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ABG analysis in four steps

    ABG analysis in four steps
             By Dr. Shami Bhagat (SKIMS)

      ABG analysis is a diagnostic test
that helps you assess the effectiveness
of your patient’s ventilation
and acid-base balance. The results
also help you monitor your patient’s
response to treatment. ABG
analysis provides several test results,
but only three are essential
for evaluating acid-base balance:
pH, PaCO2, and HCO3

-. Memorize these normal values for adults:
• pH: 7.35 to 7.45
• PaCO2: 35 to 45 mm Hg
• HCO3 -: 22 to 26 mEq/L.

Remember, the key to interpreting
ABG values at the bedside is
consistency. Follow these four simple steps every time:

• Step 1. List the results for the
three essential values: pH, PaCO2,
and HCO3-.
 pH =7.15
PaCO2 = 30mmHg
HCO3-. = 10meq/l

• Step 2. Compare them with
normal values. If a result indicates
excessive acid, write an A next to it. If a result indicates
excessive base, write a
B next to it. And if a result indicates
a normal balance, write
an N next to it. The pH will
tell you whether the patient
has acidosis or alkalosis.

pH =7.15                     A
PaCO2 = 30mmHg    B
HCO3-. = 10meq/l    A

• Step 3. If you’ve written the same
letter for two or three results, circle them. If you circle pH and
PaCO2, your patient has a respiratory
disorder. If you circle pH
and HCO3
-, your patient has a
metabolic disorder. If you circle
all three results, your patient has
a combined respiratory and
metabolic acid-base disturbance.
pH =7.15                     (A)
PaCO2 = 30mmHg    B
HCO3-. = 10meq/l    (A)
Here, pH =7.15          (A)
HCO3-. = 10meq/l    (A)

• Step 4. To check for compensation,
look at the result you didn’t
circle. If it has moved from
the normal value in the opposite
direction of those circled,
compensation is occurring. If
the value remains in the normal
range, no compensation has occurred.


Once compensation is
complete, the pH will return to

Keep in mind that several factors
can make ABG results inaccurate:
• using improper technique to
draw the arterial blood sample
• drawing venous blood instead of
arterial blood
• drawing an ABG sample within
20 minutes of a procedure, such
as suctioning or administering
respiratory treatment
• allowing air bubbles in the
• delaying transport of the sample
to the lab.

Case history 1
Mary Barker, 34, comes to the
emergency department (ED) with
acute shortness of breath and pain
on her right side. She smokes one
pack of cigarettes a day and recently
started taking birth control
pills. Her blood pressure is 140/
80 mm Hg; her pulse is 110
beats/minute; and her respiratory
rate is 44 breaths/minute. Her
ABG values are as follows:
• pH: 7.50
• PaCO2: 29 mm Hg
• Partial pressure of arterial oxygen
(PaO2): 64 mm Hg
• HCO3
-: 24 mm Hg
• Oxygen saturation (SaO2): 86%.
Interpretation: These ABG values
reveal respiratory alkalosis without
compensation. The patient’s pH
and PaCO2 are alkalotic, and her
- is normal, indicating no
compensation. You would administer
oxygen (O2) therapy, as ordered,
to increase SaO2 to more
than 95%; encourage the patient to
breathe slowly and regularly to decrease
CO2 loss; administer an analgesic,
as ordered, to ease pain; and
support her emotionally to decrease
anxiety. Based on the clues, the
probable underlying cause is pulmonary
Case history 2
John Stewart, 22, is brought to the
ED for an overdose of a tricyclic
antidepressant. He’s unconscious
and has a respiratory rate of 5 to 8
breaths/minute. His ABG values are
as follows:
• pH: 7.25
• PaCO2: 61 mm Hg
• PaO2: 76 mm Hg
• HCO3
-: 26 mm Hg
• SaO2: 89%.
Interpretation: These ABG values
reveal respiratory acidosis without
compensation. The patient’s pH and
PaCO2 are acidotic, and his HCO3
- is
normal, indicating no compensation.
You would administer O2, as ordered.
The patient may be intubated
to protect his airway and placed on
a mechanical ventilator. You would
also treat the underlying cause by
performing gastric lavage and administering
activated charcoal. This
patient’s condition may progress to
metabolic acidosis. If so, you would
give sodium bicarbonate to reverse
the acidosis.

Case history 3
Steve Burr, 38, has type 1 diabetes.
He hasn’t been feeling well
for the last 3 days and hasn’t eaten
or injected his insulin. He’s
confused and lethargic. His respiratory
rate is 32 breaths/minute,
and his breath has a fruity odor.
His serum glucose level is 620
mg/dL. While receiving 40% O2,
his ABG values are:
• pH: 7.15
• PaCO2: 30 mm Hg
• PaO2: 130 mm Hg
• HCO3
-: 10 mm Hg
• SaO2: 94%.
Interpretation: These ABG values
reveal metabolic acidosis with
partial respiratory compensation.
The patient’s pH and HCO3
- indicate
acidosis. His PaCO2 is lower
than normal, reflecting the lungs’
attempt to compensate. Because
pH is abnormal, you know compensation
isn’t complete.

ABG values only
Try interpreting this set of ABG values
without a clinical scenario:
• pH: 7.49
• PaCO2: 40 mm Hg
• PaO2: 85 mm Hg
• HCO3
-: 29 mm Hg
• SaO2: 90%
Interpretation: These values reveal
uncompensated metabolic alkalosis.
The pH and HCO3
- indicate
alkalosis. PaCO2 is normal, indicating
no compensation.

Now, interpret these values:
• pH: 7.25
• PaCO2: 56 mm Hg
• PaO2: 80 mm Hg
• HCO3
-: 15 mm Hg
• SaO2 : 93%
Interpretation: These values reveal
mixed acidosis. The pH, HCO3
and PaCO2 all indicate acidosis.

Causes of acid-base imbalances at a glance
Listed below are specific causes of the four acid-base disorders.

1. Respiratory acidosis:

The primary problem is alveolar hypoventilation (increased partial pressure of arterial carbon dioxide [PaCO2]), which may result from:

• acute pulmonary edema
• central nervous system depression
• chronic respiratory disease
• disorders of respiratory muscles and chest wall
• inadequate mechanical ventilation
• oversedation
• severe pulmonary infections.
2. Respiratory alkalosis
The primary problem is alveolar hyperventilation (decreased PaCO2), which may result from:

• anxiety
• early sepsis
• excessive mechanical ventilation
• exercise
• fear
• heart failure
• hypermetabolic states such as fever
• hypoxemia
• liver failure
• pain.

3. Metabolic acidosis

The primary problems are increased acid and decreased bicarbonate (HCO3-).

Increased acid results from:

• anaerobic metabolism
• hyperalimentation
• ketoacidosis
• renal failure
• salicylate intoxication
• severe sepsis
• starvation.

Decreased HCO3- results from:

• anhydrase inhibitors such as acetazolamide
• diarrhea
• hyperkalemia
• intestinal fistulas.

4. Metabolic alkalosis

The primary problems are increased HCO3- and decreased acid. Increased HCO3-
results from:

• excessive ingestion of antacids
• excessive use of bicarbonate
• lactate administration in dialysis.

Decreased acid results from:
• hyperaldosteronism
• hypokalemia
• hypochloremia
• loop or thiazide diuretics
• nasogastric suction
• steroids
• vomiting.

  1. Get a blood gas. Put it in ice, send it to the lab.
  2. Look at pH: Less than 7.4? Acidosis. Greater than 7.4? Alkalosis.
  3. Look at pCO2 and bicarb. Do they move in the same direction as the pH, or the opposite direction? (Nl pCO2 = 40, nl bicarb = 24.) If they move in the saME direction, it’s primary MEtabolic. If they move in a diffeREnt direction, it’s primary REspiratory.
  4. Is the non-primary system compenstating appropriately? (Calculate that with those annoying equations I can never remember.)
  5. Is there an anion gap? (Na – Cl – bicarb > 12) If no, you’re done.
  6. If yes, take the anion gap – 12. Add that to the bicarb level. If it’s greater than 26, you’ve got a metabolic alkalosis as well. If it’s less than 22, you’ve got a non-anion gap metabolic acidosis, too. Classic pimping: You can have 3 disorders co-existing, but not 4. (Your lungs can either be making respiratory acidosis or alkalosis, not both.)
And on to the mnemonics for the causes:
Anion Gap Metabolic Acidosis: MUDPILERS
  • Methanol
  • Uremia
  • DKA/Alcoholic KA
  • Paraldehyde
  • Isoniazid
  • Lactic Acidosis
  • Etoh/Ethylene Glycol
  • Rhabdo/Renal Failure
  • Salicylates
Non-Anion Gap Acidosis: HARDUPS
  • Hyperalimentation
  • Acetazolamide
  • Renal Tubular Acidosis
  • Diarrhea
  • Uretero-Pelvic Shunt
  • Post-Hypocapnia
  • Spironolactone
Acute Respiratory Acidosis (Chronic Respiratory Acidosis = COPD/restrictive lung dz): any hypoventilation state
  • CNS Depression (drugs/CVA)
  • Airway Obstruction
  • Pneumonia
  • Pulmonary Edema
  • Hemo/Pneumothorax
  • Myopathy
Metabolic Alkalosis: CLEVER PD
  • Contraction
  • Licorice*
  • Endo: Conn’s/Cushing’s/Bartter’s)*
  • Vomiting
  • Excess Alkali*
  • Refeeding Alkalosis*
  • Post-hypercapnia
  • Diuretics
* = Associated with High Urine Cl levels
Respiratory Alkalosis: CHAMPS (think speed up breathing)
  • CNS disease
  • Hypoxia
  • Anxiety
  • Mech Ventilators
  • Progesterone
  • Salicylates/Sepsis

Differential Diagnosis Mnemonics

A Differential Diagnosis Mnemonics Handbook - and the Parts of the Medical History
By Allan Platt, PA-C, MMSc
Mnemonics are memory tools to help in the memorization of long lists. These differential diagnosis and medical history mnemonics are intended to aid memorization. These mnemonics are not all inclusive and should be used in conjunction with standard textbooks of medical diagnosis and differential diagnosis. The electronic text in PDF or word has hyperlinks to navigate.
Acute Abdominal Pain: "Bad Gut Pain"
Females Acute With Pelvic Pain: "Ectopic"
Amylase elevation – “Parotid”
Anemia: Macrocytic = "Big Fat Red Cells"
Normocytic = "Normal Size"
Microcytic = "Tics”
Hemolytic = "Hematologists"
Arthritis – “ Arthritics”
Arthritis Autoimmune – “Suppress”
Atrial Fibrillation – “Irregular P Waves”
Back Pain : "Disk Mass"
Bradycardia – “Bradycardias”
Chest Pain: "An Aching Heart Can Play A Part"
Clotting Disorders “Calf Dips” and “5Ps Had Caused Clots”
Clubbing: “Club”
Coma - Altered Mental Status : "Acute Clouding"
Cough: "Hacking"
Cramps in muscles – “Cramps”
Dementia – “Dementias”
Diarrhea: "Diarrheal"
Disseminated Intravascular Coagulation – “DICs”
Dyspnea – “Acute Dyspnea”
Ear Ache: "Otitis"
Eye Inflammation - Red Eye: "Iritis"
Headache: "Vint Heent"
Hematuria – “ Pops Got Hematuria”
Hemoptysis – “Hemoptysis”
Hiccups (Prolonged) – “Hiccups”
Hoarsness – “Hoarseness”
Hypercalcemia – “Calcemias”
Hypertension "Pressure"
Jaundice: "Hot Thined Sap"
Metabolic Acidosis: “ Kussmal”
Nasal Congestion: "Nose Hairs"
Nodules – “Nodular”
Palmar Rash – “Palm Grease”
Pancreatitis – “Pancreatitis”
Pedal Edema/bilateral – “Can Large Legs Ruin Thin Veins?”
Pedal Edema/unilateral – “Big Toes”
Pericarditis – “Pericarditis”
Pharyngitis: "Throat Pain"
Pleuritic Chest Pain – “5 Ps”
Pruritis: "Itching”
Seizures – “Grand Mals”
Shock – “AMS and Crash” Dr.Shami Bhagat
Shoulder Pain – “Capsulitis”
Sickle Cell Disease Complications – “HBSS Pain Crisis”
Stridor – “Gasper”
Syncope – “Syncopal Faint”
Urinary Frequency "Voided"
Vaginitis: "Vag Itch"
Vertigo – “Sick Spin”
Wheezing – “Asthmatic”
Parts of the Medical History
Chiefly History in the Past tells your Family Social Review
CC - Chief Complaint - quote patient x duration
HPI – History of the Present Illness with “LOCATES”
PMH – Past Medical History with “A History”
FH – Family History with Genetics and household contact
SH – Social History with the “Flames”
ROS – Review of Systems
Emotions and Difficult Interviews
Anger – “Anger”
Fear/Anxiety – “Afraid”
Depressed – “ Flat line and Grasp”
Demanding/Dependant – “Reflects”
Rambling – “Lost”
Quiet – “Open”
Setting the Stage – “Knocks Privately”
Facilitating the Interview – “I can keep interest going”
Giving Bad news – “Stop and Pray”
B - Bowel obstruction
A - Appendicitis, Adenitis (mesenteric)
D - Diverticulitis
Diabetic Ketoacidosis
Dysentary/Diarrhea Drug withdrawal
G - Gastroenteritis
Gall bladder disease/stones/
U - Urinary tract obstruction (stone)
infection (pyelo/cystitis)
T - Testicular Torsion
Toxin - Lead, black widow spider bite
P - Pneumonia/Pleurisy
Perforated bowel/ulcer
A - Abdominal aneurysm
IN - Infarcted bowel
Infarcted myocardium (AMI)
Incarcerated hernia
Inflammatory bowel disease
S - Splenic rupture/infarction
Sickle cell pain crisis
sequestration crisis Index
* For FEMALES with acute PELVIC pain, think "ECTOPIC" as well as the above causes
E - Ectopic (This is your priority rule out always)
C - Cyst rupture (corpus leutium cyst rupture)
T - Torsion of ovary or cyst
O - Ovulation: Mittelschmerz
P - Pelvic Inflammatory Disease,
salpingitis, tubo - ovarian abscess
I - Incomplete abortion
C - Cystitis/pyelonephritis Index
P - Pancreatitis acute and chronic
Pancreatic pseudocyst
Parotitis (mumps, alcohol, any
parotid inflammation)
Perforated bowel
A - Abdominal trauma, Acute burns
R - Ruptured ectopic pregnancy
Renal failure
O - Obstructed intestines
T - Tumor of pancreas, lung, ovary, esophagus
I - Infarcted bowel
D - Diabetic ketoacidosis
Drug - Morphine/Demerol Index
B-B12 Malabsorbtion
G-Gastrointestinal disease or surgery
F-Folic Acid Deficiency
T-Thiamin responsive
R-Reticulocytes miscounted as large RBCs
E- Endocrine - hypothyroid
C-Chemotherapeutic Drugs
E-Erythro Leukemia
L- Liver Disease
L- Lesch-Nyhan Syndrome
S-Splenectomy Index
N - Normal Pregnancy
O - Over hydration
R - Renal Disease
M - Myelophthistic
A - Acute Blood loss
L - Liver Disease
SI - Systemic Infection or Inflamation
Z - Zero production - Aplastic
E - Endocrine: Hypothyroid, hypoadrenal,
decreased androgen Index
T - Thalassemias
I - Iron Deficiency: Source: GI Bleed 56%
Menses 29%
Diet 19%
C - Chronic Inflammation
S - Sideroblastic -lead toxicity Index
H - Hemoglobinopathy: Hb SS, SC, S beta Thal
Hemoglobinuria: Paroxysmal Nocturnal Hemoglobinuria.
E - Enzyme Deficiency- Inherited Pyruvate Kinase (PK) deficiency and pyrimidine-5'-nucleotidase deficiency
M - Medication - Drug induced immune hemolytic anemias
A - Antibodies, autoimmune
T - Trauma to the red cells. Fragmentation (Microangiopathic)
O - Ovalocytosis - This is an autosomal dominant disorder seen in people from South East Asia. Signs and symptoms are minimal.
L - Liver disease .
O - Osmotic fragility in Hereditary spherocytosis and in Hereditary Eliptocytosis
G - Glucose - 6 - Phosphate Dehydrogenase Deficiency (G6PD)
I - Infection: Intra-erythrocytic parasites (malaria and babesiosis)
S - Splenic destruction in hyperslenism. Splenomegaly,
T - Transfusion related
- Thalassemias - Index
A - Autoimmune Arthritis
R - Rheumatic Fever
T - Trauma Acute or Chronic (DJD)
H - Hepatitis Type B
Hypertrophic Pulmonary
R - Reiter's Syndrome
I - Infection/Septic Joint (GC,SBE)
T - Treponema - Lyme Disease,
I - Infarction :sickle cell disease, avascular
necrosis, Osteochondritis Dessicans
C - Crystals: Gout (urate) and pseudogout
S - Sarcoidosis
Serum Sickness Index
U - Ulcerative Bowel Disease
P - Psoriasis
P - Polymyositis - Dermatomyositis
R - Rheumatoid and Juvenile RA
E - Erythema Nodosum
S - Scleroderma
S - Sjogrens
Sponylitis/Ankylosing Index
I - Infarction: myocardial
Intoxication ETOH
R - Rheumatic Heart Disease
R - Recent Thoracotomy
E - Endocrine - Hyperthyroid
G - Geriatric
U - Unknown - Idipathic
L - Lung Disease - COPD
A - Atherosclerotic Heart Disease
R - Reduced Oxygen - Hypoxia
P - Pericarditis
W - Worry/Stress
A - Atrial Septal Defect
V - Valvular Lesion - Mitral
E - Embolus - Pulmonary
S - Systemic Arterial Hypertension Index
D - Degeneration: DJD, Osteoporosis, Spondylosis
I - Infection: UTI, PID, Potts, Osteo, Prostatitis
- Injury/Fracture, compression fracture
S - Spondylitis, Ankylosing
- Spondyloarthropathies (Rheumatoid,
Reiters, SLE.....)
K - Kidney stones/infarction-infection (Pyelonephritis /abscess)
M - Multiple Myeloma, - Metastasis from breast,
prostate, lung, thyroid, kidney CA
A - Aneurysm - Abdominal
S - Slipped Disk, Spondylolisthesis,
Spinal Stenosis
S - Strain, Scoliosis/lordosis - Skin: Herpes Zoster Index
B - Beta Blockers
R - Rising intracranial pressure
A - Athlete
D - Digoxin intoxication
Y - Yellow jaundice Biliary obstruction
C - Carotid sinus sensitivity
A - Acute nephritis with hypertension
R - Reserpine
D - Decreased thyroid hypothyroid
Decreased temperature hypothermic
I - Infections: mycoplasma, diphtheria, influenza
Infarction/myocardial usually inferior
A - A-V node dysfunction/Blocks
S - S-A node dysfunction
Sick sinus syndrome Index
*CHEST PAIN: "An Aching Heart Can Play A Part"
A - ANXIETY: Hyperventilation
Syndrome (Diagnosis of exclusion!)
H - HEART: Angina - effort and spasm
Acute Myocardial Infarction
Valvular - AI,MS,MVP,IHSS
C - CHEST WALL PAIN: Trauma, Fracture
strain, Herpes Zoster, costochondritis,
Tietzie's syndrome, Breast lesions
P - PLEURITIC PAIN: "Five P's of pleuritic pain"
Pericarditis, Pulmonary Embolus, Pneumothorax
Pleurisy: infiltrate or inflammation, Pneumomediastinum
A - ABDOMINAL CAUSES: Peptic Ulcer Disease, gall stones
Esophagitis, Reflux, Pancreatitis
Bleeding too much – CALF DIPS
C - Cirrhosis/Liver Disease and Coumadin
A - Aspirin and other drugs NSAIDs
L - Leukemia, Lupus anticoagulant
F - Factor Deficiency – Hemophilia
D - Disseminated Intravascular Coagulation
I - Idiopathic Thrombocytopenic Purpura
P - Platelet Deficiency (TTP, HUS, DIC, Heparin- HIT) or
Platelet Dysfunction (vWD)
S - Scurvy: Vitamin C Deficiency Index
Clotting too Much – “5 Ps HAD CAUSED CLOTs”
P - Pregnancy - Increased blood viscosity, fibrinogen and factor VIII.
Post Partum - Hypercoaguable state
P – Prothrombin 20210 mutation,
P - Protien S, C, deficient – Inherited
P - Polycythemia vera - increased viscosity
P – Paroxysmal Nocturnal Hemoglobinuria
S- Smoking
H – HIT Heparin Induced Thrombocytopenia
A – Antithrombin III Deficiency
D – Dysfibrinogenemia
C – CHF or Congestive Heart Failure
A – Antiphospholipid Syndrome
U – Uremia – Chronic Renal Failure
S – Surgery – Orthopedic is greatest risk
E – Estrogen
D – Diabetes
C - Cholesterol elevation, Cancer - procoagulant effects,
L – Leiden Factor V mutation – Activated Protein C resistance
O – Obesity and Cholesterol elevation
T - Trauma, Travel (immobility) - Stasis of blood flow and release of tissue throboplastin in trauma
T – Thyroid disease hyper or hypo
S – Sepsis Index
C - Cardiac: SBE, Congenital heart disease
-Congenital clubbing - benign
L - Lung: Carcinoma, chronic infection (TB..)
U - Ulcerative Bowel disease
B - Biliary Cirrhosis Index
A - Alcohol excess/withdrawal (DTs)
Anemia - acute blood loss (GI,Trauma,....)
C - CVA bleed or blockage
Carbon Monoxide
U - Upper motor Neuron lesion/mass/mets
T - Trauma - subdural, concussion, contusion
Temperature problem, hyperthermia, hypothermia
E - Epilepsy - postictal state or status seizures
Endocrine - hyper/hypo thyroid, hyper/hypo adrenal, hyper/hypo pituitary
Electrolytes - hyper/hypo Na, hyper/hypo Ca, hyper/hypo Mg, hyper/hypo K
C - Cardiovascular - pump failure
- MI, Tamponade, Hypertensive crisis
L - Liver failure (Hepatic encephalopathy)
Lupus cerebritis
O - Oxygen deficiency - hypoxia from any cause
U - Uremia/Renal failure
D - Drugs excess/withdrawal
(dilantin, sedatives, opiates, salicylates)
I - Infection - CNS (meningitis, encephalitis...),
N - Nutritional - Thiamin - Wernicke's encephalopathy
Niacin, B12
G - Glucose -Hypoglycemia/ Hyperosmolar coma Index
H - Hilar adenopathy: Sarcoid, TB, Hodgkins...
A - Aneurysm, Asthma, Bronchospasm
Aspiration, Autoimmune Lung DZ
C - Congestive Heart Failure
Cerumen Impaction
K - Killer Neoplasms
I - Infections: Viral, Bacterial,
TB, Fungal...Pnemonia/Bronchitis
Infarcted Lung - PE
Inhalation - occupational
N - Nasal Drip
G - Growth on vocal cord Index
C - Calcium deficiency
R - Rupture of tendon, Rhabdomyolysis
A - Arterial Insufficiency, claudication
M - Magnesium deficiency, Myotonia
P - Potassium deficiency, Polymyalgia
S - Strain/overuse of muscle Index
D - Drugs: Sedatives, Bromide, Narcotics, Atropine
Dopamine decrease - Parkinson's
E - Endocrine: Hypothyroid,
Hypoglycemia, Hyperparathyroid
M - Metabolic: Renal/Hepatic failure,
E - Emotional
N - Nutritional: Deficient Thiamin, Niacin, B12
Normal Pressure Hydrocephalus
T - Tumor in CNS
Trauma-subdural hematoma
Thyriod - Myxedema
I - Infections: TB, SBE, Crypto, Herpes, AIDS,
Syphilis, Creutzfeldt-Jakob, Mad Cow...
A - Atherosclerosis, CVA, ALS,
S - Sensory Deficit: Hearing or
Vision loss Index
D -Drugs:Laxatives, antibiotics, colchicine,
I - Irritable Bowel Syndrome
Infarction of bowel
Infection: Viral - Most common
Bacterial -Salmonella, Shigella, Campylobacter, Yersinia, C. Difficle
Toxin -Staph, Cholera, Botulism, E.Coli,
Protozoa - Giardia, amebiasis
A - Autoimmune - Ulcerative Colitis, Crohn's
R - Rapid Transit - Dumping Syndrome
R - Renal Failure
H - Hypersecretory -Zollinger Ellison
E - Endocrine -Hyperthyroid, Diabetes, Addisons
A - Absorption Problem - Pancreatic Insufficiency
L - Lesion/Neoplasm Index
D - Disseminated Infection/Sepsis
I - Intrauterine Pregnancy: Toxemia,
Abruptio, Dead fetus
C - Carcinomas
S - Shock , Stroke (Heat) Index
A - Asthma - Airway obstruction
Angioneurotic Edema
Aspiration, Altitude sickness
Carbon Monoxide toxicity
U - Upper Motor Neuron Lesion or Event
T - Tracheal Obstruction, Tamponade
E - Endocrine: Hyperthyroid
Environmental Inhalation
D - Deformed Chest Wall: Flail Chest,
Y - hYperventilation syndrome
S - Sarcoid, Shock
P - 5 P's of Pleuritic Pain:
Pulmonary Embolus,
N - Neoplasm
E - Edema/Pulmonary: Cardiac and
A - Anemia
Acidosis: DKA, AKA, Salicylism Index
O - Other referred pain: parotid, tooth, lymphadenitis
T - TM Joint
I - Infection: Otitis Media/Externa, Bullous Myringitis
T - Trauma: Q-Tip, Blunt injury
I - Impaction: Cerumen, Insect, Foreign Body
S - Syndrome, Ramsey Hunt facial neuralgia Index
I - Increased Pressure: Acute closed angle glaucoma
R - Reduced Tears:Keratoconjunctivitis Sicca
I - Iritis, Iridocyclitis
T - Trauma: Entropion, abrasion, foreign body
I - Infection: Conjunctivitis -
Bacterial, viral, allergic, irritative
,chemical, autoimmune
S - Scleritis/Episcleritis
Subconjunctival hemorrhage Index
Migraine, Cluster, CVA, TIA, AVM, Temporal
Arteritis, SABleed, hypertension,
Meningitis, Abcess, Encephalitis
SYSTEMIC- Viral syndrome
Pseudotumor Cerebri
N - NEOPLASM: Tumor,Mets
T - TRAUMA: Subdural Hematoma
TENSION: Most common HA cause
TOXIN: Carbon Monoxide Toxicity
TAP: post lumbar puncture
H - HEAD: Neuralgia, C - Spine Disease, Scalp Lesions
E - EYE: Acute Closed Angle Glaucoma, Strain
E - EAR: Otitis, Mastoiditis
N - NOSE: Sinusitis
T - TM JOINT: TMJ syndrome
THROAT: URI, Viral syndrome, Bacterial
TAP- Post LP tap Index
P - Papillary necrosis,
Polyarteritis nodosa,
O - Osler-Weber-Randu
P - Prostatitis
S - Stricture
Sickle Cell Disease or Trait
G - Glomerulonephritis
Goodpasture's Syndrome
O - Other Source such as Menstrual Blood
T - Tumor: Bladder, Kidney, Prostate
H - Hemorrhagic Cystitis
E - Exercise, Endocarditis
M - Medication - Analgesics
Malignant Hypertension
A - Autoimmune Disease: SLE, Polyarteritis
T - Trauma to GU Tract
U - Urethritis
R - Renal Calculi
I - Infarction: SBE, Sickle Cell, ITP, TTP
A - Allergic Nephropathies: Henoch - Scholein Purpura Index
H - Hereditary hemorrhagic
E - Epistaxis
M - Mitral stenosis
O - Oropharyngeal lesion
P - Pulmonary Embolus,
Pulmonary Edema
Pulmonary hypertension
T - Tumors, carcinomas
Y - CYstic Fibrosis
S - Sequestration
I - Infection - Bronchitis, Bronchiectasis, fungus,
abcess, pneumonia, TB
S - Swallowed foreign body Index
H - Hilar Adenopathy
I - Intake of excessive Alcohol Smoke
C - Cardiac: Inferior MI
C - Carcinoma
U - Upper Motor Neuron Lesion
P - Pneumonia
S - Subdiaphragmatic Irritation Index
H - Hilar Adenopathy: TB, Sarcoid
O - Occupational: Singer...
A - Aneurysm
R - Rheumatoid Arthritis
S - SLE Ulceration
E - Edema of the Vocal Cords
N - Neoplasm of the Vocal Cords or lung
E - Endocrine: Hypothyroid
S - Sjogrens: Salivary Deficiency
S - Syphilitic/TB Ulcer on cords Index
C - Carcinoma
A - Antacids containing Calcium
L - Lymphoma, Leukemia, Hodgkin's, Low phosphate
C - Calcium Supplements
E - Endocrine: Hyperparathyroid,
Thyroid disease hyperthyroid
M - Multiple Myeloma
Metistatic Lesions to Bone
Milk-alkali syndrome
I - Iatrogenic: Thiazide Diuretics, Vitamin D
A - Addison's Disease, Acromegaly
S – Sarcoid Index
P - Pheochromocytoma;
R - Renovascular (7%)
E - Endocrine: Hyperthyroid,
Cushing, Aldosteronism,
S - Substances: Estrogens (BSP),
Caffeine, Cocaine,
sympathomimetics, ETOH withdrawal
S - Structural: Coarctation, AI,
U - Upper Motor Neuron Problem:
Elevated intracranial pressure
R - Renoparenchymal (0.5%):
Glomerulonephritis, Diabetic nephropathy
E - Essential: 90% of hypertension
Error in cuff size Index
Pre Liver
H - Hemolytic process
O - Other - Idiopathic
T - Transport problem:
Gilbert's Syndrome,
Crigler Najjar Syndrome
T - Toxin: Alcohol, carbon tetrachloride..
H - Hereditary: Dubin Johnson, Roter Syndrome
I - Infection: Viral - A,B,C,D, E, Mono, CMV Toxo, Syphilis, Ameba
N - Neoplasm: Hepatoma, Mets
E - End Stage Liver disease: Cirrhosis
D - Drugs: INH, Halothane, Estrogens, NSAIDS, Acetaminophen, PTU, Sulfas
Post- Liver
S - Stones: Gall stones, Sclerosing cholangitis
A - Atresia
P - Pancreatic neoplasm/inflammation Index
L - Lues: secondary syphilis
Y - Yersinia Pestis (Plague)
M - Mononucleosis/CMV/Toxo
P - Procainamide (Pronestyl), Phenytoin (Dilantin)
H - Hodgkin's, Lymphomas, leukemia
N - Neoplasm metastasis
O - Obvious local infection or inflammation
Other infections: Hepatitis B, Rubella,
Tularemia, Cat scratch
D - Deficient Immune System AIDS or
preAIDS lymphadenopathy
E - Endocrine - Addisons, Hypothyroid
S - SLE/Rheumatoid arthritis
- Serum sickness
- Sarcoid Index
K - Ketoacidosis, DKA
U - Uremia
S - Salicylates
S - Substance Abuse (Ethylene Glycol)
M - Methanol
A - Alcohol, AKA
L - Lactic Acidosis (Shock, Seizure, AMI, Sepsis) Index
N - Neoplasm
O - Over - reactive mucosa
-vasomotor rhinitis
S - Structural: Polyps, Deviated septum
E - Estrogens: Oral contraceptives, Pregnancy
H - Hypothyroidism
A - Allergic rhinitis
I - Infection: Bacterial, Viral, Fungal
R - Rhinitis Medicamentosa: Rebound
From overuse of nasal spray
S - Substances: Reserpine, Aldomet,
Beta- Blockers, Aspirin Index
N - Neurofibromas
O - Osteoarthritic Heberden's nodules
D - Dupuyten's contracture nodules
U - Urate crystals in gouty tophi
L - Lipids in lipomas and xanthomas
A - Acute Rheumatic Fever
R - Rheumatoid nodules Index
P - Psoriasis
A - Atopic Dermatitis
L - Lips: Hand - Foot - Mouth Disease
M - Meningococcemia
G - Gonococcemia
R - Rocky Mountain Spotted Fever
E - Erythema Multiforme
A - Allergic/Contact Dermatitis
S - Syphilis - Secondary Lues
E – Eczema Index
P - Postoperative, Penetrating peptic ulcer,
Parathyroidism, Pregnancy
A - Alcoholism, AIDS
N - Neoplasm of bile duct or ampula
C - Cholelithiasis *common*
R - Renal failure
E - Estrogens, Elevated lipids
A - Antibiotics (TCN, sulfonamides)
T - Trauma
I - Idiopathic, Infection: Mumps, Viral hepatitis, Legionnaire's, Mycoplasma, Ascaris
T - Thiazides, Lasix
I - Infection: Viral mumps, mono, hepatitis
S - Scorpion bite, Shock Index
*PEDAL EDEMA - BILATERAL: "Can Large Legs Ruin Thin Veins"
C - Congestive Heart Failure
Constrictive Pericarditis
L - Liver: Cirrhosis, portal hypertension
L - Lymph obstruction
R - Renal: Nephrotic Syndrome
T - Thyroid: Pretibial Myxedema
V - Venous Insufficiency Index
B - Baker Cyst Rupture, Bleed into muscle
I - Insufficient Veins
G - Groin/Pelvic Mass Obstructing Lymph Flow
- Gout
T - Thrombophlebitis
- Trauma/Fracture/Sprain
- Tendon Rupture - Plantaris Longus or Achilles tendon
O - Osteomyelitis/Cellulitis
E - Elephantiasis - Lymph obstruction
S - Sting/Allergic Reaction to contact or bite Index
P - Post Traumatic
E - Endocrine: Hypothyroid
R - Renal Failure
I - Infection: TB, Viral, Fungal, AIDS, Bacterial
C - Collagen Vascular Disease (SLE, RA)
A - Aneurysm
R - Rheumatic Fever- Radiation
D - Drugs: Hydralazine, Minoxidil, Procainamide
I - Infarction - AMI
TI - Tumor Invasion
S - Syphilis, Scleroderma, Serum Sickness Index
T - Thyroiditis
H - Herpangina ,Hodgkin's
R - Retropharyngeal abscess
O - Oral ulcers: Aphthous, Syphilis,TB, Herpes
A - Angioneurotic edema
T - Toothache/abscess
P - Peritonsillar abscess
A - Angina: Vincent's, Ludwigs
I - Infection: Bacterial -
Streptococcus (Group B and G,),GC
H FLU, Mycoplasma, Diptheria Viral-Mono, CMV, Herpes, Influenza, HIV/AIDS...
Fungal - Candida( Immunosupression)
Other - Syphilis, Chlamydia, Toxic shock
N – Neoplasm Index
P - Pneumothorax
P - Pleurisy from Pneumonia,
Infarction, Inflammation
P - Pulmonary Embolus/Infarction
P - Pneumomediastinum
P – Pericarditis Index
I - Insulin Deficiency: Diabetes
T - Thyroid: Hyper or Hypo
C - Conjugated Bilirubin: Jaundice
- Calcium: Hyper or Hypo
H - Hodgkins, Leukemia, Lymphoma
- Heat: Dry skin, Hyperthyriodism
- Hookworm
I - Increased RBC's: Polycythemia Vera
- Intrauterine Pregnancy
N - Non Organic: Neurodermatitis,
Anxiety, Drugs
G - Glomerular Disease: Uremia Index
G - Glucose too low
R - Rising Blood Pressure, Toxemia - Eclampsia
Rye's syndrome, Renal failure
A - Alcohol Withdrawal
N - Neoplasm, Primary or Mets
Neurological Infections - meningitis
D - Drugs, Overdose or withdrawal
M - Metabolic: Hepatic/Renal Failure, Hypothyroid
A - Arterial Disease: CVA, AVM, TIA, Aortic
Dissection, Arrhythmia
L - Lytes: Hypo Na, Ca, Mg
S - Subdural Hematoma
- Subarachnoid Bleed Index
A - Acute neurologic event/trauma (brain injury)
M - Metabolic/toxic cause (brain insulted from blood born toxin, infection, chemistry imbalance.
S - Shock - Mnemonic "CRASH"
(brain is not receiving blood)
C - Cardiogenic
R - Rapid blood or water loss
A - Anaphylaxis
S - Septic
H - Head injury (BP regulation center) Index
C - Cuff Problem - Rotator Cuff rupture
A - Arthritis (see Differential Diagnosis)
- Avascular Necrosis (Sickle Cell)
P - Plexus Problems - Brachial Plexus
S - Spondylosis - DJD Cervical Spine
with Nerve Root irritation
U - Under Diaphragm Irritation: Free
Air, Blood, Pancreatitis,
Spleen, Cholecystitis, Peritonitis
L - Lung Causes: Pancoast Tumor, PE,
Pulmonary Infarction
I - Ischemia - Cardiac referred.
Arteritis, Atherosclerosis
T - Tendonitis/Bursitis
- Trauma
- Thoracic Outlet Syndrome
I - Inflamed Soft Tissues: Fibrositis
S - Spinal Cord Lesion/Tumor Index
S - Surgery Post Op
I - Infection: CNS - meningitis,
Lung - TB, Fungal, Bacterial
A - Anti - Diuretic Hormone Producing
D - Drugs: Narcotics, Diuretics...
H - Head Lesion CNS trauma, tumor, CVA Index
H - Hemolysis, Hand - Foot syndrome
B - Bone Marrow Hyperplasia/Infarction
S - Skin ulcers (primarily leg)
S - Stroke: Sub Arrachnoid Bleeds/Thrombotic
P - Pain Crisis, Priapism, Psychosocial Problems
A - Aplastic Crisis, Anemia,
Avascular Necrosis
I - Infections: CNS, Bone, Joints, GU, Pulmonary
N - Narcotic side effects/ tolerance/ dependence
C - Cholelithiasis, Cardiomegally,
Congestive Heart Failure
R - Retinopathy, Renal Failure,
Renal concentrating Defect
I - Infarction: Bone, Muscle, CNS,
Bowel, Renal, Spleen
S - Sequestration Crisis: Spleen/Liver
I - Infertility
S - Sepsis Index
G – Glottic blockage: food or foreign body
A – Angioneurotic Edema
S – Sub Glottic lesion nodule or neoplasm
P – Peritonsilar Abscess
E – Epiglottis
R- Retropharyngeal Abscess Index
S- Seizure
Y – hYperventilation, hYsteria
N – Neuropathy (Diabetic)
C – Cardiac : Arrythmia, MI, IHSS, AS, Pump failure
O- Orthostatic syncope
P – Pedal Pooling from venous insufficiency
A – Arterial insufficiency
L- Low Blood Volume: Bleeding, dehydration
F- Fainting – Vasovagal
A – Adrenal Insufficiency (Addisons Disease)
I – Iatrogenic from Medications
N – Nutritional (Not eating, hypoglycemia)
T – Toxin: alcohol and others Index
V - Vaginitis irritating urethra
O - Obstruction: Prostate, Bladder Stone, Cystocele
Osmotic Particles: Protein
I - Intrauterine Pregnancy
- Infection in Urethra, Bladder, Kidney, Appendix
D - Diabetes: Mellitus or Insipidus
E - Electrolytes: Hyper K, Ca, Na
D - Drugs: Caffeine, Diuretics...
- Drinking Excessive Fluids Index
V - Vaginal irritant: Spermicide,
douche, tampon, non - cotton clothing
A - Atrophic vaginitis from estrogen deficiency
G - Gardnerella (Clue cells) Gonococcus
I - Infection: PID, Salpingitis Infestation: Lice...
T - Trichomonas
C - Candida, Carcinoma, Chlamydia
H – Herpes Index
S - Salycilates - aspirin toxicity also other NSAIA
I - Infection: Bacterial - otitis media Viral - labrythitis, Herpes,
C - Cerebellar tumor, TIA, infarct, degeneration
K - Klog: cerumen impaction
S - Subclavian steal, Sea sick - motion
P - Positional vertigo
I - Infrequent: Miniere's disease
N - Neuroma (Acoustic) Index
Asthma, Bronchospasm
S - Smoke or irritant inhalation
T - Thyroid enlargement causing obstruction
H - Heart Failure - Pulmonary Edema
M - Medication (Aspirin, Beta Blocker)
A - Anaphalaxis
T - Tumor, Thyroid
I - Infection: Pneumonia, Bronchitis,
Infarction - Pulmonary Embolus, Sickle Cell Chest Syndrome
C - Cystic Fibrosis Index
*The Medical History - Sections
Chiefly History from the Past tells your Family Social Review (CC, HPI, PMH, FH, SH, ROS)
CC = Chief Complaint in patient's own words and duration.
*HPI = History of Present Illness including the LOCATES:
L – Location and radiation
O - Other associated symptoms
C - Character
A - Alleviating and aggravating factors
T – Timing, constant/intermittent, happened in past
E - Environment or setting
S - Severity or disability (0 - 10 scale)
*PMH = Past Medical History: A HISTORY:
A - Allergies,
H - Hospitalizations,
I – Illnesses /major - Immunizations,
S - Surgeries,
T- Trauma,
O - Oral medications,
R - Reproductive history, contraception
Y - Youth illnesses. Index
* FH = Family History - Pedigree, genetic diseases, household contacts. Cover family history of cancer , diabetes, heart disease, hypertension, anemia, arthritis
*SH = Social History: FLAMES
F - Family, Food
L - Lifestyle
A - Abuse of substances and of the body
M - Marital or significant other relationships.
E - Employment ,
S - Support Systems: home life, friends, family, Religion
Sexual and or Spiritual history if appropriate Index
*ROS Review of Systems:
General Endo-Head Loves Brass, Crass And Gas to Pass Near the Mass.
GEN = General and skin: Weight change, fever/chills, night sweats, Skin rash, itching, mole change, skin cancer, abnormal bleeding or bruising, anemia, pica, HIV risk factors, lymphadenopathy, fatigue,
EN = Endocrine: Hot/cold intolerance, thyroid goiter, nodules or radiation, diabetes, increased thirst or appetite
HE = Head - pain, Ear- pain, tinnitus, hearing loss, vertigo, Eye – pain, vision change, glaucoma, redness, excessive tearing/ discharge, cataracts Nose - sinusitis, epistaxis, blockage, Throat/Mouth- pharyngitis, hoarseness, postnasal drip, Teeth – cavities, abscess, Gums- Bleeding, lesions
LU = Lung : dyspnea, cough, sputum production , hemoptysis, wheezing, TB, PPD, CXR, pneumonia, asthma, bronchitis, smoking, environmental inhalation
BR = Breast: nodule, discharge, chest wall or breast pain – tenderness, self exam
CV = Cardiovascular : Exercise level, orthopnea, PND – paroxysmal nocturnal dyspnea, DOE- dyspnea on exertion, chest pain or discomfort, palpitations, syncope, edema, claudication, CV drugs, hypertension, DVT – blood clots, past heart disease. Rheumatic fever, family history heart disease/clotting. leg/foot ulcers, varicose veins
AB = Abdominal : nausea, vomiting, hematemesis, dysphagia, indigestion, heartburn/ dyspepsia/GERD, abdominal pain, swelling, jaundice, hematochezia, melena, change in stool caliber, diarrhea, constipation, hernias, hemorrhoids, peptic ulcer disease /PUD, surgery, gallbladder disease, pancreatitis, liver disease, hepatitis, alcohol intake.
GU = Genitourinary: urinary frequency, urgency, dysuria, nocturia, hematuria, flow, hesitancy, incontinence, urethral discharge, genital lesions, , STD sexually transmitted diseases, UTIs, stones, flank pain, family history renal disease.
Males: prostate, testicular mass/pain, erectile dysfunction; Females: age at menarche/menopause, LMP, amount and duration of flow, pelvic pain, vaginal discharge, abnormal bleeding, amenorrhea, pelvic mass, pregnancies. Both: birth control method, sexual history.
PSY = Psychiatric: previous psych problems or hospitalizations, interpersonal relationships, mood swings, anxiety/nervousness, depression, hallucinations, loss of control, vegetative dysfunction (sleep, eating, pleasure activities), substance abuse, suicidal thoughts and plans
NE = Neurologic: Headaches, seizures, episodic neurologic symptoms (talking, walking, seeing..)
impaired speech, paresthesias, weakness, head trauma, stroke, dizziness, tremor, confusion, memory loss, gait problems
MS = Musculoskeletal: joint pain/arthritis, stiffness, swelling, muscle cramps, family history.
A - acknowledge and apologize
("I'm sorry you feel angry about this")
N - no negative responses
G - gather the facts - hear person out
E - empathize
R - resolve what you can
*ANXIOUS - The Patient with Fear Index
A. -Acknowledge fear as the emotion seen
F.- Face the object feared
R.- Real or Imagined fears
A. -Allow the patient to vent fears
I.- Infuse with knowledge
D. -Develop plan together to address fears
F - Flat Affect
L - Low love life
A - Apathy
T - Tired
L - Low Self Esteem
I - Insomnia
N - No fun in life
E - Eating Disorders
G - good things in life
R - restore hope
A - acknowledge depression
S - suicidal thoughts and plans
P - plan for support
R- reflect back patient responsibilities
E - empathize
F- find out any hidden agendas
L - limit personal involvement
E - expectations must be clear
C - calm yourself
T - time constraints on interview
S - staff splitting is common Index
L –Limit Time
O – Observe the main reason for the visit
S- Stop the wrong direction gently
T- Take conversation back on track Index
O - Open ended questions
P - Pointed questions
E - Encourage talking
N - Notice secondary causes: depression,
dementia, denial Index
*Setting the Stage: KNOCKS PRIVATELY
K - Knock on the door - do not barge in
N - Never uses titles like "honey" or "sweetie"; use respectful sir titles like Mr., Ms....
O - Open ended questions to start with: "What can I do for you?"
C - Comfort; ask if you can make them more comfortable
K - Keep quiet after asking the main question. Let them respond for at least 2 minutes.
S - Space between bodies. Maintain proper Body Space
P - Privacy. Interview in private if possible, or a look of privacy
R - Read the chart ahead of time. Learn about the individual if you can.
I - Introduction - Introduce yourself and shake hands
V - Voice tone and inflection are important
A - Ask about family, hobbies, or interests as an ice breaker and a show of concern
T - Titles - Use the appropriate sir title for the patient and not first name
E - Eye level, be at eye level
L - Look the part, be professional
Y - Your role on the health care team Index
I - "I'm listening"
C - Confrontation - You say you don't know what brings on these headaches, yet before every episode you describe a stressful event."
A - Ask for clarification "What do you mean by dizziness"
N - No Shopping list questions are banned, like "do you have nausea, vomiting or diarrhea?"
K - Keep Quiet, do not interrupt, use silence to keep the patient talking
E - Empathize: " I understand why you felt that way".
E - Eye contact
P - Phrase repetition; repeat the last phrase back to the patient
I - Interpretation - you interpret your patient's words or behavior, "You say you 're not angry, but your words express anger."
N - Nod in approval
T - "Tell me more"
E - Energize the conversation with hand gestures and face animation.
R - Reflection. Repetition of the last statement
E - Encourage continuation with "Ah ha, Hmmm...."
S - Summarize the conversation back to the individual "Let me repeat your history to see if I have it right."
T - Take notes sparingly
G - Glad you came; legitimize the visit
O - Open ended questions first
I - Involve the patient's ideas about what is going on, "What do you think?"
N - No leading questions, "You don't have chest pain, do you?"
G - "Go on" Index
*Giving Bad News: "STOP AND PRAY
S. Setting the Stage a. Privacy, schedule time, empathy and provide for comfort.
b. Ask patient who they want to be with them, ask permission.
c. Approach as "we've got some decisions to make"
d. Eye contact, speak slowly, clearly, no medical jargon.
T. Test the patient's knowledge up to that point.
O. Oppositions: Is the patient in pain, tired or
under medications?
P. Patient education tools with patient reflection to
show understanding.
A. Acknowledge and validate patient emotions and reactions.
N. Never take HOPE away
D. Define Support Systems
D. Describe unknown support systems:
Hospice, counselors, clergy....
P - Pray: If you are of like faith, offer to pray for
the patient. Prayer keeps hope alive
R - Referrals and follow-up.Make close follow-up appointments
Make consultations and referrals to consultants who will support patient
Let patient know how to reach you (via service or office) Call them at home to support them. Call if questions
A- Alternatives for treatment, study protocols...Medline or Internet resources (NIH, NCI....) Warnings about alternative treatments .Patients on study do better
Y- Your mental health
You need to be comfortable with your mortality. Have a healthy way to vent
Know how to recognize and prevent burn-out Have a good life - remember what is really important.
Thanks to the "Great Physician":
J - Justifies
E - Everyone
S - Seeking
U - Undeserved
S - Salvation (Eternal life, healing, health, deliverance, peace, and provision)