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Acute Pelvic Pain

Key Concepts Acute pelvic pain in women is often from a gynecologic source, but urinary and intra-abdominal sources are also common. Less frequently, the pain may arise from vascular, musculoskeletal, neurologic, or psychiatric disorders. Potentially lethal diagnoses associated with acute pelvic pain include ectopic pregnancy, ovarian cyst with significant hemorrhage, and domestic violence; highly morbid conditions presenting with acute pelvic pain include pelvic inflammatory disease and…

Constipation

Key Concepts Constipation is a variable term used by patients and may refer to straining with defecation, hard or infrequent stools, pain with a bowel movement, a sensation of incomplete evacuation, or abdominal bloating. Primary constipation is caused by functional abnormalities of the gastrointestinal tract. Secondary constipation is due to diet, related medical or psychiatric disorders, or medication side effects. The etiology of constipation can frequently…

Diarrhea

Key Concepts Hospital-acquired Clostridioides difficile and norovirus infection are the most prevalent causes of fatal illness from diarrhea in the United States. Key elements of the history in the patient with diarrhea include recent travel, hospitalization or antibiotic use, dietary factors, immunosuppression, fever, and presence of blood in stool. Acute diarrhea is most often viral and treated with supportive therapy. Fluids and foods with excess sugar,…

Gastrointestinal Bleeding

Key Concepts Routine placement of a nasogastric tube in patients with suspected upper gastrointestinal bleeding (UGIB) is not recommended, because this procedure fails to reliably provide useful data to guide management and is associated with unnecessary patient discomfort and potential complications. Patients older than 35 years with UGIB should have an electrocardiogram (ECG) performed early in their evaluation, because patients with UGIB and coronary disease (including…

Nausea and Vomiting

Key Concepts Nausea and vomiting can result from a primary problem in the gastrointestinal (GI) tract but can also result from problems in the neurological, vestibular, urogenital, cardiac, or other systems. In the acutely vomiting patient, associated symptoms and medication history are most helpful in narrowing the differential diagnosis. Laboratory studies are not necessary for all patients with vomiting. In patients with severe or protracted vomiting,…

Jaundice

Key Concepts Jaundice is the clinical manifestation of elevated serum bilirubin, which arises through the metabolism of hemoglobin. Elevated bilirubin occurs when: (1) increased bilirubin is produced due to hemolysis, (2) liver dysfunction prevents conjugation of bilirubin, (3) an obstruction prevents secretion of bilirubin into the intestines. Jaundice is usually not evident on physical examination until the total serum bilirubin concentration rises above 2.5 mg Jaundice…

Abdominal Pain

Key Concepts While the etiology of abdominal pain is frequently benign, requiring little work-up or intervention, abdominal pain can also be the presenting symptom of catastrophic illness, requiring life-saving interventions to be implemented within minutes to hours (see Table 23.1 ). TABLE 23.1 Critical Causes of Abdominal Pain Cause Epidemiology Etiology Presentation Physical Examination Useful Tool(S) Pearls/Pitfalls Ruptured ectopic pregnancy Occurs in females of childbearing age.…

Chest Pain

Key Concepts Tension pneumothorax is a clinical diagnosis, treated with needle decompression, followed by tube thoracostomy. Patients with suspected acute coronary syndrome (ACS) are risk-stratified by history, electrocardiogram (ECG), and troponin levels. Those with ST segment elevation myocardial infarction (STEMI) undergo revascularization via fibrinolysis or percutaneous coronary intervention (PCI). Those with non–ST segment elevation myocardial infarction (NSTEMI) do not require immediate PCI. Those with a nondiagnostic…

Dyspnea

Key Concepts Dyspnea results from a variety of conditions, ranging from nonurgent to life-threatening. Neither the clinical severity nor the patient’s perception correlates well with the seriousness of underlying pathology. Dyspnea is subjective and the differential diagnosis can be divided into acute, acute on chronic, and chronic causes, of which the majority are cardiopulmonary. Other causes include metabolic, infectious, neuromuscular, traumatic, psychiatric, and hematologic conditions. Chronic…

Hemoptysis

Key Concepts Hemoptysis is caused by infection, trauma, cancer, or coagulopathy or as a complication of invasive pulmonary procedures. “Massive hemoptysis” is defined as greater than 100 mL of blood loss or approximately ½ cup of blood in a 24-hour period or a bleeding rate ≥100 mL Plain radiographs are the initial screening test in most cases of massive hemoptysis, although high-resolution chest computed tomography scans…

Sore Throat

Key Concepts Sore throat can indicate a range of pathology, from simple pharyngitis to deep space infection, with or without airway compromise. Physical examination, supplemented by nasopharyngoscopy when appropriate, is key to determining threats to the airway and establishing a diagnosis. If oropharyngeal examination reveals minimal findings, lower or deeper structures may be involved, and endoscopic examination of the upper airway is recommended. The modified Centor…

Red and Painful Eye

Key Concepts Critical diagnoses, such as caustic injury, orbital compartment syndrome, and narrow angle (acute angle closure) glaucoma, require immediate treatment and ophthalmology consultation. Prompt and prolonged irrigation is essential for patients who experience caustic injury to the eye. Headache and nausea may be prominent symptoms in patients with narrow angle glaucoma. Complete abolition of a foreign body sensation after instillation of local anesthetic solution indicates…

Diplopia

Key Concepts The diagnostic approach to diplopia is aimed at determining (1) if the diplopia is monocular, (2) if there is a restrictive or mechanical issue in the orbit or orbital structures, (3) if there is a palsy of one or more of the oculomotor cranial nerves, (4) if there is a neuroaxial process involving the brainstem and related cranial nerves, or (5) if there is…

Headache

Key Concepts Patients with a known headache disorder who present with a change in the character of the headache should be evaluated for potential serious causes. The physical examination in the headache patient focuses primarily on mental status, funduscopic exam, meningeal signs, and neurologic examination, particularly cranial nerves (CNVs) II, III, IV, and VI, as well as specific cerebral territories. Mild to moderate primary and nonspecific…

Dizziness and Vertigo

Key Concepts Neurologic complaints, such as imbalance, dysarthria, or numbness in patients with dizziness/vertigo raise the likelihood of transient ischemic attack (TIA) or stroke as the cause. Benign paroxysmal positional vertigo (BPPV) requires head movement to elicit symptoms. Consequently, the Hallpike test should not be performed if the patient is actively symptomatic during history taking (and the patient’s head has not been recently moved) because such…

Seizures

Key Concepts Lifetime seizure incidence reaches up to 10% in the US population and depends upon multiple factors including age, history of epilepsy, structural brain or neurodegenerative disease, genetic predisposition, acuity and severity of metabolic derangements. Seizures are the result of an imbalance in the excitation and inhibitory neuronal synapses in the cerebral cortex or limbic system. Epilepsy is a condition associated with a lower seizure…

Confusion

Key Concepts Confusion and delirium are symptoms, not a diagnosis. Focal cortical dysfunction, such as from tumor or stroke, typically does not cause confusion. Any underlying clinical process that disrupts optimal central nervous system (CNS) functioning can result in confusion. Emergent causes of confusion that need immediate detection and treatment include hypoglycemia, hypoxemia, hypotension, sepsis, and toxic ingestions. Assessment of attention is fundamental for the assessment…

Depressed Consciousness and Coma

Key Concepts Coma is a state of depressed consciousness in which a patient is not aware, is not awake, and does not respond to vigorous stimulation. Consciousness consists of arousal (subcortical) and awareness (cortical). Damage to the dorsal brainstem, thalamus, axonal projections to the cortex, or extensive injury to bilateral cortices may result in depressed consciousness or coma. Toxicologic, metabolic, infectious, and other disorders causing diffuse…

Syncope

Foundations Epidemiology Syncope is a common clinical entity with a lifetime prevalence between 20% and 40%, and is slightly more common in women than in men. Key Concepts Syncope is defined as a sudden, spontaneous loss of consciousness and postural tone with rapid, complete, and spontaneous recovery. This loss of consciousness typically lasts seconds to minutes and is not followed by a persistent alteration in mental…

Cyanosis

Key Concepts Cyanosis occurs due to an absolute amount of desaturated hemoglobin (∼5 g/dL) rather than a percentage; anemic patients exhibit cyanosis at a lower Pa o 2 than those with normal hemoglobin levels. Cyanosis is an insensitive indicator of tissue oxygenation; its presence suggests hypoxemia, but its absence does not exclude it. Central cyanosis is most commonly due to global arterial hypoxemia or abnormal hemoglobin…