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. A 67 year old man had a sudden severe headache, vomited and then lapsed into a coma. He has a past history of hypertension and diabetes mellitus. On examination he is unconscious. On painful stimulation he moves his left upper and lower extremity in a non-purposeful manner.

Cerebral hemorrhage: ( If headache is severe and of sudden onset, think subarachnoid hemorrhage or meningitis)

A 16 year old woman is being treated for recurring episodes of loss of consciousness. On recovering from the episodes of unconsciousness her tongue is usually sore and she has wet herself. On examination she has gingival hyperplasia.

Epilepsy If there is more than one seizure considers epilepsy which is defined as two or more seizures. Generalized epilepsy begins in childhood or adulthood or adolescence; adult seizures are usually partial

A 20 year old army recruit has fever, sore throat, severe headache and macular rash for 2 days. Several recruits in the same regiment were hospitalized with similar symptoms recently.

Meningitis Fever and stiff neck, or nuchal rigidity, are two of the classic signs
of headache from meningitis. Even without other signs such as rash or
papilledema, they strongly suggest an infectious process.

Secondary Headaches are d/t

infection, brain tumor or metastatic growth in brain, hemorrhage

Primary Headaches

Tension headache
->Most commonly occurring headaches
Cluster Headache
Migraine Headache

hemorrhage symptoms

Diplopia or Double vision & headache

In irritative lesions due to epilepsy
or early cerebral hemorrhage, which way do the eyes look

eyes "look away" from the affected

Seizures -

seizures may be the initial manifestation in 15% of patients with a brain tumor, especially with tumors that are superficial and slow growing. Focal and partial complex seizures are more likely than grand mal seizures

Acute symptomatic seizures

Common causes include head trauma;alcohol, cocaine and other drugs; withdrawl from alcohol benzodiazepines and barbiturates metabolic insults from low or glucose or low calcium or sodium; acute stroke and meningitis or encephalitis

Signs of meningeal irritation

Blood (subarachnoid haemorrhage) , infection (meningitis), Tumor
- Neck rigidity
- Kernig's sign
- Brudzinski's sign

Neck stiffness

-caused by spasm of the cervical muscles leading to tension headache.
-Neck stiffness may also result from meningeal irritation as in meningitis.

A 38-year-old woman has a 2 day history of frequent urination associated with burning and passing blood in her urine. On examination her vital signs are normal. There is no costovertebral angle tenderness, but she is tender in the suprapubic region.

Cystitis Suprapubic pain associated with frequency of urination may be due to cystitis.

Filtration is non selective

Each kidney receives 1/8 of the cardiac output through its renal artery and filters blood through the glomeruli at the rate of about 125ml/minute in an adult.

Nephrolithiasis :

The symptoms of a kidney stone are sudden onset of flank tenderness along with nausea
and vomiting. The patient experiences more colicky-type pain and moves around a lot, in an attempt to alleviate the pain. There may be fever and chills if the stone obstructs the ureter and causes a
urinary tract infection

Acute Pancreatitis

The pain from acute pancreatitis is generally in the epigastric or left upper quadrant, radiating into the back. Although there is vomiting associated with it, there is no diarrhea. patient will be tender but will not generally have a rigid abdomen


acute cholecystitis generally is in the epigastric or right upper quadrant, radiating into the right
scapular region. There is often vomiting but no diarrhea associated with it. On exam, there will
often be a positive Murphy's sign but no rigid abdomen.


Urgency in bladder infection or irritation. In men, painful urination without frequency or urgency

A 22-year-old man has a 2 day history of pain in the abdomen that began near his navel and one day later moved to his right lower abdomen. The pain was initially colicky, but became constant during the past 24 hours. Nausea and two episodes of vomiting were associated with the pain. On examination he is lying very still in bed.
His temperature is 100.60F, pulse
112/min blood pressure 118/82mmHg and respirations 16/min

Appendicitis: Symptoms:
Pain (classically central moving after a few hours to RIF)
Anorexia Nausea constipation diarrhea Fever (usually low grade) High rectal tenderness

Common DRE findings

Acute Appendicitis: Differential
Diagnosis for YOUNG Women

Urinary tract infection
Ectopic pregnancy
Pelvic inflammatory Disease.
Ovarian cyst

Acute Appendicitis: Differential
Diagnosis Male/female:

Inflammatory Bowel disease.
Renal calculus .
Nonspecific abdominal pain

Acute Appendicitis: Differential
Diagnosis Child

Mesentric adenitis Intussusception : inflammation of the lymph nodes in the Gut

Abdominal Pain

"Now I am going to ask you about your
social history."

Transition. Verbal road map that signal the transition from one line of question to another
"Now, I am going to ask about your social history"

"Is there anything else apart from your chest pain and shortness of breath?"

Setting the agenda. " Eliciting the patient's key concerns"

A 35-year-old farmer presents with a 6-month history of progressive shortness of breath on exertion and episodes of paroxysmal nocturnal dyspnea. He has a previous history of rheumatic fever in childhood. On examination hepatojugular reflux is increased and there is pitting edema of his legs. Urinalysis is normal.

Congestive heart failure. Aggravated by lying down & Exertion,
In patients with symptom of left ventricular failure (pulmonary edema),, peripheral edema fluid is reabsorbed in the supine position, causing increased blood volume, pulmonary hypertension and pulmonary edema. This process takes hours, unlike orthopnea, which occurs immediately with recumbency. Associated with cough and frothy sputum

A 44-year-old woman presents with swelling of her left hand and arm for 2 weeks. She had a mastectomy followed by radiation therapy for breast cancer 2 months ago. On examination there is non-pitting swelling of her left upper extremities.

Lymphatic edema Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy. Lymphedema is non-pitting and tends to be unilateral and irreversible ( pg 300 LM)

Four days after left hip replacement surgery for a fracture, a 68-year-old woman complains of pain in her left calf. On examination there is left pre-tibial and left ankle pitting edema

Venous insufficiency Edema present and may be sever. Skin changes: brownish discoloration, thickened
ulcerations seen in the in the vicinity of the medial malleolus; Pain, background aching, not usually intense

paroxysmal nocturnal dyspnea

patients typically are awaken from sleep with difficulty breathing in the
early hours of the morning. Standing upright brings some relief.


dyspnea on recumbency due to excess fluid in the lungs in this position. It is caused in part by a shift of blood from systemic and splanchnic blood vessels to the pulmonary circulation as well as a higher diaphragm and lower vital capacity during recumbency.

Exertional dyspnea

caused by failure of the left ventricular output to rise with exercise, resulting in increased pulmonary venous pressure and reduced lung compliance

Lymph node that drains the scalp ?

(superficial cervical nodes

What lymph node drains the feet?

inguinal nodes

Causes of generalized lymphadenopathy include

Infections (viral, bacterial and protozoa)
Connective tissue diseases

What are the characteristics of NORMAL
Lymph nodes


Venous thrombosis.


Thrombophlebitis of the communicating veins leads to

with destruction of the valves lead to
venous insufficiency.

venous thrombosis what is it and what leads to it:

Obstruction to flow & Acute Pulmonary Embolism

If edema is present, look for possible causes in the peripheral vascular system.
These include

(1) recent deep venous thrombosis, (2) chronic venous insufficiency due to previous deep venous thrombosis or to incompetence of the venous valves,
(3) lymphedema

Marcus Gunn

Swinging Flashlight Test:

Swing a light back and forth in front of the two pupils and compare the reaction to stimulation in both eyes.
When light reaches a pupil there should be a normal direct and consensual response.
An RAPD is diagnosed by observing paradoxical dilatation when light is directly shone in the affected pupil after being shown in the healthy pup

Adie's (Tonic) Pupil

Common in women in the 3rd/4th decade of life (but also can be present in men)
*Either no or sluggish response to light (both direct and consensual responses)
Thought to be caused from denervation in the postganglionic parasympathetic nerve
Associated with Holmes-Adie syndrome described with Adie's pupil and absent deep tendon reflexes

Argyll Robertson Pupil

This lesion is a hallmark of tertiary neurosyphillis
Pupils will NOT constrict to light but they WILL constrict with accommodation
Pupils are small at baseline and usually both involved (although degree may be asymmetrical)

A 70-year-old woman complains of worsening vision for two years. She says the main problem is with her peripheral vision and that she is able to read the newspaper. She has been on treatment for severe glaucoma for 21 years. On examination her visual
acuity with spectacles is 20/30 in each
eye. There is bilateral and severe concentric constriction of her visual fields.

Optic atrophy The pressure rise is slow and insidious but blindness that should be preventable is common due to this. All persons over the age of 60 years should have their intraocular pressure checked regularly.
Diffuse redness can be seen in conjunctivitis, uveitis and glaucoma

Glaucoma can cause :

severe glaucoma causing trauma to optic nerve=relative afferent pupillary defect (RAPD, Marcus Gunn Pupil)

A 45-year-old man is seen in the emergency room complaining of severe headache and blurred vision for
2 days. He has no significant past medical history. Vital signs are: blood
pressure 260/136 mmHg, respirations 16/min, pulse 64/min regular.

Papilledema= swelling of the optic disk. Findings include blurring of the disc margin, loss of spontaneous venous pulsation, hyperemia hemorrhage and exudates on the disc. The commonest cause is due to raised intracranial pressure. Seen in Hypertensive Retinopathy

How do you diagnosis Glaucoma

By shining the light, When this angle is narrowed by bowing of the iris forward, thus decreasing the space between the cornea and iris, a crescentic shadow is seen on the medial side of the iris.

Optic atrophy: Primary -

The disc is chalky white, sharply demarcated and with normal retinal vessels. The optic nerve degenerates in an orderly fashion. This may be caused by a pituitary tumor, optic nerve tumor, traumatic optic neuropathy and multiple sclerosis.

Optic atrophy: Secondary

- The architecture of the nerve is lost. The disc is grey with poorly defined margins. Drusen and tortuous veins may be observed. Progressive contraction of the visual fields may be observed. Secondary atrophy is secondary to papilledema

Optic atrophy: Consecutive-

Consecutive- The disc is waxy pale with normal disc margin. The arteries are markedly attenuated. This type can be seen in retinitis pigmentosa, myopia and central retinal artery occlusion.

Optic atrophy: Glaucomatous -

There is marked cupping of the disc. There is bayoneting and nasal shifting of the retinal vessels. Splinter hemorrhage may be observed at the disc margin.

Optic atrophy: Temporal pallor -

The disc is pale (more pronounced on the temporal side) with a clear demarcated margin. The vessels are normal. This type is observed in traumatic or nutritional optic atrophy and is most often seen in multiple sclerosis.

An 83-year-old retired carpenter complains of gradually worsening vision for 2 years. His visual acuity is
20/100 in each eye and with binocular vision. Physical examination is otherwise normal

Absent red reflex= cataract; Gradual painless loss of vision (usually bilateral) Slow gradual vision loss is the complaint. ( pg 171 LM)

A 76-year-old man presents with recurring pain and swelling in both knees for 2 weeks. He has been treated for knee osteoarthritis for 6 years. His symptoms improved after fluid was withdrawn from both knees six months ago.

Ballotment With the index and middle fingers of the right hand push the patella gently backwards. If there is excess fluid present, the patella will be initially ballotable
-Continued pushing will result in the patella colliding with the femoral condyles, thus producing a palpable impact (palpable tap).

A 65-year-old woman complains she has had low back pain for 3 years. It has been radiating down the back of her left thigh and leg for the past 3 weeks. On examination the left ankle reflex is 1+.

The bowstring maneuver - Check for sciatic nerve root irritation or entrapment " in a patient experiencing pain at 60 (30 to 70) degrees elevation, from the position of 60 (30 to 70) degrees elevation, lower the leg until the pain is just relieved, then dorsiflex the foot. Recurrence of the above pain on dorsiflexion is confirmatory evidence of sciatic nerve root irritation or entrapment"

A 19-year-old high school athlete visits a sports medicine physician 6 weeks after being hit on his left knee during practice. The left knee swelling and pain that was present 4 weeks ago is now gone. However the left knee becomes sore after running, and occasionally gives way

McMurray: Cartilaginous (medial and lateral menisci) injury

McMurray is for :

Cartilaginous (medial and lateral menisci) injury


Joint effusion The fluid in the knee will now be forced behind the patella. With the index and middle fingers of the right hand push the patella gently backwards. If there is excess fluid present, the patella will be initially ballotable. Continued pushing will result in the patella colliding with the femoral condyles, thus producing a palpable impact (palpable tap).

Sacroiliac joint

The sacroiliac joint stress maneuver - ask the patient to lie supine, as flat as possible, but very close to the near edge of the couch. The examiner must be in a position to prevent the patient from falling if this occurs. Ask the patient to fully flex the knee and hip of the lower limb further away from the edge of the couch, and to hold the knee tightly against the abdominal wall with both hands clasping the flexed knee.

A 34-year-old man is being rehabilitated for an abnormal gait 8 weeks after dislocating his right knee in a motor cycle accident. On
examination, the knee is normal.
However, there is wasting of the right anterior tibial muscles and he is unable to dorsiflex his right foot or extend the right hallux against resistance. Plantar flexion is normal

High-stepping: Neuropathic gait.
Affected foot show no dorsiflexion in swing phase.
Leg (on affected side) has to be lifted higher up to avoid foot scraping the floor.
usually secondary to lower motor neuron disease. Compression or injury of peroneal nerve or peroneal muscle atrophy can cause high steppage gait. Also seen in multiple sclerosis.

A 54-year-old man, currently on treatment for severe hypertension, is receiving physical therapy for a right hemiparesis that occurred 4 weeks ago

Circumventive In spastic hemiplegic gait the stiff legs
swings in half circle (circumduction); often the arm does not swings on paretic side. The spastic gait is either paraplegic or

A 51-year-old man complains of numbness and tingling in his feet for the past 3 months. He has a 15 year history of type 2 diabetes mellitus. He has loss of touch, vibration and position sensation in his lower limbs.



spasticity is an increased resistance to the passive movement of a joint due to abnormally high muscle tone (hypertonus)
-While rigidity is an increased resistance to the passive movement of a joint which is constant throughout the range of joint displacement
spasticity is typically caused by damaged to the corticospinal tract, while rigidity is usually extra-pyramidal in origin

The spastic gait

is either paraplegic or hemiplegic: Spastic Hemiparesis Associated with lesion in corticospinal tract, as with stroke
The spastic paraplegic patient walks with legs held together, moving in stiff manner with the toes dragging. Excessive abduction of thigh can give rise to "scissor gait"

Shuffling or Festinant Gait

Patient may has difficulty initiating the movements of feet or steps.
short (bradykinesia) accelerated steps (Shuffle or festinant) once starts walking.

Choreiform gait

Seen in Huntington's chorea; a hyperkinetic walk with jerks in all extremities.

Waddling Gait aka Myopathic gait.

The pelvis drops as the leg leaves the
ground because pelvis is not supported on the swinging leg side by the weak glutei.
Body swings towards the weight
bearing leg to support the body weight and during this lumber spine becomes hyperlordotic.
Causes: pregnancy, muscular
dystrophies, osteomalacia.

Antalgic Gait

A limp seen when patients tries to avoid pain in the weight bearing hip in arthritis or hip pain. The stance phase is short

Quadriceps Gait

Patient hyper-extends the knee of the affected leg and trunk lurches forward on each step.

Peripheral Nervous System Disorders

Gait in conversion disorders/Helicopd gait

Foot makes half circle on walking. Base is not constant in stance phase. Patient lurches wildly in different
directions & falls only when some one is around to catch the patient.
Loss of function due to progressive lower limb weakness. A psychiatric problem; rare; seen in adolescents, non intentional or no malingering.

A 25-year-old woman presents with a 2-day history of severe colicky midline abdominal pain associated with
nausea and vomiting. Three years ago the patient had an appendectomy for acute appendicitis. On examination the abdomen is distended with high pitched frequent bowel sounds.

Small bowel obstruction High-pitched tinkling sounds
suggest intestinal fluid and air
under tension in a dilated bowel.
Rushes of high-pitched sounds
coinciding with an abdominal
cramp indicate intestinal

Sensory Ataxic Gait

Wide base gait where feet strike the ground heavily as strength required is not precise due to lack of coordination & lack of propioception,
Patient looks to ground to get visual cues.
+ive Romberg test: Patient falls with feet together and eyes closed.
Conditions that impair sensory nerves and receptors of
propioception can cause sensory ataxia: Subacute combined degeneration. & diabetes


Early obstruction produces hyperactive peristalsis proximal to the obstruction


Irritable Bowel
Early Partial intestinal Obstruction

A 67-year-old man presents with fatigue and left abdominal fullness for the past 6 months. He had a regular bowel movement every morning until 9 months ago when he became progressively more constipated, despite regular use of laxatives

Left colon obstruction Pain and constipation are early features of colonic obstruction.
Constipation can be defined as bowel movements that are infrequent (three or fewer per week) or hard to pass.

1. Diarrhea can result from pathology in the : ?
2. Small frequent stools tend to point to
3. vvoluminous stool tend to suggest

1. small or large intestine.
2.left colon or rectal etiology
3. small bowel or right colon causes.

Causes of Ascites: transudates vs. Excudates

Cardiac failure
Constrictive pericarditis
Meig's Syndrome
Nephrotic syndrome
Malignancy (esp. Colon,
ovary, pancreas,


INFECTIONS :bacterial(Typhoid)
Viral (infectious mononucleosis)
Parasitic (hydatid)
Protozoal (malaria)
Chronic myeloid

A 53-year-old man is admitted to hospital with a 2 day history of severe vomiting and epigastric pain that radiates to his back. The pain is exacerbated by lying down and improved by sitting up and leaning forward. His wife states that he has consumed alcohol heavily for at least 25 years. There is no history of trauma. On examination his mucosae are dry. Pulse is 120/min, blood pressure is 90/64mmHg and his temperature
is 10Q.80f . Abdominal examination reveals subcutaneous bruising in both flanks and tenderness with guarding in the epigastrium.

Ecchymoses around the umbilicus. Acute Pancreatitis Inspection:
distension, Cullen's sign (intraperitoneal bleeding), Grey (retroperitoneal bleeding) - Turner's sign positive.
Grey Turner's sign is bluish discoloration of the flanks.

Acute Pancreatitis:
Associated disorders

Abdominal operations ,
hyperlipidemia , trauma
hypercalcaemia ,
pregnancy, peptic ulcer,
Symptoms: Pain
(epigastric through to
back) nausea, vomiting

Epigastric pain that is relieved by sitting up and leaning forwards may indicate

acute pancreatitis

Cullen's sign

is bluish discoloration of the umbilicus

A 58-year-old man complains that during the past 3 months he has been becoming increasingly unsteady on his feet. At night he often stumbles and falls. On examination he has a wide-based stomping gait. He is able to stand with his feet together when his eyes are open but he becomes very unsteady with his eyes closed.

Impaired vibration sensation
A stamping gait is seen in patients with injury to the dorsal column. There is loss of position sense. The patient is unable to judge where the ground is and lifts the leg high and brings it down hard on the ground. This is often done with the patient looking at his feet.

A stamping gait is seen in

patients with injury to the dorsal column. There is loss of position sense. The patient is unable to judge where the ground is and lifts the leg high and brings it down hard on the ground. This is often done with the patient looking at his feet.

Fasciculations in calf muscles. is a sign of

Lower motor neuron injury

Dysdiadochokinesia is associated with

Cerebellar disease

The physician who pays attention to what the patient is communicating, who is aware of the patient's emotional state and who uses verbal and nonverbal skills to encourage the patient to describe his/her concerns, is using the communication skill of:

Active listening Closely attend to what the patient is communicating, verbally and non-verbally including being aware of the patient's feelings.

How to localize the APex beat

Placing the patient in the left lateral decubitus position Apex beat - point of
maximum impulse
• Find its general position
with flat of fingers, then
with the tip of one finger.
• Measure the size

Apex beat description:

•Amplitude - usually small and
• Diameter - normally one
interspace and less than 2.5 cm
• Duration - normal through first 2/3
of systole.

A double impulse

mix AS and AI,
left ventricular aneurysm

A 39-year-old woman complains of gradual loss of hearing affecting her left ear over the past 3 years. On examination, Whisper test is impaired in the left ear, Weber's test lateralizes to the right and air conduction is twice as long as bone conduction in the left ear.

Sensorineural deafness.


perception of sounds as excessively loud and irritating. This occurs on the side of damage. Hyperacusis is due to loss of function of the stapedius muscle which dampens incoming sounds. Hyperacusis accompanying facial nerve derangement places the lesion close to the facial nerve origin in the brain stem.


Hearing loss associated with

Conductive deaf


A 35-year-old man has a 6 month history of shortness of breath on exertion. For the past 2 months he has had to sleep on 3 pillows to avoid shortness of breath at night. On examination he has a pulse of 104/min, blood pressure 104/78 mmHg and respirations 18/min. The apex beat cannot be localized. On auscultation a murmur is heard near the mitral area. Which of the following will help you to determine whether the murmur is systolic or diastolic?

Palpating the carotid pulse while auscultating the heart.


Cause of Conductive deafness. calcified plaques may be seen on the surface of the membrane and is usually due to scar formation secondary to incomplete healing of otitis media. These are generally asymptomatic unless protruding into the tympanic cavity, in which case, they may cause conductive deafness.

A 50-year-old man has a 3-year history of failing eyesight. He has had diabetes mellitus for 18 years but has not complied with medications and has never seen an ophthalmologist. His vital signs are BP 110/80 mmHg, pulse 78/min respiratory rate
18/min, temperature 980F. Glycosylated hemoglobin (A1C) is very elevated.

Proliferative retinopathy.= Preretinal vessels arising on the disc and extending across the margins. Can see fibrous proliferations at this stage.
Nonproliferation: Microaneurysms with exudates and white spots

Hypertensive Retinopathy With Macular Star

Punctate exudates are readily visible: some are scattered; others radiate
from the fovea to form a macular star. Find the flame-shaped hemorrhages

Normal Fundus of an Older Person

The blood vessels are straighter and narrower than those in younger people, and the choroidal vessels can be seen easily.

A 22- year- old woman, GO, has a 2-month history that her breasts are tender prior to her menses and that on breast self examination she thinks she feels lumps. On your examination, there is diffuse tenderness and irregular breast tissue in the upper outer quadrants. There is no discrete mass. You re-examine her in two months, after her menses, and the outer quadrant density is decreased. Your clinical diagnosis is:

Fibrocystic Change
Dense, usually bilateral, upper outer breasts= Nodular, ropelike
• Not a discrete mass
• Increased premenstrual
• Resolves or decreases post menses
• PLAN: re-evaluate post menses in 1-2 cycles
• Consider Ultrasound of breast if persistent or
Strong Family History of breast cancer


• Cyclic Changes in Reproductive age females
• Increased tenderness premenstrual
(Increased Estrogen & Progesterone)
• Fibrocystic Change
• Pregnancy

Palpation Order for the breast

Lymph nodes


• Young women ages 15-25
• Mobile
• Firm, rubbery
• Well circumscribed
• May/may not be tender
• Diagnosis:
Ultrasound (also may be seen on mammogram)
FNA (Fine Needle Aspiration)/excise
or observe

The upper outer quadrants of the breast are most common for

for fibrocystic changes and malignancies

Breast Cyst

Ages: 25-50
• Most common breast mass
• Soft, well circumscribed, round, mobile mass,
tiny or large
• May be tender
• One or both breasts
Diagnosis: Aspirate /cytology
Ultrasound: fluid filled structure

Age of breast pathology presentations

Important to know ages

A 23-year-old woman has a 6-month history of palpitations and weight loss of 12
pounds. She has also been feeling restless and anxious. On examination she has
exophthalmos, her palms are sweaty and she has a fine tremor.
Which of the following findings is most compatible with this presentation?

Irregular pulse of 116/min. amplitude is +3
Common symptoms include:
Widened pulse pressure
Heat intolerance
Weight loss

Common symptoms include:
Cold intolerance
Weight gain
Decreased appetite
Loss or thinning of eyebrows
Pale, dry skin


A 28-year- old man presents to the Emergency Department at 2.00 a.m with a one-hour history of pain and swelling in his penis that began after sexual intercourse. He has no significant previous medical history. On examination of his penis, the prepuce is retracted, erythmatous and tender. The prepuse cannot be brought over the glans penis.

Retracted prepuce that cannot be returned over the
Untreated may result in gangrene.


Painful and prolonged erection
Secondary to leukemia, sickle cell disease, drugs.


Prepuce cannot be retracted over glans


Developmental abnormality.
The urethral opening is on the ventral aspect of the penis.

A 53-year-old woman has a 2 year history of worsening pain and stiffness in her joints.
This is worse on awakening in the mornings. Physical examination reveals soft tissue swelling and tenderness in the MCP joints of the hands, wrists, knees and the MTP joints of both feet. There is a mobile, 1cm diameter, non-tender subcutaneous nodule just distal to each olecranon process, on the ulnar surface of the forearm.
Which one of the following additional clinical features is consistent with this presentation?

Ulnar deviation of the MCP joints.
Rheumatoid arthritis: after resting- early morning. Can be classified as inflammatory. Often accompanied with systemic general features such as malaise and fatigue
1 (mono),
2-4 (oligo)
5 or more (poly) joints

Sacroilitis occurs in > 90% of patients with

ankylosing spondylitis(HLA B27-related , typically in young men). Symptoms include low back pain and stiffness, with slowly progressive immobility of the spinal joints

A 50 year old former football player presents with pain and
swelling of his right knee of 6 months duration. The pain started
gradually but is increasing in intensity. Examination reveals a
swollen non tender right knee. There is no increase in warmth
over the joint. What is the most likely differential diagnosis?
A. Ankylosing spondylitis
B. Gonococcal arthritis
C. Psoriatic arthritis
D. Rheumatoid arthritis
E. osteoarthritis


A 35 year old female presents with a 5 month history of pain and
swelling in both hands, together with morning stiffness. There is
also the feeling of malaise and fatigue. Examination reveals
swelling and tenderness of the PIP and MCP of both hands.
Which one of the following is the most likely diagnosis
A. ankylosing
B. gonococcal
C. psoriatic
D. rheumatoid
E. osteo


A 68-year-old woman complains of unsightly veins and discoloration in her legs for the past 2 years. On examination large varicosities are seen on her left leg and a smaller one on her right leg. The Trendelenburg test is done and the results are
positive-negative, on her left leg.

The communicating veins only
Postive -Negative = Rapid filling of the superficial veins while the saphenous vein is occluded indicates incompetent valves in the communicating veins. Blood flows quickly in a retrograde direction from the deep to the saphenous system.

Negative-Positive = Sudden additional filling of superficial veins after release of compression indicates incompetent valves in the saphenous vein.

A 58-year-old man complains that 24 hours ago he coughed up small clots of blood,
twice. He also has a 9 month history of non-productive cough and weight loss of 30
pounds. There is no history of chills or fever. He has a 50 pack year smoking history.
On examination he has partial ptosis on the right and his chest reveals a *dull
percussion note, egophony and whispering pectoriloquy*, in the right upper zone.
Which one of the following additional findings is most likely to be observed in this

Right pupil is smaller than the left. Horners The affected pupil, though small, reacts briskly to light and near effort. Ptosis of the eyelid is
present, perhaps with loss of sweating on the forehead of the same side.

A 55-year-old man presents with a 3 month history of loss of appetite and weight loss of 15 pounds. Two weeks ago his wife noticed that his eyes were yellow; around the same time his urine darkened in color. On examination he is cachectic and icteric. A soft, non-tender mass, approximately 6 cm in diameter, is felt in the right hypochondrium. Rectal examination reveals clay-colored stool with positive occult blood.
Which of the following findings is most consistent with this presentation?

Skin marks of puritus.
Presentation & Symptoms:
loss of weight
abdominal distension
Everted umbilicus
Abnormal liver span (small or large)
Hepatic mass

A 39-year-old woman has a 1 year history of numbness and 'pins and needles' in her right hand, which are worse at night. She also gives a history of dropping objects, such as money, from her right hand. On examination there is reduced sensation to light
touch and pain over the palmar surface of her right thumb, index and middle fingers.
Which one of the following additional findings in her right upper extremity is/are consistent with this presentation?
A. Contracture of the 4th and 5th fingers.
B. Wasting of the hypothenar muscles.
C. Reduced brachioradialis tendon reflex.
D. Wasting affecting the thenar muscles.
E. Presence of Hoffman's reflex.

Wasting of the thenar muscles.= Recurrent Median
hypothenar muscles. = Radial nerve

A 25-year-old patient who you saw professionally 4 weeks ago stops you in the hospital
corridor and tells you he has developed a severe itch on his genitalia.
Your most appropriate response is?

"Please make an appointment for my next clinic and we will discuss this further."

A 55-year-old man has a 6 month history of swelling of his ankles, and breathlessness with cough that awakens him a few hours after falling asleep. For 21 years he has
been treated for hypertension. On examination, he has laboured breathing. His pulse rate is 110/min, BP 160/110 mmHg, and respirations 30/min. He has elevated JVP, basallu g crackles. tender hepatomegaly, an S3 gallop rhythm, and pitting edema at his ankles.

Pulmonary edema.

The mother of a 2-year- old child complains that the child has been feverish, crying a
lot, and pulling on her right ear for 2 days. There has been no discharge from the ear.
On examination the external auditory meatus appears normal. The tympanic
membrane appears erythematous and bulging laterally. There is tenderness over the
right mastoid process.

Otitis media Movement of the auricle and tragus (the "tug test") is painful in acute otitis externa (inflammation of the
ear canal), but not in otitis media
(inflammation of the middle ear).
Tenderness behind the ear may be
present in otitis media.

A 54-year-old man presents with a 24-hour history of double vision. He has been treated for diabetes mellitus for about 19 years. On examination his vital signs are normal. There is severe ptosis of his left eye. When the patient is asked to look straight ahead, his left eye is deviated downwards and outwards. The right eye is normal.
Which one of the following cranial nerves may be involved?

Oculomotor. innervates the Levator palpebrae superioris
to elevate upper eyelid


Ptosis is a drooping of the upper lid.
Causes include myasthenia gravis,
damage to the oculomotor nerve, and
damage to the sympathetic nerve supply
(Horner's syndrome). A weakened
muscle, relaxed tissues, and the weight
of herniated fat may cause senile ptosis.
Ptosis may also be congenital.

A 50-year-old woman, G1P1, is seen urgently for a mass in her right breast that she found on self examination 2 days ago. Her recent mammogram was negative. Her LMP was 1 week ago. Her mother, sister and a cousin have breast cancer. On examination, there is a 3 em diameter, hard, irregular, non-mobile mass in the upper outer quadrant of the right breast. You proceed to examine the lymph nodes.


A 55-year-old man has a 7-month history of intermittent headache that has been worsening recently. He has been treated for diabetes mellitus and hypertension for 2 years. He states that his son, who recently returned home after many years abroad, says that his father's facial appearance has changed greatly. The patient also noticed that his wedding ring became too small about one year ago. On examination he has coarse facial features with a prominent lower jaw. Blood pressure is 150/88mmHg, pulse 80/min, regular, respirations 18/min.

Which of the following additional findi gs is consistent with the most likely diagnosis in this patient?

Frontal bossing.Common symptoms include:
Coarsening of facial features
Enlarged hands and feet
Thickening of the soft tissue
(palms and soles)
Carpal tunnel syndrome
Excessive sweating

A 15-year-old boy complains of a painless swelling in the left scrotum that has varied in size over the past several months. There is no history of trauma. On examination a cystic mass is felt in the left scrotum, the upper extent of which can be clearly defined within the scrotum. The lesion transilluminates well. No inguinal nodes are palpable
and the examination is otherwise normal.

The most likely diagnosis is:

Hydrocele.Accumulation of fluid in the tunica vaginalis. Fingers can get above the swelling
Positive transillumination

A 22-year-old college athlete presents with pain and swelling of his right knee for the past two days. On examination he has an antalgic gait that protects the right lower extremity. The right knee is swollen, warm to touch and somewhat tender.

Which one of the following tests/signs will confirm a diagnosis of knee effusion?

Bulge. Effusion (fluid)- Visible swelling, bulge sign, Ballotment

A 34-year-old previously healthy woman presents with pain and swelling in her left leg.
She is taking oral contraceptives. Three days ago she returned home to Grenada from a business trip to London. On examination there is swelling and pitting edema of her left leg. The left calf circumference is 3cm greater than the right.

Which one of the following tests/signs is most likely to be positive?

Homan. Dorsiflexion of the foot with the knee extended
Risk factors for the development of deep vein thrombosis
Immobilization/Bed rest
Surgery - pelvic and long bones
Oral contraceptives
Economy class syndrome - prolonged maintenance of the
sitting position

Signs and symptoms of deep
vein thrombosis

Pain - usually of a dull ache that may
be relieved by elevation of the leg
• Swelling and tightness of the leg
• Erythema
• Increased warmth of affected limb

A 38-year-old man is seen in the Emergency Department one hour after he was stabbed in his back. He is short of breath, restless and centrally cyanosed. Pulse rate
is 128/min and blood pressure 88/70 mmHg, respiration 25/min. There is a stab wound on the upper right posterior chest. Percussion note is stony dull in the right lower chest. Auscultation reveals decreased breath sounds over the right lower chest.

The abnormal percussion note is most likely due to?


Dullness replaces resonance in the lungs when:

fluid or solid tissue replaces
air-containing lung or occupies
the pleural space beneath your
percussing fingers. Examples
include: lobar pneumonia, in which
the alveoli are filled with fluid and
blood cells; and pleural accumulations
of serous fluid (pleural
effusion), blood (hemothorax),
pus (empyema), fibrous tissue,
or tumor.

A 25-year-old woman presents to the clinic with a history of dysuria and right flank pain for the past 5 days. She also complains of nausea and fever.

On examination which one of the following is most likely to be positive?

C.V.A tenderness Abnormal Kidneys
• Costovertebral tenderness ( CVAT ) : place
hand over area of kidney and strike your hand
with your fist : tenderness is abnormal , due
to infection , calculi

A 65-year-old woman has a 3-week history of numbness and tingling in her right thumb and right upper limb. For the past 3 years she has also had intermittent pain in her
neck and right shoulder, diagnosed as neck osteoarthritis. On examination she has reduced pain, light touch, and vibration sensation over her entire right thumb, and the lateral dermatome of her right forearm and lower aspect of the right arm.

The nerve root involved is most likely:


During her annual health screen, a 25-year-old woman expresses concern about her risk for ovarian cancer because her mother died of the disease.

Which of the following is the most appropriate course of action?

Obtain a more detailed family history of cancer.

A 53-year-old obese woman with type 2 diabetes mellitus is seen during a follow-up visit. She is being treated with a diet and oral hypoglycemic medication (metformin). The physician notes that her weight has increased by 4 pounds since her last visit and that her blood glucose level is above the optimal level.

Which of the following responses by the physician is most appropriate?

" Let us discuss your weight and blood sugar levels to see how we can do better".

51. A 73-year-old man presents with a 4 month history of progressive dyspnea on exertion
and two fainting spells that occurred about 2 weeks ago. On examination his pulse is
11 0/min, blood pressure 102/76 mmHg and respirations 16/min.The cardiac apex beat
has increased amplitude, and is in the sixth left intercostal space 1 em lateral to the
mid-clavicular line. A grade 3/6 crescendo-decrescendo systolic murmur is heard at the
2nd right intercostal space parasternally.

Both sides of the neck.
Location. Right 2nd interspace
Radiation. Often to the neck and
down the left sternal border, even to
the apex
Intensity. Sometimes soft but often
loud, with a thrill
Pitch. Medium; at the apex, it may
be higher
Quality. Often harsh; at the apex it
may be more musical
Aids. Heard best with the patient
sitting and leaning forward

. A 22-year-old man is seen in the outpatient clinic complaining of left ear pain. He has also noticed some hearing loss and discharge from the same ear. On examination of
his left ear there is pain when his tragus is pressed or his lobule is pulled. His ear canal is swollen and there is pus present. The tympanic membrane is intact. Hearing tests
are performed.

Which one of the following is the most likely result of the tests?

C. Whisper: decreased on the left. Weber: lateralized to left. Rinne: BC>AC

Weber Test:

This is useful when hearing loss is asymmetric. Weber tests hearing ability by bone conduction in both ears together. If the sound is lateralized to the side with decreased hearing, the hearing defect is due to a conductive hearing loss. Lateralization to the "normal" ear indicates a sensori-neural hearing loss.

A 52-year-old fisherman complains that there is something growing in his eyes for the past 4 months, and that it is beginning to affect his vision in his left eye. On examination there is a painless pale-yellow triangular raised lesion on the nasal side of both sclerae. On the left the lesion has encroached on the cornea and pupil.
Which is the most iikely diagnosis?

Pterygium. pterygium(may
encroach on the pupil). Both (Pinguecula & Pterygium) are situated on
the nasal bulbar conjunctiva. side. Reddening may occur
intermittently. A pterygium may interfere
with vision as it encroaches upon the pupil.

mitral regurgitation

Location. Apex
Radiation. To the left axilla, less often
to the left sternal border
Intensity. Soft to loud; if loud,
associated with an apical thrill
Pitch. Medium to high
Quality. Blowing
Aids. Unlike tricuspid regurgitation, it
does not become louder in inspiration.

A 23-year-old woman, GO, complains of a "sore" on her vulva that was first noticed by
her boyfriend 3 days ago. She states that whi le on a business trip 2 weeks ago, she
had unprotected sex with a man she met at a club. She has no other complaints. On
examination there is a shallow 'punched out lesion' with a smooth base and rol led edge
on the left labia majora. There are no other lesions.
Which lymph nodes will be first affected?

LOWER Vagina and Vulva ( External Genitalia ) to Inguinal Lymph Nodes
Middle and upper vagina drain into iliac lymph nodes
Nerve Supply: sympathetic -lower thoracic T10-12 some parasympathetic (S2-S4)

Uterus ,ovaries , tubes and drain into

internal iliac and paraortic lymphatics

A 49-year-old man complains of numbness and tingling in his feet, hands and around his mouth for the past 5 days. He has a prior history of alcoholism. On examination he appears undernourished and has pretibial pitting edema. His pulse is 102/min, respirations are 16/min and blood pressure by palpation is 120 mm/Hg. While taking his blood pressure by auscultation the cuff was inadvertently inflated to 170 mm/Hg for several minutes, causing flexor spasm at his wrists and metacarpophalangeal joints.

This spasm is most likely due to:

Common symptoms include:
Tetanic contractions
Numbness of the extremities
Tingling of the extremities
Laryngeal stridor (Due to smooth
Dysphagia muscle contraction)
Dry skin (Chronic changes)
Brittle nails
Chronic pruritis

A 32-year-old man complains of aching in his left testicle for several months. He says that the pain increases during the day, but he is pain free when he arises in the mornings. There is no pain with urination. He notes that he and his wife have been trying unsuccessfully this past year, to have another baby. On examination of the scrotum you palpate a soft mass-like structure that feels like a "bag of worms". Elevation of the scrotum reduces the size of the mass.

What is the most likely diagnosis?

Varicocele. However, varicoceles and hernias may
be apparent only when the patient
stands up.
Multiple tortuous
veins surrounding
the spermatic cord.
"bag of worms"
Reduced fertility

A 35-year-old secretary complains of pain and tingling in the thumb, index and middle fingers of her right hand for the past 2 months. She is concerned about her job as her symptoms limit her use of the computer. Light touch and pain sensation are reduced on the palmar surface of the symptomatic fingers.

Which one of the following movements at her wrist is most likely to reproduce her symptoms?

Tinel sign: percuss over
carpal tunnel
• Phalen test: full flexion
of both wrists
• Please test for evidence of nerve compression in the hand - sensation at
tip of fingers and opposition of the

A 35 yr old baseball player complains of pain at the
base of his right thumb. Examination reveals
tenderness at the right carpometacarpal joint (CMJ)and
painful limitation of opposition of the right thumb.
What type of joint is at the site of pathology?

B. saddle

. A 59-year-old farmer presents with a 2 week history of difficulty in walking. He has had numbness and tingling in both feet for 6 months and has a history of diabetes mellitus for 15 years. On examination, he is obese, with blood pressure 148/88mmHg, pulse
76/min, regular, and respirations 18/min. There is decreased sensation to touch,
position and vibration, over both feet. Ankle reflexes are reduced

On the plantar surface of forefoot During inspection of the lower
extremities ALWAYS inspect the soles
of the feet as ulcers due to peripheral
neuropathy often develop there.

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