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3 Key questions to ask in arthralgia?
Inflammatory or not?
Number and pattern of joints?
Other organs involved?
Types of inflammatory arthritis:
Rheumatoid
Spondyloarthropathies
SLE
Types of non-inflammatory arthritis:
Osteoarthritis
Gout
3 signs of inflammatory arthritis:
Morning stiffness > 1hr
Constituational symptoms
Worst pain after inactivity
3 signs of non-inflammatory arthritis:
Brief morning stiffness
No constitutional symptoms
Worst pain after activity
DDx of monoarthritis:
Infection
Trauma
Crystaline arthropathies
INFECTIOUS DDx of polyarthropathies:
bacterial sepsis
viral (Parvo, HIV, HepC)
Lyme
Subacute bacterial endocarditis
Rheumatic fever
NON-INFECTIOUS DDx of polyarthropathies:
RA/Juvenile rheumatoid arthritis
SLE and other connective tissue diseases
Spondylarthropathies
Gout and pseudogout
Vasculitis
Sickle-cell disease
Osteoarthritis
Joints involved in RA vs OA:
RA: Hands(MCPs), spine, hips, knees, feet NOT wrists, elbows
OA: Hands, wrists, elbows, knees, feet NOT lower back
Symmetrical polyarthritis usually...
RA
Assymmetrical polyarthritis usually...
OA, Gout
Polyarthritis with important spinal involvement...
Spondyloarthropathies (Ankylosing Spondylitis, Psoriatic, Reactive, IBD-related)
Metacarpal squeeze...
If positive sign of RA.
Raynaud’s phenomenon
Blanching of ring, pinky finger.
ENA (the ANA profile): measures what and each indicates what?
Anti-DNA: lupus
Anti-Smith: lupus
Anti-Ro and anti-La: Sjogren’s syndrome
Anti-RNP: mixed connective tissue disease
Rheumatoid factor
Present in 2/3 pts w rheumatoid arthritis.
Other autoimmune diseases
Predicts poor outcome.
Anti-CCP antibodies
CCP= cyclic citrullinated peptides
More sensitive and specific for rheumatoid arthritis
HLA B-27
Associated with spondyloarthropathies
ANCA
Associated with vasculitis
Stepwise EKG analysis:
Rate
Rhythm
Axis
Intervals
Hypertrophy
Infarct
Ischemia
EKG Morphology heirarchy:
LBBB > LVH > MI
P wave axis should be positive in...
I, II, III, aVF
QRS axis in youth vs elderly
+90 (vertical)
to
-30 (elderly)
Normal PR interval
.12-.21
Normal QRS interval
<.10
QTc interval, definition and normal
Time from Q start to T END.
observed QT/sqrt(RR) interval
<.46s

RR = time between QRS complexes.
T wave should be pointing:
In direction of QRS complex of that lead.
High voltage...
Can be benign in youth... check for axis near +90
"Improper standardization"
Check voltage standard... = 10mv

Check paper speed, normal 25mm/s
Atrial bigeminy
PAB coupled at the end of each normal beat... couplets.
RBBB
Long QRS interval. Bunny ears in V1, V2.
LBBB
Long QRS interval. R, R' "plateau" in V5, V6
"Posterior axis"
Significantly negative R waves in V1, 2, 3, 4 and even 5.
Right atrial enlargement
Check II, V1 for large P waves, diphasic P waves.
Evolution of MI
Acute: ST elevation, peaked T
T wave inversion, Q waves
ST returns, T inversion continues
Qs persist ST and T may return.
Significant Q waves...
> 1 small box wide OR >1/3 amplitude of QRS.

Sign of necrosis.
T wave inversion...
Symmetrical in ischemia. Usually in lead that shows infarction (Q waves, ST elevation).
POSTERIOR infarct: vessel and signs
RCA
Large R with ST depression in V1, V2.
Inferior infarct: vessel and signs
RCA or LCA
Qs in inferior leads II, III, AVF

OR if no Qs, ST elevation in those.
Lateral infarct: vessel and signs
Circumflex
Qs in lateral leads I, AVL

OR if no Qs, ST elevation in those.
Anterior infarct: vessel and signs
L. Anterior Descending artery
Qs in V1, V2, V3, V4

OR if no Qs, ST elevation in those.
Stress test: sign of postive
ST depression. Locate just like infarct.
Hyperkalemia:
Moderate: wide/flat P, wide QRS, peaked T
Extreme: no P, VERY wide QRS
Hypokalemia:
Moderate: Flat T, U wave after T
Extreme: prominent U wave after T
Very peaked T waves:
Hyperkalemia
Prolonged QT:
Drugs... may lead to polymorphic VT escape rhythms.
Low voltage: values and causes
< 5mm in limb
< 10mm in chest
Obesity, hypothyroid, pericardial fluids, COPD, improper leads
9 basic causes of chest pain:
Heart - CAD, valves, carditis
Lung - pneumonia, PE
Aortic - dissection, rupture
Chestwall - ribs, muscle, pleura
Esophogeal - ulcer, reflux, tear
Abdominal - infection/flammation
Trauma
Tumors/Masses
Anxiety/Panic disorder
Pneumothorax on CXR:
Check for LACK OF ANY vascular markings beyond a certain point.
Aortic dissection on CXR:
Huge aortic knob, very visible aorta.
Aortic dissection on CT:
Look for dual lumen.
3 types of headaches:
Vascular
Tension
Traction/Inflammatory
Types of vascular headache
Migrane: w/ or w/o aura. May be complicated by hemiplegia.
Cluster headaches: toxic vascular, hypertensive
Types of tension headache
Primary tension type headache (episodic)
Chronic anxiety states
Depression
Cervical Osteoarthritis
Chronic myositis
Types of traction headache
Diseases of the eyes, ears, nose, throat, sinuses, and teeth
Mass lesions
Arteritis, phlebitis, cranial neuralgias
Occlusive vascular disease
Atypical facial pain
Temporomandibular disease
Physiology of migraine:
During a migraine there is cerebrovascular vasodilatation and a generalized systemic vasoconstriction
Nerve source of migraine:
Trigeminal. releases substance P and CRCP (calcitonin gene related peptide) into dural and meningeal blood vessels. Degranulation of mast cells --> PMNs. Vasodilation results.
Serotonin receptors, role in migraine:
Block neurogenic inflammation. (5-HT 1D).
Criteria of migraine w/o aura
4-72 hrs.
2/4: Unilateral pain, Throbbing Aggravation on movement, Pain of moderate or severe intensity.
1/2: Nausea or vomiting, Photophobia or phonophobia
What is an aura in migraine?
15% of patients have it.
Precede or accompany the attack.
Usually visual (lights, dark spots, jagged lines) or sensory (face or arm numbness).
Duration of aura usually less than an hour.
Medication for mild/moderate migraine:
NSAIDS, caffeine, "Midrin" (aspirin, isometheptene, dichloralphenazone)
Triptans, what are they and when to use.
Seratonin agonists.
Use in patients with severe, diabilitating, rapid, and unresponsive migraine.
Stratified treatment for migraines:
Acute treatment drug A
Backup treatment drug B
Rescue treatment drug C
Tension headache characteristics:
Bilateral, pressing or tightning quality. Not associated with vomiting or physical activity.
Cluster headache characteristics:
1:1000
Male:female 5:1
Unilateral severe headache in V1 and V2 trigeminal nerve distribution
conjunctival injection, lacrimation, rhinorrhea, ptosis, miosis, and nasal congestion
Gross hematuria:
GU malignancy until proven otherwise.
50% with bladder cancer (age greater than 50).
Anticoagulation does not cause hematuria.
Approach to chest xray:
TTABC:
Technique
Tubes
Abdommen
Bone
Chest
Intussusceptum
Prolapse of the Ileum into the cecum
UTI definition:
100,000 bacteria/cc mid stream diagnostic.
Ureterocele
The distal ureter balloons at its opening into the bladder, forming a sac-like pouch. More common with duplicated collecting system.
Turners syndrome is associated with this anomaly of the GU tract:
Kidney missing, horseshoe kidney etc.
Drooping lily sign:
Identified at excretory urography in patients with duplicated renal collecting systems.
UVJ obstruction
ureter/bladder junction obstruction.
UPJ obstruction
ureter/pelvic(Renal) junction obstruction
Vesicoureteral reflux:
Strong familiar assocation.
Primary abnormality NOT secondary to obstruction/infection.
Often causes UTI...
Vesicoureteral reflux grading:
1-5.
1. partial ureter
2. to pelvis
3. slightly dilated pelvis
4. moderately dilated pelvis
5. VERY dilated pelvis and ureter
Visceral abdominal pain
Dull and aching, but can be colicky.
Poorly localized to the mid-epigastrium, peri-umbilical region, or lower mid-abdomen.
When severe, patients may move or writhe in agony.
Parietal abdominal pain
Noxious stimulation of the parietal peritoneum. Generally more intense & more precisely localized than visceral pain. Aggravated by movement or coughing. Patients with peritonitis generally don’t move for fear of aggravating pain.
Referred abdominal pain examples:
Usually well localized.
diaphragmatic irritation from a ruptured spleen or subphrenic abscess can be referred to the shoulder. Pain from an inflammed gallbladder can be referred to the scapular area. The pain associated with a ureteral stone can radiate from the flank down to the ipsilateral testis or vulva.
Functional abdominal pain
Patients perceive pain related to heightened sensitivity of gut neurons to endogenous stimuli (visceral hypersensation). Examples: Irritable bowel syndrome, functional abdominal pain, nonspecific dyspepsia
Extra-abdominal causes of abdominal pain, examples:
Extra-abdominal causes (e.g. MI, pneumonitis)
Acute systemic illnesses (e.g. porphyria, lead poisoning)
“Acute Abdomen”
Sometimes used interchangeably with “abdominal emergency.”
Questions to ask about pain:
Chronology
Location
Radiation
Intensity and character
Aggravating and alleviating factors
Associated symptoms
Questions to ask in history of abdominal pain:
Pain characteristics
Menstrual history in women
Sexual history (can be important)
Current meds
Past medical history
Review of symptoms
Family and social history
10 specific causes of acute abdomen
Acute appendicitis
Acute colonic diverticulitis
Acute intestinal obstruction
Perforated duodenal ulcer
Biliary colic & acute cholecystitis
Choledocholithiasis
Acute pancreatitis
Acute mesenteric ischemia
Ruptured abdominal aortic aneurysm
Other causes
Acute appendicitis: characteristics
Most common acute abdominal emergency.
Begins as a vague peri-umbilical or epigastric pain.
Within 6-8 hrs, the pain migrates to the RLQ and peritoneal signs develop.
Diagnosis can be made on clinical grounds 50-60% cases.
US or CT can help if diagnosis not certain.
Acute colonic diverticulitis: characteristics
Most common in the sigmoid colon.
Initially, a visceral-type lower abdominal pain.
Later, as localized peritoneal irritation occurs, LLQ parietal pain occurs.
Classic features = LLQ pain, fever, leukocytosis.
Mild cases can be diagnosed on clinical grounds.
CT = best test to confirm diagnosis.
Acute intestinal obstruction: characteristics
Commonest cause of SBO – postop adhesions.
Higher the obstruction, the more severe the symptoms.
Colicky peri-umbilical pain that comes in waves.
Vomiting common
PE: Periods of increased high-pitched BS; later BS disappear. Distention & tenderness also common.
Initial evaluation = abdominal x-ray series
Perforated duodenal ulcer: characteristics
Free perforation into peritoneal cavity = life-threatening emergency
Sudden onset of severe epigastric pain, later generalized (chemical peritonitis)
Nausea & vomiting common
PE: Diffuse peritonitis Deterioration over a period of hours
Initial evaluation = abdominal x-ray series
Biliary colic: characteristics
Caused by intermittent obstruction of cystic duct by a stone.
Pain of biliary colic visceral & felt in RUQ or epigastrium
Colic a misnomer (pain usually steady)
Resolves within 4-6 hours
Initial evaluation: WBC, LTs, amylase, upper abd US
Acute cholecystitis: characteristics
Biliary colic with stone remains impacted -> damage GB mucosa -> release intracellular enzymes -> inflammation
Pain of AC similar to biliary colic, except doesn’t go away. As inflammation progresses, parietal pain localized to RUQ occurs
Tests: WBC, LTs, amylase, upper abd US
Acute pancreatitis: characteristics
Acute inflammatory condition of pancreas...most common causes = CBD stone & ETOH
Rapid onset of severe constant epigastric pain that can radiate into the back.
Tests: elevated serum amylase, results of abdominal xray, US
Acute mesenteric ischemia: characteristics
Causes: SMA embolus or thrombosis (60%), non-occlusive mesenteric ischemia (25%).
Presentation with acute, often sudden, crampy peri-umbilical pain.
Pain out of proportion from PE.
Evaluation = abdominal x-rays, CT, angiography.
Ruptured abdominal aortic aneurysm (AAA): characteristics
Acute severe pain of sudden onset (mid-abdomen, back or flank). [often “tearing”]
Classical triad of hypotn, pulsatile mass & pain (75%).
Dx requires high index of suspicion, & requires emergent surgery.
Causes of chronic abdominal pain:
Chronic pancreatitis
Gallstones
Peptic ulcer disease
Inflammatory bowel disease
Malignancy
Irritable bowel syndrome
Sphincter of Oddi dysfunction
6 rare, unusual and misc. causes of abdominal pain:
Lead & arsenic poisoning
Acute porphyrias
Hereditary Mediterranean Fever
Angioedema syndrome
Abdominal epilepsy & migraine
Abdominal wall pain
9 absolute contraindications to exercise stress testing:
Acute MI
Unstable angina
Uncontrolled arrhythmias
Severe Aortic stenosis
Decompensated CHF
Acute PE
Acute myocarditis/pericarditis
Acute aortic dissection
Acutely ill patients
7 absolute indication to STOP stress testing:
Systolic drop in BP>10mmHg w/ischemia
Moderate to severe angina
ST elevation without underlying Qs
Neurologic symptoms
Signs of poor perfusion
Patient desire to quit
Sustained VT
Stress testing protocols:
Bruce protocol:
Stage I 1.7mph, 10%grade
Increase ~0.8mph, 2%grade each 3 min.
Signs of a positive stress test:
ST segment depression.
New left axis
1 mm horizontal depression 80 msec after the J point, 3 beats in a row
How does a resting RBBB, LVH, or ST-T abnormalities effect the stress test?
Difficult to interpret because of pathology.
5 findings associated with severe CAD in stress testing:
Marked ST depression
Early positive (< Stage II)
Hypotension with exercise
Prolonged recovery
Exercise-induced VT
Inability to increase HR
Duke treadmill score system, predictor
Exercise time – 5 x (ST depression) - 4 x angina index (0,1,2)

< -11 high risk
-10 to 4 moderate risk
> 5 low risk
Angina index (3 factors)
Improves with rest.
Exertional
Substernal
Agent used in pharmacologic stress testing?
Adenosine -- increases coronary blood flow.

Side effects: bronchospasm, AV block
Transitional cell carcinoma, sign on IVP:
Champaign glass of ureter.
Wilms tumor: signs
“Claw” sign (normal renal tissue at periphery of mass)
Large, exophytic growth
3-6-9 rule for bowel dilation:
Dilated if more than:
3cm small bowel
6cm large bowel
9cm cecum
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