Health

state of complete physical, mental, and social well being and absence of disease

Disease

any deviation from normal body function; can affect individual organs or entire body system; can be acute or chronic

PathophysiologyPathologyPhysiology

altered healthstudy of structure/functional changes in cells, tissues, organs caused by diseasedeals with normal functions of living organisms

EtiologyPathogenesisMorphologyClinical manifestationsDiagnosis Clinical course

cause of disease (biologic, physical forces, chemical agents, genetics, nutrition)sequence of cellular/tissue events from time of initial contact until presentation of diseasefundamental structure of form of cellssigns and symptomsdesignation as to nature/cause of diseaseevolution of disease

Infectious diseaseNon-infectious disease

bacterial, viral, fungal, parasitic; transmitted by microorganism; contagious genetic/hereditary, congenital (accident that happened in utero or during birthing process), environmental; not transmitted by microorganism; not contagious

Pathogens

______ = microorganisms which can cause diseaseNot all microorganisms cause disease (yeast promote normal bacteria in colon and microflora on skin is normal)

in air, water, food, and body fluids (saliva, blood, semen); by touching; by another organism i.e. mosquito (these transmitters are called vectors)

How are pathogens transmitted?

another person, contaminated objects, animal bites, environment

Pathogens can come from:

BacteriaVirusesFungiParasites

______ produce toxins that cause cell death______ use our cells to reproduce and then cause cell death______ grow and produce toxins______ live and grow in our body destroying tissue

DiagnosisDifferential diagnosisWorking diagnosis

designation as to nature/cause of health problem (includes history i.e. symptoms and physical exam i.e. signs)weighing competing possibilities and selecting most likely one but listing in order of likelihoodbased on info so far i.e. history, physical exam and diagnostic testing results currently available

Headaches (cephalgia)

pain anywhere in region of head or neck; symptom of number of different conditions of head and neck; brain tissue itself lacks pain receptors (meninges are pain sensitive)

PrimarySecondary

General classification of headaches - ______ = migraine, tension type, cluster and chronic daily headache, others______ = tumor, sinus, medication overuse, cervicogenic, infection, trauma, bleed, etc; based on etiology not symptoms

Tension type headacheMigraineClusterChronic daily headache

mild to moderate intensity, bilateral, non throbbing headache (band-like) without other associated factorsoften unilateral and tends to have throbbing or pulsatile quality with or without auraunilateral, often severe headache attacks and typical accompanying autonomic symptomsencompasses several different headache syndromes i.e. chronic migraines, chronic tension type headache, hemicrania continua, new daily persistent headache; frequency is 15 or more days a month for longer than three months

History - age at onset; presence/absence of aura and prodrome; frequency, intensity and duration of attack; number of headache days per month; time and mode of onset; quality, site and radiation of pain; family history of migraine

Approach to headaches

Is this the worst headache of your life?*RED FLAG

What do you ask all patients with a chief complaint of headache?

fever associated w/headache; sudden onset of headache; absence of similar headaches in past; worsening pattern; change in mental status, personality or change in level of consciousness (LOC)

Other red flags in headache syndromes

head trauma, dizziness/vertigo, syncope/loss of consciousness, earaches/drainage/discharge, vision status (eye pain/redness/tearing), toothaches

Good ROS will help with differential diagnosis and approach to patients with headache

Exam should include - obtain blood pressure/pulselisten for bruit at neckinspect head for any trauma, swelling or asymmetryexamine ears for any erythema, swelling, dischargelook up nose for any swelling of turbinates, bleeds, massestap on sinuses for any tendernesscheck for lymphadenopathypalpate for tenderness of head, neck and shoulder regionsPERRLAgood neurological exam

Differential diagnosis of headache depends on good HPI, PMH, ROS, and exam

Chronic nasal stuffiness or chronic respiratory symptoms suggest diagnosis of sinusitisImpaired vision or seeing "holes" around light suggests the presence of glaucomaVisual field defects suggest the presence of a lesion of the optic pathwaySudden, severe, unilateral vision loss suggests the presence of optic neuritisHeadache, fatigue, generalized aches and pains, and night sweats in subjects age 55 yo or older suggest presence of temporal arteritisIntermittent headaches with high blood pressure are suggestive of pheochromocytoma

Other features suggesting a specific headache source:

neck stiffness and especially meningismus (resistance to passive neck flexion) suggests meningitispapilledema (swelling of eye)focal neurologic signs suggest an intracranial mass lesion

Danger signs on examination for headache

everything depends on good history and physical examexam will guide your treatment plan or further workup

Differential diagnosis

Core body tempFeverHypothalamus

balance of heat gain and heat losselevation of body tempthermal control center for body; receives info for central and peripheral thermoreceptors; balances heat loss and gain*increase temp = vasoconstriction, shiveringdecrease temp = vasodilation, sweating

Objective feverSubjective feverShiveringSweating100.4 deg F

actually taking temp to check for feverfeeling forehead for hotness to check for feverwe develop a fever by ______ whereas a fever breaks through ______a temp greater than ______ is a good indicator for fever

Pyrogen Exogenous pyrogenEndogenous pyrogen

substance that causes feverderived from outside host i.e. organism itself is causing fever onto usderived from inside host i.e. own immune system is ramping up to battle organism

infectious disease, various skin inflammations, immunological diseases, tissue destruction, reactions to incompatible blood products/drugs, cancers, metabolic disorders, thromboembolic processes*persistant fever that cannot be explained is fever of unknown origin

Differential diagnosis of fever

Urinary tract*CBC = complete blood countBMP = basic metabolic panelUA = urinalysis

HPI, ROS and physical exam will guide workup of fever. Examine head to toe looking for source of fever. Think ______ in kids with fever and no obvious source. Consider: CBC, BMP to check electrolytes, blood cultures on temps >102, UA to rule out UTI and to check hydration status

Cough

sudden and often repetitively occurring reflex which helps to clear large breathing passages from secretions, irritants, foreign particles/microbes; reflex is initiated by receptors located in tracheobronchial wall; frequent indicates presence of disease

duration - acute, subacute (3-8 weeks), or chronic (>8 weeks)character - wet or dryquality - barking, whooping, etctiming - at night versus day

Cough can be classified by

infections (respiratory tract infections), asthma, COPD, gastroesophageal reflux, lung cancer, nonasthmatic eosinophilic bronchitis, foreign body, ACE inhibitors, psychogenic cough (common in children w/emotional and psych problems), post nasal drip

Differential diagnosis of cough

CBC, H. pylori if history of GERD, sed rate (inflammation), CXR (chest X-ray), spirometry (lung function)often symptomatic, antibiotics, corticosteroids

Diagnostic approach to coughTreatment

Edema

palpable swelling produced by expansion of interstitial fluid volume

alteration in capillary hemodynamics that favors movement of fluid from vascular space into interstitial; retention of dietary and IV sodium and water by kidneysheart failure, cirrhosis, nephrotic syndrome, renal failure, medications, venous stasis disease, lymphedema

Pathophysiology of edemaDifferential Diagnosis of edema

coronary disease, alcohol abuse, hypertension, hepatic or renal disease, medicationsHEENT, respiratory, CV, abdominal, extremities, edema 1+ to 4+

HPI, ROS, medication review and exam will guide workup of edemaHistory very important (flip)Exam (flip)

how many mm you go in, just divide by 2*Ex. if you go in 4mm, the grade is 2+

How to grade edema

Deep vein thrombosis

Don't miss acute onset unexplained unilateral leg edema! Should raise possibility of ______. Check for history of long drive/flight, tobacco use, birth control use, and recent surgery

CBC, CMP (checks electrolytes and LFTs), TSH, EKG, CXR, duplex ultrasound if concerned about DVT

Workup of edema

Weight lossVoluntaryInvoluntary Cachexia

loss of 5% body weight over 6-12 monthsdiet or exercisingconcerning i.e. progressive not on purpose weight loss often indicates serious underlying medical/psychiatric illnessweakness and wasting of body due to severe chronic illness; lose muscle mass

hyper/hypothyroidism, dental problems, GI diseases, chronic kidney disease (lose protein uncontrollably), cirrhosis (don't properly store/convert proteins), malignancy/cancer, HIV, advanced cardiac/pulmonary/renal disease, drugs

Differential diagnosis of weight loss

overall appearance, affect i.e. how they present themselves, skin changes, lymphadenopathy, cardiopulmonary status, hepatosplenomegaly, abdominal mass, rectal exam w/positive stool hemoccult

HPI, PMH, FH, PSH, ROS and head to toe exam of weight loss

CBC w/differential, CMP (complete metabolic panel), TSH, hemoglobin A1C, UA, stool hemoccult, ESR and/or C reactive protein, consider CXR

Work up of weight loss

DizzinessLightheadedness

Differential diagnosis of vague neurological complaints i.e. syncope, dizziness, numbness/tingling - rotational sensation i.e. either I'm spinning or room isstanding up and feeling like I'm going to pass out

SyncopeTrue syncope

clinical syndrome defined as transient loss of consciousnessresult of abrupt drop of systemic blood pressure; typically brief duration; spontaneously self-limited

reflex syncope - seeing blood, scared, etcorthostatic syncope - standing up out of chair too quickly i.e. change in positioncardiac arrhythmias - watch for in athletes i.e. suddenly fainting/dying on fieldstructural cardiopulmonary disease

Differential diagnosis of true syncope

seizures, sleep disturbances, accidental falls, some psychiatric conditions

Differential diagnosis of transient loss of consciousness not "true syncope

was LOC complete?was LOC transient with rapid onset and short duration?did patient recover spontaneously and without sequelae?history of syncope, heart disease, diabetes, dehydration, or stress?full HPI, PMH, FH, PSH, SOC, ROS, vitals and exam from head to toe with thorough neurologic examorthostatic vitals

Questions about/how to do work up for syncope

dizzy patients have:peripheral vestibular dysfunction > other problems (pre syncope, disequilibrium) > psychiatric disorder > central brainstem vestibular lesion > etiology uncertain

Patient description is critical in making diagnosis regarding dizziness

NumbHypoesthesiaAnesthesiaHypalgesiaAnalgesia

deprived of power of sensationdiminished ability to perceive pain, temp, touch, or vibrationcomplete inability to perceive pain, temp, touch, or vibrationdecreased sensitivity to painful stimulicomplete insensitivity to painful stimuli

Mononeuropathy, distal sensory polyneuropathy ("glove and stocking"), spinal cord lesion, brainstem lesion, thalamic lesion, sensory cortex lesion*goal of sensory examination is to localize lesion

Differential diagnosis of numbness/tingling

Higher/cognitive functions (alert and oriented to person, place, time), cranial nerves, sensory system, motor system, reflexes, cerebellum (allows smooth coordinated movements)

Physical exam for neurologic symptoms*workup for vague neurological complaints is anything under sun

Inflammation

localized physical condition in which part of body becomes reddened, swollen, hot, and often painful especially as reaction to injury/infection; body's attempt at self protection; remove harmful stimuli to begin healing process i.e damaged cells, irritants, pathogens

1) arterioles dilate2) capillaries become permeable3) neutrophils and some macrophages migrate out of capillaries and venules and move into interstitial spaces

Three main processes of inflammation

Acute inflammationChronic inflammation

rapid onset and quickly becomes severe; only present for few days and can persist for few weekslong term inflammation; last for several months and years

pain, redness, immobility, swelling, heat*PRISH

5 cardinal signs of inflammation

infection vs inflammation, trauma/overuse, unilateral (long drive, tobacco use, birth control = think DVT), bilateral

Differential diagnosis of inflammation of lower extremity

CBC, sed rate/c reactive protein, CMP, UA, plain films

HPI, PMH, FH, PSH, ROS, medications and exam of inflammation