MCCEE Review

1.
Abdominal Distension
Ascites
1. Exudative: Low serum-to-ascites albumin gradient (e.g., peritoneal

carcinomatosis)
2. Transudative: High serum-to-ascites albumin gradient (e.g., portal hypertension)
2. Bowel dilatation
1. Mechanical obstruction (e.g., adhesions, volvulus)
2. Paralytic (e.g., toxic megacolon, neuropathy)
3. Other
1. Abdominal mass
2. Irritable bowel syndrome
3. Organomegaly (e.g., hepatomegaly)
4. Pelvic mass (e.g., ovarian cancer)
Abdominal / Pelvic Mass
Organomegaly
1. Hepatomegaly
2. Splenomegaly
3. Enlarged kidneys (e.g., cysts, hydronephrosis)
2. Neoplasms (benign/malignant)
1. Lymphoma/Sarcoma
2. Gastrointestinal tumors (e.g., gastric, colon, pancreas, hepatoma, gastrointestinal
stromal tumor)
3. Gynecologic tumors (e.g., ovarian, uterine)
4. Renal/adrenal
5. Neuroblastoma
3. Gynecologic
1. Ovary (e.g., benign or malignant)
2. Tube (e.g., ectopic pregnancy)
3. Uterus (e.g., leiomyoma, pregnancy)
4. Bladder/prostate (e.g., urinary retention, cancer)
5. Other
1. Pancreatic pseudocyst
2. Vascular (abdominal aortic aneurysm)
3. Abdominal wall masses
Hepatomegaly
Hepatomegaly, enlargement of the liver, is an uncommon but importsnt clinical presentation.
1. Congestive (e.g., right heart failure)

2. Infiltrative
1. Malignant
2. Nonmalignant
3. Proliferative
1. Infectious
2. Inflammatory
Splenomegaly
1. Congestive (e.g., cirrhosis)

2. Infiltrative
1. Malignant
2. Nonmalignant
3. Proliferative
1. Infectious
2. Inflammatory
3. Other hematologic conditions
Hernia (Abdominal Wall and Groin)
1. Congenital hernia
1. Infantile inguinal hernia
2. Umbilical
2. Acquired hernia
1. Inguinal hernia
1. Indirect
2. Direct
2. Femoral hernia
3. Umbilical hernia
4. Ventral (incisional) hernia
Abdominal Pain (Children)
1. Lower abdominal
1. Appendicitis
2. Constipation
3. Gastroenteritis
4. Mesenteric lymphadenitis
5. Inflammatory bowel disease
6. Inguinal hernia (incarcerated)
7. Urinary tract infection
8. Gynecological cause in pubertal children
2. Generalized pain
1. Peritoneal inflammation
2. Bowel
1. Infantile colic
2. Obstruction
3. Malabsorption
3. Flank pain
1. Pyelonephritis
2. Kidney stones
4. Periumbilical recurrent abdominal pain
5. Epigastric pain
1. Gastroesophageal reflux
2. Peptic ulcer
3. Biliary tract disease
4. Pancreatitis
Acute Abdominal Pain
1. Localized pain
1. Upper abdominal region
1. Biliary tract disease
2. Pancreatitis
3. Peptic ulcer disease, gastritis
4. Gastroesophageal reflux disease
5. Acute hepatitis, hepatic abscess
6. Splenic infarct, splenic abscess
7. Referred cardiothoracic pain
8. Musculoskeletal pain
2. Lower abdominal region
1. Appendicitis
2. Mesenteric lymphadenitis
3. Diverticulitis
4. Incarcerated hernia
5. Pelvic inflammatory disease
6. Ectopic pregnancy
7. Ovarian (e.g., torsion or ruptured cyst)
8. Urinary tract infection
9. Renal colic
11. Bowel obstruction
2. Diffuse pain
1. Generalized peritonitis
2. Ruptured abdominal aortic aneurysm
3. Ischemic bowel disease
4. Gastroenteritis
Chronic Abdominal Pain
1. Upper abdominal region

1. Gastric cancer
2. Ulcer and non-ulcer dyspepsia (e.g., heartburn)
3. Biliary disease
4. Pancreatic disease
5. Hepatic disease
6. Referred cardiothoracic pain
2. Lower abdominal region
1. Bowel disease
2. Diverticular disease
2. Genitourinary disease
1. Endometriosis
2. Benign or malignant tumors
3. Urinary tract disease
4. Pelvic inflammatory disease
Anorectal Pain
1. Anorectal disease
2. Fissures, fistulas
3. Hemorrhoids
2. Dermatologic disease
1. Psoriasis
2. Contact dermatitis or atopic dermatitis
3. Malignancy (dermatologic or other)
4. Infections
1. Sexually transmitted
2. Bacterial, fungal, or parasitic
5. Trauma
6. Coccygeal pain
Allergic Reactions and Atopy
Allergic reactions may be present with the following clinical manifestations:
1. Anaphylaxis
1. Drugs, food allergens, insect stings, idiopathic
2. Urticaria or angioedema
1. Drugs, food, physical stressors (e.g., cold, exercise) or congenital causes
3. Atopic dermatitis
4. Respiratory allergy (e.g., pollen, dust mites)
Given a patient with an allergic reaction, the candidate will
1. list and interpret critical clinical findings, including

1. history of drug ingestion, food ingestion, stings, environmental exposures,
exercise, or family history;
2. appropriate physical examination;
2. list and interpret critical investigations, including
1. appropriate use of tests designed to identify allergens;
3. construct an effective management plan, including
1. emergency management of anaphylaxis with appropriate measures;
2. long-term management including patient education and counseling.
Attention, Learning, and School Problems
-Causal Conditions Back to Top
1. Developmental disorders (e.g., attention deficit hyperactivity disorder [ADHD] , learning

disability, autism spectrum disorder)
2. Sensory impairment (e.g., hearing or vision impairment)
3. Neurological disorders (e.g., seizure disorder, fetal alcohol spectrum disorder)
4. Mental health disorders
5. Psychosocial stressors (e.g., hunger, adverse childhood experience)
6. Chronic medical disease (e.g., obstructive sleep apnea)
7. Substance abuse
Upper Gastrointestinal Bleeding
1. Ulcerative or erosive processes

1. Peptic ulcer disease
2. Esophagitis
3. Gastritis
2. Portal hypertension
3. Trauma (e.g., Mallory-Weiss tear)
4. Tumors
Lower Gastrointestinal Bleeding
1. Colorectal cancer or polyps

2. Diverticulosis
3. Angiodysplasia
5. Enterocolitis
6. Brisk bleeding from the upper gastrointestinal tract
7. Rectal trauma
Given a patient with lower gastrointestinal tract bleeding, the candidate will

1. assess through history and physical examination, including a rectal examination
as part of the initial assessment;
2. assess the hemodynamic status;
2. list and interpret critical clinical investigations, including
1. perform colonoscopy as appropriate;
2. select additional investigations as appropriate;
3. construct an effective initial management plan, including
1. identify patients in need of immediate resuscitation and referral for specialized
care.
Blood in Sputum (Hemoptysis)
1. Airway disease
1. Inflammatory (e.g., bronchiectasis, bronchitis)
2. Neoplasms (e.g., bronchogenic carcinoma)
3. Other (e.g., foreign body, trauma)
2. Pulmonary parenchymal disease
1. Infectious (e.g., tuberculosis, necrotizing pneumonia)
2. Inflammatory/Immune (e.g., vasculitis)
3. Other (e.g., coagulopathy)
3. Cardiac/Vascular
1. Pulmonary embolus with infarction
2. Elevated capillary pressure (e.g., mitral stenosis, left ventricular failure)
3. Arteriovenous malformation
Blood in Urine / Hematuria
Causal Conditions Back to Top
1. Transient hematuria
1. Urinary tract infections
2. Exercise-induced
3. Trauma to urinary tract
4. Endometriosis
5. Use of anticoagulants
2. Persistent hematuria
1. Extraglomerular hematuria
1. Kidney
1. Tumors
2. Tubulointerstitial diseases
3. Vascular diseases
4. Hematological disorders
2. Ureters, bladder, and urethra
1. Tumors
2. Stones
3. Vascular diseases
4. Infections
2. Glomerular diseases
Hypertension
1. Primary
2. Secondary
1. Renal parenchymal disease (e.g., renal failure, polycystic kidney disease)
2. Metabolic or endocrine (e.g., adrenal adenoma/hyperplasia, thyroid)
3. Vascular (e.g., unilateral renal artery stenosis, coarctation of the aorta)
4. Catecholamine excess (e.g., pheochromocytoma, drugs)
Hypertension in Childhood
1. Neonates and young infants

1. Renal artery thrombosis after umbilical artery (UA) catheter
2. Coarctation of the aorta
3. Congenital renal disease
4. Renal artery stenosis
2. Children aged 1-10 year
1. Renal disease
2. Coarctation of the aorta
3. Over 10 years of age
1. Essential hypertension
2. Renal disease
3. As with 1-10 years (less common)
Hypertensive Disorders of Pregnancy
Hypotension, Shock
1. Cardiac output diminished

1. Hypovolemia
1. Hemorrhage
2. Third space loss
3. Other loss
2. Cardiac dysfunction
1. Intrinsic
1. Myopathy (e.g., ischemic)
2. Rhythm abnormalities
3. Mechanical (e.g., valvular disease)
2. Extrinsic or Obstructive
1. Pulmonary embolus
2. Pulmonary hypertension
3. Tension pneumothorax
4. Pericardial disease
5. Aortic dissection
6. Venacaval obstruction
2. Distributive (diminished systemic vascular resistance)
1. Sepsis
2. Anaphylaxis
3. Inadequate tissue oxygenation
1. Neurogenic, autonomic blockade
2. Drugs
3. Spinal shock
4. Addisionian crisis
Breast Lump, Breast Cancer Screening
1. Breast carcinoma
1. Noninvasive
2. Invasive
2. Non-cancerous conditions
1. Fibrocystic change
2. Lumps
3. Breast infections
4. Associated with lactation
5. Not associated with lactation
Breast Discharge
1. Galactorrhea
1. Idiopathic
2. Hyperprolactinemia
1. Physiologic
2. Drugs, including herbal remedies
3. Pituitary tumors
2. Breast neoplasm
Gynecomastia
1. Physiologic
1. Newborn
2. Adolescence
3. Elderly
2. Pathologic
1. Deficient production or action of testosterone or receptor blockade
2. Increased estrogen or precursors
3. Medications or illicit drugs
4. Primary malignancy of the breast
Burns
1. Thermal
2. Electrical
3. Chemical
4. Radiation
Calcium Disorders
1. Hypocalcemia
1. Loss of calcium from the circulation
1. Hyperphosphatemia (e.g., renal insufficiency)
2. Pancreatitis
3. Osteoblastic metastases
4. Drugs (e.g., EDTA)
5. Rhabdomyolysis
2. Decreased vitamin D production or action
1. Renal failure
2. Rickets
3. Malabsorption
4. Neonatal
3. Decreased parathyroid hormone production or action
1. Postoperative
2. Autoimmune
3. Diminished response
4. Post parathyroidectomy
4. Low magnesium
2. Hypercalcemia
1. Increased intestinal absorption
1. Increased intake (e.g., milk-alkali syndrome)
2. Vitamin D mediated (e.g., sarcoidosis)
2. Increased bone resorption
1. Malignancy
2. Hyperparathyroidism
3. Hyperthyroidism
4. Immobilization
5. Paget's disease
3. Diminished excretion (e.g., diuretics)
Cardiac Arrest
1. Coronary artery disease

2. Cardiac conduction abnormalities
3. Myocardial abnormalities
Non-cardiac causes (e.g., pulmonary embolus)
Given the patient with cardiac arrest, the candidate will

1. pulseless circulatory state;
2. features that may help determine the cause of the arrest;
2. list and interpret critical investigations
3. construct an effective management plan, including
1. initiation of basic and acute cardiac life support protocols;
2. communication with family members concerning the event, including
1. outcome
2. breaking bad news
3. organ donation
4. autopsy request.
Chest Pain
1. Cardiovascular
1. Ischemic
1. Acute coronary syndromes
2. Stable angina pectoris
2. Non-ischemic
1. Aortic aneurysm
2. Pericarditis
2. Pulmonary or mediastinal
1. Pulmonary embolus or pulmonary infarct
2. Pleuritis
3. Pneumothorax
4. Malignancy
3. Gastro-intestinal
1. Esophageal spasm or esophagitis
2. Peptic ulcer disease
3. Mallory-Weiss syndrome
4. Biliary disease or pancreatitis
4. Anxiety disorders
5. Chest wall pain (e.g., costochondritis)
Bleeding Tendency, Bruising
1. Disorders of primary hemostasis

1. Platelet number or function
1. Congenital (e.g., von Willebrand disease)
2. Acquired (e.g., medication)
2. Vessel abnormality
1. Congenital (e.g., collagen disorders)
2. Acquired (e.g., medications)
2. Disorders of secondary hemostasis
1. Congenital (e.g., factor VIII)
2. Acquired (e.g., vitamin K deficiency)
3. Fibrinolysis (e.g., disseminated intravascular coagulopathy (DIC))
Venous Thrombosis, Hypercoagulable State
1. Congenital (e.g., sickle cell anemia)

2. Acquired (e.g., pregnancy)
Adult Constipation
1. Diet, lifestyle
3. Drugs
4. Neurogenic (central or peripheral)
5. Myopathic
6. Metabolic
7. Pregnancy
8. Obstructive lesions
Pediatric Constipation
1. Neonate and Infant

1. Dietary
2. Anatomic (e.g., Hirschsprung disease)
2. Older child
1. Dietary
2. Psychologic
3. Anatomic (e.g., bowel obstruction)
4. Neurologic
5. Endocrine/metabolic
6. Other (e.g., celiac disease, cystic fibrosis)
Contraception
1. Non-permanent contraception
1. Hormonal contraception
2. Barrier methods
3. Intrauterine devices
4. Other (e.g., abstinence)
2. Permanent contraception
1. Male sterilization
2. Female sterilization
Cough
1. Acute cough
1. Infectious
2. Irritant
3. Other (e.g., cardiac)
2. Chronic cough (lasting 3 weeks or longer)
1. Upper respiratory tract
2. Pulmonary
3. Gastrointestinal (e.g., gastroesophageal reflux)
4. Cardiac
5. Other (e.g., medications)
Cyanosis, Hypoxia
1. Central cyanosis or hypoxemia

1. High alveolar-arterial (A-a) gradient
1. Shunting (e.g., tetralogy of Fallot, acute respiratory distress syndrome)
2. V/Q (ventilation-perfusion) mismatch (e.g., cystic fibrosis, pulmonary
embolus)
3. Diffusion impairment (e.g., restrictive lung disease)
2. Normal A-a gradient
1. Hypoventilation (e.g., opioid overdose)
2. High altitude
2. Peripheral (e.g., low cardiac output, cold exposure)
Limp In Children
1. Congenital (lower limb, spine)

2. Acquired (lower limb, spine)
1. Infection
2. Inflammation
3. Tumors
1. Benign
2. Malignant
3. Other
1. Growing pains
2. Pain amplification syndromes
Developmental Delay
1. Global developmental delay

1. Neurological disorders (e.g., fetal alcohol spectrum disorder, cerebral dysgenesis)
2. Genetic and metabolic disorders (e.g., trisomy 21, congenital hypothyroidism)
3. Toxic exposures (e.g., lead)
4. Severe psychosocial deprivation
2. Speech and language delay
1. Hearing impairment
2. Developmental language disorder
3. Autism spectrum disorders (when associated with atypical social and behavioral
features)
3. Motor delay
1. Cerebral palsy
2. Muscular dystrophies
3. Developmental coordination disorder
Adults with Developmental Disabilities
1. Unknown etiology
2. Known etiology and associated conditions
1. Genetic syndromes (e.g., Down Syndrome)
2. Autism spectrum disorder
3. Fetal alcohol spectrum disorder
4. Brain injury (e.g., cerebral palsy)
5. Central nervous system infection
6. Other
Acute Diarrhea
1. Infection
1. Viruses
2. Bacteria
3. Parasites
2. Drugs or toxins
3. Ischemic
5. Metabolic disease (e.g., hyperthyroidism)
Chronic Diarrhea
1. Steatorrhea
1. Luminal
1. Pancreatic insufficiency
2. Cholestasis
3. Ileal disease or resection
4. Bacterial overgrowth
2. Mucosal
1. Lactase deficiency
2. Celiac disease
2. Large bowel
1. Secretory diarrhea (e.g., villous adenoma)
2. Inflammatory diarrhea
2. Infection
3. Other (e.g., radiation, ischemic colitis)
3. Motility disorder (e.g.,irritable bowel syndrome)
3. Small bowel
1. Osmotic diarrhea
2. Secretory diarrhea
1. Tumors
1. Neuroendocrine (e.g., carcinoid)
2. Neoplasia (e.g., lymphoma)
2. Mucosal
3. Motility disorders (e.g., diabetic neuropathy)
Pediatric Diarrhea
1. Infant
1. Infections
2. Diet-related (e.g., milk protein intolerance)
3. Ischemic intestinal damage (e.g., intussusception)
2. Child
1. Infections
2. Malabsorption
1. Lactase deficiency
2. Cystic fibrosis
3. Celiac disease
3. Other causes
1. Drugs
2. Laxative abuse
Diplopia
1. Monocular diplopia (e.g., refractive error, cataract)

2. Binocular diplopia
1. Oculomotor nerve dysfunction
1. ischemia
2. diabetes-associated
3. multiple sclerosise
4. intercranial mass (e.g., aneurysm)
2. Myasthenia gravis
3. Graves' orbitopathy
4. Orbital inflammation, infection, or tumor
5. Fracture of orbital floor or "blow out"
6. Decompensation of childhood phoria (e.g., squint)
Dizziness, Vertigo
1. Vertigo
1. Peripheral vestibular dysfunction
1. Benign positional vertigo
2. Peripheral vestibulopathy
3. Ménière's disease
4. Drugs (e.g., aminoglycosides)
5. Acoustic neuroma
2. Central vestibular dysfunction
1. Cerebrovascular
2. Multiple sclerosis
3. Drugs (e.g., anticonvulsants, hypnotics, alcohol)
3. Other dizziness
1. Hyperventilation
2. Disequilibrium (e.g., poor mobility, peripheral neuropathy)
3. Presyncope
4. Anxiety or panic disorder
Dysphagia
-Causal Conditions (list is not exhaustive) Back to Top
1. Oropharyngeal dysphagia
1. Structural
1. Peritonsillar abscess
2. Pharyngitis
3. Tumor
4. Zenker diverticulum
2. Neuromuscular
1. Central (e.g., cerebrovascular accident (CVA))
2. Cranial nerves (e.g., amyotrophic lateral sclerosis (ALS))
3. Systemic myopathies (e.g., dermatomyositis)
3. Xerostomia
2. Esophageal dysphagia
1. Mechanical obstruction
1. Intrinsic
1. Intermittent (e.g., lower esophageal ring, web)
2. Progressive (e.g., carcinoma, peptic stricture)
3. Foreign object
2. Extrinsic (e.g., mediastinal mass)
2. Neuromuscular disorder
1. Intermittent (e.g., diffuse esophageal spasm)
2. Progressive (e.g., scleroderma, achalasia)
Dyspnea
1. Cardiac causes
1. Myocardial dysfunction (e.g., ischemic cardiomyopathy)
2. Valvular heart disease
3. Pericardial disease (e.g., tamponade)
4. Increased cardiac output (e.g., anemia)
5. Arrhythmia
2. Pulmonary causes
1. Upper airway (e.g., foreign body, anaphylaxis)
2. Chest wall and pleura (e.g., pleural effusion)
3. Lower airway (e.g., asthma, chronic obstructive pulmonary disease)
4. Alveolar (e.g., pneumonia)
3. Central causes (e.g., metabolic acidosis, anxiety)
Pediatric respiratory distress
1. Upper airway problems

1. Croup
2. Foreign body aspiration
3. Laryngeal disorders
4. Epiglottitis
5. Retropharyngeal abscess
6. Choanal atresia
2. Lower airway, pulmonary disorders
1. Tracheitis, bronchiolitis
2. Pneumonia, atelectasis
3. Asthma, bronchospasm
4. Respiratory distress syndrome of the neonate
5. Tracheo-esophageal fistula
6. Pulmonary embolus
3. Pleural disorders
1. Pleural effusion, empyema
2. Pneumothorax
4. Neurologic disorders (e.g., drugs)
5. Other (e.g., extrapulmonary restriction)
6. Cardiac disorders
1. Congestive heart failure (left-to-right shunt, left ventricular failure)
2. Cardiac tamponade
Ear Pain
1. External ear pain

1. Infections
1. Otitis externa (e.g., fungal, bacterial)
2. Auricular cellulitis
3. Perichondritis
4. External canal abscess
2. Trauma (e.g., frostbite, piercings)
3. Other (e.g., foreign body, cerumen impaction)
2. Middle and inner ear pain
1. Infections or inflammation
1. Acute otitis media
2. Serous otitis media
3. Mastoiditis
4. Myringitis
2. Trauma (e.g., perforation, barotrauma)
3. Neoplasms
3. Referred pain
1. Infections (e.g., sinusitis, dental disease)
2. Trigeminal neuralgia
3. Other (e.g., temporomandibular joint dysfunction, thyroiditis)
Generalized Edema
1. Increased capillary hydrostatic pressure

1. Increased plasma volume due to renal sodium retention
1. Heart failure
2. Reduced systemic vascular resistance (e.g., cirrhosis)
3. Primary renal sodium retention (e.g., renal disease, drugs)
4. Pregnancy
5. Premenstrual edema
2. Decreased arteriolar resistance (e.g., calcium channel blockers, idiopathic)
2. Decreased oncotic pressure (hypoalbuminemia)
1. Protein loss (e.g., nephrotic syndrome)
2. Reduced albumin synthesis (e.g., liver disease, malnutrition)
3. Increased capillary permeability (e.g., burns, inflammation)
4. Increased interstitial oncotic pressure (e.g., myxedema)
Localized Edema

1. Venous insufficiency (including postphlebitic syndrome)
2. Deep venous thrombosis (DVT)
3. Trauma
4. Lymphedema (e.g., malignancy, primary)
5. Infection (cellulitis/soft tissue/bone)
6. Inflammation (e.g., ruptured Baker cyst, chronic dermatitis)
Eye Redness
1. Lids, lashes, orbits, lachrymal system

1. Congenital
2. Acquired
2. Conjunctiva, sclera
3. Cornea
4. Anterior chamber, iris
5. Trauma
Frailty in the Elderly
Often multi-factorial, including
1. Medications
2. Environmental/Social (e.g., isolation, poverty, elder abuse, neglect)
3. Medical disease
4. Malnutrition (e.g., from poor dentition, malabsorption, dysphagia)
5. Psychiatric (e.g., mild cognitive impairment, dementia, depression, psychosis)
6. Changes in visual acuity
7. Changes in auditory acuity
8. Decreased mobility
Failure to Thrive (Infant, Child)
1. Prenatal
1.Placental insufficiency
2.Intrauterine infections
3.Genetic
4.Maternal
1. Pre-existing conditions (e.g., diabetes, renal disease)
2. Use of medications, drugs, tobacco, or alcohol
2. Postnatal
1. Inadequate calorie intake
1. Caregiver
1. Inadequate feeding skills
2. Inappropriate food for age
3. Neglect
4. Insufficient lactation
5. Disturbed mother and child relationship
2. Infant
1. Sucking or swallowing dysfunction (e.g., cleft palate)
2. Chronic disease (e.g., infection, metabolic disorders)
2. Inadequate caloric absorption (e.g., gastroesophageal reflux)
3. Increased caloric requirements (e.g., hyperthyroid, congenital heart disease)
4. Social determinants (e.g., poverty, societal disorder)
5. adverse childhood experience)
Falls
1. Medical conditions (e.g., vertigo, gait disturbances, syncope)

2. Psychiatric conditions (e.g., cognitive impairment, substance abuse )
3. Medications
4. Environmental or behavioral risk factors (e.g., walking surface, choice of footwear)
5. Other contributors (e.g., decreased vision, urinary urgency)
Fatigue
Causal Conditions (list not exhaustive; characterized by fatigue as a Back to

predominant symptom) Top
1. Iatrogenic/pharmacologic
1. Hypnotic
2. Antihypertensives
3. Antidepressants
4. Drug abuse
2. Idiopathic
1. Idiopathic chronic fatigue
2. Chronic fatigue syndrome
3. Fibromyalgia
3. Other disease categories associated with fatigue
1. Psychiatric
2. Endocrine-metabolic
3. Cardiopulmonary
4. Infectious
5. Connective tissue disorders
6. Sleep disturbances
7. Neoplastic-hematologic
Fractures/Dislocations
causal conditions Back to Top
1. High energy injury

1. Acute - fracture/dislocation
2. Chronic - delayed/nonunion/mal-union
2. Low energy injury
1. With exercise - stress fracture
2. Without exercise - pathologic fracture
1. Metabolic bone disease
2. Tumors (benign, malignant, primary, secondary)
3. Non-accidental injuries (violence)
-Applied Scientific Concepts Back to Top
1. Briefly outline the process of cell division, regeneration, and differentiation as it pertains
to bone healing.
2. Describe the various mechanisms responsible for fractures (i.e., linear, spiral, depressed
etc.).
Ataxia (Gait)
1. Cerebellar ataxial
1. Tumors
2. Vascular
3. Hereditary
4. Multiple sclerosis
5. Drugs
6. Alcohol
2. Sensory ataxia
1. Vestibular
2. Proprioceptive
3. Visual
3. Other disorders of locomotion
1. Other central nervous system (e.g., cerebral)
2. Parkinson's disease
Genetic Concerns
1. Chromosomal (e.g., aneuploidy, rearrangements)

2. Single-gene
1. Mendelian (e.g., autosomal dominant)
2. Non-Mendelian (e.g., mitochondrial, epigenetic)
3. Prenatal Exposure
1. Drugs or toxins (e.g., fetal alcohol spectrum disorder)
2. Infectious (e.g., congenital rubella)
3. Maternal disease (e.g., maternal diabetes)
4. Multifactorial (e.g., neural tube defects)
Recognize where disease in an individual might reflect the existence of risk factors inherent to a
given population (e.g., Tay-Sachs disease).
Ambiguous Genitalia
1. Genetic Males
1. Androgen insensitivity
2. Defective androgen or 5 alpha-dihydrotestosterone (DHT) synthesis
3. Androgen-producing maternal ovarian mass
2. Genetic females
1. Exogenous progestin or androgen administration
2. Female hormone-producing maternal tumor
3. Adrenal tumor or hyperplasia
3. Gonadal dysgenesis
Congenital Anomalies, Dysmorphic Features
1. Teratogenic disorders (e.g., fetal alcohol spectrum disorder, congenital cytomegalovirus

infections)
2. Genetic disorders (e.g., Down syndrome, fragile X syndrome)
3. Mechanical forces (e.g., constriction band syndrome)
Glucose Abnormalities
1. Hypoglycemia
1. Postprandial
2. Fasting
1. Secondary to overutilization of glucose (e.g., sulfonylureas)
2. Secondary to impaired glucose production (e.g., adrenal insufficiency)
2. Hyperglycemia
1. Diabetes mellitus
2. Endocrine
3. Drugs
Diabetes Mellitus
1. Type 1
1. Autoimmunity
2. Idiopathic
2. Type 2
1. Obesity
2. Other (e.g., genetic predisposition, medications)
3. Gestational diabetes mellitus
Alopecia
1. Scarring absent
1. Androgenetic alopecia (most common in adult men and postmenopausal women)
2. Telogen effluvium (loss of mature hair) due to acute illness, surgery
3. Anagen effluvium (loss of growing hair) due to chemotherapy
4. Alopecia areata, alopecia totalis (localized or total loss of body hair)
5. Traumatic alopecia (e.g., trichotillomania)
6. Infections (e.g., tinea capitis)
2. Scarring present (associated with fibrosis and scar tissue)
1. Androgenetic alopecia (most common in 30 to 40% of adult men and
postmenopausal women)
2. Infection (e.g., severe folliculitis, dissecting cellulitis)
3. Skin conditions (e.g., bullous diseases)
4. Chemical alopecia
5. Tumors
6. Traction alopecia
Nail Complaints
1. Local nail problems (e.g., paronychia, herpetic whitlow, ingrown toenails)

2. Underlying condition
1. Shape changes (e.g., clubbing)
2. Surface changes (e.g., pitting from psoriasis)
3. Color changes (e.g., black from melanoma)
Headache
1. Primary headache (e.g., migraine, chronic daily headache with medication overuse)
2. Secondary headache
1. Associated with vascular disorders (e.g., severe arterial hypertension)
2. Associated with non-vascular disorders (e.g., intracranial infection)
3. Other (e.g., systemic viral infection)
Hearing Loss and Deafness
1. Conductive hearing loss

1. External ear pathology
1. Congenital (e.g., atresia)
2. Inflammation or infection (e.g., otitis externa)
3. Obstruction of canal (e.g., wax, foreign body)
2. Middle ear pathology
1. Congenital (e.g., atresia)
2. Infection (e.g., otitis media)
3. Ossicular pathology (e.g., otosclerosis)
4. Trauma (e.g., tympanic membrane perforation)
5. Tumors (e.g., glomus, adenoma)
2. Sensory - neural hearing loss
1. Acquired (e.g., presbycusis, noise-induced hearing loss)
2. Congenital (e.g., Alport syndrome)
Hemiplegia, Hemisensory Loss with or without Aphasia
1. Ischemic stroke
1. Thrombosis (e.g., atherosclerosis, vasoconstriction)
2. Embolism
1. Cardiac (e.g., atrial fibrillation)
2. Aortic source
2. Hemorrhagic stroke
1. Intracerebral hemorrhage (e.g., hypertension)
2. Subarachnoid hemorrhage
3. Other
1. Subdural hematoma
2. Infectious or inflammatory (e.g., brain abscess, multiple sclerosis)
3. Tumors
4. Migraine
Anemia
1. Normocytic
1. Red blood cell loss
1. Obvious (e.g., trauma, metro/menorrhagia)
2. Occult
2. Decreased red blood cell production
1. Marrow production (e.g., stem cell disorder, bone marrow replacement)
3. Increased destruction (e.g., sickle cell anemia, immune-mediated, mechanical)
4. Multi-factorial (e.g., anemia of chronic disease)
2. Microcytic (e.g., iron deficiency, hemoglobinopathies)
3. Macrocytic (e.g., vitamin B12 or folate deficiency, alcohol use)
Elevated Hemoglobin
1. Red cell mass increased

1. Polycythemia vera - low or normal erythropoetin (EPO)
2. Secondary erythrocytosis - elevated EPO
1. Appropriate EPO elevation (e.g., hypoxemia)
2. Inappropriate EPO elevation (e.g., EPO secreting tumor)
3. Relative polycythemia (decreased plasma volume)
Hirsutism, Hypertrichosis
-Rationale Back to Top
Hirsutism refers to male-type terminal hair growth and distribution usually caused by excess
androgen. In women, it may be associated with virilization. Hypertrichosis is a generalized
increase in immature (lanugo-type) hair which is not androgen driven. Virilization includes the
features of hirsutism in addition to other features of male phenotype.
1. Hirsutism
1. Familial (no endocrine disorder)
2. Androgen excess (may be associated with virilization or irregular menses)
1. Ovarian source
1. Polycystic ovary syndrome
2. Idiopathic
3. Ovarian tumor (arrhenoblastoma)
2. Adrenal
1. Congenital adrenal hyperplasia
2. Cushing syndrome
3. Adrenal tumor
3. Other
1. Drugs
2. Obesity
3. Aging in women
2. Hypertrichosis
1. Idiopathic
2. Drugs (e.g., phenytoin, minoxidil)
3. Systemic illness (e.g., hypothyroid, anorexia)
Speech And Language Disorders
1. Language disorder
1. Delayed and developmental language impairment (e.g., learning disability,
autism, neglect, abuse)
2. Degenerative, vascular, or other central nervous system disorders (e.g., stroke)
3. Head injury
2. Speech disorder
1. Articulation disorder (e.g., dysarthria)
2. Fluency (e.g, stuttering, Parkinson disease)
3. Speech apparatus lesions (e.g., cleft palate, head and neck neoplasm)
Acid-base Abnormalities Hydrogen
1. Metabolic acidosis
1. High anion gap
1. Increased acid production
1. Exogenous (e.g., methanol)
2. Endogenous acids (e.g., ketoacidosis)
2. Decreased renal acid excretion (renal failure)
2. Normal anion gap
1. Gastrointestinal bicarbonate loss (e.g., diarrhea)
2. Renal bicarbonate loss (e.g., renal tubular acidosis, interstitial nephritis)
2. Metabolic alkalosis
1. Expanded effective arterial blood volume (e.g., mineralocorticoid excess)
2. Contracted effective arterial blood volume
1. Gastrointestinal loss (e.g., vomiting)
2. Renal loss (e.g., diuretics)
3. Exogenous ingestion
3. Respiratory acidosis
1. Neuromuscular causes (e.g., drugs)
2. Pulmonary causes of decreased alveolar ventilation (e.g., chronic obstructive
pulmonary disease)
3. Kyphoscoliosis
4. Hypoventilation (e.g., due to obesity)
4. Respiratory alkalosis
1. Hypoxemia
2. Metabolic (e.g., hepatic failure)
3. Cardio-pulmonary disorders (e.g., pneumonia, embolism)
4. Central nervous system disorders (e.g., subarachnoid hemorrhage)
5. Drugs (e.g., salicylate)
6. Miscellaneous (e.g., fever, pain, pregnancy)
Infertility
1. Female
1. Ovulatory dysfunction (e.g., hypogonadotropic hypogonadism, polycystic ovarian
syndrome)
2. Tubal and peritoneal abnormalities (e.g., pelvic inflammatory disease [PID])
3. Uterine and cervical factors (e.g., fibroids)
2. Male
1. Testicular dysfunction (e.g., hypogonadotropic hypogonadism, viral orchitis)
2. Post-testicular dysfunction (e.g., abnormal sperm transport)
Fecal Incontinence
1. Pelvic floor intact

1. Neurologic conditions
2. Overflow (e.g., impaction)
2. Pelvic floor affected
1. Acquired (e.g., traumatic birth)
2. Congenital
Incontinence, Urine, Adult
1. Transient
1. Polyuria
2. Impaired ability and/or willingness to reach toilet
3. Drugs, alcohol
2. Neurologic (e.g., cauda equina syndrome)
3. Anatomic
1. Stress incontinence
2. Urgency incontinence (e.g., cystitis)
3. Overflow incontinence (e.g., prostate enlargement, multiple sclerosis)
Incontinence, Urine, Pediatric / Enuresis
1. Primary enuresis (e.g., family history)

2. Secondary enuresis (e.g., urinary tract infection, vesicoureteral reflux)
Erectile Dysfunction
1. Neurologic (e.g., diabetes mellitus)

2. Cardiovascular
3. Pharmacologic (e.g., alcohol)
4. Hormonal (e.g., testosterone deficiency)
5. Psychological or emotional (e.g., performance anxiety)
6. Chronic systemic disease (e.g., renal failure)
Jaundice
1. Unconjugated hyperbilirubinemia (pre-hepatic)

1. Overproduction (e.g., hemolysis)
2. Decreased hepatic uptake (e.g., congestive heart failure)
3. Decreased bilirubin conjugation (e.g., Gilbert syndrome, neonatal jaundice)
2. Conjugated hyperbilirubinemia (hepatic)
1. Intrahepatic cholestasis (e.g., drugs, cirrhosis)
2. Extrahepatic cholestasis (e.g.,cholelithiasis)
3. Hepatocellular injury (e.g., sepsis, hypoperfusion)
4. Other (e.g., infiltrative states, fatty liver)
Neonatal Jaundice
1. Unconjugated hyperbilirubinemia
1. Increased bilirubin production
1. Hemolytic causes (e.g., Coombs positive, Coombs negative)
2. Decreased bilirubin conjugation
1. Metabolic or genetic (e.g., Gilbert syndrome, hypothyroidism)
2. Physiologic (e.g., breast milk jaundice)
3. Gastrointestinal (e.g., sequestered blood)
2. Conjugated hyperbilirubinemia
1. Decreased bilirubin uptake
1. Infections (e.g., sepsis, neonatal hepatitis)
2. Cholestasis (e.g., total parenteral nutrition)
3. Metabolic
4. Genetic
2. Obstructive (e.g., biliary atresia)
Oligoarthralgia (Pain in One to Four Joints)

1. Acute joint pain
1. Injury (e.g., meniscal tear)
2. Infection
3. Crystal
4. Hemarthrosis (e.g., clotting disorder)
5. Acute reactive arthritis
2. Chronic joint pain
1. Osteoarthrosis
2. Periarticular disease (e.g., bursitis, tendonosis)
3. Pediatric disorders (e.g., slipped epiphysis, Osgood-Schlatter)
3. Non-articular disease (e.g, bone malignancy, leukemia)
Polyarthralgia (Pain in More Than Four Joints)
1. Inflammatory joint pain (e.g., rheumatoid arthritis, juvenile polyarthritis)

2. Mechanical joint pain (e.g., Osteoarthritis)
3. Non-articular disease (e.g., fibromyalgia, polymyalgia rheumatica)
Non-Articular Musculoskeletal Pain
1. Generalized Pain
1. Acute pain (e.g., viral infections)
2. Chronic pain (e.g., fibromyalgia, polymyalgia rheumatica)
2. Localized Pain
1. Acute
1. Trauma (see also Fractures and Dislocations )
2. Infection (e.g., osteomyelitis, necrotizing fasciitis)
3. Vascular (e.g., compartment syndrome, sickle cell disease)
2. Chronic
1. Mechanical (e.g., tendonopathy, bursitis)
2. Vascular (e.g., intermittent claudication)
3. Neoplastic
4. Neuropathic
Back Pain and Related Symptoms (e.g., Sciatica)
1. Mechanical back problems

1. Common back pain
2. Acute, discogenic nerve root entrapment
3. Spinal Stenosis and/or cauda equina syndrome
2. Inflammatory arthritis (e.g., ankylosing spondylitis)
3. Infections
4. Fracture
1. Neoplasm
2. Others (e.g., referred pain)
Neck Pain
1. Mechanical problems
1. Neck strain
2. Spondylois
3. Acute, discogenic nerve root entrapment
4. Spinal stenosis and/or cord compression
2. Inflammatory arthritis (e.g., ankylosing spondylitis)
3. Infections
4. Fracture
1. Neoplasm
2. Pain from soft tissue structures (e.g., thyroid, pharynx)
Abnormal, Serum Lipids
1. Hypercholesteremia (elevated low-density lipoprotein, lipoprotein (a))

1. Primary causes
1. Familial combined hyperlipidemia
2. Polygenic
3. Familial hypercholesterolemia
2. Secondary causes
1. Endocrine (e.g.,diabetes mellitus, hypothyroidism)
2. Cholestatic liver disease
3. Nephrotic syndrome, chronic renal failure
4. Other
1. Cigarettes
2. Obesity
3. Drugs (e.g., steroids)
2. Hypertriglyceridemia
1. Primary causes (familial hypertriglyceridemia)
2. Secondary causes
1. Obesity
2. Diabetes mellitus
3. Nephrotic syndrome, chronic renal failure
4. Drugs (e.g., estrogen)
5. Alcohol
3. Low high-density lipoprotein
1. Primary
2. Secondary
1. Obesity
2. Drugs (e.g., anabolic steroids)
3. Metabolic syndrome
Abnormal Liver Function Tests
1. Hepatocellular
1. Acute (e.g., infection, medication)
2. Chronic (e.g., infection, medication)
2. Cholestatic
1. Intrahepatic (e.g., pregnancy)
2. Extrahepatic (e.g., gallstones)
3. Congenital abnormalities (e.g., Gilbert disease)
4. Other (e.g., celiac disease)
Lump / Mass (Musculoskeletal)
1. Neoplastic
1. Soft tissue
1. Benign (e.g., lipoma)
2. Malignant (e.g., leiomyosarcoma)
2. Bone (e.g., cyst)
1. Benign (e.g., cyst)
2. Malignant (e.g., Ewing sarcoma)
2. Non-neoplastic
1. Infectious (e.g., osteomyelitis)
2. Traumatic (e.g., hematoma)
3. Inflammatory (e.g., rheumatoid nodules, tendonitis)
Lymphadenopathy

1. Localized
1. Reactive (e.g., tonsillitis)
2. Neoplastic (e.g., metastatic cancer)
2. Diffuse
1. Infectious (e.g., viral)
2. Inflammatory (e.g., sarcoidosis)
3. Neoplastic (e.g., lymphoma)
Mediastinal Mass
1. Anterior
1. Tumors (e.g., thymoma, lymphoma)
2. Other (e.g., aneurysm)
2. Middle
1. Tumors (e.g., bronchogenic cancer)
2. Other (e.g., sarcoidosis)
3. Posterior
1. Tumors (e.g., esophageal cancer)
2. Other (e.g., hiatal hernia)
Amenorrhea, Oligomenorrhea
1. Primary
1. Central
1. Hypothalamus (e.g., functional)
2. Pituitary
2. Ovary (e.g., ovarian dysgenesis, polycystic ovarian disease)
3. Vaginal, outflow tract (e.g., imperforate hymen)
2. Secondary
1. Pregnancy
2. Central
1. Hypothalamus (e.g., functional, exogenous hormones)
2. Pituitary (e.g., prolactinoma)
3. Other endocrine (e.g., thyroid disorders)
4. Ovary (e.g., oophorectomy, chemotherapy)
5. Uterus (e.g., Asherman syndrome)
Dysmenorrhea
1. Primary/Idiopathic (no pelvic abnormality)

2. Secondary (acquired) (e.g., infections, endometriosis, adnexal abnormalities)
Premenstrual Syndrome (PMS)
While the cause of premenstrual syndrome is unknown, there are many theories as to the
pathogenesis of this condition.
Menopause
This Objective relates solely to physiological menopause.
Coma
1. Focal disease (e.g., tumor, stroke)

1. Diffuse
1. Vascular (e.g., hypertensive encephalopathy, syncope)
2. Infectious (e.g., meningitis, encephalitis)
3. Trauma
4. Metabolic (e.g., uremia, hypercalcemia, hypoglycemia)
5. Substance abuse and overdose
2. Seizures
Delirium
Delirium is a disturbance of cerebral function secondary to an underlying medical condition.

Delirium is extremely common in hospitalized patients. The presenting syndrome is altered level
of consciousness, impaired cognition and reality testing with a fluctuating course. Delirium is
associated with increased risk of death, prolonged hospitalization and institutionalization.

1. Medications (e.g., sedative, anti-cholinergic)
2. Metabolic (e.g., fluid and electrolyte disturbance)
3. Hypoxia (e.g., anemia, hypoperfusion)
4. Infection
5. Endocrine (e.g., hypothyroidism)
6. Neurological (e.g., stroke, dementia, infection)
7. Post-surgical
8. Withdrawal (e.g., alcohol, benzodiazepines)
9. Trauma
Dementia
Dementia is a diminution in cognition in the setting of a stable level of consciousness. It is a

major issue for families and caregivers and is increasing in prevalence with the aging population.
Alzheimer's disease is by far the most common form of dementia in the elderly.
1. Alzheimer disease
2. Vascular dementia (e.g., multi-infarct, lacunar infarcts)
3. Brain trauma (e.g., postconcussive, anoxia)
4. Drugs (e.g., alcohol, substance abuse)
5. Toxins (e.g., heavy metals, organic toxins)
6. Neurodegenerative disorders (e.g., Parkinson disease, Lewy Body, Huntington disease)
7. Normal pressure hydrocephalus
8. Intracranial masses (e.g., tumours, subdural masses, brain abscesses)
9. Infections (e.g., human immunodeficiency virus, neurosyphilis)
10. Endocrine, metabolic, and nutritional disorders (e.g., hypothyroid, vitamin B12
deficiency)
Mood Disorders
Back to Top
-Rationale
Depression is one of the top five diagnoses made in the offices of primary care physicians.
Depressed mood occurs in some individuals as a normal reaction to grief, but in others it is
considered abnormal because it interferes with the person's daily function (e.g., self-care,
relationships, work, self-support). Thus, it is necessary for primary care clinicians to detect
depression, initiate treatment, and refer to specialists for assistance when required.
Back to Top
-causal conditions
1. Depressive disorders
1. Major depressive disorder
2. Dysthymic disorder
3. Atypical depression
2. Depression with associations
1. Timing (seasonal, postpartum)
2. Mood disorder due to medical condition/therapy
3. Substance-induced mood disorder
3. Grief and bereavement
4. Depression with manic episode
1. Bipolar disorder
2. Cyclothymic disorder
Back to Top
-Applicable Basic Principles of Law
Legal Aspects of Consent
Issues
 Voluntary and informed consent as a fundamental legal requirement

 The elements and practical aspects of consent to investigation, treatment, or research
 The right to refuse consent
 Exceptions to the requirement for consent
Depressed Mood
-Causal conditions Back to Top
1. Major depressive disorder (e.g., melancholic, seasonal affective, atypical depression)

2. Bipolar disorder (type I, type II)
3. Dysthymia
4. Cyclothymia
5. Normal grief
7. Mood disorder secondary to a general medical condition
Mania/Hypomania
Mania/Hypomania is an extremely disabling and potentially harmful behavioral syndrome that

indicates an underlying central nervous system disorder. Mania can lead to harm to self or others,
and may be accompanied by features of psychosis.
-Causal conditions Back to Top

1. Bipolar disorder (type I, type II)
3. Mood disorder due to a general medical condition
4. Cyclothymia
Mouth Problems
1. Congenital (e.g., cleft palate)

2. Acquired
1. Infection (e.g., sexually-acquired diseases)
2. Malignancy (e.g., leukoplakia)
3. Poor oral hygiene (e.g., caries, periodontal disease)
4. Trauma (e.g., abuse)
5. Toxic ingestion
6. Sialolithiasis
7. Conditions in elderly (e.g., xerostomia)
3. Other (e.g., oral lesions associated with systemic disease)
Movement Disorders, Involuntary / Tic Disorders
Movement disorders are classified as excessive (hyperkinetic) or reduced (bradykinetic) activity.

Diagnosis depends primarily on careful observation of the clinical features.
1. Hyperkinetic
1. Tics
1. Primary (sporadic and inherited)
1. Tourette syndrome
2. Huntington disease
2. Secondary
1. Infections (e.g., encephalitis, Creutzfeldt-Jakob)
2. Drugs (e.g., stimulants, levodopa)
2. Dystonia
1. Primary (sporadic and inherited)
2. Dystonia plus syndromes (e.g., medication)
3. Stereotypies (typically with mental retardation or autism)
4. Chorea/Athetosis/Ballism
5. Essential tremor
6. Myoclonus
2. Bradykinetic
1. Parkinson disease
2. Wilson disease
3. Huntington disease
3. Tremor
1. Resting (e.g., Parkinson, severe essential)
2. Intention (e.g., cerebellar disease, multiple sclerosis)
3. Postural/Action (e.g., enhanced physiologic, essential)
Neck Mass, Goiter, Thyroid Disease
1. Benign
1. Congenital (e.g., thyroglossal duct cyst)
2. Inflammatory (e.g., reactive lymph nodes)
3. Neoplasms (e.g., lipomas)
2. Malignant
1. Thyroid
2. Non-thyroid head and neck cancers
3. Lymphoma
Neonatal Distress
1. Prematurity
2. Pulmonary (e.g., meconium aspiration, pneumothorax)
3. Decreased respiratory drive (e.g., maternal medications, asphyxia)
4. Cardiovascular (e.g., anemia, congenital heart disease)
5. Infection
Numbness / Tingling / Altered Sensation
1. Peripheral neuropathy (e.g., diabetic neuropathy, carpal tunnel syndrome)

2. Central nervous system (e.g., multiple sclerosis, radiculopathy)
3. Dermatological (e.g., herpes zoster, angioedema)
4. Mental disorders (e.g., panic attacks)
Pain
Back to Top
-Causal Conditions
1. Nociceptive (tissue damage)

1. Visceral (acute, chronic)
2. Somatic (including somatic complaints)
1. Local (upper/lower limb, spine)
2. General (fibromyalgia, associated with physical exercise)
2. Neuropathic (abnormal neural activity)
1. Sympathetic
1. Complex regional pain syndrome
2. Reflex sympathetic dystrophy
2. Central (abnormal central nervous system activity)
1. Phantom limb
2. Post spinal cord injury
3. Post stroke
3. Non-sympathetic (damage/pressure to peripheral nerve)
1. Post herpetic
2. Neuropathy (herniated intervertebral disc, trigeminal neuralgia)
3. Neuroma formation
Back to Top
-Ethics
Consent to Investigation or Treatment
Detailed Objectives
 To recognize factors which can alter capacity (e.g., disease, drugs, depression).
Although prolongation of life without regard for quality of life is not ideal, consider each
patient's assessment of what makes life worth living, and factor in such variables as religious
belief, values, fear of death, severity of disease, effect of drugs, and psychiatric co-morbidity.
Controversial and Evolving Ethical Issues in Practice
Issues
 Euthanasia
 Physician assisted suicide
Back to Top
-Applied Scientific Concepts
1. Outline the neural basis of pain including the specialized nociceptors that are the nerve
terminals of primary afferent fibers (myelinated A-delta fibers and unmyelinated C
fibers).
2. Contrast the first immediate sharp pain of A fibers to the delayed dull pain of C fibers,
and the visceral afferents that travel with sympathetic and parasympathetic fibers.
Generalized Pain Disorders
1. Fibromyalgia / Chronic fatigue syndrome

2. Polymyalgia rheumatica (PMR)
3. Mental health disorders (e.g., depression, somatoform disorders)
Local Pain, Shoulder/Elbow/Wrist/Hand
1. Shoulder (85%)
1. Intrinsic
1. Injury/Trauma (see TRAUMA/ACCIDENTS)
2. Inflammation
1. Peri-articular
1. Rotator cuff injury (impingement, tendinitis, tear)
2. Frozen shoulder (adhesive capsulitis from rotator cuff
tendinitis)
3. Biceps tendonitis/Rupture
4. Subcapsular bursitis
2. Articular
1. Acromioclavicular arthritis
2. Glenohumeral arthritis (osteoarthritis, pseudo-gout, gout)
3. Shoulder instability
2. Referred (shoulder movement normal)
1. Cervical spine (disc herniation, spinal stenosis)
2. Medical problems (nerve entrapment, diaphragmatic irritation, hepatic
capsule distension, myocardial ischemia)
2. Elbow
1. Intrinsic
1. Peri-articular
1. Epicondyles (lateral epicondylitis/tennis elbow, medial/golfer's
elbow)
2. Bursae (olecranon bursitis from sepsis, gout, trauma)
3. Nerves (ulnar, radial, median entrapment)
2. Articular
1. Sero-negative spondyloarthropathy, gout/pseudo-gout, sepsis
2. Osteoarthritis (prior intra-articular fracture, avulsion,
osteonecrosis)
2. Referred (cervical radiculopathy C6-7, shoulder)
3. Wrist (most susceptible)
1. Trauma (see under TRAUMA/ACCIDENTS)
2. Repetitious use (carpal tunnel, DE Quervain tenosynovitis, dorsal ganglion,
radiocarpal arthritis)
4. Hand
1. Arthritis (osteoarthritis, rheumatoid arthritis)
2. Vascular (embolus, Raynaud, thoracic outlet)
3. Other (trigger finger, Dupuytren contracture, carpal tunnel)
Local Pain, Hip/Knee/Ankle/Foot
1. Hip
1. Articular
1. Arthritis (osteoarthritis, septic)
2. Osteonecrosis (steroid, alcohol use, renal failure)
3. Occult hip fracture
4. Aorto-iliac vascular occlusive disease
2. Peri-articular
1. Bursitis (trochanteric, gluteus medius)
2. Metastatic bone cancer
3. Nerves (lateral femoral cutaneous nerve entrapment)
3. Referred (inguinal hernia, abdominal disease, radiculopathy L2-3, L4-5)
2. Knee
1. Articular (osteoarthritis, gout/pseudogout, septic)
2. Patellar (patella-femoral syndrome, patellar tendonitis, pre-patellar bursitis,
Osgood Schlatter disease)
3. Periarticular (bursitis, effusion, Baker cyst, ilio-tibial band synd., ligamentous)
4. Referred (L5-S1, sacro-iliac joint, hip)
3. Ankle (tendinitis, achilles tendinitis/rupture)
4. Foot (plantar fasciitis, gout, spurs, periostitis, painful heel pad synd., bunions)
5. Other (muscle strain/tear, arterial/venous insufficiency/phlebitis/lymphangitis)
Local Pain, Spinal Compression/Osteoporosis
1. High turnover osteoporosis (?bone resorption>?bone formation

1. Menopause/Gonadal failure (estrogen/testosterone definciency male:female =1:6)
2. Endocrine (hyperparathyroid/thyroid, hypogonadism, hypercortisolism)
3. Drugs (cyclosporine)
2. Low turnover osteoporosis (?bone formation>?bone resorption)
1. Age related male:female=1:2 (<50 years)
2. Liver disease (primary biliary cirrhosis)
3. Diet/Life style/Disuse
1. Disuse (lack of weight-bearing activity/inactivity/prolonged bed
rest/paralysis/paresis/weightlessness in space)
2. Malnutrition/Anorexia nervosa/Malabsorption/?calcium/Vitamin C, D
3. Alcoholism/Smoking
3. Increased bone resorption and decreased bone formation
1. Drugs (increased cortisol, methotrexate, heparin)
2. Rheumatoid arthritis/SLE/Psoriatic arthritis
3. Genetic (peak bone mass, osteogenesis imperfecta)
4. Metabolic acidosis
5. Neoplasms (myeloma/lymphoma)
Local Pain, Spine/Neck/Thoracic
1. Intrinsic to muscles
1. Muscle spasm/Cervical strain (awkward posture, certain occupations)
2. Whiplash, myofascial pain syndromes
2. Intrinsic to cervical spine
1. Degenerative arthritis/Cervical spondylosis
1. Disc herniation/Foraminal encroachment (C5-6, C6-7, C7-T1)
2. Diffuse idiopathic skeletal hyperostosis
3. Spinal stenosis
2. Systemic disease (rheum. arthritis, polymyalgia rheumatica, metastases)
3. Infections (osteomyelitis, soft tissue)
4. Tumors
3. Referred
1. Angina pectoris
2. Meningitis
Applied Scientific Concepts Back to Top
1. Outline the anatomy of the cervical spine, identify C4 - C7 as the sites of greatest wear
and tear, with the nerve roots of C5, 6, and 7 passing through these foramina.
2. Since the diaphragm is innervated by C3 - C5, respiratory paralysis may be present with
injuries above C4.
Local Pain, Spine/Low Back Pain
1. No nerve involvement (non-radicular)

1. Mechanical low back or leg pain (97%)
1. Idiopathic (lumbar strain or sprain) (70%)
2. Disk and facet degeneration
3. Osteoporotic compression fracture
4. Spondylolisthesis
5. Congenital disease (kyphosis, scoliosis, transitional vertebrae)
2. Non-mechanical spinal conditions (1%)
1. Neoplasia (myeloma, metastases/primary, lymphoma/leukemia)
2. Infections (osteomyelitis, septic discitis, abscess, shingles)
3. Inflammatory arthritis (associated with HLA-B27)
1. Ankylosing spondylitis
2. Psoriatic
3. Reiter syndrome
4. Osteochondrosis
5. Paget disease
2. Nerve root involvement (radicular)
1. Herniated disk/Cauda equina syndrome (4%)
2. Spinal stenosis (3%)
3. Compression fracture (4%), traumatic fracture
4. Spinal cord tumor/Peripheral nerve neuropathy
3. Referred Pain - visceral disease (2%)
1. Pelvic organs (prostate, endometriosis, PID)
2. Renal (stones, infection, abscess)
3. Aortic aneurysm, retroperitoneal neoplasm/infection
4. Gastrointestinal (pancreatitis, cholecystitis, penetrating ulcer)
Sympathetic / Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy
1. Regional trauma
2. Myocardial infarction
3. Diabetes
4. Stroke
5. Idiopathic
Neuropathic Pain
1. Metabolic (e.g., diabetic neuropathy)

2. Nerve entrapment (e.g., carpal tunnel syndrome, lymphoma, trigeminal neuralgia)
3. Infectious (e.g., post-herpetic neuralgia)
4. Central (e.g., phantom limb pain, spinal cord injuries)
5. Sympathetic (e.g., reflex sympathetic dystrophy)
Palpitations

1. Supraventricular
1. Sinus tachycardia
1. Increased demand (e.g., pregnancy, anemia)
2. Metabolic (e.g., thyrotoxicosis, pheochromocytoma)
3. Anxiety
4. Pharmacologic (e.g., cocaine, caffeine)
2. Atrial fibrillation/flutter
3. Supraventricular tachycardia (atrioventricular nodal reentrant tachycardia), Wolff-
Parkinson-White syndrome
4. Junctional tachycardia
5. Premature junctional complexes and premature atrial contractions
2. Ventricular
1. Ventricular tachycardia
2. Premature ventricular contractions
3. Ventricular fibrillation
Anxiety
Anxiety disorders are caused by a complex interaction of biological (e.g., genetic, substance
use), social (e.g., domestic violence), and psychological factors (e.g., uncertainty). They
frequently co-exist with other psychiatric (as well as medical) conditions, but may present in
isolation. Common anxiety disorders include:
1. Generalized anxiety disorder

2. Post-traumatic stress disorder
3. Obsessive compulsive disorder
4. Phobias
5. Panic disorder
Crying or Fussing Child
1. Functional (e.g., hunger, irritability)

2. Colic
3. Trauma
4. Illness
Hypotonic Infant
1. Neurologic (e.g., perinatal asphyxia, spinal muscular atrophy, myasthenia gravis)
2. Disorders of skeletal muscle (e.g., muscular dystrophy)
3. Genetic/metabolic (e.g., Prader-Willi, hypothyroidism)
4. Systemic illness (e.g., sepsis, dehydration)
Pelvic Pain
1. Pregnancy related (e.g., ectopic, molar, abruption)

2. Gynecological
1. Ovary (e.g., ruptured cyst, torsion)
2. Tube (e.g., pelvic inflammatory disease, endometriosis)
3. Uterus (e.g., leiomyoma, endometriosis)
3. Other (dysmenorrhea, ovulation pain, dyspareunia)
4. Systemic conditions
1. Urologic (interstitial cystitis, renal colic)
2. Musculoskeletal (fibromyalgia)
3. Gastrointestinal (irritable bowel, diverticulitis, inflammatory bowel disease,
hernias)
5. Mental health issues
1. Depression, somatization
2. Sexual, physical, and psychological abuse/domestic violence
Periodic Health Examination (Phe)
Conditions to consider based on patient age Back to Top
1. All ages
1. Injury prevention (e.g., noise control, seat belts, bicycle helmets)
2. Lifestyle modification (e.g., physical activity, smoking prevention/cessation, sun
exposure)
3. Immunization
2. Infant and child
1. Nutrition, growth, development
2. Abuse/neglect
3. Other (e.g., hearing, amblyopia)
3. Adolescence
1. Substance abuse
2. Sexual activity (e.g., contraception, sexually transmitted infections [STI])
4. Young adult
1. Female reproductive health (e.g., Papanicolaou smear, STI screening, folic acid)
2. Occupational health issues (e.g., stress, exposures)
5. Middle-aged adult
1. Cardiovascular health risks (e.g., blood glucose, blood pressure, lipid profile)
2. Cancer screening (e.g., breast, colon, prostate, skin)
3. Osteoporosis
6. Older adult
1. Fracture and fall prevention (e.g., osteoporosis screening)
2. Nutrition
3. Elder abuse
4. Dementia screening
Newborn Assessment
Given a newborn for routine assessment, the candidate will

1. maternal and perinatal history (e.g., intrapartum fever, medications);
2. neonatal history (e.g., Apgar scores, feeding and elimination);
3. psychosocial history (e.g., maternal mental health, home environment, family
supports);
4. systematic newborn physical examination, with particular attention to indications
of an acute illness (e.g., jaundice, hydration status);
5. screening for important congenital malformations (e.g., red reflex, heart murmur);
6. caregiver(s)' concerns;
1. screening tests for acute illness (e.g., serum glucose);
2. screening tests for clinical abnormalities (e.g., echocardiogram, genetic testing);
3. bilirubin measurement;
1. manage any acute illness appropriately, including referral for specialized care if
needed;
2. counsel caregiver(s) regarding breastfeeding and infant nutrition;
3. counsel caregiver(s) about routine infant care (e.g., umbilical cord care) and
safety (e.g., car seat, prevention of sudden infant death syndrome);
4. address any parental concerns;
5. discuss with caregiver(s) newborn metabolic screening.
Infant and Child Immunization
Pre-operative Medical Evaluation
1. Optimal care of chronic diseases (e.g., coronary artery disease, diabetes mellitus)
2. Identification of perioperative risk
1. Cardiopulmonary
1. Myocardial (e.g., ischemia, heart failure, arrhythmia)
2. Pulmonary (e.g., chronic obstructive pulmonary disease, infection)
2. Anaesthesic
1. Systemic (e.g., malignant hyperthermia, sleep apnea)
2. Intubation/airway (e.g., C-spine stability)
3. Thromboembolic (prior deep vein thrombosis, thrombophilia)
4. edication-related (e.g., prednisone use, immunosuppressants)
Work-related Health Issues
1. Occupation-related injury or illness

1. Musculoskeletal strain/injury (e.g., back pain)
2. Skin (e.g., contact dermatitis, burns)
3. Occupational lung disease (e.g., asbestosis, asthma)
4. Psychological stressors (e.g., harassment)
5. Sensory (e.g., hearing loss, eye injuries)
2. Disability
3. Prevention
4. Assessment
Personality Disorders
Causal condition Back to Top
The emergence of a personality disorder is a complex interaction of biological (e.g., genetic),

social (e.g., poverty), and psychological factors (e.g., stress).
Pleural Effusion
1. Transudative (e.g., congestive heart failure, nephrotic syndrome, cirrhosis)

2. Exudative
1. Infectious causes (e.g., parapneumonic, empyema, tuberculosis)
2. Neoplastic causes (e.g., primary, metastatic, mesothelioma)
3. Cardiac/Vascular (e.g., pulmonary embolus, collagen vascular disease)
4. Gastrointestinal causes (e.g., ruptured esophagus, pancreatitis, chylothorax)
Poisoning
1. Common
1. Household items (e.g., cleaning substances, cosmetics, plants)
2. Anticholinergics (e.g., antihistamines, tricyclics)
3. Sympathomimetic (e.g., cold remedies, amphetamines, cocaine)
2. Depressants (e.g., alcohol, opiate, sedatives, hypnotics)
1. Cholinergics (e.g., insecticides, nicotine)
3. Serotonergics (e.g., selective serotonin reuptake inhibitors )
4. Analgesics (e.g., acetylsalicylic acid [ASA], acetaminophen)
5. Cardiovascular drugs (e.g., digoxin, B-blopckers, calcium channel blockers)
6. Others (e.g., hallucinogens)
Concepts of Health and Its Determinants
Population Health
Assessing and Measuring Health Status at the Population Level
Hyperkalemia
1. Increased intake (usually associated with low excretion)

2. Redistribution
1. Decreased entry into cells (e.g., insulin deficiency, beta 2 blockade)
2. Increased exit from cells (e.g., metabolic acidosis, rhabdomyolysis)
3. Reduced urinary excretion
1. Decreased glomerular filtration rate (e.g., acute or chronic renal failure)
2. Decreased secretion (e.g., aldosterone deficiency, drugs)
Hypokalemia
1. Decreased intake (e.g., anorexia nervosa)

2. Redistribution (e.g., alkalemia, insulin, beta 2-adrenergic stimulating drugs)
3. Increased losses
1. Renal losses
2. Gastrointestinal (GI) losses (e.g., vomiting, diarrhea)
Early Pregnancy Loss / Spontaneous Abortion
The cause is usually not determined but may include:
1. Genetic factors (e.g., chromosomal abnormalities)

2. Reproductive tract abnormalities (e.g., uterine anomalies)
3. Prothrombotic factors (e.g., thrombophilia)
4. Endocrinologic factors (e.g., polycystic ovary syndrome)
5. Immunologic factors (e.g., antiphospholipid syndrome)
Preterm Labour: Preterm birth (prior to 37 weeks gestation)
1. Fetal (e.g., multiple gestation, congenital anomalies)

2. Placental (e.g., abruption, placental insufficiency)
3. Uterine (e.g., cervical anomalies)
4. Maternal (e.g., substance abuse, chronic illness, infection)
5. Iatrogenic (indicated induction of labour e.g., eclampsia, intrauterine growth restriction,
premature rupture of membranes)
Uterine Prolapse, Pelvic Relaxation
This condition is usually multifactorial. Potential causal conditions include:
1. Damage to vagina and pelvic support system

1. Vaginal birth
2. Prior pelvic surgery
3. Chronic increase in intra-abdominal pressure (e.g., chronic cough)
2. Neurogenic dysfunction of pelvic floor
3. Connective tissue disease
4. Genetic predisposition
Given a patient with prolapse/pelvic floor relaxation, the candidate will
1. list and interpret critical findings, including

1. the severity of symptoms, effect on activity, predisposing factors;
2. the results of a physical examination aimed at determining the anatomical
abnormality;
1. investigation for urinary tract infection;
3. conduct an effective initial management plan, including
1. discussing benefits and limitations of treatment options (e.g., pelvic floor
exercises, pessary, surgery) and strategies to slow progression;
2. determining whether the patient needs to be referred for specialized care.
Proteinuria
1. Orthostatic proteinuria
2. Tubulointerstitial (interstitial nephritis)
3. Glomerular
1. Active urine sediment
1. Primary (e.g., IgA nephropathy, membranoproliferative
glomerulonephritis)
2. Secondary (e.g., systemic lupus erythematosus (SLE), post-infectious)
2. Non-active urine sediment
1. Primary (e.g. minimal change, focal segmental glomerulosclerosis)
2. Secondary (e.g., diabetes, amyloid)
Pruritus
1. Skin lesions
1. Primary skin disease
1. Blisters (e.g., dermatitis herpetiformis)
2. Rash (e.g., psoriasis, lichen planus)
2. Parasitosis (e.g., scabies, pediculosis)
3. Allergy (e.g., eczema, allergic dermatitis, urticaria)
4. Arthropod bites
5. Factitious dermatitis
2. No skin lesions
1. Dry skin
2. Drugs/Foods
3. Obstructive biliary disease
4. Uremia/Renal failure
5. Haematological
1. Polycythemia vera/Microcytic anemia
2. Leukemia
3. Lymphoma
6. Carcinoma/Carcinoid syndrome
7. Endocrine (diabetes, thyroid disease)
3. Psychiatric/Emotional disorders
Given a patient with pruritism, the candidate will
Psychosis
1. Psychotic disorders (e.g., schizophrenia , schizoaffective disorder)

2. Psychotic disorder due to a medical condition (e.g., seizure disorder, central nervous
system tumors)
3. Substance induced psychotic disorder (e.g., corticosteroids, cocaine)
Acute Renal Failure (Anuria or Oliguria)
1. Pre-renal causes
1. Renal hypo-perfusion (e.g., hepato-renal syndrome, angiotensin-converting
enzyme inhibitor with bilateral renal artery stenosis)
2. Systemic hypo-perfusion (e.g., shock, hypovelemia)
2. Renal causes
1. Tubulointerstitial (e.g., acute tubular necrosis, interstitial nephritis)
2. Glomerular (e.g., glomerulonephritis, thrombotic thrombocytopenic
purpura/hemolytic uremic syndrome)
3. Vascular (e.g., cholesterol emboli)
3. Post-renal/Obstruction (e.g., prostatic hypertrophy, cervical cancer, calculi)
Chronic Renal Failure
1. Pre-renal causes (e.g., blood pressure)

2. Renal causes
1. Glomerular (e.g., IgA nephropathy, diabetic nephropathy)
2. Tubulo-interstitial (e.g., drug toxicity)
3. Ischemic
4. Congenital (e.g., dysplasia, polycystic kidney disease)
3. Post-renal (e.g., obstructive uropathy)
Scrotal Mass
1. Cystic (e.g., hydrocele)

2. Solid
1. Benign (e.g., hematoma)
2. Malignant (e.g., seminoma)
3. Inflammatory or infectious (e.g., orchitis, scrotal abscess)
Given a patient with a scrotal mass, the candidate will

1. history and physical examination results, in particular to diagnose an urgent case
(i.e., right-sided varicocele, malignant testicular tumor, and torsion);
1. laboratory and radiological studies, in particular, tumor markers, Doppler
ultrasound, or computed tomography (CT) scan, as appropriate;
1. in the case of a young patient, counsel and educate him about regular testicular
self-examination;
2. determine whether the patient requires an urgent or a non-urgent referral;
3. counsel, educate, and reassure the patient with a benign scrotal mass.
Scrotal Pain
causal Conditions Back to Top
1. Testicular torsion
2. Inflammation (e.g., acute epididymitis, orchitis, trauma)
3. Incarcerated/Strangulated hernia
4. Hemorrhage into testicular tumor
Seizures / Epilepsy
1. Primary neurological disorders (e.g., idiopathic epilepsy, head trauma, encephalitis)

2. Systemic disorders (e.g., hypoglycemia, electrolyte disorders)
3. Other (e.g., febrile seizures, withdrawal)
Abnormal Pubertal Development
1. Delayed puberty
1. Variant of normal constitutional delay of puberty
2. Primary gonadal disorders
1. Congenital
1. Chromosomal (e.g., Turner and Kleinfelter Syndromes)
2. Congenital malformations
2. Acquired gonadal disorders (e.g., gonadal infection, trauma, neoplasm)
3. Secondary gonadal disorders
1. Functional (e.g., chronic illness, malnutrition)
2. Hypothalamic dysfunction (e.g., hyperprolactinemia, exogenous steroids)
3. Pituitary dysfunction (e.g., central nervous system [CNS] tumor)
2. Precocious puberty
1. Central precocious puberty (gonadotropin-dependent)
1. Idiopathic
2. Central nervous system (e.g., neoplasms, hydrocephalus)
2. Peripheral precocious puberty (gonadotropin-independent)
1. Autonomous gonadal function (e.g., ovarian cysts, Leydig cell tumors of
ovaries or testes)
2. Adrenal pathology (e.g., tumors, congenital adrenal hyperplasia)
3. Exogenous sex hormone exposure
3. Incomplete precocious puberty (e.g., premature thelarche, premature adrenarche)
Sexually Concerned Patient
1. Sexual dysfunction
1. Psychological or emotional (e.g., depression, abuse)
2. Hormonal (e.g., menopause)
3. Neurologic dysfunction (e.g., spinal cord injury)
4. Vascular insufficiency (e.g., diabetes mellitus)
5. Drug side effects (e.g., beta blockers)
6. Trauma (e.g., episiotomy)
2. Sexual paraphilias (e.g., pedophilia)
3. Sexual identity disorders (e.g., transgender states)
4. Special populations
1. People with disabilities
2. Gays and lesbians
3. Children and adolescents
4. The elderly
5. Sexual addiction
Skin Tumors and Ulcers
1. Tumors
1. Benign (e.g., epidermal inclusion cyst)
2. Premalignant (e.g., actinic keratosis)
3. Malignant (e.g., melanoma)
2. Ulcers
1. Vascular (e.g., arterial insufficiency)
2. Infectious (e.g., bacterial)
3. Autoimmune (e.g., vasculitis)
4. Pressure ulceration
5. Tumors (e.g., Marjolin's ulcer)
6. Toxic (e.g., spider bite)
Skin Rash
Causal conditions Back to Top
1. Macules
1. Exanthems (e.g., infectious, drugs)
2. Photo-distributed macules (e.g., drugs, photoallergy)
3. Hypopigmented macules (e.g., tinea versicolor, vitiligo)
4. Hyperpigmented macules (e.g., purpura, melanoma)
2. Papules
1. Isolated
1. Tumors (e.g., dermatofibroma, basal cell carcinoma)
2. Infections (e.g., fungal, pyogenic granuloma)
3. Keratoses (e.g., actinic, keratoacanthoma)
2. Eruptions
1. Acne (e.g., rosacea,vulgaris)
2. Dermatitis (e.g., seborrheic, contact, atopic)
3. Infections (e.g., molluscum contagiosum, folliculitis)
4. Systemic conditions (e.g., urticaria, vasculitis)
5. Arthropod bites (e.g., scabies, pediculosis)
6. Drug eruptions
3. Plaques
1. Infections (e.g., fungal, lyme disease)
2. Systemic conditions (e.g., acanthosis nigricans)
3. Other dermatologic (e.g., eczema, psoriasis)
4. Blisters
1. Vesicles, bullae, and pustules
1. Infections (e.g., herpes simplex virus, impetigo, varicella virus)
2. Other (e.g., contact dermatitis, Stevens-Johnson)
Urticaria, Angioedema
1. Idiopathic
2. Associated with identifiable causes
1. Allergic (e.g., drugs, insects, food)
2. Direct mast cell release (e.g., opiates, radio-contrast agents)
3. Complement-mediated (e.g., serum sickness, infections)
4. Physical (e.g., dermatographism, cold)
5. Other (e.g., mastocytosis, hereditary angioedema)
Sleep Disorders

1. Poor sleep environment (e.g., noise)
2. Circadian rhythm disturbance (e.g., jet lag, shift work)
3. Psychiatric factors (e.g., depression, anxiety)
4. Physical disorders (e.g., pain, dyspnea)
5. Obstructive sleep apnea
6. Substance abuse/dependency
7. Primary sleep disorders (e.g., central sleep apnea)
8. Neurologic disorders (e.g., restless legs)
Hypernatremia
1. Water depletion (dehydration)

1. Decreased intake of water (e.g., impaired thirst)
2. Increased loss
1. Renal loss (e.g., osmotic diuresis)
2. Gastrointestinal loss (e.g., diarrhea)
3. Increased insensible loss (e.g., prolonged exercise)
2. Sodium gain (e.g., hypertonic fluid replacement)
Hyponatremia
1. Hyponatremia with normal serum osmolality (e.g., hyperlipidemia)

2. Hyponatremia with high serum osmolality (e.g., hyperglycemia)
3. Hyponatremia with low serum osmolality
1. Total body water low, elevated antidiuretic hormone (ADH) level (e.g.,
gastrointestinal loss, diuretic use)
2. Total body water volume normal (e.g., SIADH, hypothyroidism, adrenal
insufficiency)
3. Total body water high, elevated ADH level (e.g., congestive heart failure,
nephrotic syndrome, cirrhosis)
Sore Throat and/or Rhinorrhea
1. Infections (e.g., viral, bacterial, candidial)

2. Allergic (e.g., chronic allergic rhinosinusitis)
3. Other (e.g., trauma, neoplasm, foreign body)
Smell / Taste Dysfunction
1. Conductive (e.g., inflammatory, neoplastic, congenital)

2. Sensory-neural (e.g., head trauma, viral damage to nerve)
Stature Abnormal (Tall Stature / Short Stature)
causal conditions Back to Top
1. Tall Stature
1. Genetic (e.g., Marfan's syndrome)
2. Endocrine (e.g., excess growth hormone)
2. Short Stature
1. Genetic (e.g., Down syndrome)
2. Systemic disorders (e.g., chronic disease and treatment complications)
3. Environmental
1. Malnutrition
2. Psychosocial deprivation
3. Toxins/drugs
4. Intrauterine growth
Strabismus and/or Amblyopia
1. Esotropia (convergent, internal, cross-eye) -- congenital and acquired

2. Transient (e.g., presents at less than 4 months of age)
3. Idiopathic (esotropia and exotropia)
4. Neurogenic strabismus (e.g., cranial nerve paresis)
5. Myogenic strabismus (e.g., mechanical restriction, neuromuscular junction defect, muscle
disease/inflammation)
6. Sensory strabismus (loss of vision due to organic ocular anomalies causing strabismus)
7. Amblyopia without strabismus
Addictions / Substance Abuse
1. Substance use
1. Stimulants
2. Depressants
3. Other substance
2. Process (behavioral) addictions (e.g., gambling)
3. Adverse childhood or traumatic experiences
4. Epigenetic changes
5. Co-morbid illness (e.g., mental illness, chronic disease states, trauma)
6. Psycho social stressors (e.g., unemployment, social isolation)
Substance Withdrawal
1. Chemical dependency (e.g.,: alcohol, illicit drugs, tobacco, prescription drugs)
Sudden Infant Death Syndrome (SIDS), Apparent Life Threatening Event (ALTE)
The causes of SIDS are generally unknown, although some risk factors have been identified,
including
1. Non-preventable factors (e.g., abnormal arousal/sleep pattern,)

2. Preventable factors
1. Maternal (e.g., smoking,)
2. Neonatal (e.g., prematurity, prone sleep position,)
Many cases of ALTE are idiopathic, but possible causes include
1. Gastrointestinal (e.g., gastroesophageal reflux disease)

2. Central nervous system (e.g., seizure)
3. Respiratory (e.g., infection, airway obstruction)
4. Cardiac (e.g., congenital heart disease)
5. Other (e.g. sepsis, poisoning)
Suicidal Behavior
1. Psychiatric disorder (e.g., depression, schizophrenia)

2. Psychosocial stressors (e.g., divorce, adverse childhood experience)
3. Substance abuse
4. Other (e.g., serious chronic disease)
Syncope and Pre-Syncope
1. Cardiovascular
1. Cardiac arrhythmia
2. Reduced cardiac output (e.g., aortic stenosis, myocardial infarction)
3. Reflex or underfilling (e.g., vasovagal, orthostatic)
2. Cerebrovascular causes (e.g., carotid artery disease, transient ischemic attack)
3. Other
1. Metabolic (e.g., hypoglycemia)
2. Drugs (e.g., anti-hypertensive medications)
3. Psychiatric (e.g., panic disorders)
Hyperthermia
1. Increased heat load

1. Heat stroke
1. Exertional
2. Non-exertional (e.g., age extremes, exposure)
2. Metabolic (e.g., thyroid, malignant hyperthermia)
2. Diminished heat dissipation (e.g., medications and illicit drugs)
Given a patient with hyperthermia, the candidate will

1. elicit a relevant history including the setting and/or predisposing factors;
2. perform physical examination to identify signicant hyperthermia;
1. select investigations for the common possible complications (e.g., renal failure,
arrhythmias);
1. ensure rapid, safe cooling;
2. determine whether the patient requires specialized care.
Fever of Unknown Origin
1. Infections (e.g., tuberculosis)

2. Neoplasms (e.g., lymphoma)
3. Inflammatory (e.g., systemic lupus erythematosus)
4. Other (e.g., toxic, factitious)
Fever in a Neonate, Fever in a Child (Most causes are self-limited viral infections)
1. Febrile illness of short duration (less than 2 weeks)

1. Viral
1. With rash (e.g., measles, varicella)
2. Without rash (e.g., common cold, adenoviral)
2. Bacterial
1. With rash (e.g., meningitis, scarlet fever)
2. Without rash (e.g., septicemia, streptococcal pharyngitis)
3. Other infectious agents (e.g., mycoplasma pneumonia)
2. Prolonged febrile illness (greater than 2 to 3 weeks) –
1. Systemic Disease (e.g., juvenile rheumatoid arthritis, leukemia)
2. Familial-hereditary diseases (e.g., nephrogenic diabetes insipidus)
Fever In The Immune Compromised Host / Recurrent Fever
1. Host defense defects

1. Cellular (e.g., human immunodeficiency virus (HIV), steroids)
2. Humoral (e.g., congenital)
3. Neutropenia (e.g., medication induced)
2. Anatomic barrier defects (e.g., surgery, burns)
3. Others (e.g., splenectomy, diabetes)
Hypothermia
1. Decreased heat production (e.g., hypothyroidism)

2. Increased heat loss (e.g., exposure)
3. Impaired thermoregulation (e.g., neurologic, metabolic, alcohol)
Tinnitus
1. Auditory
1. External/Middle ear (e.g., otitis, wax)
2. Cochlear-vestibular end organ (e.g., medications, otosclerosis, environmental
exposure)
3. Cochlear nerve (e.g., acoustic neuroma)
4. Brainstem/Cortex (e.g., ischemia, infection)
2. Para-auditory (e.g., venous hum, arterial bruits)
Trauma
1. Blunt trauma (e.g., blast injuries, deceleration injuries)

2. Penetrating trauma (e.g., stabbing, shooting)
Abdominal Injuries

Insect Stings and Bites
1. Immediate local reaction (e.g., mosquito bite)

2. Toxic or systemic effects (e.g., anaphylaxis, neurotoxic agents)
3. Infection (e.g., malaria)
Bone or Joint Injury
1. High energy trauma

2. Non-accidental injuries (e.g., domestic violence, child abuse)
3. Falls
4. Repetitive strain injuries (e.g., work related injuries)
5. Pathologic conditions pre-disposing to injury (e.g., osteoporosis, ligamentous laxity)
Fractures and Dislocations
1. Accidental injury
2. Non-accidental injury (e.g., abuse, violence)
3. Repetitive-use injury
4. Pathological conditions predisposing to injury (e.g., osteoporosis)
Chest Injuries

Drowning (Near-drowning)
1. Inability to swim (e.g., overestimation of capability)

2. Risk-taking behavior/boat accidents
3. Alcohol and substance abuse (>50% of adult drowning deaths)
4. Inadequate adult supervision
5. Concomitant clinical difficulties
1. Trauma
2. Seizures
3. Cerebrovascular accident
4. Cardiac event
Facial Injuries
1. Trauma (e.g., blunt, penetrating, crush injury)

2. Burns
Hand and/or Wrist Injuries
1. Damage to tendons (e.g., laceration, tendonitis)

2. Damage to nerves (e.g., carpal tunnel syndrome)
3. Damage to bones and/or joints (e.g., fracture, dislocation)
Head Trauma / Brain Death / Transplant Donations
1. Skull fracture, penetrating injury

2. Hemorrhage, hematoma (subdural, epidural, subarachnoid, shaken baby syndrome)
3. Cerebral contusion
4. Edema (midline shift)
Nerve Injury
1. Compression, stretch
2. Contusion
3. Laceration
Skin Wounds
1. Lacerations
2. Puncture wounds (e.g., bites, needle sticks)
3. Crush injuries
4. Other (e.g., avulsions, abrasions)
Spinal Trauma
1. Traumatic (e.g., fracture/dislocation of vertebral column, penetrating injury)

2. Acute disc rupture
Urinary Tract Injuries
1. Kidney
2. Bladder and urethra
1. Distal urethra (e.g., straddle injuries bicycle riding, monkey bars)
2. Proximal urethra/bladder (e.g., pelvic fracture, abdominal injury)
Urinary Tract Injuries
1. Kidney
2. Bladder and urethra
1. Distal urethra (e.g., straddle injuries bicycle riding, monkey bars)
2. Proximal urethra/bladder (e.g., pelvic fracture, abdominal injury)
Fractures and Dislocations
1. Accidental injury
2. Non-accidental injury (e.g., abuse, violence)
3. Repetitive-use injury
4. Pathological conditions predisposing to injury (e.g., osteoporosis)
Dysuria, Urinary Frequency and Urgency, and/or Pyuria
1. Urinary tract infection (e.g., cystitis, urethritis, prostatitis, pyelonephritis)

2. Non-infectious urinary tract inflammation (e.g., traumatic, interstitial cystitis, bladder
carcinoma, bladder stones, urethral stricture)
3. External to lower urinary tract (vulvo-vaginitis)
Polyuria and/or Polydipsia
1. Water diuresis
1. Excessive intake
2. Excessive loss - diabetes insipidus
2. Osmotic diuresis
1. Sugar - diabetes mellitus
2. Urea - chronic renal disease
3. Salts - organic anions
Urinary Tract Obstruction
1. Upper Urinary Tract

1. Intrinsic (e.g., calculi, neoplasm, stricture, clot)
2. Extrinsic (e.g., bowel, cervical or prostate cancer, lymphoma, retroperitoneal
fibrosis)
2. Lower Urinary Tract
1. Congenital (e.g., urethral valves and strictures)
2. Acquired (e.g., benign prostatic hypertrophy, urethral strictures, stones,
malignancy)
Vaginal Bleeding, Excessive/Irregular/Abnormal

1. Pre-menarchal (e.g., trauma, sexual abuse)

2. Pre-menopausal
1. Ovulatory
1. Inter-menstrual (e.g., oral contraceptive, benign growths)
2. Menorrhagia
3. Neoplasms-Coagulation disorders
4. Other (e.g., endometritis, hypothyroidism)
2. Anovulatory
1. Age related-Endocrine/Metabolic (e.g., thyroid)
2. Neoplasms (e.g., prolactinoma, ovarian tumor)
3. Other (e.g., polycystic ovary, weight loss/exercise/stress, structural
disease)
3. Pregnancy-related
3. Post-menopausal-Structural/Systemic
1. Genital tract disease (exclude trauma)
2. Systemic disease
3. Drugs (e.g., hormone replacement therapy, anticoagulants)
Vaginal Discharge / Vulvar Pruritis / Sti
1. Physiologic discharge and cervical mucus production

2. Non-physiologic
3. Genital tract infections
4. Genital tract inflammations (e.g., irritants)
Child Abuse
1. Physical abuse
2. Mental abuse
3. Sexual abuse
4. Emotional abuse
5. Neglect
6. Exposure to domestic violence
Elder Abuse

1. Physical abuse
2. Sexual abuse
3. Emotional or psychological abuse
4. Financial or material exploitation
5. Neglect (e.g., physical, social, emotional)
Adult Abuse / Intimate Partner Abuse
Causal Conditions
Abuse may be classified into several types:
1. Physical abuse
2. Psychological abuse
3. Emotional abuse
4. Social isolation
5. Sexual abuse
6. Economic
Acute Visual Disturbance/Loss
1. Painless
1. Vascular (e.g., retinal artery occlusion, giant cell arteritis)
2. Neurologic (e.g., optic neuritis)
3. Retinal (e.g., retinal detachment)
4. Other (e.g., conversion disorders)
2. Painful
1. Glaucoma
2. Inflammatory (e.g., uveitis, corneal ulcer)
3. Other (e.g., traumatic)
Chronic Visual Disturbance / Loss
1. Glaucoma
2. Cataract
3. Macular degeneration
4. Retinopathy due to chronic illness
Vomiting and/or Nausea
1. Gastrointestinal system
1. Esophagus/Stomach/Duodenum (e.g., obstruction, gastroenteritis, reflux,
gastroparesis, peptic ulcer disease)
2. Small bowel/Colon (e.g., acute infectious enteritis, obstruction, inflammatory
bowel disease, neoplasm)
3. Hepato-biliary disease or pancreatic disease (e.g., acute hepatitis / pancreatitis /
cholecystitis)
4. Peritoneal irritation (e.g., appendicitis)
2. Central nervous system
1. Increased intracranial pressure (e.g., infection, trauma, tumor)
2. Vestibular nerve lesions
3. Brain stem lesions
4. Psychiatric/Psychological conditions
3. Other
1. Endocrine and/or metabolic (e.g., diabetes, hypercalcemia, pregnancy)
2. Cancer
3. Sepsis (e.g., pyelonephritis, pneumonia)
4. Drugs and toxins (e.g., chemotherapy, food poisoning)
5. Miscellaneous (e.g., acute myocardial infection, uremia)
Weakness, Paralysis, Paresis, and/or Loss Of Motion
1. Objective muscle weakness

1. Generalized
1. Myopathies (e.g., muscular dystrophy, inflammatory, metabolic)
2. Neuromuscular junction disorders (e.g., myasthenia gravis, botulism)
3. Peripheral neuropathies (e.g., diabetic, alcoholic, genetic, toxic,
medication-induced; Guillain-Barré syndrome, B12 vitamin deficiency)
4. Anterior horn cell involvement (e.g. amyotrophic lateral sclerosis, polio,
West Nile syndrome)
2. Localized or Regional
1. Upper motor neuron disease of the spinal cord and/or brain: (e.g., stroke,
multiple sclerosis, cancer, abscess, trauma)
2. Peripheral neuropathies (e.g., diabetes, vasculitis, local compression,
radiculopathy)
2. Chronic illness (e.g., cardio-pulmonary, anemia, infection, malignancy)
3. Depression
4. Deconditioning
5. Conversion disorder
Weight Gain, Obesity

(list non exhaustive, generally multifactorial)
1. Increased energy intake

1. Dietary (e.g., progressive hyperphagic, frequent eating, high fat diet, overeating)
2. Social and behavioral (e.g., socioeconomic, psychological)
3. Iatrogenic (e.g., drugs, hormones, hypothalamic surgery)
2. Decreased energy expenditure (e.g., sedentary lifestyle, smoking cessation)
3. Neuroendocrine (e.g., hypothyroidism, Cushing syndrome, polycystic ovarian syndrome)
1. Genetic (e.g., Prader-Willi)
2. Epigenetic
Weight Loss / Eating Disorders / Anorexia
1. Decreased nutritional intake

1. Psychiatric disease (e.g., anorexia nervosa, bulimia)
2. Medical disease (e.g., chronic illness, esophageal cancer)
3. Illicit drugs or medications (e.g., alcohol, opiates, cocaine, amphetamines,
anticancer)
2. Increased energy expenditure
1. Hormonal (e.g., hyperthyroidism)
2. Chronic illness (e.g., chronic obstructive pulmonary disease, congestive heart
failure)
3. Malignancy
4. Infection
5. Excessive physical activity (e.g., runners)
3. Caloric loss
1. Malabsorption (e.g., diarrhea)
2. Diabetes
Intrauterine Growth Restriction
1. Maternal (e.g., nutritional status)

2. Fetal (e.g., genetic syndrome, intra-uterine infection)
3. Placental (e.g., maternal smoking
White Blood Cells, Abnormalities of
1. Leukocytosis
1. Reactive (e.g., bacterial infection, infectious mononucleosis)
2. Neoplastic (e.g., leukemias)
2. Leukopenia
1. Increased destruction (e.g., bacterial infection, human immunodeficiency virus)
2. Decreased/Ineffective production (e.g., marrow suppression)
3. Leukocyte dysfunction (e.g., HIV, chronic granulomatous disease)

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1.

1. Exudative: Low serum-to-ascites albumin gradient (e.g., peritoneal

Abdominal / Pelvic Mass

Hepatomegaly, enlargement of the liver, is an uncommon but importsnt clinical presentation.

1. Congestive (e.g., right heart failure)

1. Congestive (e.g., cirrhosis)

Hernia (Abdominal Wall and Groin)

Abdominal Pain (Children)

Acute Abdominal Pain

1. Upper abdominal region

Allergic Reactions and Atopy

Allergic reactions may be present with the following clinical manifestations:

Given a patient with an allergic reaction, the candidate will

1. list and interpret critical clinical findings, including

Attention, Learning, and School Problems

-Causal Conditions Back to Top

1. Developmental disorders (e.g., attention deficit hyperactivity disorder [ADHD] , learning

Upper Gastrointestinal Bleeding

-Causal Conditions Back to Top

1. Ulcerative or erosive processes

Lower Gastrointestinal Bleeding

-Causal Conditions Back to Top

1. Colorectal cancer or polyps

1. list and interpret critical clinical findings, including

Blood in Sputum (Hemoptysis)

-Causal Conditions Back to Top

Blood in Urine / Hematuria

Causal Conditions Back to Top

Causal Conditions Back to Top

-Causal Conditions Back to Top

1. Neonates and young infants

Hypertensive Disorders of Pregnancy

-Causal Conditions Back to Top

-Causal Conditions Back to Top

1. Cardiac output diminished

Breast Lump, Breast Cancer Screening

-Causal Conditions Back to Top

-Causal Conditions Back to Top

-Causal Conditions Back to Top

-Causal Conditions Back to Top

-Causal Conditions Back to Top

1. Coronary artery disease

Non-cardiac causes (e.g., pulmonary embolus)

Given the patient with cardiac arrest, the candidate will

-Causal Conditions Back to Top

Bleeding Tendency, Bruising

-Causal Conditions Back to Top

1. Disorders of primary hemostasis

Venous Thrombosis, Hypercoagulable State

Causal Conditions Back to Top

1. Congenital (e.g., sickle cell anemia)

-Causal Conditions Back to Top

Causal Conditions Back to Top

1. Neonate and Infant

-Causal Conditions Back to Top

-Causal Conditions Back to Top

Causal Conditions Back to Top

1. Central cyanosis or hypoxemia

Causal Conditions Back to Top

1. Congenital (lower limb, spine)

-Causal Conditions Back to Top

1. Global developmental delay

Adults with Developmental Disabilities