TIA is suspected and Carotid occlusion found
The first Step is to take the vital signs and make certain there is no evidence shock, irregular heart beat, or extreme temperatures (sepsis). may not be able to give them a definite diagnosis (because there are approxmiately 20 Causes .) and you might not be able to give them treatment.
thri
Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.

That a dizziness can be a symptom of a mild illness or an indication of serious and dangerous problem.
That you will be happy to evluate their dizziness but the evaluation may not be enough to determine the cause of dizziness.
Sometime other test such as CT scan or MRI may be necessary to determine the cause of a headache.
If you feel you can not identify the cause of the dizziness, you will refer them to higher level of care. .

The third step is to think of and to R/O the worst causes of Dizziness: In this case these are probably: shock, any of a varity of cardiovascular causes (e.g. atrila fib), Stroke, TIA, Sepsis. or Brain problems (e.g. tumor)

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible

MOST DANGEROUS:
Cardiovascular Causes: Arrythmia or hypovolemia
Stroke
TIA
Herpes Zoster Oticus (Ramsy Hunt Syndrome)
Central Vertigo (Various Brain Causes)
Disequilibrium
Acoutic Neuroma
Chiari Malformation
Ototoxic
Temporal Lobe Epilepsy


LEAST DANGEROUS
Drug and Alcohol Abuse
Peripheral Vertigo
Benign Paroxysmal Positional Vertigo
Vestibular Neuritis
Meniere Disease
Labyrinthine Concusssion
Perilyphatic Fistula
Semicircular C. Dehiscence
Cogan Syndrome
Aminglycoside Toxicity
Otitis Media
Psychogenic Causes





Cough


Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:

Most Dangerous
R/O Myocardial Infraction
1. Is there SOB with exertion? | yes
2. Is there Radiation of chest pain? | yes
3. Is there Simulataneous diphoresis? | yes
4. Is there a Family History or early MI? | yes

R/O CHF
1. Is there pretibial edema?
2. Is there pedal edema?
3. Is there rales?


R/O Pulmonary Embolism
1. Was there Recent surgery? | yes
2. Is there a history of Cancer? | yes
3. Is there current or recent Estrogen use? | yes
4. Is there current previous history of smoking? | yes
5. Has there been Prolong immobility (eg flying)? | yes
6. Is there or has there been recent Swelling of calf? | yes

R/O Asthma
Is there a history of asthma? | yes

R/O Aspiration Syndrome
Is there a history of choking on food or an object? | yes

R/O Drug Induced Lung Disease
Is there a recent change of medication or illicit substance used? | yes

R/O Bacterial Pneumoniae

Has there been a fever? | yes . .

R/O Atypical Pneumonia (viral)
1. Has there been a fever? | yes
2. Has there been noticable shortness of breath (eg walking up stairs)? | yes
3. Has there been noticable shortness of breath (eg walking up stairs)? | yes

R/O Pneumocystis Jiroveci Pneumonia:

1. Is there a possibility of immune suppression due to a disease such as cancer or hiv/aids or being on a
2. medication that suppresses the immune system such as Prednisone? . | yes
3. Has there been a fever? | yes . . .
4. Has there been noticable shortness of breath (eg walking up stairs)?| yes

R/O Bird Flu

Has there travel to Asia within the last month? | yes

R/O Histoplasmosis
Has there possible contact with mouse feces? | yes

R/O Aspergillosis
Has there been exposure to bird feces? | yes

R/O Lung Abscess

R/O Lung Cancer
1. Has there a history of smoking? | yes
2. Has there been night sweats?. | yes
3. Has there been weight loss?. | yes

R/O Tracheal Tumor

R/O Tuberculosis of the Lung
1. Has there a history of being exposed to TB? | yes
2. Has there a history of internation travel? | yes
3. Has there been night sweats?. | yes
4. Has there been weight loss?. | yes

R/O Esophageal Cancer

R/O Thymic Cancer (cancer of thymus gland)


R/O GERD
Is there any nausea or heart burn?| yes

R/O Rib fracture
Is there any trauma to the rib cage? | yes

R/O Bronchietasis

R/O Cough Headache Syndrome

R/O Acute Bronchitis
Has there been a recent cold? | yes
Is there coughing up of secretions? | yes
Is there a high pitch wheeze heard? | yes

R/O Chronic Bronchitis (COPD)
Is there a known history of COPD and medications taken for it? | yes

R/O Sarcoidosis

R/O Chiari Malformation

R/O Measles
Is there a recent history of measles?| yes

R/O Tularemia
Is there recent contact with rabits? | yes

R/O Common Cold
Has there been a recent cold? | yes

R/O Human Metapneumovirus

R/O Tracheomalacia

R/O Hypersensitivity Pneumonitis

R/O Pnemoconioses

R/O Sickle Cell Anemia
Has there a history of Sickel Cell Anemia? | yes

R/O Wegener's Granulomatosis

R/O Microscopic Polyangiitis

The Sixth Step is to to the Appropriate and Necessary Physical

MOST DANGEROUS

R/O Myocardial Infarction

1. Is EKG abnormal? |yes
2. Are trepnon levels abnormal? |yes

R/O CHF
Is there carotid distention? |yes
Are the heart sounds normal without a gallop? |yes

R/O Pulmonary Embolism
Is age greater than 50? |yes
Is the Po2 normal? |yes
Is there calf Swelling? |yes
Has there a prolonged period of immobility? |yes
Is there a history of Cancer? |yes
Is there recent surgery? |yes
Is there estrogen use? |yes

R/O Asthma
Is there wheezing? |yes

R/O Aspiration Syndrome (needs CXR)

R/O Bacterial Pneumoniae
Is there rales, fever, and REAL SOB? |yes

R/O Atypical Pneumonia (viral)
Is there rales, fever, and REAL SOB? |yes

R/O Pneumocystis Jiroveci Pneumonia:
Is there rales, fever, and REAL SOB? |yes

R/O Bird Flu
Is there rales, fever, and REAL SOB? |yes

R/O Histoplasmosis
Is there rales, fever, and REAL SOB? |yes

R/O Aspergillosis
Is there rales, fever, and REAL SOB? |yes

R/O Lung Abscess (needs CXR)
R/O Lung Cancer (needs CXR)
R/O Tracheal Tumor (needs XR)
R/O Tuberculosis of the Lung (needs CXR)
R/O Esophageal Cancer (needs XR)
R/O Thymic Cancer (cancer of thymus gland) (needs CXR)


R/O GERD
Generally Made by History

R/O Rib fracture
Is there focal rib pain? |yes

R/O Bronchietasis

R/O Cough Headache Syndrome

R/O Acute Bronchitis
Is there wheezing? |yes
Is there decreased air perfussion to any parts of the lungs? |yes

R/O Chronic Bronchitis (COPD)
Is there wheezing? |yes
Is there decreased air perfussion to any parts of the lungs? |yes

R/O Sarcoidosis (needs CXR)

R/O Chiari Malformation

R/O Measles

R/O Tularemia

R/O Common Cold - MOST COMMON

R/O Human Metapneumovirus

R/O Tracheomalacia

R/O Hypersensitivity Pneumonitis

R/O Pnemoconioses

R/O Sickle Cell Anemia

R/O Wegener's Granulomatosis


R/O Microscopic Polyangiitis

WARNING: If f AGE >65 y, Resp. >30, BUN > 19, BP < 90 and Confusion send to ER . WARNING: If patient is truly dyspnic (Short of Breath), send to either ER or urgent care depending on their gravity--or call 911

The First Step: observe patients respiratory rate, use of abdominal muscles, and facial color to make assessment of Respiratory Problems that would require emergency interventions (example: acute asthma or Respiratory distress due to a foreign body lodged in airwar). .he Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis for dyspnea because there are over 20 different cause and that you might not be able to given them the treatment they need either. .

A cough can be a MAJOR or Minor infection.
Tell the patient that you will can evaulate there cough as best you can without having a Xray machine of other test. A definite cause might not be determined, and also that you might not be able to prescribe the treatment for the illness.

You do not have the equipment to test for some Major Causes such an MI or a PE.

That you will be a treat a minor cough with some Albuterol Inhaler and Tesalon Pearls.

If you feel you can not identify the cause of the nausea, you will refer them to higher level of care.

The third step is to think of and try to rule out the most dangerous causes: .

In this case these things are : (heart attack, pulmonary emboli, foreign object lodged in airway)

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible. . .

MOST DANGEROUS
Pulmonary Emboli
Tularemia
Asthma
Aspiration Syndromes
Bacterial Pneumonis
Tuberculosis
Lung Abscess
Sickle Cell Anemia
Bird Flu
Histoplasmosis
PCP
Pulmonary Edema (secondary to CHF)
Human metapneumovirus

LESS DANGEROUS 
Influenza
Parainfluenza Virus
Bronchiectasis
Aspergillosis
Cough Headache Syndrome
Bronchitis
Common Cold
COPD
Esophagel Cancer
Thymic Cancer
Tracheal Tumor
Measles
Sarcoidosis
Trachemalacia
Hypersensitivity Pneumonitis
Pnemoconioses
Relapsing Fever
Wegener's Granulomatosis
Microscopic Polyangitis
Drug Induced Lung Disease



Seventh: if labs or test are needed and available order them consider:
UA, Strep, rapid flu test, gluocse. Consider CBC, Pro calitonin, CRP, CXR, EKG, CD4, Pertusis Titer, D-Dimer, Acid Fast Bacilli culture, CXray, CT of chest (especially if smoker), peak flow, bronchoscopy
Eighth: if uncertain of the diagnosis or treatment call MD for consult
Ninth: make diagonosis based on available information: "Cough"
Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Treatments:

Medrol dose pak, Robitussin with Codeine, Albuterol inhaler, Tesalon Pearls, Ipratropium nasal spray, Antihistamine, Azithromycin (Prolong QT), Rocephin Injection




Dyspnea: Short of Breath (SOB)

Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:


R/O MI
Is there SOB with exertion? | yes
Is there Radiation of chest pain? | yes
Is there tearing back or abdominal pain? | yes
Is there any nausea or heart burn? | yes
Is there Simulataneous diphoresis? | yes
Is there a Family History or early MI ? | yes
Was there Recent surgery? | yes
Is there a history of Cancer? |yes
Is there current or recent Estr ogen use? | yes
Is there current previous history of smoking? | yes
Has there been Prolong immobility (eg flying)? | yes
Is there or has there been recent Swelling of calf? | yes

R/O Rib Fracture
Is there a history of recent vomiting? | yes
Is there any tenderness of the rib cage? | yes
Is there any history of HIV or AIDS? | yes

R/O Asthma
Is there a known history of asthma? | yes

R/O Pneumonia
Is there a fever? | yes

The Sixth Step is to to the Appropriate and Necessary Physical

R/O Pulmonary Embolia
Physical Exam: Is age greater than 50 years? |yes
Is the Po2 normal? |yes
Is there calf Swelling? |yes

R/O CHF
Is there rales? |yes
Is there wheezing? |yes
Is there carotid distention? |yes
Are the heart sounds normal without a gallop? |yes Is the respiratory rate normal at rest? |yes
Is the respiratory rate normal after walking a marching in place? |yes
Is there a regular rate heart beat? |yes
Is there pedal edema? |yes
Is there pretibial edema? |yes

R/O Abdominal Aortic Anuerysm
Is the abdomen without murmurs and without a pulsatile mass? |yes

R/O Asthma

Is there Wheezing? |yes

R/O Pneumothorax:
Is the trachea deviated? |yes
Are there any lung fields were breath sounds can not be heard? |yes

R/O Cardiac Tamponade:
Is there a difference in the blood pressure more than 10 mm of Hg when the person inspires? |yes

R/O Pericarditis:
Is there a pericoardial friction rub? |yes

R/O Rib Fracture:
Is there focal rib pain? |yes

Seventh: if labs or test are needed and available order them consider:
Strep, rapid flu test, gluocse. Test to consider are: CBC, Pro calitonin, CRP, CXR, EKG, CD4, Pertusis Titer, D-Dimer, Acid Fast Bacilli culture, CXray, CT of chest (especially if smoker), peak flow, bronchoscopy Lab: Alpha-1 Antiprysin Def. (emphysema test); Tests: Inspirometer, pulmonary function test

Eighth
: if uncertain of the diagnosis or treatment call MD for consult .

Ninth:
make diagonosis based on available information: "Dyspnea unspecified or Asthma or COPD"

Tenth:
refer out, or send home with apppropirate meds, and follow up instruction pain

Eleventh: Possilble Treatments:
Albuterol Inhaler, Doxycycline, Azithromycin (Prolongs QT), Rocephin, Benzonotate

Education Notes
Myocardial infartion . - Family cardia HX? Radiating Pain? Diaphoresis? SOB upon exertion? Low BP?
Epiglotitis - Vacinated for HIB? Leaning forward and drolling? Fear of having to open mouth?
Angioedema - Facial edema? Swelling of tongue?
Pulmonary Emboli - D-Dimer, recent travel? recent immobility, recent surgery? HX of PE or thrombophebitis, estrogen? smoking? HX of cancer? swelling of a calf?
Arythmia - irrgular pulse, PVCs, a-fib?, other (EKG if possible)
Intracadiac Shunt - Heart murmur know or present?
Acidosis - (eg ketoacidosis) HX of diabetes, family hx diabetes, fruity breath
Foreign Body Aspiration - palying with a small object or eating steak or taking pills prior to event
Shock - low blood pressure, especially when standing, often times edema of extremities
Asthma - wheezing with decreased PO2 . , history of asthma
Brief SOB after coughing . - not hypoxemia, but patient does feel SOB
Pneumonia . - fever, rales with decreased PO2
Bronchitis - cough with wheeze or cough with mucous production from the lun
Reactive airway disease . no history of asthm normal
CHF . - usually pretibial edema or ankle edema
Laryngeal obstruction . - early stridor
Tracheitis . : early stridor
Airway masS: here early stridor
Chest wall trauma: History of trauma
Drug induced condition (e.g crack lung, aspirin overdose) . : history of drug abuse
Pulmonary effusion (due to either infection or CHF)
Pulmonary hypertension -
Restrictive lung diseases -(various Interstital Lung Disease)

CARDIAC
Coronary Artery Disease - SOB on exertion, diaphoresis, radiating chest pain
Intracardiac shunt - murmur
Left Ventricle Failure (CHF) - pretibial or ankle edema of extremities
Myoma - tumor in the heart that may obstruct a valve usually
Pericardial disease - pericardial friction rub
Valvular Disease of the heart - murmur

NERVE PROBLEMS: - CNS disease - look for other indication of nerve problems: peripheral neuropathy, CNII-XII, Rhomberg, Fine motor coordination, heal to toe walk, pronator drift, deep tendor reflexes, muscle strength test
Myopathy and neuropathy - muscle strength test
Phrenic Nerve and disphragmatic disorders - CNS test
Spinal cord Disorders - CNS tests

Systemic neuromuscular disorders: CNS test: particularly decreased eye and eyelid movements

OTHER:
Acidosis : glucose test, other blood test (chemistry) .
Altitude Sickness : history of recent travel
Anaphylaxis : know allergy history?
Anemia : history or recent blood loss, ortho static blood test
Thyroid Disorders : thyroid palpation, examine eyes for bulging
Psychgenic: anxiety history
Sepsis : history of illness PEDIATRIC . - Croup: Stridor? See croup score to determine how bad the croup is.
congenital anomalies of the airway: listen to birth history
congenital heart disease: murmur, history, other congenital abnormalities?
Foreign body aspiration: history of playing with a small toy or eating beef prior to onset
nasopharyngeal obstruction: history of playing with a small toy
shock: low blood pressure Possible treatment for cough due to a cold: Medrol dose pak, Robitussin with Codeine, Albuterol inhaler, Tesalon Pearls, Ipratropium nasal spray, Antihistamin e
Asthma: goal is at least PO of 95% (If a person has chronic resp. problem the goal may be 90%)

The first Step is to determine if the patient really is currently breathing sufficiently by listening to their lungs, taking a respiratory rate and and taking a po2

* Then clarify if they feel as if it hard to catch there breath after coughing--or is their respiratory rate higher than normal and remains higher then normal for a hours. [True shortness of breath will not resolve quickly--but rather take minutes to hours]

2nd: The second step is to tell the patient that your clinic is designed to treat MINOR infections and injuries. That you might not be able to determine the cause because there are over 20 causes, and you also might not be able prescribe any antibiotics that will help them.

That shortness of breath can be a symptom of a mild illness or an indication of serious and dangerous problem
That you will be happy to evluate their difficulty breathing but the evaluation may not be enough to determine the cause of shortness of breath due to insufficient tests available.
Sometimes other test such as a CXR, a CT scan, or EKG may be necessary to determine the cause of a shortness of breath.
If you feel you can not identify the cause of the nausea, you will refer them to higher level of care. .

The third step is to think of and try to rule out the most dangerous causes: . In this case it is most likely:
* Asthma, MI, myocarditis, heart failure, pneumonia, thoracid aortic aneurysm,

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible

Asthma
Pulmonary Edema
Atypical Pneumonia
Pulmonary Emboli
Bacterial Pneumonia
Heart Attack
ARDS
Thoracic Aortic Aneurysm
Anaphylaxis
Pericardial Effusion
Aspiration Syndromes
Sicle Cell Anemia
Tularemia

COPD
Pulmonary HTN
Sarcoidosis
Lung Cancer
Iron Deficiency Anemia
Cardiac Amyloidosis
Myocarditis
Aortic Stenosis
Pulmonary AV Fistula
Cardiomyopathy
Ebstein Anomaly of the Tricuspid Valve
Leukemia
Thymic Cancer
Heart Cancer
Hypersensitivity Pneumonitis
Interstial Lung Disease
Pleurisy
Systemic Lupus Erythematosus
Human Metapneumovirus
Drug Induced Lung Disease
Erdheim- Chester Disease
Cytomegalovirus
Non-Hodgkin Lymphoma.





Hypertension Emergency

The first Step is to determine if the person evidence of end-organ damage: eg. Patient may have pretibial, and pedal edema and crackles in lung if the heart is being damaged.

Education Note: A hypertensive emergency is a blood pressure greater than 180/120 and they have evidence of end-organ damage.

Evidence of  End-OrganDamage: Evidence of CHF (edema, jugular vein distention, rales, decreased urine output, encaphlopathy (confused, poor concentration)


Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:


The Sixth Step is to to the Appropriate and Necessary Physical

R/O Hypertensive Encephalopathy
Is there mental confusion? |yes

R/O evidence of stroke
1. Is neuro exam WNL? |yes
14. Is fundoscopic exam WNL (flame homorrages, cotton wool spots, papilledema)?

15. Is CT of head normal? |yes

R/O evidence of MI or angina
1. Is there chest, jaw, or arm pain? |yes
2. Is there abnormal EKG? |yes
3. Is there elevated treponin? |yes
4. Is there an enlarged heart on xray -- widened mediastinum (aortic aneurysm)?
|yes
5. Is BNP Pro-brain Natriuretic peptide normal? |yes

R/O evidence of Kidney disease (decreased urination)

Is specific gravity too high or too low or is there excessive blood, protein or albumin?
|yes
Is creatine and BUN and electrolytes Abnormal? |yes

R/O Hemolytic Uremic Syndrome
Is there a normal CBC? |yes
Is there a normal microangiopathic hemmolytic anemia? |yes

R/O Disecting Aorta Aneurysm

1. Is there a pulsatile abdominal mass? |yes
2. Is there an abdominal bruit? |yes
3. Is blood pressure too high or too low? |yes
4. Is there back or abdominal pain? |yes
5. Is there a normal chest CT with contrast dye (look for aneurysm)? |yes

R/O Is there eclampsia

1. Is there known pregnancy? |yes
2. Is urint postive for HCG? |yes

R/O Pulmonary Hypertension
1. Is there repiratory crackles? |yes
2. Is there JVD? |yes

R/O CHF:
1. Is there pretibial edema or pedal edema? |yes
2. Is there rales? |yes

Seventh: if labs or test are needed and available order them consider:
UA, Strep, rapid flu test, gluocse

Eighth
: if uncertain of the diagnosis or treatment call MD for consult

Ninth:
make diagonosis based on available information: "essential (primary) hypertension"

Tenth:
refer out, or send home with apppropirate meds, and follow up instruction Chest Pain

Eleventh: Possible Treatments

JCH 8 Guidelines,Antihypertensive Medications, diuretics (need to check potaisum levels), IV Nitroglycerin (in ER)

Second: Tell the patient that your clinic is designed to treat MINOR infections and injuries and that you may not be able to determine the cause nor treat it. That the Minute Clinic Policy is to refer patients to there PCP for treatment for routine elevated blood pressure--but it usually requires adjustment in medication over a period of time. We will call 911 or send to ER if there is evidence of a hypertensive emergency.

Third: Look for the worse causes of Hypertension: Bacterial Meningitis, Aterial Aneurysm, Aortic Aneurysm, , Elevated Intracranial Pressure, Hypertensive Encepahlopathy, Heavy Metal Intoxication

Fourth: Think of and try to rule out if there any other causes of hypertension:

MOST DANGEROUS
Bacterial Meningitis
Aterial Aneurysm
Aortic Aneurysm
Elevated Intracranial Pressure
Hypertesnive Encaphalopathy
Heavy Metal Intoxification


LESS IMMEDIATELY DANGEROUS
CHF

Kidney
Adrenal Cancer
Renal AV Fistula
Ateriolar Nephrosclerosis (Kidney Disease)
Diabetic Nephropathy
Second Aldosteronism
Glomerulnephritis
Kidney Cancer
Interstitial Nephritis

Lung or Heart
Portal Hypertension
Pulmonary Hypertension
System Sclerosis
Aortic Arach Syndrome
Rheumatic Heart Disease
Tricuspid Insufficiency
Pathological Hypercalcemia
Other
System Lupus Erythematosus
Pseudoxanthoma Elasticum
Cirrhosis
Empty Sella Syndrome
Sleep Apnea Cryglobulinemia


,


Chest Pain


Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:


R/O Myocardial Infarction
* Is there SOB with exertion? | yes
* Is there Radiation of chest pain? | yes * Is there any nausea or heart burn? | yes
* Is there Simulataneous diphoresis with the chest pain? | yes *Is there a Family History or early MI? | yes

R/O PULMONARY EMBOLI

* Does it hurt to take a deep breath? . | yes
* Was there Recent surgery? | yes
* Is there a history of Cancer? | yes
* Is there current or recent Estrogen use? | yes
* Is there current previous history of smoking? | yes
* Has there been recnt Prolong immobility (eg flying)? | yes
* Is there or has there been recent Swelling of calf? | yes
* Are you coughing up blood? | yes

R/O AORTIC ANEURYSM:

* Is there tearing back or abdominal pain? | yes

R/O PNEUMOTHORAX
Was there recent trauma?
Was there a recent forceful cough?

R/O RIB FRACTURE
* Was there recent trauma? .. | yes
* Is there tenderness a focal rib spot? .. | yes

R/O MUSCULAR STRAIN

*Was there recent muscular activity? . | yes
* Can the chest pain be reproduced by moving in a certain way? . | yes

R/O PLEURITIS
* Is there a history of a creent cold? . | yes
* Is there increased pain with a deep breath? . | yes

R/O Pneumonia
* Is there fever? . . | yes
* Is there dyspnea, (shortness of breath, a need to breathe more frequently or rapidly after walking up stairs)? | yes

R/O BOERHAAVE SYNDROME (ESOPHAGEAL RUPTURE)
Is there a history of recent vomiting? | yes

R/O PERICARDIAL EFFUSION
Was there recent trauma? | yes
Was there recent surgery or invasive heart testing? | yes

R/O PERICARDITIS
Does sitting forward decrease the chest pain? | yes

R/O GASTROINTESTINAL CAUSES
Is there recent nausea, vomiting, or diarrhea? | yes
Is there a history of GERD? yes

Miscellaneous Questions if not already answered:
If questions have not previously answered, then ask them: |yes
Is Pain present during exeration or rest? |yes
Is there psychological stress? |yes
Is pain occuring during respiration or couphing? |yes
Is there dificulty swallowing? |yes
Is there a relationship to meals? |yes
Is there anything that relieves pain (leg, lying flat, leanving forward? |yes
Are there previous similar epidsodes? |yes
Are there Palpitation? |yes
Was there Syncope? |yes
Is there Diaphoresis? |yes
Is there or was there Nausea or vomiting..? |yes
Is there a Cough? |yes
Is there a Fever? |yes
Is there Chills? |yes

The Sixth Step is to to the Appropriate and Necessary Physical

R/O MI
* Is there bilateral rales? |yes
* Is there an irregular heart rate? |yes
* Is the heart beat too high or too low for there age? |yes
* Is the blood pressure too high or too low for there age? |yes

R/O PE
* Is there pulse greater than there systomlic blood pressure? |yes
* Is age greater than 50? |yes
* Is the Po2 normal (96 or better)? |yes
* Is there calf Swelling? |yes

R/O Thoracic & Aortic Aneurysm

Is the pulse rate regular? |yes
* Is the abdomen without murmurs and without a pulsatile mass? |yes

R/O Rib Fracture
* Is there focal rib pain? |yes
.
R/O Muscular Strain
* Does having the patient rotate torso, bend forward or backward, or move arms in flexion or extension reproduce pain? |yes

R/O Pleuritis
Is there pain in deep inspiration AND there is little chance that patient has a PE? |yes

R/O Pneumonia
* Is there rales AND SOB? |yes
R/O Boerhaave Syndrome (Esophageal Rupture)
Is there evidence of crepitus anywhere in the neck or upper chest clavicular area? |yes
R/O Pneumothorax
Is the trachea deviated? |yes .
Are there any lung fields were breath sounds can not be heard? |yes . .

R/O Pericardial Effusion
Is the blood pressure low? |yes . .
Is there repiratory rate greater than 20? |yes . .
Is the patient complaing of SOB? |yes . .

R/O Pericarditis: Is there a difference in the blood pressure more than 10 mm of Hg when the person inspires?
|yes

R/O Gastrointestinal Causes:
Is the abdomen rigid? |yes . .
Is there hepatomegally? |yes . .
Is there splenomegally? |yes . .
Is there a positive Blumberg (Rebound tenderness)? |yes . .
Is there a positive Murphy sign? |yes . .
Is there a postive McBurny Poiont? |yes . .
Is there a positive Psoas? |yes . .
Is there a positive obturator? |yes . .
Is the rectal exam positive for blood? |yes . .
.
Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse. Tests: EKG?, CXR?, treponin?,D-Dimer, Helical CT of lungs, lipsase?, BNP, CK-MB?
Ultrasound? ventilation/perfusion scan?, angiography, MRI, CBC, Pro-calcitonin, CRP?

Eighth: if uncertain of the diagnosis or treatment call MD for consult .

Ninth: make diagonosis based on available information: "chest pain, unspecified"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction .

Eleventh: Possible Treatments:

EDUCATION NOTES
Cardiac Causes of Chest Pain
Acute Coronary Syndrome or acute .MI Is there an increase in pain during exercise? Is there sweating? radiating pain?
Aortic Dissection - Does pain radiates to back, Is there abdominal pain, Bruit in back, or abdomen? Does anything seem odd? Heart heard more on right than on left? . . Pulmonary Causes of Chest Pain
Pulmonary Embolism PE - Is there a recent Hx of surgery? sitting (airplane travel)?, inactivity?, swollen calf?, estrogen use? cigarette smoking?
Tension Pnemothorax Possibly Pneumothorax- Is there decreased lung sounds, or a deviated trachea, or Po2 less than 96%? .
Asthma- Is there wheezing that responds to albuterol/ipatropium--or the noise in the laryn area and does not repond to albuterol? .
Pleurisy - Is there sharp pain on inspiration? (need CXR) . . .
Pnemonia - Is there crackles, shortness of breath (more than normal) and a decreased PO2? (need CXR)
Bronchitis (bronchial inflammation): Is it mild? Is PO2 normal? Are there cold symptoms? Is it constant? Does it repond to ibuprofen?
Pericarditis: Friction Rub when sitting up?
Gastrointestinal Causes of Chest Pain
Esophageal reflux- Is there heartburn or GERD history?
Esophageal abrasion - Is there a Hx of choking? . .
Esophageal foreign body - Is there a HX of choking? . .
Peptic Ulcer Disease- Is there pain that is better or worse after eating? . .
Mallory-Weiss Tear- Was there recent retching? . .
Pancreatitis - Is there upper abdominal pain? (must get Lipase) . .
Cholecystitis - Is there RUQ pain, is there a positve Murphy test? . .
Cholelithiasis - is there RUQ pain, that is referred to R shoulder? . .
Hepatitis - Is there Upper R. quardrant pain, dark urine, light stool? .

Musculoskeletal Causes of Chest Pain . .
A. Costochondritis- Is there reporducible pain the patient moves in a certain way or when pressure is applied to the cartiledge Between Sternum& ribs(costo)?
B. Muscoloskeletal chest wall strain: Is there recent HX of straining, is pain reproduciable with movement?
C. Cervical Disc Dis.- Could it be a compressed nerve? Is there any can parethesia?
Psyhchogenic Causes of Chest Pain
A. Anxiety- usu. Panic Disorder or Depression: When did the chest pain start? Are you anxious or depressed? How is you work? Your finances? Your relationship? Other Causes:
A. Herpes Zoster: Are there vesicles in a dermatomal pattern?
B. Breast Disease * Mass/Tumor/CA - Is there a palpable mass? *
Mastitis - Is the breast inflammed and swollen? *
Fibrocystic Disease - Does the breast hurt monthly during ovulation  

Chest Wall Causes of Chest Pain:
A. Chest wall hematoma
B. Chest wall laceration
C. Throbophlebitis of the thoracoepigastric vein
D. Xiphistenal Arthritis - arthritis of the cartilage between the xiphoid and sternum
E. Aiposis Dolorosa - multiple painful lipomas
F. Breast Abscess, fibroadenosis, carcinoma Still Other Causes of Chest Pain:
A. Chest wall twinge syndrome: sharpt chest pain lasting 30 seconds ot 3 minutes

B. Pleurodynia
C. Splenic ruptuer
D. Subdiaphramatic abscess
E. Intercostal myositis
F. Pectoralis minor strain
G. Pneumonitis
H. Rib Fracture
I Rib periostitis
J. Slipping cartilage
K. Thoracic aortic dissection
L. Esophagitis
M. Esophageal spasm
N. Esophageal Hyperalgesia
M. abnormal motility pattens and achalasia


The first Step is to determine if the person's has an irregular pulse due to an arrythmia that is currently occurring. Also, determine is blood pressure if appropriate for patient (BP may be changed either high or low with MI or arrythmia)

Second: Tell the patient that your clinic is designed to treat MINOR infections and injuries and that you may not be able to determine the cause nor treat it. While most of the time when young people have chest pain and a cold it is a result of inflammation of the bronchial or pleural space. However, some causes of chest pain are impossible to determine without special tests (EKG, CXR, Helical CT, Treponin levels.)

Third: Look for the worse causes of Hypertension:
* MI, Angina (CAD), Aortic Aneurysm, Pulmonary Emboli, Heart Failure

Fourth: Think of and try to rule out as many causes of chest pain as possible:

MOST IMMEDIATELY DANGEROUS
MI
Angina
Aortic Aneurysm
Pulmonary Emoboli
Heart Failure
Tularemia
Aspiration Sundrome
Pneumomediastinum
Atypical Pneumonia
Esophageal Perforation
Lung Abscess
Pericardial Effusion
Pleural Effusion

Myocarditis

LESS IMMEDIATE DANGEROUS
Pericarditis
Prinzmetal's Variant Angina (angina at rest)
Lung Cancer
Thymic CancerCostchondritis
Pleurisy
Shingles
Acortic Stenosis
Diffuse Esophageal Spasm
Lung Tuberculosis
Precordial Catch Syndrome
Pulmonary Hypertension
Schatzki Ring
Esophagitis
Achalasia - difficulty getting food down the esophagus
GERD
Interstitial Lung Disease
Systemic Lupus Erythematosus
Aortic Insufficiency




Diarrhea


Fifth step
is to take the Appropriate and Necessary History

 

NOT FINISHED

General Information:
Onset:
Location:
Duration:
Character:


Note: Diarrhea with blood is always a REFER OUT

Crohns Disease:
1. Is there a personal or family history of Crohn's Disease

Gastroenteritis
1. Is there any close friends of family memebers who also have diarrhea?
2. Is there also cramping and abdominal pain?
3. Is there also fever and headache?

Drug Induced Colitis
1. Is there any recent medication (especially antibiotics) that might be causing the diarrhea?

Irritable Bowel Syndrome (84% of people with IBS will have SIBO)
1. Is there a history of both constipation and diarrhea?
2. Is there an absence of fever (usually)?

Strongyloidiasis ( a type of worm)
1. Is there upper abdominal pain or burning?
2. Is there alternating diarrhea and constipation?
3. Is there a cough?
4. Is there a rash--especially hives around the anus?
5. Is there vomiting?
6. Is there weight loss?

Lactose Intollerance:
1. Is there an increase flatulance, nausea, or diarrhea after eating or drinking dairy problucts (especially mild)
2. Is there a positive hydrogen breath test after drinking a lactose beverage?

Microscopic Colitis Syndrome (requires a microscope to see the damage of the colon)
1. Is there diarrhea that comes and goes without little other symptoms?)

Food Posioning?
1. Are other people sick with the same sypmtoms? |yes
2. Did the effected people eat the same food? |yes
3. Is there crampling, nausea, vomiting, diarrhea, and fever? |yes

R/O) Tularemia?
1. Is there any recent travel to forested areas? |yes
2. Is there any possible contacts with rabits, beavers, or ticks or deer flies? |yes

Carcinoid Syndrome
1. Is there a known history of cancer?

Giardiasis Infection
1. Has there been any recent travel out of the country or to lake areas? |yes

Pancreatic Cancer
1. Is there a history of alcohol abuse? |yes | no | NOT Done
2. Is there epigastric or left upper quadrant abdominal pain? |yes | no | NOT Done
3. Is there unintended weight loss?
4. Is there a personal or family history of cancer?

Diabetic Neuropathy
1. Is there known diabetes?
2. Is there dysphagia, early satiety, reflux, constipation, abdominal pain?
3. Is there nausea, vomiting, or diarrhea?

CMV Colitis
1. Is there is decreased immune system due to HIV, cancer treatment, or medications that decrease the immune system?

Celiac disease
1. Is there someone else in the family with known celiac disease?
2. Is there pale, foul-smelling, or fatty stool?
3. Is there weigh loss?
4. Is there intermittant constipation?
5. Is there chronic diarrhea?

Fecal Impaction
1. Is there a history of constipation? |yes
2. Has the person had a bowel movement in the last 24 hours? |yes
3. Is the person able to pass gass? |yes

Vibrio Parahemoltyicus Infection (cause bacteria, V. parhaemolyticus)
1. Have you recently eaten uncooked sea food?
2. Is anyone sick with the same symptoms?
3. Have you had any fecal oral contact?

Shigella Infections
1. Is there obvious blood in the stool?
2. is there fever, diarrhea, and stomach cramps?

Whipple Disease (caused by a bacteria: Tropheryma Whipplei)
1. Is there Chronic Diarrhea?
2. Is there weight loss, abdominal pain, weight loss, and joint pain?
3. Is there fat in the stool?
4 Is there peripheral edema due to low albumin?
5. Is there confusion, or memory loss, seizures?

Blind Loop Syndrome (this is also called Small Intestine Bowel Overgrowth)

SIBO: Small Intestinal Bacterial Overgrowth
1. Is there similar symptoms to IBS; however, more diarrhea than constipation?
2. Is there a positive Lactulose breath test?

Escherichia Coli Infection (particularly E. coli 0157:H7)
1. Is there diarrhea, abdominal pain, and fever?
2. Is there bloody diarrhea?
3. Is there a weakened immune system?
4. Is there easy brusing?
5. Is there blood in the urine?
6. Is there decreased urine output? (kidney disease)

Bowel Cancer
1. Is there unintended with loss?
2. Are stools more narrow than normal?
3. Is there rectal bleeding?
4. Is there frequent gas pain, bloating, fullness, or abdominal Pain?
5. Is there black tarry stool?

Ulcerative Colitis
1. Is there any personal or family history of colitis?
2. Is there any abdominal Pain?
3. Is there mucous and blood seen in the stool?

Radiation Colitis
1. Was there recent for cancer with radiation?

Amebiasis
1. Is there any history of possible contamination from infected water--or a chance rectal area to mouth contact?
2. Is there 3-8 semiformed stools per day?
3. Is there ecessive gas?

Heavy Metal Intoxication (mainly iron overdose)
1. Is there any unusal intake of food, for example from one's own garden, or a friends garden, or work or play in a metal contaminated area?

Postcholecystectomy Syndrome:
1. Did the patient recently have their gallbladder removed?



Malabsorption Syndrome:
1. Is there noticeable fat in the stools
2. Is there anemia due to insufficeint iron or B12
3. Is there weight loss

The Sixth Step
is to to the Appropriate and Necessary Physical .

General Physcial:

Tularemia
Hirschsprung disease
Food Poisoning

Acute (Viral) Dirrhea
Crohn's Disease
Ulcerative Colitis
Gastroenteritis
Irritable Bowel Syndrome
Lactose Intolerance
Celiac Disease
Carcinoid syndrome
CMV Colitis
Pancreatic Cancer
Fecal Inpaction
HIV/AIDS
Endometriosis
Radiation Colitis
Amebiasis
Giardiasis Infection


Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse. . Consider: Labs: UA for women,
Preg. for women, blood, leukocytes, O&P, C-diff . . .
Tests: consider: upright and flat plate of abdomen . .
Diarrhea more than 7 days requires tests: fecal leukocytes, lactoferin, O&P, bacterial cultures. Diarrhea that is more severe:   .6 liquid stools per day, fever, requires more urgent testing. (page 576 Current Med algorithm chart) . .

Eighth: if uncertain of the diagnosis or treatment call MD for consult .

Ninth: make diagonosis based on available information: "Diarrhea, unspecified"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction .

Eleventh Treatment: . Diarrhea lasting more than 5 - 7 days probably needs a more comprehensive workup. .
Zofran 8 mg, Peptobismol, Kaopectate, Rice, Cheese

The first Step is to rule out emergency problems by taking vital signs: (Being certain to determine rate of heart and low blood pressure that might come from hypovolemic shock)

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis because there are over 10 different causes, and you might be able to give the treatment they need. .

Diarrhea can be either minor illness or something they ate -- or it might be a major illnes (such as clostridium difficil)
Tell the patient that you will can evaulate them for Minor causes but can not evaluate for all of the causes.
That you if they are too ill you may not be able treat them, but will have to refer them out.
Of If you feel you can not identify the cause of the diarrhea, you will refer them to higher level of care.

The third step is to think of and try to rule out the most dangerous causes: .

In this case (Tularemia, carcinoid syndrome, clostridium difficil, Chrohns, collitis) .* .

Note: Diarrhea with blood is always a REFER OUT

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible.

MOST IMMEDIATELY DANFEROUS
Tularemia
Hirschsprung disease
Food Poisoning


LESS IMMEDIATELY DANGEROPUS
Clostidium Dificil
Crohn's Disease
Gastroenteritis
Irritable Bowel Syndrome
Lactose Intolerance
Strongyloidiasis (hookworm)
Celiac Disease
Acute Diarrhea
Carcinoid syndrome
Giardiasis Infection
CMV Colitis
Pancreatic Cancer
Vibrio Parahemolyticus ...infection (roundworm)
Fecal Inpaction
HIV/AIDS
Ulcerative Colitis
Endometriosis
Eschericha Coli Infections
Diabetic Neuropathy
Whipple disease
Radiation Colitis
Amebiasis
Bowel Cancer
Postchholecystectomy Syndrome







Nausea:

Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:

R/O MI
Does the nausea or heartburn change with rest? |yes
Does the nausea or heartburn change with exertion (walking upstairs)?
|yes
Is there a history of any vascular disease including peripheral vascular disease?
|yes
Is there a history of atrial fibrilation? |yes
Is there any diaphoresis associated with the nausea? |yes
Is there any radiaiton of nausea? |yes
Is there any Shortness of Breath (dyspnea)? |yes
Is there any Cocaine or amphetamine use? |yes
Is there any abdominal pain? |yes If yes, see abdominal pain differential

R/O Pyelonephritis
Is there any back pain?

R/O Neurological Causes
Are there any visual changes? |yes . .
Are then any balance prblems? |yes . .
Are then weakness in any extermeties? |yes
Is there any decrease in sensation? |yes

R/O Concussion
Was there any recent head or neck trauma or abrupt stop head movements? |yes

R/O Brain Tumor
Has there been increasing headaches or weight loss? |yes

R/O Addisons Disease
Is there extreme fatigue?
Is there salt craving?
Is there darkening of the skin?
Is there weight loss?
Is there depression or irritability?

R/O Hepatitis:
1. Is there known history of Hepatitis? |yes
2. Is there alcohol use? |yes

R/O Mesenteric Ischemia
Does the patient have any history of vascular problems (MI, peripheral vascular disease)? |yes
Does the nausea or abdominal discomfort get worse after eating? |yes . .

R/O Intestinal Obstruction
Is there a history of constipation? |yes . .
Is the patient able to pass gas? |yes . .
Has there been a good bowel movement in the last 12 hours? |yes . .

R/O trauma
Has there been adminal trauma or rectal trauma from sex? |yes . .

R/O Infection
Is there a fever? |yes . .
Is there a history of recent travel to forested areas? |yes . .
Is there a history of internation travel? |yes . .
Is there diarrhea (more than 3 liquid Bowel Movement in 24 hours?) |yes . .

R/O Food poisoing:
Is there diarrhea? |yes . .
Is there bloody diarrhea? |yes

R/O Pancreatitis:
Is there a history of alcohol abuse? |yes

R/O Gastritis:
Is there a history of GERD or heartburn? |yes . .

R/O RockyMountain Spotted Fever:
1. Has there been any recent camping? |yes
2. Is there a petechial rash, fever, nausea, abdominal pain, conjunctivitis? |yes

R/O Viral Meningitis
1. Is there fever, headache, and neck stiffnesss? |yes

R/O Pelvic Inflmmatory Disease
1. Is the patient sexually active? |yes
2. Is there mid-right ot mid-left abdominal pain? |yes
3. Is there cervical tenderness, painfull sex, a vaginal discharge, or irregular menstruation? |yes

R/O Carbon Monoxide Poisoning
1. Is there use of a gas heater? |yes

R/O) Tularemia?
1. Is there any recent travel to forested areas? |yes
2. Is there any possible contacts with rabits, beavers, or ticks or deer flies? |yes

R/O Ovarian Cancer
1. Is there any feeling of being bloated or difficulty passing gas? |yes
2. Is there any history of cancer in the family or patient? |yes
3. Is there any unintended weight loss? |yes

Hepatitis A, B, or C
1. Is there light colored stool or dark colored urine? |yes
2. Is ther known hepatitis? |yes

Human Granulocytic Anaplasmosis
1. Has there been any recent travel to forested areas and possible contact with a tick? |yes

Food Posioning?
1. Are other people sick with the same sypmtoms? |yes
2. Did the effected people eat the same food? |yes
3. Is there crampling, nausea, vomiting, diarrhea, and fever? |yes

Gallstones?
Is there abdominal pain that is colicky (waxes and wanes)? |yes

Stomach Cancer?
Is there history of personal or family cancer? |yes
Is there a history of indestion or heart burn? |yes
Is there unintended weight loss? |yes

Gastritis
1. Is there a history of belching or heartburn? |yes
2. Is there Nausea, vomiting, and diarrhea that came on slowly? |yes
3. Is there an absence of fever? |yes

Ovarian Cysts
1. Is the pain occurring during midovulation? |yes
2. Is there any personal or family history of ovarian cyst? |yes

Giardiasis Infection

1. Has there been any recent travel out of the country or to lake areas? |yes

Babesiosis
1. Has there been any travel to forested area where a tick bite was possible? |yes

Cirrhosis
1. Is there any history of alchol over use? |yes

Drug Induced Colitis
1. Is there any recent medication (particularly antibioitics) that could have caused colitis? |yes

Fecal Impaction
1. Is there a history of constipation? |yes
2. Has the person had a bowel movement in the last 24 hours? |yes
3. Is the person able to pass gass? |yes

Hypotensive Disorders

1. Is there any history of low blood pressure--or there currently low blood pressure, possibly due to hypovolemia? |yes

Osteitis Fibrosa Cystica (hyperparathyroidism)

1. Is there also a history of bone fractures, bone tenderness or pain, constipation? |yes

Substance Abuse
1. Is there a history of recent or past alcohol, heroine, or other non prescribed mediction (particularly pain medicaitons)? |yes

Canabinoid Hyperemesis
1. Is there excessive marijuana use causing toxicity? |yes

Associated with Acute Diarrhea
1. Nausea associated with one of many other viral or bacterial conditions: |yes

Work Related Nausea
1. Is there a smell or other working conidions that can be causing this symptoms? |yes
2. Does the symptoms go away when not at work? |yes

Peptic ulcer
1. Is there a gnawing abominal pain between meals or during the middle of the night? |yes
2. Does eating reduce the abdominal pain? |yes
3. Is there a history of heartburn? |yes

CMV colitis
1. Is there some type of immune deficiency: due to HIV, cancer treatment, or other immune suppressive medicaitons? |yes

Meninngococcal Meningitis

1. Is there a petechia rash or echymosis? |yes
2. Is there fever? |yes
3. Is there neck stiffness? |yes
4. Is there a headache? |yes

Amoebic Meningoencephalitis

1. Is the person severely sick? |yes
2. Has there recent travel to fresh water lakes or streams? |yes
3. Is there confusion, hallucinations, lack of attention, ataxia, or seizures? |yes
4. Is there a change in taste or smell? |yes
5. Is ther fever, headache, nausea, or vomiting? |yes

Relapsing Fever (cause is both ticks and body lice {more dangerous-not in US})
1. Was there recent travel to a forested area or otherwise endemic area? |yes
2. Is there a sudden onset of fever and chills? |yes
3. Is there headachess, muscles or joing point? |yes
4. Is there a rash? |yes
5. Do the symptoms last for 9 days, then stop, and then return several weeks later? |yes

Round Worm

1. Is there weight loss? |yes
2. Is there lose stools? |yes
3. Are worms seen in the stool? |yes
4. Is there abdominal pain? |yes

Upper Urinary tract infection
1. Are there any UTI symptoms? |yes

Pregnancy
1. Is there a possibility the patient could be pregnant? |yes
2. Do the symptoms occur primarily in the morning? |yes

R/O Various other causes:
Is there a history of any of the following? |yes . .
Lactose Intollerance? |yes . .
Celiac Disease? |yes . .
Crohn disease? |yes . .
Irritable bowel syndrome? |yes . .
Diverticulosis or diverticulosis? |yes . .
Hyperthyrodism? |yes . .
Opiate use? |yes . .
Laxative use? |yes . .

Use of herbal supplement to improve muscle gain

The Sixth Step is to to the Appropriate and Necessary Physical

R/O Acute Abdomen and Abdominal Pain
Is there a positive Murphy test? |yes
Is there a positve Rebound tenderness (Blumberg's test)?
|yes
Is there McBurney Point tenderness? |yes
Is Murphy Sign Negative? |yes
Is there speenomegally? |yes
Is there hepatomegally? |yes
Does the patient prefer to remain motionless? |yes
Is there a positive psoas (pull leg backward)? |yes
Is there a positive obturator (flex knee and push medially)? |yes
Is there abdominal mass? |yes
Is there an abdominal bruit? |yes
Is there a rigid abdomen? |yes
Is there abdominal pain? |yes
A yes answer for abdominal pain-unless obvious muscular pain--should ideally be a refer out to urgent care or ER for ultra sound, flat plate xray, or CT scan.

R/O Aortic Aneurysm
1. Is there any murmurs in the abdomen? |yes
2. Are any masses felt in the abdomen? |yes

R/O Acute Abdomen:
Is the abdomen rigid? |yes

R/O Hepatitis:
Is there hepatomegally? |yes
Is there splenomegally? |yes
Is the abdomen protruberant? |yes

R/O Appendicitis:
Is there a positive Blumberg (Rebound tenderness)? |yes
Is there a postive McBurny Poiont? |yes
Is there a positive Psoas? |yes
Is there a positive obturator? |yes

R/O Intestinal bleeding:
Is the rectal exam positive for blood? |yes

R/O shock:
Is the Orthostatic BP abnormal? |yes
Is the Capillary Refill Time greater than 2 seconds? |yes

R/O Pancreatitis:
Is there tenderness at the substernal or epigastric region? |yes

R/O Cholecystis (or Bile Duct Problem)
Is there a positive Murphy sign? |yes
Is there abdmoinal pain out of proportiion to the abdominal exam? |yes
Is there decreased posterior tibial or dorsalis pedis pulses? |yes Is the neurolgical exam normal? |yes
1. Is patient able walk in a normal way? |yes
2. CNIII to XII WNL? |yes
3. Is there any obvious nystagmus? |yes
4. Is patella reflex WNL? |yes
5. Is grip strength WNL? |yes
6. Is finger to eye coordination WNL? |yes
7. Head impulse test is WNL? |yes
8. Test of skew test is wNL? |yes
9. Is Nystagmus present with a primary gaze to the right gaze or to the left? |yes
10. Toe-heal-walk test is WNL? |yes
11. Rhomberg test is negative? |yes
12. Pronator drift wNL? |yes

13. Dix Hall-Pike test WNL? |yes

Seventh: if labs or test are needed and available order them consider:
UA, Strep, rapid flu test, gluocse

Eighth: if uncertain of the diagnosis or treatment call MD for consult

Ninth: make diagonosis based on available information: "Nausea alone"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Treatment:

First: Rule out emergency problems by taking vital signs: (Being certain to determine rate of heart (check for irregular beat) and low blood pressure that might come from hypovolemic shock or a Inferior Wall MI) .

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis for nausea because there are over 20 different cause and that you might not be able to given them the treatment they need either. .
.
Nausea and Vomitting can be either minor illness or major illnes (such as a heart attack)
Tell the patient that you will can evaulate them for Minor causes but can not evaluate it for the Major Causes such an MI.
That you might treat nausea and vomitting.
If you feel you can not identify the cause of the nausea, you will refer them to higher level of care.

The third step is to think of and try to rule out the most dangerous causes: .

*MI (Myocardial Infarcation), Abdominal Aortic Aneurysn, Messenteric Ischemia, Colon Obstruction .

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible.

MOST DANGEROUS

Acute Appendicitis
Pyelonephritis
Concussion
Adrenocortical Insuficiency
Ectopic Pregnancy
HELLP
Pre-eclampsia
Brain Tumor
Addision's Disease
Pancreatitis
Rocky Mountain Spotted Fever
Pelvic Inflammatory Disease
Environmental/Work Esposure
Hepatits B
Primary Amoebic-Meningoencephalitis
Viral Meningoencephalitis
Carbon Monoxide Toxicty
Acute Mountain Sickness

LESS DANGERPOUS

Hepatitis C
Ovarian Cancer
Hepatitis A
Pyelonephritis
Concussion
Human Granulocytic-Anaplasmosis
Stomach Cancer
Gallstones
Acute Fatty Liver of Pregnancy
Hyperparathyroidism
Ovarian Cyst
Pregnancy
Giardiasis Infection
Wilkie Syndrome
Babesiosis
Cirrhosis
Drug Induced Colitis
Fecal Impaction
Gastritis
Hypotensive Disorders
Osteitis Fibrosa Cystica
Abdominal Migraine
Canabinoid Hyperemesis
Acute Diarrhea
CVM Colitis
Diverticuliti




Nausea & Vomiting



Fifth Step is to take the Appropriate and Necessary History

General Information:
Onset:
Location:
Duration:
Character:


R/O MI
Does the nausea or heartburn change with rest? |yes
Does the nausea or heartburn change with exertion (walking upstairs)?
|yes
Is there a history of any vascular disease including peripheral vascular disease? |yes
Is there a history of atrial fibrilation? |yes
Is there any diaphoresis associated with the nausea? |yes
Is there any radiaiton of nausea? |yes
Is there any Shortness of Breath (dyspnea)? |yes
Is there any Cocaine or amphetamine use? |yes
Is there any abdominal pain? |yes
If yes, and uncertain of the diagnosis then refer out



R/O Babesiosis
1. Has there been any travel to forested area where a tick bite was possible? |yes

3. Is ther fever?
4. Is there an increase in WBCs?
5. Is there a history of constipation? R/O Gastritis
Is there a history of GERD or heartburn? |yes

R/O Hydronephrosis (excess fluid in the Kidney-due in obstruction of the kidney outflow) - or - Upper Urinary Tract Obstruction
1. Is there pain flank or CVA pain?
2. Is the UA positive for blood or bacteria?

R/O Leptospirosis
1. Has there been any travel to forested area?
2. Has there been any travel to farm area?
3. Has there been any contact with wild animal or rodents?
4. Has there been lighter stool and darker urine?
5. Has blood been seen int he urine?
6. Is there a decreased ability to concentrate?
7. Has there been intense headaches?
8. Is there injection of the conjunctiva without exudates?

R/O Mesenteric Ischemia
Does the patient have any history of vascular problems (MI, peripheral vascular disease)?
|yes
Does the nausea or abdominal discomfort get worse after eating?
|yes

R/O Neurological Causes

Are there any visual changes? |yes
Are then any balance prblems? |yes
Are then weakness in any extermeties? |yes
Is there any decrease in sensation? |yes

R/O Pancreatitis:
Is there a history of alcohol abuse? |yes

R/O Pelvic Infalmmatory Disease

R/O Stomach Cancer
Has there been weight loss?
Has there been black tarry stool?
Has there been UPPER abdominal pain?
Is there a personal history of family history of cancer?

R/O trauma
Has there been adminal trauma or rectal trauma from sex?
|yes

R/O Ovarian Cancer
1. Is there weight loss?
2. Is there a feeling of abdominal bloating?
3. Is there a feeling of difficulty passing gas?

R/O Pyelonephritis
1. Is there a fever?
2. Is there CVA pain?
3. Is there blood in the urine?

R/O Relapsing Fever (cause is both ticks and body lice {more dangerous-not in US})
1. Was there recent travel to a forested area or otherwise endemic area? |yes
2. Is there a sudden onset of fever and chills? |yes
3. Is there headachess, muscles or joing point? |yes
4. Is there a rash? |yes
5. Do the symptoms last for 9 days, then stop, and then return several weeks later? |yes

R/O Rocky Mountain Fever

MOST CONCERNING HISTORY
Is thre lower right quadrant pain? |yes
Is there sharp abdominal pain? |yes
Is there severe abdominal pain? |yes
Is there sudden abdominal pain? |yes




R/O MI
Is there abdominal pain with Chest (MI) or Shoulder Pain (MI)?
|yes
Is there diaphoresis with abdominal pain? |yes
Is there dyspnea with abdominal pain? |yes


R/O GI bleed:
Is there abdominal pain and bloody vomit? |yes

R/O colitis, Crohn's, colon cancer
Is there abdominal pain and bloody diarrhea? |yes

R/O Acute [Surgical] Abdome- Peritonitis
Is the abdomen stiff, hard, and tender to touch? |yes

Physical Exam

R/O Acute Abdomen and Abdominal Pain
Is there a positive Murphy test? |yes
Is there a positve Rebound tenderness (Blumberg's test)?
|yes
Is there McBurney Point tenderness? |yes
Is Murphy Sign Negative? |yes
Is there speenomegally? |yes
Is there hepatomegally? |yes
Does the patient prefer to remain motionless? |yes
Is there a positive psoas (pull leg backward)? |yes
Is there a positive obturator (flex knee and push medially)? |yes
Is there abdominal mass? |yes
Is there an abdominal bruit? |yes
Is there a rigid abdomen? |yes
Is there abdominal pain? |yes
A yes answer for abdominal pain-unless obvious muscular pain--should ideally be a refer out to urgent care or ER for ultra sound, flat plate xray, or CT scan.

R/O Aortic Aneurysm

Is there any murmurs in the abdomen? |yes
Are any masses felt in the abdomen? |yes

R/O Acute Abdomen:
Is the abdomen rigid? |yes

R/O Hepatitis:
Is there hepatomegally? |yes
Is there splenomegally? |yes
Is the abdomen protruberant? |yes

R/O Appendicitis:
Is there a positive Blumberg (Rebound tenderness)? |yes
Is there a postive McBurny Poiont? |yes
Is there a positive Psoas? |yes
Is there a positive obturator? |yes

R/O Intestinal bleeding:
Is the rectal exam positive for blood? |yes

R/O shock:
Is the Orthostatic BP abnormal? |yes
Is the Capillary Refill Time greater than 2 seconds? |yes

R/O Pancreatitis:
Is there tenderness at the substernal or epigastric region? |yes

R/O Cholecystis (or Bile Duct Problem)
Is there a positive Murphy sign? |yes
Is there abdmoinal pain out of proportion to the abdominal exam? |yes
Is there decreased posterior tibial or dorsalis pedis pulses? |yes


Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse. . Test to Consider: Labs: UA for women, Preg. for women, blood, leukocytes, O&P, C-diff . Tests: consider: upright and flat plate of abdomen . Diarrhea more than 7 days requires tests: fecal leukocytes, lactoferin, O&P, bacterial cultures. Diarrhea that is more severe:   .6 liquid stools per day, fever, requires more urgent testing. .

Eighth: if uncertain of the diagnosis or treatment call MD for consult .

Ninth: make diagonosis based on available information: "abdominal pain, unspecified" or Specify the site

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Treatments: Tylenol -- but strongtly cosider referral for RLQ abominal pain, and other abdominal pain that is severe




Abdominal Pain









Neck Pain Or Swelling


Fifth step is to take the Appropriate and Necessary History

NOT YET FINISHED



General Information:
Onset:
Mechaniusm of Injury:

Location:
Duration:
Character:

R/O TIA
R/O CVA

Is there noticeable edema of the neck? |yes
Is there swollen lymph nodes in the neck? |yes
Does motion anteriorly-posteriorly increase the pain? |yes
Is kerneg test postive? |yes
Is Brudzinskin test Positive? |yes
Is there a fever? |yes

Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse

Eigth:
if uncertain of the diagnosis or treatment call MD for consult .

Ninth:
make diagonosis based on available information: "cephalagia" or "pain, unspecified"

Tenth:
refer out, or send home with apppropirate meds, and follow up instruction .

Eleventh: Possible Treatment:
Any orthoopedic Injury: Prednisone .5 mg/kg prednisone for up to 10 days, Flexeril 5-10 mg tid prn x 7-10 day .

EDUCATION:
A. Cervical Disc Prolapse-Herniated, partially protruding from spinal canal .
B. Spinal Spondylosis- degenerative osteoarthritis, ~facet syndrome .
C. Spinal Stenosis- narrowing of spinal canal .
D. Cervical Strain (Whiplash)- due to hyperextension or hyperflexion, eg. car accident .
E. Impact Stinger - Radial Nerve tapped inadvertently in elbow .
F. Cervical Disc Pain - pain at the site of the Cervical Disc .
H. Coronary Artery Disection -May lead to stroke, separating of carotid artery (Listen to carotid arteries for murmurs)
I. Myofascial Pain Syndrome~similar to a localized fibromyalgia with trigger point
Herpes Zoster - tingling, burning, vesicles .
B. Spinal Epidural Abscess-Very Dangerous,No Outward signs, but HX of IV drugUse .
C. Cardiac [Heart] Ischemia - Heart Attack [consider need for EKG, and treponin] .
E. Peritonsilar Abscesss - fever, exudates, throat P., .
F. Parapharyngeal Abscess - Usually a raised area and pain in Pharynx, deviated uvual .
G. Retropharyngeal abscess - Usually a raised area and pain in Pharynx .
H. Epiglottitis - HX of no Influenza afraid to open mouth
I. Ludwig's Angina - Cellulitis Of bottom Of Mouth, usu. 2nd. to Tooth Infection .
J. Osteomyelitis - Infection of the Bone .
K. Diskitis - infection of the disk, usu. 2nd. ostemyelitis [infec. Of bone] .
L. Cervical Epidural Abscess - Early SX back Pain, Middle Radiating Pain but Later--> complete Paralysis .
M. Mastoiditis infection of the bone behind ear, ear sticks out .
N. Otitis - ear infection, fever, ear pain, bulging TM .
O. Dental Infections - Pulpitis, pulp is under enamal .
P. Infection of congenital structures - (Brachial Cleft Cysts-congenital, arises from side of neck; Thyroglossal Duct Cysts-congenital-cyst in front on neck) .
Q. Pharyngitis - Pharynx - unspecified infection (viral or bacterial) .
R. Esophagitis - various CXes: allergies, fugal/bacterial infection .
S. Lemierre's Syndrome -strep throat-->throat abscess-->carotid vein thrombus-->PE-->pneumonia--> possible Sepsis--> possible death .
T. Deep Cervical Plane Infection -Deep Connect Tissue infection, trimus (difficulty opening mouth), dysphagia .
Q. CMV Infection - CMV of the Brain or eyes can make people feel generally sick (usually people who are HIV Positive) .


The first Step is to Ask the patient if there has been any trauma to the head or neck: If there is focal neck tenderness above the spine the patient may need an immediate neck brace-and be told to keep there neck as still as possible. The patient will also probably need to be sent to either urgent care or ER for xray or CT scan. (Simple Xray may not be sufficient)
.
The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis for neck pain or swelling because there are over 20 different cause and that you might not be able to given them the treatment they need either.

Neck pain might be either minor or major.
That you are happy to examine them but you may not have all the tests and equipment necessary to determine the exact cause of there neck pain.
That you might have to refer them out to a facility with more diagnostic equipment to get a specific diagnosis. .

The third step is to think of and try to rule out the most dangerous causes: .

Stroke, TIA, carotid or vertebral disection, Cervical neck Fracture, Fusobacterial (leimeres disease), mumps, parotid stone, parotidis, SVC Syndrome (Superior Vena Cava) compression .

Fourth Look at most of the possible causes of neck pain

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible. .

MOST IMMEDIATE DANGER
Carotid Artery Disection
Vertebral Artery Disection
Arterial Aneurysm
West Nile Encephalitis
Bacterial Meningitis
Brain Abscess
Lemierre's Syndrome
Menigitis/Encephalitis
Brian Tumor
Epidural Abscess
Intracranial Hemorrhage
Retropharyngeal Abscess
Atlantoanxial Instability
Spinal Cord Trauma
Spinal Infectioins
Throacic Aortic Aneurysm
Neck Trauma
Tetanus .

LESS IMMEDIATE DANGER
Cervicogenic Dizziness
Cervical Spondylosis
De Quervain's Thyroiditis
Migraine
Osteoarthritis
Hydrocephalus
Mouth Cancer
Thyroid Cancer
Tonsillitis
Polymyalgia Rheumatica
Hodgkin Disease
Laryngeal Cancer
Temporomandibular Joint Syndrome
Devic's Disease
Esophageal Cancer
GERD
Klippel_Feil Syndrome
Myelitis
Trench Fever
Ankylosing Spondylitis
Radiation Myelitis
Whiplash








.Ankle and Foot Pain and Injury

The first Step is to do a quick check: color, paleness, frank bleeding, bone eruption through skin. .
TEST: Active ROM, passive rom, Strength flex, extend, and lateral motions, Anterior Drawer (compare ankles), talar tilt test Ottowa Ankle

Do squeeze test along calf .


Fifth step is to take the Appropriate and Necessary History.



General Information:
Onset:
Mechanism of Injruy:
Location:
Duration:
Character:
Mechanism of Action:


History:

Was patient able to bear weight on the ankle immediately after the injury and take a few steps?
|yes


NOTE: When an ankle is turned inward or medially during the injury--it may iamge the 4 ligaments on the medial side of the foot (the four are refered to as the Deltoid Ligament). Often times it is recommended that the patient have their ankle immobillized for a few weeks and for the first days after the injury use to crutches to prevent weight bearing. This is even though an xray is not needed. However, if excess laxity is suspected for either medial or lateral ankle ligaments and xray be required to rule out excess joint space. The lateral ankle ligaments do not usually need or require immobilzation or the prevention of weight bearing.

Physical Exam:
GENERAL
Is the patient able to bear weight on the ankle at this time and take a few steps?
|yes
Is there echymosis and edema? |yes
Is the color WNL? |yes
Is the color pale? |yes
Is the sensation beyond the injury WNL? |yes
Is dorsalis pedis pulse WNL? |yes
Is posterior tibia pulse WNL? |yes
Is there focal tenderness in ANY area? |yes
Is there focal tenderness at the end of the tibia (posterior medial malleolus)?
|yes
Is there focal tenderness at the end of the fibia (posterior lateral malleolus)?
|yes
Is there focal tenderness at the fifth metatarsal area? |yes
Is there focal tenderness over the navicular bone? |yes
LIGAMENT TESTS
Is the anterior drawer test positive? |yes
Do the ligaments stop rotation of the ankle (Talar Tilt Test) at the correct locations?
|yes

LATERAL ANLKE
Is there focal tenderness of the lateral anterior talofibular ligament? |yes
Is there focal tenderness of the calcaneofibular ligament? |yes
Is there focal tenderness of the lateral posterior talofibular ligament? |yes

MEDIAL ANKLE
Is there focal tenderness of the medial anterior tibiotalar ligament? |yes
Is there focal tenderness of the tibionavicular ligament? |yes
Is there focal tenderness of the tibiocalcaneal ligament? |yes
Is there focal tenderness of the medial Posterior tibiotalar ligament? |yes
Is there ability to stand on toes? |yes
Is there ability to raise on heels? |yes


TEST: Active ROM, passive rom, Strength flex, extend, and lateral motions

The Sixth Step is to to the Appropriate and Necessary Physical

Seventh: if labs or test are needed and available order them consider: xray and MRI, CRP, ANA

Eighth:
if uncertain of the diagnosis or treatment call MD for consult

Ninth: make diagonosis based on available information: "pain in joint, ankle and foot"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Treatment

Ace Wrap, tylenol, Advil, Ice, Heat, ankle boot, crutches

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible. . Fourth: Rule out complete tendon tears . achilles tendon - Thompson test (squeeze calf muscle--should cause foot to extend or downward) . posterior talofibular ligaments are most common - ankle rules outward or counter clockwise, no crutches, or cast (complete tear will have an increase tilt) .. anterior talofibular ligament ("high ankle sprain"- ankle rolls clockwise, REQUIRES A CAST and CRUTCHES (complete tear will have an increase tilt) .

MORE IMMEDIATE DANGER
Ankle Fracture
Ankle Dislocation
Osteomyelitis and Septic Arthritis
Transient Ischemic Attack
Arterial Thrombosis
Toxic Shock Syndrome
Sickle Cell Anemia
Angina


LESS IMMEDIATE DANGER
Ankle Sprain
Osteoarthritis
Rheumatoid Arthritis
Gout
Heel Spur
Complex Regional Pain Syndrome
Ankylosing spondylitis
Raynauds Disease


RARE
Tarsal Tunnel Syndrome
Achilles Tendon Syrndrome
Ankle Impingement Syndrome
De Quervain's Tendinitis
Charcot's Joint
Leukemia
Stress Fracture of the Leg
Pigment Villonodular Synovitis
Benign Bone Tumors
Psoriatic Arthritis
Reiter's Disease
Sarcoidosis
Thromboangiitis
Thromboangitis Obliterans
Chiblain





Knees


Fifth step is to take the Appropriate and Necessary History
[the assessment tool has not been written yet] .

General Information:
Onset:
Location:
Duration:
Character:

Mechanism of Action:

The Sixth Step is to to the Appropriate and Necessary Physical .

Anterior Drawer is positive (Crucial ligament tear)? |yes
Lachman Test is positive (Crucial ligament tear)? |yes
Posterior Drawer is positive (Crucial ligament tear) ? |yes
Pivit shift test is positive (meniscus test) ? |yes
McMurray (meniscus test) is positive? |yes
Valgus stress (lateral to medial pressure) is positive (Non crucial ligament)?
|yes
Varus stress (pressure medial to lateral) is positive(Non crucial ligament)?
|yes
The sag sign (obvious sagging of tibia) is positive? |yes
Is there pain in the area underneath or around the patella (Patella Tendon Syndrome)?
|yes
Is there a bump behind the knee (baker cyst) ? |yes
Is all of the joint painful (septic arthritis) ? |yes
Is there crepitus to the joint (arthritis)? |yes
Is the knee extremely painful at a focal point (gout)?
|yes

Seventh: if labs or test are needed and available order them consider: CBC, ANA, RA, CRP, xray, MRI, bone scan

Eighth: if uncertain of the diagnosis or treatment call MD for consult

Ninth: make diagonosis based on available information: "pain in knee, right" or "pain in knee, left"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

A knee x-ray series is only required for knee injury patients with any of these findings:

Eleventh: Possible Treatments:

Ace Wrap, tylenol, Advil, Ice, Heat, ankle boot, crutches

Ottowa Knee


The first Step is to do a quick look: color, paleness, frank bleeding, boney eruption, osteomyelitis. .

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis for knee pain because there are over 10 different cause and that you might not be able to given them the treatment they need either. .

The third step is to think of and try to rule out the most dangerous causes:

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible. .

Most IMMEDIATELY DANGER
Fracture of the Knee
Knee Dislocation
Patella Dislocation
Osteomyelitis and Septic Arthritis
Spinal Infection
Decompression Illness (from diving)

Malignant Bone Cancer

COMMON
Meniscus Injury
Osteoarthritis
Anterior Cruciate Ligament Injury
Soft Tissue Injuries of the Knee
Ligament Knee Sprains (non crucial-lateral or medial colateral ligament)
Turf Knee
Discoid Lateral Meniscus
Gout
Herniated Disk (referred pain)
Hip Fracture (referred Pain)
Tendinitis - Patella
Osgood Schlauter Patella Femoral Joint Disorders
Ankylosing Spondylitis (referred pain)


RARE
Orthopedic Prostheses Infection
Bone Osteochondroma
Reiter's Disease
Charcot's Joint
Paget's Disease
Popliteal Cyst
Coccidioidomycosis - Infection
Femoral Nerve Injury
Leukemia
Lyme Disease
Plica Syndrome
Pyomyositis? Tropical Pyomyositis
Benign Bone Tumor
Pigmented Villonodular Synovitis
Psoriatic Arthritis
Pyarthosis
Sarcoidosis



  Shoulder and Upper Extremity Pain and Injury

Fifth step is to take the Appropriate and Necessary History

General Information:
Onset:
Meacansim of Injury:
Location:
Duration:
Character: .

Ask question to Rule out MI:

The Sixth Step is to to the Appropriate and Necessary Physical

Arpehensive Test is positive? |yes
Drop Arm Test is positive? |yes
Neer test is positive? |yes
Hawkins test test is positive? |yes
Shouder Stability Test is positive?
|yes
Is there pain in the area underneath or around the shoulder? |yes
Is the skin around the joint erthematous (Infection)? |yes
Is all of the joint painful (septic arthritis) ? |yes
Is there crepitus to the joint (arthritis)? |yes

Third: Check the joint below and the joint above: neck (focal tenderness-ROM) and elbow (focal tenderness-ROM) ANY FOCAL tenderness REQUIRES neck SUPPORT and refer out because of risk of neck FX) .*

Seventh: if labs or test are needed and available order them consider: . .
UA, Strep, rapid flu test, gluocse

Eighth: if uncertain of the diagnosis or treatment call MD for consult .

Ninth:
make diagonosis based on available information: "Pain in Should (or shoulder region), (left or right)

Tenth:
refer out, or send home with apppropirate meds, and follow up instruction .



EDUCATION

Arpehensive Test: see below
Drop Arm Test:
Neer test: see below
Hawkins test: see below

Shouder Stability Test: (push humerous head forward, backward, and down) check for laxity; : if positive=large tear. .

Most Dangerous Test: APPREHESION TEST: have patient lie down, extend shoulder above head but have elebow at 90 degree. Slowly apply pressure: Monitor patient face: is he aprehensive that the should will come out.

CAUTION: Sufficient pressure may cause a dislocationAny Positive means "impingement syndrome" or rotator cuff tear .

The degree of pain and laxity give an indication of how torn a ligament may be Neer Test . Neer Test: Neer Test

Hawkin Test. Hawkins Test.  
Caution: Extreme flexion may dislodge shoulder. .
Aprehension test.Apprehesion Test .

Education
A. Fracture Shoulder: usually focal pain, must get xray.
B. Torn AC joints: Pain will be at AC joint, if there is complete tear there will be increase subluxation, straight arm cross-body abduction test will be positive
C. Arthritis in Shoulder: Decreased ROM, slow onset, crepitus with motion .
D. Labrial Tear: SLAP stands for "superior labrum, anterior to posterior; "obrien's test" (like an eagle with thumb dumb-resitance is applied when pt. tries to raise arm) positive if deep pain occurs; no pain should occur with thumbs up. This can occur from falling outstretched hands. CAUTION: a positive Obiren' test may also occur with a rotator cuff tear .
E. Impingement Symdrome: The Tendon is what is impinged--not a nerve. This is a general term for any type of rotator cuff tear except a labrial tear, which is the lining of the scapula
F. Rotator Cuff Tear: Any of the tendons of the arm can be torn, usually partially
-. Superspinitis Tear: MOST COMMON (biggest tendon) Drop arm Test: positive= large tear. Neer test positive, Hawkins test positive, (pressure with neer and Hawkins is even further confirmation) -. -Infraspinitis Tear: Easy to test: test chest strength with elbows at 90 Degrees (anterior and posterior), like on machine at gym for chest, also this tendon is supreficial on posterior lateral shoulder area and easily palpable
-Subscapularis: Tests: put hand on addomen, try to push both elbows forward G. Subacromial bursitis: similar to rotator cuff tendinitis--but might have subacromial crepitus .H. Bicep Tear - examin bicep, and bicep strength
I. Shoulder Instability: worried about possible dislocation. Xray if possible to RO dislocation. In no xray, examine shoulder position in ROM. Test Humerous Glenoid joint for laxity, crepitus, and tenderness. Push it anterior, posteriorly, and downward. .
J. Adhesive Capsulits: Frozen Shoulder- extreme decrease in ROM, passive and active ROM are equal .
 

First - Rule out Heart attack (SOB?, radiation?, Exertional?, perspiration?)

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
..You may not be able to give them a definite diagnosis for shoulder pain because there are over 10 different cause and that you might not be able to given them the treatment they need either.

The third step is to think of and try to rule out the most dangerous causes: .

*MI, pulmonary emboli, cholecystitis, osteolmyelitis, necrotizing myosistis

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible. .

MOST IMMEDIATELY DANGEROUS
Myocardial Infarct
Clavicular Fracture
Pericarditis
Pulmonary Emboli
Pleural Effusion
Amoebic Liver Abscess
Brachial Plexus Injury
Cholecystitis
Incracranial Hemorrhage (referred pain)
Abdominal Trauma (referred pain)
Giant Cell Arteritis
Tetanus


COMMON
Frozen Shoulder
Shouder Sprain
Osteoarthritis
Shoulder Tendinitis
Shoulder Impingement Syndrome
Lung Cancer
Gallstones
Polymyalgia Rheumatica
Rheumatoid Arthritis
Clavicular Fractures
Ankylosing Spondylitis (referred pain)
Brachial Plexus Injury
Herniated Disk
Tendinitis
Angina (referred pain


RARE
subacrominal Bursistis
Cervical Spondylosis (referred pain)
Pancoast's Syndrome
Leukenia
Liver Cancer (referred pain)
Subphrenic Abscess



Necrotizing Fasciitis
Osteomyelitis and Septic Arthritis





Back Pain

Fifth step is to take the Appropriate and Necessary History. .



General Information:
Onset:
Location:
Duration:
Character:



R/In Back strain:
1. Was there a recent event that caused the back pain?| yes | Not ask |
2. Is pain reproducible with anterior/ posterior or lateral movement?| yes | Not ask |

R/O sciatica:
Is there shooting pain that travels down one leg?| yes | Not ask |

R/O Herniated Disk:
Can you stand on toes and on your heals? | yes | Not ask |

R/O Cauada Equina Syndrome:
1. Are you able to void normally? | yes | Not ask |
2. Are you able to defecate normally?| yes | Not ask |
3. Do you have any numbness on the area of your body that you sit and the medial posteior thighs?
| yes | Not ask |

R/O Appendicitis: Is there abdominal pain, nausea and fever in conjunction with back pain?
| yes | Not ask |

R/O abdominal aortic aneurysm disection:
Is there tearing back pain? | yes | Not ask |

R/O thoracic aortic aneurysm:
Is there tearing back pain? | yes | Not ask |
|
R/O Lumbar Fractures:
Was there recent trauma and Is there one area of the backbone that hurts more than other?
| yes | Not ask |

R/O Coccygeal Faccture:
Was there recent trauma and Is there one area of the buttocks bone that hurts more than other? | yes | Not ask |

R/O Hypotensive Disorders:
Do they feel like they are going to faint when standing up? | yes | Not ask |

R/O Spinal Infections:
Is there fever and pain?

R/O epidural abscess:
Is thre a history of abusing IV drugs? | yes | Not ask |

R/O Pyelonephritis:

Is there fever and one-sided midback pain and recent UTI symptoms? | yes | Not ask |

R/O Pneumonia:
Is there fever, difficulty breathing, and back pain? | yes | Not ask

R/O Cancer:
Does the patient have previous cancer or is there a family history of cancer? | yes | Not ask

R/O Pelvic Inflammatory Disease:

Is there fever, abdominal pian, and back pain? | yes | Not ask | .

R/O Osteomyelitis:
Is there fever and pain? | yes | Not ask |

R/O Cholecystitis:
Is there fever, back pain, and right upper qudrant abdominal pain? | yes | Not ask |

R/O Septic Arthritis:
Is there a history of arthritis and fever and pain? | yes | Not ask |

R/O Viral Infection:
Is there a history of recent upper respiratory symptoms or diarrhea and pain? | yes | Not ask |

R/O Coccidioidmyscosis:

Is there fever plus pneumonia symptoms and back and other joint pain? | yes | Not ask |

R/O Gallstones:
Is the pain colicy (intense but coming and going? | yes | Not ask |

R/O Kidney Stones:
Is the pain colicy (intense but coming and going) on oneside? | yes | Not ask |

R/O Lyme Disease:
Is there a history of camping or hunting in a forested area? | yes | Not ask |

R/O Ankylosing Spondylitis:
Is there less pain when standing or sitting and leaning forward? | yes | Not ask |

R/O Sacrolitis:
Is there focal pain at one of the two sacroilliac joints?| yes | Not ask |

R/O Cystititis (Urinary Infection):
Is there UTI symptoms such as frequency, urgency, and dysuria? | yes | Not ask |

R/O Ovarian Cancer:
Is there patient or family history of cancer or weight loss or night sweats?| yes | Not ask |

R/O Ovarian cysts:
Is there patient or family history of ovarian cysts? | yes | Not ask |

R/O Degenerative Spinal Disorders:
Is there more back pain when gettin out of bed in the morning? | yes | Not ask |

R/O Marfan Syndrome:
Is there a family history of Marfan syndrome? | yes | Not ask |

R/O Spinal Cord Tumors (or cancer):
Is there any history of tumors? | yes | Not ask |

R/O Breast Cancer:
Is there a patient of family history of cancer? | yes | Not ask |

R/O Osteoarthritis:
Is there more back pain when gettin out of bed in the morning? | yes | Not ask |

R/O Paget's Disease (An osteoclastic disease that affects spinal bones and orther bones:
Is there focal pain (minifractures) in the back an other bones? | yes | Not ask |

R/O Pelvic Organ Prolapse:
Is there a history of Pelvic Organ Prolapse? | yes | Not ask |

R/O Cirrhosis:
Is there a history of heavy alchol use? | yes | Not ask |

R/O Uterine Fibroids:
Is there a history of Uterine fibroids? | yes | Not ask | .

R/O Multiple Myeloma (cancer of the bone marrow):
Is there rib pain as well as back pain and malaise?

R/O Retroperitoneal Hemorrhage:
1. Is there a black and blue area on back? | yes | Not ask |
2. Grey Turner Sign| yes | Not ask |

R/O Prostatitis:
Is there difficulty urinating or painful ejaculation? | yes | Not ask |

R/O Herpes Zoster:
Is there numbness, tingling, burning, or itching on one side of the back? | yes | Not ask |

The Sixth Step is to to the Appropriate and Necessary Physical .

R/In back strain (nonspecific back pain)?
Is there pain with anterior/posterior or lateral movement? | yes | Not Done |

R/O Herniated Disk?
Is there a positive straight leg test, positve sciatica? | yes | Not Done |

R/O sciatica?
Is there a positive straight leg test, positive sciatica? | yes | Not Done |

R/O Appendicitis?
Is there a positive psoas, obturator sign, Rovsing, Mc Burney point, or Rebound Tenderness? | yes | Not Done |

R/O abdominal aortic aneurysm:
Is there low blood pressure, a pulsatile mass, an abdominal bruit? | yes | Not Done |

R/O thoracic aortic aneurysm:
Is there low blood pressure, a pulsatile mass? | yes | Not Done |

R/O Cauda Equina Syndrome:
Is there decreased sensation in the buttocks area and decreased anal sphincter tone?
| yes | Not Done |

R/O Lumbar Fractures?
Is there focal tenderness of spinal bone? | yes | Not Done |

R/O Coccygeal Faccture
Is there focal tenderness of cocyx bone? | yes | Not Done |

R/O hypotensive Disorders:
Is the blood pressure low (especially after standing for more than 3 minutes)? | yes | Not Done |

R/O Spinal Infections:
Is there a fever and focal back pain? | yes | Not Done |

R/O epidural abscess:
Is the ESR elevated with a history of IV drug abuse? | yes | Not Done |

R/O Pyelonephritis:
Is there fever and costal vertebral angle (CVA) pain? | yes | Not Done |

R/O Cancer:
This requires CT, MRI, or Bone Scan

R/O Pelvic Inflammatory Disease:
Is there pain upon cervix movement? | yes | Not Done |

R/O Osteomyelitis?
Is there a fever and focal back pain? | yes | Not Done |

R/O Cholecystitis?
Is there a positive Murphy test? | yes | Not Done |

R/O Septic Arthritis?
Is there a fever and back pain? | yes | Not Done |

R/O Viral Infection?
Is there a fever? | yes | Not Done |

R/O Coccidioidmyscosis?
Is there a fever, back pain, and respiratory deficits? | yes | Not Done |

R/O Pneumonia?
Is there rales, dyspnea, and backpain? | yes | Not Done |

R/O Gallstones:
Is there a positive Murphy test? | yes | Not Done |

R/O Kidney Stones:
Is there a positive xray or ultrasound? | yes | Not Done |

R/O Lyme Disease:
Is there a positive Lyme titer test? | yes | Not Done |

R/O Ankylosing Spondylitis:
Is there less pain when leaning forward? | yes | Not Done |

R/O Sacrolitis:
Is there folcal pain over the sacroiliac joint? | yes | Not Done |

R/O Cystititis (Urinary Infection):
Is there a postive UA for WBC, blood, or Nitrites? | yes | Not Done |

R/O Ovarian Cancer:
Is there a positive ultra sound? | yes | Not Done |

R/O Ovarian cysts:
Is there a positive ultrasound? | yes | Not Done |

R/O Degenerative Spinal Disorders:

Is the pain less focal? | yes | Not Done |

R/O Marfan Syndrome:
Is the length of arms greater than the length of the body? | yes | Not Done |

R/O Spinal Cord Tumors (or cancer)?
needs MRI

R/O Breast Cancer?
Needs mamorgram

R/O Osteoarthritis:
Is the pain less focal and more gernal pain? | yes | Not Done |

R/O Paget's Disease:
Are there other joint with pain and edema? | yes | Not Done |

R/O Pelvic Organ Prolapse:

need pelvic exam

R/O Cirrhosis:
Is there hepatomegally? | yes | Not Done |

R/O Uterine Fibroids:
need ultrasound

R/O Multiple Myeloma:
needs a blood test

R/O Retroperitoneal Hemorrhage:
Is there a positive Grey Turner Sign (back echymosis)? | yes | Not Done |

R/O Prostatitis:
Is the prostate large and tender? | yes | Not Done |

R/O Herpes Zoster:
Is there vesicular rash on and erythematous base on one side of the body?
| yes | Not Done |

Seventh: if labs or test are needed and available order them consider
UA, ESR Step

Eighth: if uncertain of the diagnosis or treatment call MD for consult

Ninth: make diagonosis based on available information: "low back pain"

Tenth: refer out, or send home with apppropirate meds, and follow up instruction

Eleventh: Possible Medications:

First Take Vital signs: rule out shock, and look for low blood pressure that is sometimes a symptoms of aortic aneurysm disection, and Fever may indicate infection (osteomyelitis, septic arthritis, influenza) .

The Second step is to tell the patient that the clinic is designed to treat to minor illness and injuries.
You may not be able to give them a definite diagnosis for back pain because there are over 20 different cause and that you might not be able to given them the treatment they need either. .

The third step is to think of and try to rule out the most dangerous causes: . Myocardial Infarct, Aortic Aneurysm, epidrual abscess (Infection of Spina common among IV drug uses), Rapidly Progrossing Neurological Conditions, Cauda Equina Syndrome, Fractures Spinal Bones, Metastatic Cancer

The fourth step is to think of and try to rule out as many possible causes as is reasonably possible.

Back Pain Differential:
Abdominal aortic aneurysm
Thoracic aortic aneurysm
Cauda Equina Syndrome
Lumbar Fractures
Coccygeal Faccture

Spinal Infections
epidural abscess
Pyelonephritis
Pelvic Inflammatory Disease
Osteomyelitis
Cholecystitis
hypotensive Disorders
Septic Arthritis
Viral Infection Gallstones
Kidney Stones
Lyme Disease
Ankylosing Spondylitis
Sacrolitis
Cystititis (Urinary Infection)
Ovarian Cancer
Ovarian cysts

Degenerative Spinal Disorders
Marfan Syndrome
Spinal Cord Tumors (or cancer)
Breast Cancer
Osteoarthritis
paget's Disease
Pelvic Organ Prolapse
Cirrhosis
Uterine Fibroids
Spondyloarthropathies
Coccidioidmyscosis
Multiple Myeloma
Retroperitoneal Hemorrhage
Prostatitis
Appendicitis

Herniated Disk
Back strain (nonspecific back paiin)
Sciatica





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