COMP Exam Review

Acute Viral Rhinitis

sx: mild - rhinorrhea, low fever

dx: clinical

tx: supportive, no abx. can → bacterial infx if prolonged (>2 wks)

Influenza

sx: abrupt, severe sx. prominant cough, congestion, high fever, HA, myalgia, fatigue, ± GI sx

dx: rapid flu test (often -)

tx: supportive, tamiflu if <48 hrs

sinusitis

sx: facial pressure, dental pain, purulent discharge

dx: clinical

tx: supportive, abx of choice: augmentin 875 mg BID x 7 days OR doxy BID x 7 days

allergic rhinitis

sx: itchy watery eyes, no fever, mild “drainage”, cough, mild sore throat, seasonal

dx: clinical

tx: antihistamines + topical nasal steroids (flonase) daily

strep pharyngitis

sx: centar score (+1 each) - no cough, exudative tonsils, painful anterior lymphadenopathy, high fever, 3-14 yo

dx: clinical + rapid strep test

tx: 0-1 = no test/no abx, 2-3 = rapid strep + culture, no abx, 4-5 = abx

abx of choice: pen g shot or amoxicillin 250 mg BID x10 days

if recent amox: augmentin

if PCN allergy: keflex 500 BID x 10 days

otitis media

sx: ear pain, ear fullness, pain relieved by pulling on pinna, otorrhea

dx: bulging, erythematous tympanic membrane w/ debris

tx: unilateral + mild = observation; otherwise amoxicillin 45mg/kg BID

PCN allergic: augmentin, z-pak taper, cefdinir

infectious mononucleosis

sx: prominent fatigue/malaise, posterior lymphadenopathy, splenomegaly, high fever, sore throat > 14 days, adolescents

dx: mono spot, monitor spleen/liver for rupture, r/o other sore throat etiologies

tx: supportive. do NOT tx with ampicillin → rash, avoid contact sports 3-4 wks

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 component to consider with HEENT

vaccination hx

“URI” PE 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

community-acquired pneumonia

typical sx: acute onset, productive cough with thick (rusty/green) sputum, high fever, SOB, hemoptysis, myalgia

atypical: gradual onset, nonproductive cough, low fever

PE: dullness on percussion, egophony, bronchial breath sounds, rales, fremitus

dx: CXR + labs

tx: outpatient = azithromycin 500 mg once → 250 mg QDx 4 days

any comorbidities add aug or just do levoquin

acute bronchitis

sx: cough 1-3 wks (viral) or >3 weeks (bacterial), low fever, dyspnea, inspiratory wheeze, normal expiratory phase

dx: no CXR finding,

tx: viral = symptomatic, bacterial = macrolide // supportive care, smoking cessation, cough suppressants, throat lozenges

tuberculosis

sx: slow onset over months, worsening cough w hemoptysis, fever/night sweats, weight loss, fever

dx: CXR and CT chest, sputum culture w AFB stain

tx: RIPE x 9 months + vitb6

COPD (obstructive)

chronic cough, COPD

emphysema = accessory muscle use, long expiratory phase, tachypnea, cough

bronchitis = hypoventilation, hypoxemia, hypercapnia, productive cough

dx: PFTs: FEV1/FVC ratio <70%, hyperinflation, no recovery w bronchodilator

CT scan dx emphysema

CXR dx bronchitis

tx: exacerbations = systemic glucocorticoids, abx // chronic management = LABA/LAMA, ICS, stop smoking

asthma (obstructive)

sx: atopic traid( asthma, allergies, atopic dermatitis), dyspnea, wheezing, cough worse at night, exacerbations

triggered by exercise, illness, smoke, GERD, animals

PE: prolonged expiratory phase, low O2 stat, tachypnea, accessory muscle use

dx: PFT = dec FEV1/FVC ratio, bronchodilator effective >12%, Peak flow meter <80% expected

tx: mild intermittent = albuterol // mild persistent = albuterol and ICS/fluticasone/budesonide

alarm signs of coughing

Weight loss, night sweats, pain, travel abroad, high fever, hemoptysis, h/o smoking

ROS questions for PULM

eneral, HEENT, Pulmonary, Cardiac

physical exam for lower resp. sx

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 for lower pulm. sx

CBC, Blood Culture, Urine Antigen, PFTs & Peak Flow, Sputum Culture w/ AFB

Imaging: CXR +/- CT

HTN

PE: AV nicking, papilledema, cotton wool spots, sx of HF

dx: 2+ BP >130/80 2x or 2+ BP at same visit >160/100 // EKG, BMP, CBC, lipids, UACR

tx: HCTZ, ACEI/ARB, BB

stage II = thiazide + ACEI/ARB/BB

diet, exercise, monitor BP, f/u monthly until BP good

peripheral artery disease

sx: intermittent claudication, weak pulses, shiny legs w/ hair loss, bruits

dx: ankle-brachial index (<0.9 = PAD)

tx: smoking cessation, statins (LDL reduction), ASA (antiplt), exercise, diet

dyslipidemia

sx: n/a, PAD, xanthelasthma, xanthomas

dx: lipid panel

tx: atorvastatin (to get CVD risk <7.5%), diet, exercise, weight loss, smoking cessation

heart failure

L: pulm sx (dyspnea, orthopnea, syncope)

R: systemic sx (edema, anorexia, weight loss)

PE: JVD, lifts, S4, hepatomegaly, ascites, edema, rales, effusion,

dx: CMP, LFTs, CXR, echo

tx: diuretic AND acei/arb AND bb AND spironolactone

low salt, exercise

stable angina pectoris

sx: substernal pressure radiates to jaw/arm/back/epigastrium, diaphoresis, reproducible w inc HR, nitroglycerine helps, GI upset, cough, syncope

dx: EKG = normal or ST depression during pain // Ck-MB + troponin (-), cbc (test for anemia), lipid (test for hyperlipidemia), stress echo, exercise stress test

tx: sublinqual nitroglycerine PRN

metoprolol (BB) if chronic angina

ASA for plt protection

atorvastatin mgmt

Unstable Angina & NSTEMI

sx: similar to stable angina BUT occurs at rest and >20 mins

dx: EKG = ST depression, T wave inversion/flattening // neg enzymes if UA and pos if NSTEMI

tx: MONA → cath lab 24-48 hr if high risk, observation if low risk

long term = ASA + BB + statin

support = bedrest 24 hrs, continuous EKG, O2

STEMI (MI)

sx: pain is severe and does not go away, starts in morning, nitro does NOT help

dx: EKG = peaked T wave → ST elevation → Q wave abnormality → T wave inversion // + CK-MB and troponin

tx: morphine, O2, nitro, ASA( MONA) ASAP!

PCI if <60 min

tPA >120 min or no PCI

bedrest 24h, O2, analgesics, NO NSAIDs

long term = BB, ASA x1 year after stenting, nitro if angina still

pulmonary embolism

sx: virchow’s triad: hypercoag, stagnant blood flow, endothelial injury, sx of DVT, tachycardia, chest pain, hypoxia, anxiety

dx: CXR, CT-PE, d-dimer

tx: heparin drip → long-term anticoag

costochondritis

sx: pain comes and goes unrelated to HR, reproducible on hcest wall palpation, nsaids help best, not relieved by rest

dx: clinical

tx: nsaids, clinical

PE consider for heart issues

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(?)

infectious non-inflammatory diarrhea

sx: <7 days, watery, profuse, nonbloody, N/V, cramping

(profuse vomiting is MC viral or s. aureus food)

dx: tests only if diarrhea >7 days, C. diff PCR if abx or hospitalization

tx: supportive, clears up in a few days

c. diff = vanco PO

infectious inflammatory diarrhea

sx: duration <14 days, small volume, bloody diarrhea with cramps, tenesmus, urgency

dx: + fecal WBCs, O+P, c. diff if on abx recently

tx: empiric = azi 500 mgx5 or levo/cipro

chronic infectious diarrhea

sx: >21 days

dx: O+P, c. diff study

tx: flagyl, depends on organism

irritable bowel syndrome (IBS)

sx: pain relieved/exacerbated by defecation, no nocturnal diarrhea, lower abd cramping pain, worse with stress

dx: criteria = abd pain 1 day/wk in last 3 months AND onset >6 mos AND pain related to defecation, change in stool frequency or appearance

tx: low FODMAP diet, exercise, sleep, laxatives/antidiarrheals

Diverticulosis / Diverticulitis

sx: LLQ pain w diarrhea/constipation, hypotension, N/V, urinary sx, fever

dx: CT w IV and PO contrast, colonoscopy in 6-8 wks to confirm

tx: clear liquid diet 2-3 days, PO abx 7-10 days, re-evaluate weekly until sx resolve

Ulcerative Colitis (IBD)

sx: young adults (20-30), smoking improves sx, diarrhea, rectal bleeding, mucus in stool, tenesmus, urgency, weight loss

dx: colonoscopy w biopsy, stool studies, CBC, CMP, ESR + CRP

tx: steroids or budesonide for induction, 5-ASA for induction + maintenance

Crohn’s Disease (IBD)

sx: younger onset than UC, smoking worsens sx, diarrhea, anorexia, weight loss, abd pain

dx: colonoscopy w biopsy, stool studies, CBC, CMP, ESR + CRP

tx: steroids or budesonide for induction, 5-ASA for induction + maintenance

chronic diarrhea warning sx

Fever, GI bleed, weight loss, onset > 50 y.o., abdominal pain is getting progressively worse

questions to ask if diarrhea complaint

travel hx

food hx

recent sick contacts

noctural diarrhea

ROS/workup things to remember for 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

acute gastritis

sx: chronic NSAID, ETOH, stress, MC asymptomatic, epigastric pain, N/V, hematemesis, anorexia

dx: clinical diagnosis, breath test if h. pylori suspected

GERD

sx: heartburn w radiating chest pain, onset 30-60 mins after eating, worse laying down, antacids help, pain on deep palpation of epigastrium

tx: stop exacerbating agents, PPI or H2A

antacids for rescue as add-on

if h. pylori = PPI + clarithromycin + flagyl OR amoxicillin

peptid ulce disease (PUD)

sx: food makes pain BETTER*, chronic NSAID, ETOH, stress, hematemesis, melena/ hx of GERD

dx: look at response to meds, EGD = definitive diagnosis

tx: stop exacerbating agents, PPI or H2A

antacids for rescue as add-on

if h. pylori = PPI + clarithromycin + flagyl OR amoxicillin

biliary colic

sx: RUQ/epigastric pain radiating to pain, <6 hours, worse laying down, not exacerbated by mvmt

dx: PE + labs normal, trans-ab U/S or CT

tx: pain control + elective cholecystectomy

acute pancreatitis

sx: epigastric pain radiates to back, worse walking, relieved by fetal position or leaning forward, cullens/grey turners sign, N/V, fever, tachycardia

dx: lipase +, CT to diagnose, ALT to check for gallstone pancreatitis

tx: IV fluids 24-48 hrs, pain mgmt (NO MORPHINE), NPO

inflammatory esophagitis

sx: odynophagia, retrosternal pain, dysphagia, hematemesis

dx: endoscopy

alarm sx of stomach pain

Weight loss,

dysphagia,

odynophagia,

melena/hematemesis

ROS/PE for dyspepsia/epigastric pain

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)

cholecystitis

sx: RUQ pain (sometimes radiates to epigastrium), sx worse 1 hr after fatty food ingestion, murphys sign, peritoneal sx, fever, tachycardia, biliary colic, N/V

dx: leukocytosis w left shift, U/S, HIDA scan if U/S unclear

tx: hospital, supportive, abx, cholecystectomy when stable

cholangitis

sx: charcot’s triad = fever/chills, RUQ pain, jaundice // reynold’s pantad = ^^ + shock + altered mental status

dx: CBC (leukocytosis), LFTs (alk phos INC, bilirubin > ALT/AST), US/CT = dilation of CBD, cholangiography once pt stable x 48 hrs

tx: abx, ERCP to extract stone

hepatitis

sx: RUQ pain + flu-like sx, jaundice, fulminant = encephalopathy, coagulopathy, edema, ascites, hyperreflexia, sexual promiscuity, IVDU, poor sanitation, malaise, arthralgia, anorexia, fever (if hep A)

dx: LFTs = ALT >AST both 500 if acute, high bilirubin, alk phos normal, CBC< coag panel

tx: acute = symptomatic (tylenol, zofran, IV), hospitalize if encephalopathy, chronic = refer to internal med

cirrhosis

sx: RUQ pain, ascites, gynecomastia, spider angioma, caput medusa, asterixis, confusion, h/o of alc/obesity/alc/dm/high cholesterol

dx: HIGH bilirubin, low albumin, INR high, U/S

tx: lactulose if encephalopathy, na restriction + diuretics if ascites, refer to hepatology

appendicitis

sx: RLQ pain, rebound/point tenderness, rigidity, + rovsing, + obturator, + psoas sign, N/V

dx: u/s → ct scan

tx: appendectomy

kidney stone

sx: renal colic (unilateral intermittent back pain/can’t sit still), flank tender, N/V, voiding sx

dx: non-contrast CT

tx: NSAIDs, no intervention if stone pass ok, tamsulosin to kick stone out, f/u in 4-6 wks, ensure good fluid intake, dec salt

pyelonephritis

back/flank pain, CVA tenderness, dysuria, polyuria, hematuria AND fever, tachycardia

UA: pyrua, nitrates, RBCs, WBC casts

urine culture

FLQ IV x 14 days

small bowel obstruction

abd distention, high-pitched tinkles on auscultation (if earlier), cramping pain worsening, vomiting

abdominal XR

NPO, IV fluids, bowel decompression via suction, surgery if strangulation on XR

large bowel obstruction

diminished bowel sounds, abd distention, cramping, n/v

abdominal XR

bowel perforation

fever, malaise, diminished bowel sounds, abd distention, cramping, n/v

abdominal xr, ct

urgent surgery!

colorectal cancer

anemia, rectal bleeding, abd pain, bowel changes

colonoscopy w biopsy, barium enema, CEA (tumor marker)

refer to GI

tension HA

tight, band-like, bilateral, no N/V or aural sx, constant pain, not worse with activities

clinical dx

episodic = nsaids, acetaminophen // chronic = amitriptyline, topamax

migraine headaches

pulsing, throbbing unilateral HA >4 hrs, triggered by physical activity, stress, auras, females in early adulthood

POUND = pulsing, 4-72 hrs, unilateral/ N/V, disabiling (must have 4/5)

acute: NSAIDs or sumatriptan

preventative: BB/CCB, TCA, anticonvulsant

avoid trigger, good sleep, exercise, weight control

cluster HA

20-30s, males, severe sudden onset pain around eye, worse at night, nasal congestion/tearing of eye, worse at night + ETOH, better w movement, 15 min-3 hours

horner’s syndrome, conjunctival injection → MRI

acute: 100% O2 + SQ sumatriptan

prophylaxis: verapamil

trigeminal neuralgia

middle ageyoung women, MS pts, brief piering extreme pain unilateral near mouth, worse with touch, diminished/no corneal reflex, jaw deviated to weak side

pe = normal

carbamazepine, oxcarbazepine

pseudotumor cerebri

obese, fertile young women, coat hanger HA, visual changes, papilledema, IOP/high CSF, ha worse with eye mvmt and position change, tinnitus

acetazolamide

LP to remove CSF

weight loss

intracranial mass lesion

tension HA worsens over time, worse with recumbency and valsava, peaks in morning, present when waking, neuro sx

MRI

giant cell arteritis

elderly white women, persistent HA w jaw claudication, scalp tenderness, visual sx

high ESR, CBC (anemia), high CRP, temporal artery biopsy

high dose steroid x6 weeks

meningitis

(sign where flexion of head = bolt of pain) fever, HA, neck stiffness

CSF: bacteria = high WBC w high neutrophils, high protein, low glucose // viral = high WBC w high lymphocytes, normal everything else, gram stain +

subarachnoid hemorrhage

sudden thunderclap HA, altered consciousness, meningeal irritation, N/V

CT w/o contrast immediately

LP if CT neg

bedrest, no exertion, analgesics, low BP

HA ROS and PE

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?

cardiac tamponade

Beck’s triad: hypotension, muffled heart sounds, JVD

Friction rub

Pulses paradoxus

Chest pain, tachypnea, dyspnea, chest fullness, edema, fatigue

EKG: PR depression, CXR: cardiomegaly. Echo = best*

911, o2, IV, cardiocentesis

pericarditis

• Pain worse with breathing/changing positions/cough

  • Pain improves sitting forward

• Pericardial friction rub heard LSB diaphragm / pleuritic chest pain

• Breath sounds normal, may hurt to inhale

• If cause by infx = fever/chills

  • EKG: widespread ST wave changes

aortic dissection

BP difference >/20 systolic for L and R arm

anterior/posterior chest pain ripping/radiating to back

Syncope

New heart murmur (aortic regurg)

Hypotension

CXR: widening of aortic silhouette

Coarctation of the Aorta (CoA)

Abnormal BP reading difference HTN UE and hypotension LE

Absent femoral pulse compared to brachial arteryr

Cold extremities

refer, BB (BP), echo, MRI

murmurs

extra "whooshing" or "swishing" sound heard between normal heartbeats d/t leaky/narrowed heart valve

can be innocent (triggered by preg, fever, exercise)

seen in stenosis, regurgitation, septal defects, hypertrophy, anemia, hyperthyroid

Rubs

scratchy/squeak sound (walking on fresh snow), outside of heart rubbing on heart sac

outer protective sac of heart is inflammed

cause: viral/bact infx, lupus, RA, kidney failure, cardio

gallops

caused by inside heart making extra sounds as blood forcefully fills heart chambers

indicates HF or volume overload

pre-diabetes

asymptomatic

dx: a1c > 5.7%, FBG > 100

lifestyle modification

type 1 DM

children/infants, thin BMI, weight loss, blurry vision, polyuria/nocturia, rapid onset, recurrent UTIs

autoAb panel + A1C > 6.5% or FBC > 126

insulin (NPH + regular, TDD = 0.3*kg body weight)

carb counting, goals, BG monitor, hypoglycemia sx and tx

type 2 DM

>40 african american, hispanic w CVD, physical inactivity, acanthosis nigricans, diabetic retinopathy, peripheral neuropathy, diabetic dermopathy, pruiritis, overweight/obese, blurred vision, polydipsia

autoab panel + a1c > 6.5% or FBC > 126

monitor BP at home, tx with ACEI/ARB if dyslipidemia, eye exam, UACR / spot test + eGFR for kidneys, inspect feet (tx with lyrica)

metformin, statins, ASA, ACEI/ARB, insulin (nph + regular) if A1C >10% or glucose > 300

weight loss, DASH diet, reduce CVD RF, foot protection

BPH

old men, decrease in force of stream, post-void dribbling, hesitancy, dysuria, nocturia

DRE: uniformly large firm rubbery prostate

UA to r/o UTI

alpha blocker (tamsulosin) + 5a reductase inhibitor (finasteride)

bladder cancer

smokers, >40 yo, painless gross hematuria

culture, UA, CBC, CMP

urinary cytology, cystoscopy w biopsy, CT w contrast

kidney stone

renal colic (unilateral intermittent back pain,) flank tenderness, fever, voiding sx, n/v

CBC, Cr, UA, electrolytes, KUB to monitor stone progression

dx = non-contrast CT

uncomplicated UTI

dysuria, polyuria, hematuria, suprapubic pain

UA +, leukocytosis +, nitrate

do urine culture

post infectious glomerulonephritis

hypertension, hx of preceding illness, edema, hematuria

labs: proteinuria 1-3g/day, low serum complement, ASO high

biopsy

rhabdomyolysis

dark brown/red urine, myalgia, diffuse tenderness to extremities, recent vigorous exercise, swelling, N/V

UA and microscopy, + hematuria but NO RBCs, HIGH CK and and LFTs

alarm sx for hematuria*

painless

proteinuria

fever

n/v

persistent flank pain

ROS/PE/dx for hematuria

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

compression fracture

elderly, acute-onset severe pain @ midline, non radiating, relieved laying down, bony tenderness

x-ray

metabolic workup if osteoporosis

narcotics, brace 3-6 mos, refer to ortho

cauda equina syndrome

radiculopathy sx AND saddle anesthesia, foot-drop, incontinence, dec anal tone, inability to get up, heel + tiptoe walking

MRI + myelogram ASAP!

emergent surgical decompression of nerve roots

herniated disc/lumbar radiculopathy

35-45 yo sedentary jobs, pain w lumbness and parasthesias down leg/foot, weakness, loss of coordination, MOA bending or lifting, pain worse with mvmt

straight leg raise (both), ROM, sensation, MRI

oral nsaids, steroid, muscle relaxers

muscle strain

no bony tenderness, normal PE, non-radicular back pain, MOA lifting motion

clinical

sx, refer to PT

spinal stenosis

men > 50, neurologic leg claudication relieved by lumbar flexion/leaning forward, chronic insidious pain

initial = xray, definitive = mri/ct myelogram

sx-atic, nsaids, analgesics, PT, steroid injections

spondylolysis / spondylolisthesis

young athletes (10-20s), shortened gait, posterior thigh pain, normal neuro exam, back pain worse with extension

lateral XR

rest 2-12 wks, brace @ 4 wks, progressive return to play

ankylosing spondylitis

young adult MALES, chronic back pain better with activities, heel pain + costochondritis, stooped posture

special test = schober test, occiput-to-wall test

work up: ESR, HLA-b27, spinal xr (bamboo spine)

refer to rheum, rest, nsaids, pt

fibromyalgia

bilateral, upper/lower body pain 3+, tenderness over pressure points, hyperalgesia, fatigue

dx of exclusion

graded exercises, SNRIs/lyrica, psychotherapy

back pain ROS/work-up/PE

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

AC separation

hx of injury, fall onto adducted shoulder, arm in neutral position

bilateral xr, positive AC crossover test

sling w early elbow ambulation, nsaids

rotator cuff tear

athletes/labor w overhead activities, painful tearing sensation, shrug sign, empty can test, reduced active ROM, weakness

clinical, MRI, athrogram w contrast

lessen lifting activity, NSAIDs, steroids, PT

impingement syndrome

localized tenderness @ lateral humerus, atrophy, hawkins sign, neers sign, pain w lifting arm

clinical

RICE, nsaids, pt

shoulder pain ROS/PE

ROS: General, MSK, Neuro

Physical Exam:

MSK: ROM (active + passive) + Strength, Palpation of joint, Hawkins + Impingement, Shrug Test, Above-head lifting

dequervains tenosynovitis

difficulty moving thumb around wrist, sticking of thumb when moving

+ finklestein sign

nsaids, ice, steroid, injection