URI Symptoms (Runny nose, sore throat, cough, etc.

)
Differential Distinctive symptoms Diagnostic Treatment
Tests/Monitoring

Acute Viral Rhinitis Symptoms are mild. Clinical Supportive, no antibiotics

Rhinorrhea Could turn into bacterial
prominent, low infection if prolonged (>2 weeks
fever, mild duration)
symptoms

Influenza Abrupt, severe Rapid Flu Test but Supportive, Tamiflu if <48 hours.
symptoms. often false (-) so
Prominent cough, don’t rely on this
congestion,
high fever,
headache,
myalgias, fatigue,
+/- GI symptoms

Sinusitis Facial pressure, Clinical Supportive usually

purulent discharge, Abx of choice: Augmentin 875mg bid x7 days
dental pain or Doxy bid x7 days.

Allergic Rhinitis Itchy, watery eyes. Clinical Anti-histamines + topical nasal

No fever, +/- mild steroids (Flonase) daily
“drainage” cough,
mild sore throat,
seasonal pattern

Strep Pharyngitis CENTAR Score = No Clinical +/- rapid Score 0-1: No test, no antibiotics. See
cough (+1), Exudate strep test viral rhinitis
(+1), Painful LAD Score 2-3: Consider rapid strep & culture,
(+1), High Fever no empiric antibiotics
(+1), Age Range Score 4-5: Empiric antibiotics
3-14 y.o. (+1). Abx of Choice: Pen G shot or Amoxicillin 250
bid x10 days, Augumentin if recent
amoxicillin, Keflex 500 bid x10 days if PCN
allergy

Otitis Media Ear pain, ear Clinical. PE = Children >6 mos with unilateral & mild
“fullness”, pain bulging, symptoms: Observation for up to 72
relieved by erythematous hours Otherwise…
pulling on pinna. tympanic membrane Amoxicillin 45mg/kg bid, Augmentin,
MC accompanied Z-pak taper, or Cefdinir if PCN allergic.
by viral URI type
symptoms.
Perforation =
otorrhea

Infectious Prominent Mono Spot Test Supportive. Do not treat with ampicillin -
Mononucleosis fatigue/malaise, can develop full-body rash!
posterior LAD, Monitor for
splenomegaly, high rupture/laceration Avoid contact sports for 3-4 weeks
fever, sore throat > of spleen/liver
14 days.
Adolescents r/o other sore
throat etiologies
When to Rx Antibiotics for URI: Most symptoms not improving >10 days, fever >102, “re-sickening”, signs of lower
infection (low O2 sat, lung sounds, etc.), general clinical picture worse than expected.
Important History: Vaccination history
ROS: General, HEENT, Pulmonary
Physical Exam Components:
HEENT – Turbinates, conjunctival injection, swelling of tonsils, pharynx, palpate lymph nodes, ears (r/o middle
ear infection), palpate the sinuses
GI: Look for hepatosplenomegaly
Heart & Lungs: r/o lower respiratory infection

Productive cough, wheezing, fever, dyspnea (Lower Resp. Symptoms)

Differential Symptoms Diagnosis Treatment

Community-Acquired Typical: Acute onset, CXR + Labs Outpatient: Azithromycin

Pneumonia productive cough w/ PE: Rales, fremitus, 500mg once → 250mg qd
thick sputum, high fever, bronchial breath sounds, x 4 days.
SOB, hemoptysis, egophony Dullness on If comorbidities, add
myalgias. Rusty or green percussion Augmentin or do just Levoquin
sputum
Atypical: Gradual onset,
nonproductive cough,
low-grade fever

Acute Bronchitis Cough x 1-3 weeks (viral) CXR: No findings Viral: Symptomatic
+ no CXR findings, Bacterial: Macrolide
low-grade fever, dyspnea,
etc. Supportive care, avoid
PE: Inspiratory wheeze, smoking, cough
normal expiratory suppressants, throat
phase Bacterial coughs lozenges/tea/gargles
will last >3 weeks

Tuberculosis Slow-onset over CXR + CT chest RIPE x 9 months + Vit B6

months. Worsening Sputum Culture w/ AFB stain
cough w/
hemoptysis, low-grade
fever & night sweats,
weight loss

COPD (Obstructive) Chronic cough, SOB. PFTs: FEV1/FVC Ratio Exacerbations: Systemic
Emphysema-Dominant: < 70%; glucocorticoids,
“Pink Puf er”. Accessory Hyperinflation; No antibiotics Chronic
muscle use, tachypnea, recovery with Management:
long bronchodilator Stop smoking,
expiratory phase, mild CT Scan: Diagnoses Pneumovax,
cough emphysema LABA/LAMA, Inhaled
Bronchitis-Dominant: CXR: Diagnoses bronchitis corticosteroids
“Blue Bloater”.
Hypoventilation,
hypoxemia, hypercapnia,
productive cough
Asthma (Obstructive) Atopic Triad (asthma, PFTs: Establishes Mild Intermittent:
allergies, atopic diagnosis. Include Albuterol Mild Persistent+:
dermatitis) Dyspnea + before/after Albuterol & Inhaled
Wheezing + Cough, bronchodilator in order. corticosteroids:
often worse at night Will show decreased Fluticasone, Budesonide
Exacerbations / FEV1/FVC ratio
Bronchoconstriction Peak Flow Meter < 80%
Triggers: Exercise, expected. “Peak
illness, smoke, GERD, Expiratory Flow”
animals
(allergies)
PE: Tachypnea, +/-
accessory muscle use (see
below),
prolonged expiratory
phase, low O2 sat

Alarm Signs: Weight loss, night sweats, pain, travel abroad, high fever, hemoptysis, h/o smoking
ROS: General, HEENT, Pulmonary, Cardiac
Physical Exam:
Pulmonary: O2 Sat, temperature, accessory muscles for breathing, rales, bronchial breath sounds, dullness to
percussion, egophony/fremitus
Cardio: Lifts, heaves, thrills, S3 or S4, rubs or bruits. R/O cardiac causes (HF = common comorbidity of
COPD) HEENT: Check for URI signs
Skin: Check for atopic or exanthematous rashes

Labs: CBC, Blood Culture, Urine Antigen, PFTs & Peak Flow, Sputum Culture w/ AFB
Imaging: CXR +/- CT

Important Cardiac Diseases

Differential Distinctive symptoms Physical Exam Diagnostic Treatment
Tests/Monitoring

Hypertension Usually none Eye Exam: AV nicking, Diagnosis: First-Line:

papilledema, cotton *Average to 2+ BP Thiazide-type
wool spots readings >130/80 taken diuretic (HCTZ)
Cardio: Signs of other at at least 2 office visits Second-Line:
cardiac disease *Average of 2+ BP ACEI
Lungs: Signs of HF readings in one office (Lisinopril),
visit that read ARB
>160/100 (Losartan),
Initial Tests: Beta-Blockers
EKG, BMP, CBC, (Propranolol).
Lipids, UACR If Stage II, start
on Thiazide +
ACEI/ARB/BB
Education: Diet,
exercise, home
BP monitoring
Follow-Up:
Monthly until
goal achieved
 Peripheral Intermittent Vascular: Peripheral Ankle-Brachial Index Smoking
Artery Disease claudication, weak pulses, bruits, etc. cessation, LDL
pulses, shiny legs Cardiac: Full reduction
with hair loss Skin: Esp. on (atorvastatin),
peripheries, antiplatelet agent
temperature, color (aspirin)
Education:
Exercise training,
diet,
exercise

Dyslipidemia Usually asymptomatic Vascular: Check for Lipid panel Drugs:

PAD Cardiac: Signs of Atorvastatin to
other cardiovascular ASCVD risk < 7.5%
disease Eyes: Lipemia Education: Diet,
retinalis, exercise, weight
Xanthelasma loss, smoking
Derm: Xanthomas cessation

Heart Failure Left: Pulm Cardiac: JVP, lifts, Labs: CMP, LFTs, Drugs: Diuretic
symptoms. S3/S4, murmurs CXR, Echo AND [ACEI or ARB,
Dyspnea (DOE, Pulmonary: Rales, Lisinopril or
orthopnea, PND), effusion Abdominal: Valsartan] AND
syncope. Hepatomegaly, ascites BB (Metoprolol)
Right: Systemic Vascular: Pulses, AND AldoAnt
symptoms. Edema, edema, skin temp (Spirono)
anorexia, weight Education: Low
gain/loss salt diet, exercise

Chest Pain
Differential Clinical Presentation Diagnosis Treatment

Stable Angina Pectoris a.) Substernal “pressure” EKG: Normal +/- ST Drugs: Sublingual
that radiates to jaw, left depression during pain nitroglycerine PRN;
arm, back, or event Work-Up: Metoprolol (BB) if
epigastrum; CK-MB & Troponin (-) chronic angina; Aspirin
Diaphoresis, GI upset, CBC: Test for anemia for platelet protection;
Cough, Syncope Lipid: Test for hyperlipidemia Atorvastatin
Management:

b.) Reproducible with Refer for exercise stress

increased HR (emotion, test or stress echo
heavy meal, exercise);
c.) Resolution with
nitroglycerin

Unstable Angina & NSTEMI Same as above but.. EKG: ST depression, ASAP Meds: MONA →
a.) Occurs at T-wave inversion or Cath lab if high risk,
rest/minimal exertion flattening 24-48hr
b.) Lasts > 20 minutes Enzymes: (-) if UA, (+) if observation if low risk
NSTEMI Long-Term Meds: Aspirin
+ BB + Statin
 Supportive: Bedrest 24
hours, continuous EKG +
O2

STEMI Same as above but… EKG: Peaked T-wave → ASAP Meds: “MONA”
a.) Pain is severe and ST Elevation → Q Wave Morphine, O2, Nitro,
does not go away Abnormality → T Wave Aspirin
b.) Usually starts in the Inversion Reperfusion:
early AM Enzymes: (+) CK-MB + *PCI (cath lab): If <60
c.) Not aided by nitro Troponin minutes
*tPA if >120 or no PCI
available
Supportive: Bedrest 24h,
O2, analgesics (no
NSAIDs)
Long-Term: BBs, ASA for
1 year after stenting,
Nitro if continuing
angina

Pulmonary Embolism Signs of DVT, CXR → CT-PE, D-Dimer Heparin drip →

Tachycardia, chest pain, long-term
hypoxia, anxiety, cardiac anticoagulation
arrest, Virchow’s Triad
[hypercoagulability +
Stagnant blood flow +
endothelial injury]

Costochondritis Pain comes and goes Clinical NSAIDs, supportive

unrelated to heart rate,
reproducible on chest
wall palpation, not
relieved by rest, NSAIDs
help best. +/- chest wall
nerve pain

GERD, Cholecystitis, See below

Pancreatitis, Achalasia, etc.

Anxiety Diagnosis of exclusion. Exclude Pulmonary, Cardio, GI, Musculoskeletal etiologies first

ROS: General, Cardiac, Pulmonary

Physical Exam Components
Cardiac: Full cardiac exam
Pulm: Rales, rhonchi
Vascular: Pulses, signs of DVT, edema, HF signs
Work-Up: CK-MB, Troponin, EKG, CT chest(?)

Acute or Chronic Diarrhea

Differential Symptoms Diagnosis Treatment

Infectious Duration < 7 days Additional tests only if Supportive, usually clears
Non-Inflammatory Watery, profuse, diarrhea > 7 days!! in a few days even if
Diarrhea nonbloody diarrhea, C. Diff PCR if recent abx bacterial. Vancomycin po if
N/V, cramping. Profuse or hospitalization C.Diff (+)
vomiting is MC viral or S.
 aureus food

poisoning. Food poisoning

starts 6-48 hours after
eating and lasts 24-72
hours

Infectious Duration < 14 days (+) Fecal WBCs Empiric: Azithromycin

Inflammatory Small-volume, bloody O&P 500mg x5 days or Levo/Cipro
Diarrhea diarrhea with cramps, C. dif studies if recently
urgency, tenesmus on Abx

Chronic Infectious Diarrhea Duration > 21 days O&P Depends on organism.

C. Diff Studies Mostly Flagyl

Irritable Bowel Syndrome Lower abdominal, Diagnosis of exclusion. Education: Low

cramping pain that comes No abnormalities in FODMAP diet, exercise
and goes. Often worse labs + sleep
with stress. Pain is either Criteria: Drugs: Second-line.
relieved or exacerbated a.) Recurrent abdominal Laxatives for constipation,
by defecation. No pain for at least 1 anti-diarrheals for
nocturnal diarrhea day/week for the last 3 diarrhea. CBT for
PE: No abnormalities months AND onset >6 psychological
months ago symptoms
AND
b.) Pain related to
defecation, change in stool
frequency, or change in
stool appearance

Diverticulosis / Diverticulitis LLQ pain with diarrhea CT w/ IV & PO contrast Clear liquid diet x2-3
or constipation Colonoscopy in 6-8 weeks days Oral antibiotics
N/V to confirm x7-10 days Re-evaluate
Urinary symptoms weekly until symptoms
Low-grade fever resolve
PE: Hypotension,
peritonitis signs.

Ulcerative Colitis (IBD) Young adults (20-30), Colonoscopy w/ biopsy Steroids or budesonide
smoking improve Stool studies for induction
symptoms Diarrhea, CBC, CMP 5-ASA for induction +
rectal bleeding, mucus in ESR + CRP maintenance
stool, tenesmus, urgency,
weight loss, fever

Crohn’s Disease (IBD) Diarrhea, anorexia,

weight loss, abdominal
pain.
Younger onset than UC
Smoking worsens
symptoms
Alarm Signs: Fever, GI bleed, weight loss, onset > 50 y.o., abdominal pain is getting progressively
worse Special Questions: Travel history, food history, recent sick contacts, nocturnal diarrhea,
ROS: General, Gastrointestinal
Work-Up: Fecal leukocytes, CBC & Iron studies, ESR + CRP, ANCA, Electrolytes, O&P, Stool culture, C-Diff
Studies Physical Exam:
Abdominal exam: Bowel sounds, peritoneal signs, palpation
Skin: Manifestations of IBD
Eye Exam: Manifestations of IBD

Dyspepsia & Epigastric Pain

Differential Symptoms Diagnosis Treatment

Acute Gastritis Chronic NSAID, ETOH, MC clinical diagnosis

or stress. Breath Test if H. pylori
MC asymptomatic suspected
Epigastric pain, N/V,
melena or hematemesis,
anorexia

GERD Heartburn with waterbrash Typical symptoms AND

& radiating chest pain. response to medications
Onset

30-60 minutes after Stop exacerbating

eating. Worse by lying agents Start PPI or
down, H2A
better with antacids. Antacids for rescue use
PE: Usually normal +/- but separate from
pain on deep palpation of PPI/H2A
epigastrum If H. Pylori (+):
#1: PPI + Clarithromycin +
Peptic Ulcer Disease Chronic NSAID, ETOH, MC confirmed by response Flagyl or Amoxicillin
or stress. to medications (Triple) #2: If PCN allergy,
Hematemesis or EGD = definitive diagnosis Clarithro exposure, or high
Melena; N/V; rates of Clarithro
epigastric pain resistance…
History of GERD
Gastric: Exacerbated by
food Duodenal: Relieved
by food

Biliary Colic Risk factors (5 Fs) PE & Labs usually Pain control & elective
Epigastric or RUQ pain, normal Trans-Ab US Cholecystectomy
may radiate to back. +/- CT (unless infected)
Intermittent attacks last
<6 hours. Worse when
laying down or after
fatty meal, not
exacerbated by
movement.
Acute Pancreatitis Constant, boring Lipase (+) IV Fluids x24-48 hours
epigastric pain +/- CT to diagnose Pain management (don’t
radiating to back Made ALT to check for use morphine)
worse by walking; gallstone pancreatitis NPO
Relieved by fetal position
or leaning forward
N/V, fever
PE: Tachycardia, watch
out for Cullen’s or Grey
Turner Signs

Inflammatory Esophagitis Odynophagia, Endoscopy Depends on etiology

dysphagia,
hematemesis,
retrosternal pain

Alarm Symptoms: Weight loss, dysphagia, odynophagia, melena/hematemesis

ROS: General, Gastrointestinal
Physical Exam:
Abdominal/Epigastrium: Palpation, bowel sounds, peritoneal signs, masses
Throat: Obstructions, swelling or erythema, masses
Heart & Lungs: Rule out cardiac or pulmonary cause (remember MIs cause epigastric pain too)

Abdominal Pain or Cramping

Differential Symptoms Diagnosis Treatment

Upper Abdominal

Cholecystitis RUQ Pain, that Ultrasound Hospitalize

sometimes radiates to (HIDA scan if unclear US) Supportive (IV, pain
the epigastrum MC 1 control) Antibiotics
hour after fatty food Cholecystecomy when stable
ingestion
Prolonged biliary colic,
fever, n/v, anorexia
PE: Fever, tachycardia,
peritoneal signs, (+)
Murphy’s Sign
Labs: Leukocytosis w/
left shift

Cholangitis Charcot’s Triad: Work-Up: Antibiotics

Fever/Chills, RUQ pain, CBC (leukocytosis) ERCP to extract stone
jaundice. LFTs (Alk Phos incr,
Reynold’s Pentad: Above Bilirubin > ALT/AST)
+ shock + altered mental US/CT: Dilation of CBD
status Cholangiography once
patient is stable x48 hours
 Hepatitis RUQ Pain + Flu-Like LFTs: Acute:
Symptoms ALT > AST, both >500 if Symptomatic (Tylenol,
Sexual promiscuity, acute Ondansetron, IV fluids,
IVDU, travel to area Bilirubin high etc.) Hospitalize if
with poor Alk Phos normal signs of
sanitation Other Work Up: CBC, encephalopathy
Prodrome: Malaise, Coag Panel Chronic: Refer to
arthralgia, fatigue, internal medicine
anorexia, n/v, URI (Hepatology?)
symptoms, +/- fever (if
Hep A)
Icteric: Jaundice
Fulminant:
Encephalopathy
(asterixis), coagulopathy,
edema, ascites,
hyperreflexia

Cirrhosis RUQ Pain Ultrasound Lactulose if signs of

H/O ETOHism, hepatitis, encephalopathy
obesity, DM, high Na-restriction +
cholesterol, drug toxicity diuretics if ascites
Fatigue, weakness, Refer to hepatology
weight loss, cramps
PE: Ascites,
gynecomastia, spider
angioma, caput
medusa,
confusion/lethargy,
asterixis
Labs: Bilirubin high,
albumin low, INR high

Lower Abdominal

Appendicitis Periumbilical → RLQ Ultrasound → CT Scan Appendectomy

pain Nausea, vomiting,
won’t extend hip
PE: Rebound
tenderness, point
tenderness, rigidity,
guarding.
(+) Rovsing, (+)
Obturator, (+) Psoas
Signs

Diverticulitis LLQ pain with diarrhea CT w/ IV & PO contrast Clear liquid diet x2-3
or constipation, N/V, Colonoscopy in 6-8 weeks days Oral antibiotics
Urinary symptoms, to confirm x7-10 days Re-evaluate
Low-grade fever, +/- weekly until symptoms
hematochezia resolve
PE: Hypotension,
peritonitis signs.

Renal colic (unilateral, Work-Up: CBC, Cr, UA, NSAIDs

intermittent back pain, Electrolytes, KUB to No intervention if
unable to sit still) monitor stone stone is likely to pass,
 progression pain is

Kidney Stone Voiding symptoms Diagnosis: Non-Contrast CT controlled, minimal

N/V obstruction, no
PE: Flank tenderness, infection Tamsulosin
low-grade fever, no = medical
peritoneal signs expulsive therapy
Follow-Up in 4-6 weeks,
adequate fluid intake,
lower salt intake,

Pyelonephritis Dysuria, polyuria, UA: Pyuria, WBC casts, Fluoroquinolone IV

hematuria AND nitrates, RBCs x14 days
Fever, tachycardia, Urine Culture
back/flank pain, n/v
PE: CVA tenderness

Gastroenteritis Duration < 5 days Additional tests only if Supportive, usually clears
(Non-Inflammatory) Watery, profuse, diarrhea > 7 days in a few days
nonbloody diarrhea,
N/V, cramping. Profuse
vomiting is MC viral or S.
aureus food poisoning

Generalized Abdominal

Small Bowel Obstruction Cramping pain, Abdominal XR Series NPO, IV fluids, bowel
mild-intermittent → decompression via suction
severe-constant
Abdominal distention, Surgery if strangulation
vomiting, obstipation on XR
or diarrhea
PE: High-pitched tinkles
on auscultation (if early)

Large Bowel Obstruction Cramping pain, Abdominal XR Series Depends on etiology

abdominal distention,
n/v,
PE: Diminished bowel
sounds

Perforation Above + fever, malaise, etc. Abdominal XR Series Urgent surgery

CT

IBD Young adults (20-30), Colonoscopy w/ biopsy Steroids, budesonide

diarrhea, rectal bleeding, Stool studies for induction
mucus in stool, CBC, CMP 5-ASA for induction +
tenesmus, urgency, ESR + CRP maintenance
weight loss, fever,
abdominal pain

Colorectal Cancer Abdominal pain, Colonoscopy w/ biopsy Refer to GI

anemia, rectal Barium enema
bleeding, change in CEA (tumor marker)
 bowel habits

Headache
Differential Symptoms Diagnosis Treatment

Tension Headache Tight, band-like, Clinical Episodic: NSAIDs,

constant pain Acetaminophen

Bilateral Chronic: Amitriptyline,

Short or long-lasting Topamax
MC in afternoon
Not worse with activity,
no N/V or aural
symptoms

Migraine Headaches MC females in early POUND Acute: NSAIDs or

adulthood Pulsing Sumatriptan
Pulsing, throbbing, 4-72 hOurs Preventative: If
unilateral headache lasting Unilateral >2-3x/month.
>4 hours Triggered by Nausea/Vomiting BBs/CCBs, TCAs,
physical Disabling Anticonvulsants, etc.
activity, stress, insomnia, 4-5 must be present to Education: Avoid
etc. Auras subside before diagnose triggers, regular sleep,
headache starts exercise,
weight control

Cluster Headache 20-30s, Males, smokers PE: Horner’s Syndrome, Acute: 100% O2 + SQ
Severe, sudden-onset, Conjunctival Injection Sumatriptan
piercing pain that MRI all suspected Transitional: Prednisone
rapidly worsens cluster patients!! x5 days
Unilateral, Prophylaxis: Verapamil =
periorbital/temporal first line
Last 15 minutes to 3
hours with quick
remission
Same season, same time
each day
Nasal congestion,
conjunctivitis,
lacrimation,
diaphoresis
Worse at night, with
ETOH Better with
movement

Trigeminal Neuralgia Middle-aged/young PE: Mostly normal Carbamazepine,

women, MS patients! Oxcarbazepine
Brief, piercing, extreme
pain. Unilateral near
mouth → eye, ear, nostril.
Lasts
seconds-to-minutes
Worse with touch,
eating, brushing teeth,
etc.
Pseudotumor Cerebri Obese, fertile, young PE: Papilledema, Acetazolamide
women. Coat-hanger limited abduction (diuretic) Removal of
headache, LP: Increased OP with CSF via LP
constant or throbbing. normal findings otherwise Weight loss
Pulsatile tinnitus,
visual changes.

Intracranial Mass Lesion Middle-to-late life MRI

Tension-type headache
that worsens over time
Usually bilateral frontal,
intermittent
Worse with
recumbency, valsalva
Peaks in morning,
present on waking
Neurological dysfunction

Giant Cell Arteritis Elderly white women Response to treatment High dose
Persistent headache with ESR high corticosteroid
jaw claudication, scalp CBC anemia immediately x6 weeks
tenderness, CRP high
constitutional Temporal Artery Biopsy
symptoms, and visual
symptoms

Meningitis Fever, headache, neck CSF: Stuff

stiffness Bacteria: High WBCs w/
PE: Meningitis signs high Neutrophils, high
protein, low glucose
Viral: High WBCs w/
high lymphocytes,
normal
everything else
Gram Stain: (+)

Subarachnoid Hemorrhage Sudden thunderclap CT w/o Contrast: Bedrest, no exertion,

headache , nausea, Immediately analgesics, keep BP low
meningeal irritation, LP if CT (-)
altered
consciousness.

ROS: General, Eyes, Head, Neck, Neuro, MSK, Cardiac

Physical Exam: Heart & Lungs plus…
Head: Scalp lesions, tenderness to palpation
Eyes: Visual acuity, PEERLA, papilledema, retinopathy
ENT: Signs of cluster headaches
MSK: Pain with claudication
Neuro: Meningitis signs, A&O x3, cognitive function, reflexes?

Diabetes
Differential Symptoms Work-Up/Diagnosis Treatment
 Pre-Diabetes Asymptomatic Diagnosis: Lifestyle modification
A1C > 5.7%
FBG >100

Type 1 DM Usually in Diagnosis: Meds: Insulin (NPH +

infants/children but can AutoAb Panel + Regular. TDD = 0.3*kg
be in adults. A1C > 6.5% or FBC > body weight)
Caucasians. 126 Monitoring: See Education: Carb Counting,
Rapid onset of symptoms. below Goals (FBC 80-130, A1C
Thin BMI. Weight loss, 7%), BG monitoring,
blurry vision, hypoglycemia signs &
polyuria/dipsia/pha treatment
gia, nocturia,
recurrent UTIs

Type 2 DM MC > 40 y.o. in African Diagnosis: Glucose panel First-Line: Metformin.

American, Hispanic w/ as above Add double therapy if not
heart disease & physical Monitoring: @ goal in 3 months.
inactivity MC HTN: Home BP log. Goal Insulin: If A1C >10% or
asymptomatic, <140/90, treat with ACEI Glucose >300. NPH +
Overweight/obese, or ARB if present Regular. TDD = 0.3*kg
blurry vision, Dyslipidemia: Screen body weight
polydipsia/-phagia/-ur q12 mos if present, q5 Education: As above,
ia, nocturia, recurrent years if not present. All weight loss, DASH diet,
UTIs. PE: May see patients on statin reduce CVD risk factors,
acanthosis CVD: All patients on foot protection.
nigricans, diabetic Aspirin if >50 y.o. + risk
retinopathy, renal factor
disease, peripheral CAD: ACEI or ARB as
neuropathy, above for prevention.
xerosis/pruritis, Eyes: Comprehensive dilated
diabetic dermopathy

eye exam q12 mos

Kidneys: UACR or Spot
Test + eGFR q12 mos. Use
ACEI/ARB.
Feet: Inspect feet each
visit, comprehensive foot
exam q12 mos. Treat
with
Pregabalin (Lyrica)

Hematuria
Differential Clinical Presentation Diagnosis Treatment

BPH Old men DRE: Uniformly large, Drugs:

Obstructive Sx: Decrease firm, rubbery prostate Alpha blocker
in force of stream, UA: To rule out UTI (Tamsulosin) + 5-α
hesitancy, post-void reductase inhibitor
dribbling (Finasteride)
Irritative Sx: Dysuria,
polyuria, nocturia, etc.
Bladder Cancer Smokers, age > 40 y.o., Work-Up: Culture, UA, Complicated
men Painless, gross CBC, CMP
hematuria, B-symptoms, Diagnosis:
urinary Urinary cytology
symptoms Cystoscopy w/ biopsy
PE: Unremarkable CT w/ contrast

Kidney Stone Renal colic (unilateral, Work-Up: CBC, Cr, UA, NSAIDs
intermittent back pain, Electrolytes, KUB to No intervention if
unable to sit still) monitor stone stone is likely to pass,
Voiding symptoms progression pain is
N/V Diagnosis: Non-Contrast CT controlled, minimal
PE: Flank tenderness, obstruction, no
low-grade fever, no infection Tamsulosin
peritoneal signs = medical
expulsive therapy
Follow-Up in 4-6 weeks,
adequate fluid intake,
lower salt intake,

Uncomplicated UTI Dysuria, polyuria, UA: (+) Leukocytosis, Bactrim x3 days

hematuria, suprapubic (+) Nitrites Macrobid x5 days
pain Urine Culture:

Post Infectious GN Hypertension, edema, Labs: Supportive

hematuria. Proteinuria 1-3 g/day ACEI/ARB if
History of preceding illness Serum complement low hypertension present
ASO high Diuretic + Salt
Biopsy Restriction if edema
present

Rhabdomyolysis Dark brown, reddish UA + Microscopy: (+) Fluids

urine. Myalgias, fatigue, hematuria but no RBCs Pain control
nausea, swelling of on microscopy
extremities. CK elevated
Recent vigorous LFTs elevated
exercise, crush injury,
statin use. PE: Diffuse
tenderness to
extremities

Alarm Symptoms: Painless hematuria!! B-symptoms, proteinuria, fever, N/V, persistent flank
pain ROS: General, GU, Cardiovascular, MSK (if rhabdomyolysis suspected), Heme
Physical Exam: DRE if indicated, flank & abdominal tenderness, HEENT if preceding illness, palpation of extremities
(edema, tenderness)

Work-Up: UA with microscopy, Serum Cr, UACR, urine culture, CMP, CBC. More individual tests as needed
Back Pain
Differential Clinical Presentation Diagnosis Treatment

Compression Fracture Elderly X-Ray Narcotics, brace x3-6

Acute-onset, severe pain @ Metabolic work-up for months Refer to Ortho
midline, non-radiating. osteoporosis
Better when supine.
PE: Boney tenderness
Cauda Equina Syndrome Radiculopathy symptoms MRI + Myelogram ASAP Emergent surgical
AND saddle anesthesia, decompression of nerve roots
incontinence, foot-drop
PE: Decreased anal tone,
inability to get up from
chair, heel + tip-toe
walking

Herniated Disc/Lumbar 35-45 y.o., sedentary Straight Leg Raise Oral NSAIDs, steroid
Radiculopathy jobs. MOI: Bending or (both sides) taper, muscle relaxers if
lifting ROM needed.
Pain with numbness & Sensation
parasthesias down leg & MRI
foot, weakness, loss of
coordination
Pain worse with movement.

Muscle Strain MOI: Lifting motion Clinical Symptomatic

Low physical fitness Referral to PT
Non-radicular, nonfocal
back pain. Paraspinal
spasms
worsen with activity
PE: No boney
tenderness, normal
exam

Spinal Stenosis Men > 50 y.o. X-Ray = initial Symptomatic

Chronic, insidious pain MRI/CT Myelogram = NSAIDs, Analgesics, PT,
Neurogenic Leg definitive Corticosteroid injections
Claudication: Relieved
by lumbar flexion - like
leaning on a shopping
cart

Spondylolysis +/- Very young athletes Lateral XR Rest 2-12 weeks, Brace @
Spondylolisthesis (10-20s) MC 4 weeks, progressive
Asymptomatic return to play
Back pain worse with
extension/twisting,
hamstring tightness
PE: Shortened gait,
posterior thigh pain,
normal neuro exam

Ankylosing Spondylitis Young adult MALES Work-up Refer to Rheumatology

Chronic low-back pain ESR Rest, NSAIDs, PT
that improves with HLA-B27
activity Spinal XR (sacroilitis,
Costochrondritis & heel bamboo spine)
pain (enthesitis)
Stooped posture,
difficulty lifting head
PE: Schober Test,
Occiput-to-Wall Test
Fibromyalgia Bilateral, upper + lower Diagnosis of exclusion Lifestyle: Appropriate
body pain for 3+ months expectations for symptom

Chronic aching pain +/- relief, graded exercise,

severe pain spikes CBT psychotherapy
Allodynia & hyperalgesia Drugs: SNRIs or Pregabalin
Fatigue,
Depression/Anxiety PE:
Tenderness over
pressure points

ROS: General, MSK, Neuro

Work-Up: Depends on history. XR only if back strain is not suspected. MRI if radiculopathy. ESR, HLA-B27, RF, ANA if AS
is suspected
Physical Exam:
MSK: ROM, Palpation of spine (boney tenderness = fracture) & paraspinal muscles, reflexes, straight leg
raise Neuro: Gait, sensation in lower extremities
Shoulder Pain
Differential Symptoms Diagnosis Treatment

AC Separation History of injury, fall onto Bilateral XR weighted Sling w/ early elbow
adducted shoulder, patient ambulation, NSAIDs
holds arm in neutral RTW @ 4 weeks
position, step-off
deformity

Rotator Cuff Tear Athletes & laborers Clinical +/- MRI Lessen lifting activity,
performing repetitive Arthrogram w/ Contrast NSAIDs, steroid injections, PT
overhead activities
Painful tearing
sensation, pain at night,
weakness of lifting
arm.
PE: Shrug sign, empty
can test, reduced active
ROM

Impingement Syndrome Insidious onset, pain Clinical RICE, NSAIDs, PT

with lifting arm, pain at
night PE: Localized
tenderness @ lateral
humerus, atrophy,
Hawkins Sign, Near
Impingement Sign

ROS: General, MSK, Neuro

Physical Exam:
MSK: ROM (active + passive) + Strength, Palpation of joint, Hawkins + Impingement, Shrug Test, Above-head lifting
Wrist or Elbow Pain
Differential Symptoms Diagnosis Treatment
DeQuervain’s Tenosynovitis Difficulty moving thumb (+) Finklestein Sign NSAIDs, Ice, Steroid
around wrist, grasping, injection
pinching. Sticking of
thumb when moving.

Carpal Tunnel Syndrome Pain, numbness, & tingling in Clinical #1: Night splints x3
median nerve distribution months #2: NSAIDs
Worst at night (wakes them
up) Exacerbated by manual
activity, flexion, extension
PE: Shrug, Carpal
Compression tests

Medial or Lateral Epicondylitis Medial or Lateral Clinical RICE, NSAIDs, PT

epicondyl pain.

Pain worse with certain

activities
PE: Tenderness over
epicondyles, pain when
resisting extension/flexion
Knee Pain
Differential Symptoms Diagnosis Treatment

Patellar Fracture Fall on flexed knee, MC Sunrise XR + Lateral Knee immobilizer + cast
young patients x6 weeks
Swelling, pain, limited
knee extension

ACL Tear Jumping, pivoting, MRI RICE, NSAIDs, refer to Ortho

plant-and-twist, valgus
blow Felt a pop, rapid
swelling, inability to bear
weight, joint instability
PE: Lachman, Anterior
Drawer, Pivot-Shift

PCL Tear Posterior blow to tibia, fall

on flexed knee
Anterior bruising, rapid
onset of swelling,
instability
PE: Posterior sag test,
posterior drawer test

Collateral Ligament Tear Valgus or varus force, ACL

tear Localized pain along
ligaments, mild
swelling, stiffness
PE: Valgus + Varus stress test
Meniscal Tear Older patient with no
specific injury, young
patients with
twisting/pivoting injury
Mechanical Signs
(popping, locking),
difficulty squatting, later
onset of swelling
PE: Pain along joint line,
McMurray’s Test,
Apley’s Test

Osgood Schlatter Disease Young (10-15), athletic, Clinical RICE, NSAIDs, Bracing
male adolescents
Localized pain over
tibial tuberosity after
activity or with kneeling.
Doesn’t limit activity
PE: Painful lump under
knee, tenderness to tibial
tubercle

Patellofemoral Syndrome Runners! X-Ray? PT (quadriceps

strength), patellar
brace

Aching pain behind the

patella during bending,
worse after prolonged
flexion
PE: PF Grind Test

Patellar/Quadriceps Overuse syndrome Clinical RICE, NSAIDs, PT

Tendonitis Recent change in activity
level PE: Localized
tenderness

Work-Up: MRI, X-Ray if patellar symptoms

Physical Exam:
MSK: ROM/Strength, Patellar apprehension test, Lachman, Anterior Drawer, Posterior Drawer, Valgus/Varus stress
test, Patellar compression test, Palpation of knee (joint lines, tibial tuberosity), assess for any boney tenderness
Neuro: LE Reflexes + sensation (if time), gait if able
Vascular: LE pulses

Joint Pain & Swelling

Differential Symptoms Diagnosis Treatment
Osteoarthritis Elderly women X-Ray shows “LOSS” Lifestyle: Weight loss,
DIP + PIP (no wrist or L: Loss of joint space exercise, PT
MCP), hip, knee, spine O: Osteophytes Drugs: Acetaminophen!!
Morning stiffness < 1 S: Subchondral
hour, worse with activity Sclerosis S:
& in the evening Subchondral Cysts
No “squishy” joint
swelling No systemic
symptoms
PE: Non-symmetrical,
poly or monoarticular
arthritis Heberden’s or
Bouchard’s Nodes if on
hands
Crepitus

Rheumatoid Arthritis Middle-aged women RF + Anti-CCP Ab Refer to Rheumatology

(40-50s) or old men ESR or CRP: To follow Methotrexate
Fluctuating severity, disease NSAIDs for inflammation
spongy swelling of joints CBC: Anemia
Morning stiffness > 1 X-Ray: Rat bite
hour, worse with rest erosions
Systemic symptoms Renal/Liver Fx
(fatigue, malaise, fever,
rheumatoid nodules,
CVD)
PE: Symmetrical,
polyarticular arthritis
of MCP + PIP joints,
knees, or ankles. No
spinal pain, no DIP
Ulnar deviation of fingers
or deformities

Reactive Arthritis Males Work-Up: NSAIDs, Treat probable

2-4 weeks after GI or (+) HLA B-27 chlamydia.
GU infection. CBC = WBCs 10-20K
Asymmetric, ESR incr.
mono-arthritis of LE

Reiter’s Syndrome = Aseptic synovial fluid culture

Arthritis + Uveitis +
Urethritis
PE: Circinate balantitis,
achilles enthesitis,
dactylitis, mucosal
ulceration
Probable chlamydia on
GU exam
 Gouty Arthritis Middle-aged, obese men Joint Aspiration with Acute Attack: NSAIDs
Gout Attacks (severe Polarized Light or Colchicine
pain, sudden-onset, Analysis Radiographs Chronic: Diet, avoid
extreme (rat bite ETOH, Allopurinol to
tenderness) erosions) slow
Podagra (swollen first progression.
MTP joint)
Desquamation
Fever, chills, malaise
If Chronic:
Polyarthritis, pain
between attacks,
resembles RA

Lupus Young women, MC Work-Up: Everyone gets

African American ANA (should be positive hydroxychloroquin
Flare-ups of fever + but positive doesn’t rule NSAIDs or Steroids for
joint pain + rash in) inflammation
Serositis, 10+ symptoms
photosensitivity,
neurological deficits,
malar or discoid rash

Septic Arthritis Large joint Work-Up: IV Antibiotics x2-4

monoarticular CBC, ESR, Blood weeks (Vanco +
arthritis, MC lower LE. Culture Joint Cephtriaxone)
Acutely ill, febrile, Aspiration (WBCs > 50K,
tachycardic, irritable mostly neutrophils) w/
Joint is hot and swollen gram-stain & culture
X-Ray

ROS: General, Skin, Cardiac, Pulmonary, GI, MSK, Hematologic

Work-Up: XR of affected joint, RF + Anti-CCP, ESR + CRP, HLA-B27, CBC, CMP w/ renal & liver function, Joint aspiration
if infection or gout suspected.
Physical: Pick and choose cause this is too much
Derm: Malar rash, palmar erythema, rheumatic nodules, other rashes
Eye: Episcleritis, scleritis, ulcerative keratitis
Mouth: Serositis, oral ulcers
Cardiac: Heart sounds
Lungs: Lung sounds (interstitial lung disease)
MSK: ROM & Strength, Palpation of joints
GI: GI manifestations

Simplest Phrases to Memorize for a Normal PE

Tips:
● All mucus membranes are “without injection” if not erythematous
● Special sensory organs: Give a few statements about appearance of “internal” + “external” structures
● Other systems can be broken down into “Inspection, Auscultation, or Palpation” statements, then just
think through your PE to remember what to write.
● Tonsils are 2+, Pulses are 2+, Reflexes are 2+, Strength is 5/5

General: Healthy-appearing in no acute distress (Always put this!!)

Skin:
Without lesions or abnormalities
 Normal and symmetrical color & temperature
Head:
Normocephalic and atraumatic
Without scalp lesions
Eyes:
External Eyes:
PERRLA
Intact visual fields & EOMs
Sclera clear with no icterus or injection.
Internal Eyes: Fundi
(+) red reflex
Disc margins sharp without papilledema
No AV nicking, exudates, or hemorrhages.
(Or, “unable to visualize fundi”)
Ears:
External Ears:
Normal configuration & location bilaterally
No lesions, drainage, or tenderness.
Internal Ears:
External canals patent
TMs without injection or erythema.
Landmarks intact.
Gross hearing intact (aka: they understood you when you talked to them)
Nose:
External Nose:
No swelling, trauma or deviation
No discharge.
No sinus tenderness
Internal Nose
Mucosal membranes without injection or swelling.
Oropharynx:
“External” Mouth: Normal appearing lips, teeth, gums, tongue.
“Internal” Mouth (Throat):
Normal appearing hard & soft palate.
Posterior pharynx without injection.
Tonsils 2+ without exudate.
Neck:
Inspect: No tracheal deviation or thyroid masses
Palpate: Supple, full ROM.
Lymph Nodes:
No palpable _____ (whatever ones you do)
Lungs:
Listen: Normal breath sounds. CTA across lung fields (Always put this!! )
Inspect: Symmetrical thorax without surface abnormalities. No use of accessory
muscles. Palpate: No chest wall tenderness
Cardiovascular:
Inspect: No visible lifts, heaves.
Listen: RRR with normal S1 & S2. No S3, S4, murmurs or rubs (Always put this!! ) Palpate: No
palpable lifts, heaves, thrills. Pulses 2+ bilaterally at ____ (wherever you did them) Abdomen:
Inspect: Non-distended with no visible scars or surface abnormalities
Listen: Normoactive bowel sounds in all four quadrants.
Palpate: Nontender, without hepatosplenomegaly
Extremities:
Inspect: No cyanosis, clubbing, edema. Capillary refill < 2 seconds bilaterally. No varicose veins.
Palpate: No temperature asymmetry or abnormality
Joints: FROM _____ (list joints tested), without swelling, or tenderness.
Muscles: 5/5 strength bilaterally of _____ (list joints tested)
Neuro:
Cognitive: A&O x3. Appropriate affect.
Motor: Symmetrical muscle mass & tone.
Sensory: Normal sensation to light touch.
Cerebellar: Normal gait, Romberg (-).
Reflexes: 2+ DTRs bilaterally (list reflexes tested)