Weakness
Specific Symptoms
By system
Performance Status
Determines the physiologic reserve of the patient
i.e. Karnofsky performance scale
Rating
Definition
100
No evidence of disease
Percent
90
Normal activity with minor signs of disease
Percent
80
Normal activity with effort; signs of disease
Percent
70
Cannot do normal activity but cares for self
Percent
60
Requires occasional assistance
Percent
50
Requires considerable assistance; frequent
Percent
medical care
40
Disabled, requires special care
Percent
30
Severely disabled; hospitalization may be
Percent
indicated
20
Very sick; hospitalization necessary for supportive
Percent
treatment
10
Moribund
Percent
0 Percent
Death
General Symptoms
Weight loss
Frequently seen in many serious diseases including
primary hematologic entities
Significant unintentional weight loss (5% body weight
over 6-12 months)
Fever
Elevation of body temperature that exceeds normal daily
variation
Increase in the
hypothalamic
set point
Mean oral
temp: 36.8 +/0.4oC
Occurs in:
Early
manifestation
of aggressive
lymphoma/acute leukemia
Accompanying immunodeficiency
Other malignancies
Fatigue/malaise/lassitude
Difficult to assess
Maybe explained by fever and muscle wasting in
patients with severe diseases
Weakness
Accompany malignant processes
Manifest as a general loss of strength/reduced capacity
for exercise
Hematologic disease
Myeloma/lymphoma: central/peripheral nervous
system invasion/compression
Specific Symptoms
Nervous system
Headache
Paresthesias
Confusion
Impairment of consciousness
Eyes
Conjunctival plethora
Diplopia
Ears
Vertigo
Tinnitus
Neck
Painless swelling
Diffuse swelling of the face
Chest/Heart
Dyspnea and palpitations
Cough
Chest pain
Nasopharynx, oropharynx, oral cavity
Epistaxis
Anosmia/olfactory hallucination
Sore tongue
Macroglossia
Gingival hyperplasia
Dryness of mouth
Dysphagia
Gastrointestinal system
Abdominal fullness/discomfort
Malabsorption
Diarrhea
Constipation
GU/Reproductive system
Impotence/bladder dysfunction
Hematuria
Priapism
Menorrhagia
Back/Extremeties
Arthritis
Hemarthroses
Bone pain
Skin
Pallor
Bronze/grayish pigmentation
Cyanosis
Jaundice
Erythromelalgia
Pruritus
Petechia/ecchymoses
Personal and Environmental History
Drug History
Sexual History
Occupational Exposure
Benzenes
Organophosphates
Herbicides
Nutrition
Dietary deficiencies
Family History
Hematologic disorders
Jaundice
History of gallstones
History of venous thromboembolism
History of hemophilia
Ethnic background
Past Medical History
Operations
Previous transfusions
Physical Examination
Pertinent body systems
Skin
Pallor/flushing
Skin color is caused by the pigment contained
therein and by the blood flowing through the
capillaries
Mucous membranes, conjunctivae, palmar creases
Cyanosis
Function of total amount of reduced hemoglobin
May be influenced by skin pigmentation
Jaundice
Observed in the skin of individuals who are not
otherwise deeply pigmented
Caused by ble pigment (direct/conjugated bile)
Petechiae
Small (1-2mm) round lesions from hemorrhages into
the skin
Present in areas of high venous pressures
No blanching on pressure
Ecchymoses
Various shapes and sizes
Blanches with pressure
Excoriations
Nails
Koilonchia
Eyes
Jaundice
Pallor
Retinal hemorrhages/exudates
Dilation of veins
Mouth
Pallor
Ulceration of oral mucosa
Bleeding
Tongue:
macroglossia
Lymph nodes
Cervical,
supraclavicular,
axillary,
epitrochlear,
inguinal, femoral
EXTENT
1.
2.
3.
Symptomatology
PE
Laboratory abnormalities
II. Edema
Palpable swelling produced by expansion of the interstitial
fluid volume
Localized or generalized
ANASARCA gross, generalized edema
Recognized in its generalized form by puffiness of the face
and indentation of the skin following pressure (pitting
edema)
(localized/generalized)
SIZE
TEXTURE
TENDERNESS
Skeleton
Spleen
Usually non palpable
Other methods:
Traubes
Nixons
Castelo
Liver
Nervous system
Cerebral impairment,
visual impairment,
cranial nerve
dysfunciton
POEMS (polyneuropathy, organomegaly,
endocrinopathy, multiple myeloma, skin changes)
Joints
Deformities: repeated hemorrhages
Edema/Urinary Complaints/Female
Genitalia
Section D 2011 - Mikey Silverman
I.
Means of Discovery
Read to
brown to
purple
Blue to
green
Porphobilin
Porphobilinogen
Uroporphyrin
Glomerular Diseases
Extraglomerular
diseases
Hemoglobinuria
Myoglobinuria
Biliverdin
Pseudomonas
infection
Non-pathologic
Phosphates
Concentrated urine
Rifampicin
Food color
Carrots
Nitrofurantoin
Natural food
pigments (beets)
Artificial food coloring
Phenothiazines
Phenazopyridines
Laxatives
(phenolpthalein,
senna)
Vitamin B complex
Phenyl salicylates
Thymol
Triamterene
Amvtriptyline
Hematuria
Macroscopic (grossly visible) red or brown urine
Microscopic (urinalysis) - >/- 2 RBCs/hpf
Origin
Kidney glomerulus dysmorphic RBC
Ureter
Bladder
Prostate
Urethra
Clotting mechanism defect
Etiology
History
Color
Transient or persistent
Partial or total
Partial
Initial anterior urethral lesion (urethritis, stricture,
meatal stenosis)
Terminal posterior urethra, bladder neck, prostate
Total (throughout urination)
Above the level of the bladder (stones, tumor, TB,
nephritis)
Associated symptoms
Frequency, dysuria, urgency, suprapubic pain
Flank or CVA pain
Passage of wormlike clots
Painful or painless
Painless hematuria
Bladder or kidney tumor
Polycystic kidneys
Acute GN
Sickle cell disease
Tuberculosis
Post-traumatic
Post-exercise
Painful hematuria
Stones
Urinary tract infection
Renal infarction
Ingestion of foods containing red vegetable dyes (beets)
Medications: aspirin, anticoagulants, laxatives
History of recent upper respiratory tract infection
Positive family history of renal disease polycystic
kidney disease, sickle cell, blood dyscrasia
Recent vigorous exercise or trauma
Travel or residence in areas endemic for Schistosoma
haematobium, or tuberculosis
Cyclic hematuria passage of hematuria during or after
menstruation
PE
Pallor
Petechiae, echymoses, lymphadenopathy, splenomegaly
blood dyscrasia
CVA tenderness and fever renal infarction
Suprapubic tenderness bladder
Bilaterally enlarged kidneys PKD
AF/valvular heart disease renal embolism/infarction
IV. Abnormalities of Urine Volume
Oliguria/Anuria
Normal load of metabolic waste product cannot be
excreted
Oliguria 24-h urine output of < 400-500 mL/day
Anuria complete absence of urine < 50 mL/day
Azotemia retention of nitrogenous waste products
(asymptomatic)
Uremia signs and symptoms brought about by azotemia
(elevated BUN and creatinine) dialysis
Etiology
Acute renal failure
Pre-renal
Renal
Post-renal
Chronic renal failure (> 3 months; irreversible)
Note: non-oliguric renal failure urine output of >500
mL/day with acute or chronic azotemia
Location of the Cause?
Caliceal stone
Asymptomatic
Small, non-obstructing
Gross hematuria
Renal pelvis stone
Asymptomatic
Flank/CVA pain (ureteropelvic junction)
Stones history
Age of onset
Family history of stone
Fractures/immobilization hypercalcemia
Previous UTI or manipulation
Renal or ureteric colic
Associated symptoms nausea, vomiting
Fever and chills (UTI)
Gross hematuria stone passage
Dietary habits/fluid intake
Stones PE
Flank tenderness
Tophi
VI. Symptoms related to the act of urination
Dysuria
Painful urination
Tingling or burning sensation in the perineum during or
just after voiding
Caused by one of the 2 conditions
Inflammation involving the urethra and bladder trigone
Inflammation involving the vaginal labia
Etiology
Etiology
Location
Lower UTI (bacterial) bladder and urethra
Acute pyelonephritis upper urinary tract
Chlamydial urethritis urethra
Gonococcal urethritis urethra
Other urethritis
urethra
No recognized pathogen
urethra
Vaginitis
vagina
History
Onset of symptoms
Nature of symptoms
Pain intensity
Timing
Initial/during urination
Urethritis
Urethral obstruction
Meatal ulcer
Terminal
Cystitis (with dull and steady suprapubic pain)
Bladder calculi
Prostatitis/seminal vasculitis
Localization
Associated Symptoms
Frequency
Nocturia
Incontinence
Hematuria
Pelvic/back pain
Fever/chills
Vaginal discharge
Last menstrual period
Sexual activity, type of contraception, symptoms in
partner
History of prior urinary or gynecologic symptoms and
infections
Conditions which might predispose to treatment failure
(diabetes, pregnancy, recent antibiotic treatment,
hospitalization, urological instrumentation, urological
anatomic anomaly)
Allergy to medications
PE
Abdominal examination
CVA tenderness acute pyelonephritis
Suprapubic tenderness cystitis
Genital exam
Prostate exam
Frequency
Frequent voiding without increased urine flow
Decreased voiding interval (<2 hours)
Pollakuria abnormal increased frequency of urination
The normal capacity of the bladder is 400 mL
Etiology
Residual urine reduces the functional capacity of the
organ
Bladder inflammation infection, stones, tumor
Bladder fibrosis TB, radiation cystitis, interstitial
cystitis, schistosomiasis
Urgency
VII.
Palpation of the
posterior surface of the
prostate gland. Feel for
the lateral lobes and
median sulcus
Enlarged Prostate
Palpation of Skene
Glands
Palpation of Bartholin
Glands
Cystocele
Internal Examination
Use a speculum cervix
Bimanual Examination
Cervix
Uterus
Adnexa and ovaries
Rectovaginal examination
Anal sphincter
Rectal walls and rectovaginal septum
Rectocele
Rectovaginal Examination
Anal sphincter
Rectal walls and rectovaginal septum
Uterus
Adnexa
Stool
Rectovaginal examination