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Physical Diagnosis All Questions

All of the questions from the 2 excel files combined If you find something wrong/want to add questions the PW to edit the file is the last name of the physician in our famous painting
STUDY
PLAY
Auricular tophi is an early presentation of ____________.
Gout
Pseudomonas manifests in the ear as tender erythematous swelling known as______.
A: Otitis externa Maligna
Pt gets her ear pierced and later notices soft, non-tender nodules on ear lobe. These are most likely __________.
Keloids
A pt has swelling in area anterior to the auricles. This is most likely due to inflammation of the _________ structures.
Periorbital (since swelling is in preauricular lymph nodes)
A compartment syndrome of the auricle invovles swelling of the auricle that blocks drainage. Thiscan eventually turn into _______.
Cauliflower Ear
Which two nerves have contributions to the geniculate ganglion that cross on the lower ear (lobar area)?
CN 7 and CN10
Pt has a tender, erythematous nodule in the external ear canal that drains purulent material. The diagnosis is _________.
Furuncle
Pt complains of decreased hearing and fullness in ear. Inspection with an otoscope is not possible due to blockage of the canal. Paitent uses q-tips. Diagnosis is ________.
Cerumen Impaction
Pt has fullness and decreased hearing in ear. Inspection shows erythmatous swelling and serious discharge from the canal. Which organisms might be responsible?
Staph or Strep infection (causing Otitis Externa)
Which type of cancer manifests as painless ulcers of the auricle with posterior auricular nodes sometimes present?
Squamous Cell Carcinoma of the auricle
Pt complains of lossing of hearing, popping with swallowing, and fullness in ear. Other symptoms include runny nose, coughing, and serous conjunctivitis. Inspection of the ear shows that you can see the umbo and malleus incredibly well and the tympanic membrane is dulled. The diagnosis is ________.
Serous Otitis Media
Pt complains of loss of hearing, severe earache, and fullness. Inspection shows the tympanic membrane is erythmatous and the umbo and maleus are not visible anymore. What is the diagnosis?
Purulent otitis media (due to Strep, H flu, or B. catarrhalis
Purulent otitis media is due to ________ infection while serous otitis media is due to ________ infection.
bacterial; viral
Pt has earache that is relieved while purulent discharge is exiting his ear. Another pt has an earache that gets worse while blood is exiting ear. The second pt is a drummer in a heavy metal rock band. Inspection of both ears suggests dullnig of the tympanic membrane, loss of cone of light reflex, and a hole in the tympanic membrane. The diagnosis is _____.
Perforation of the tympanic membrane
Just redness in the middle ear tells you ______.
NOTHING!
Pt breaks nose. There is no bleeding. What does this tell you?
Patient's nose should be getting larger and his pants are on fire. He is a liar.
Most of the nose (excluding the lower tip) is innervated by ______ of the trigeminal nerve.
v1 division
Pt has rosacea (redness all over face), sebacious gland enlargement, telangiectasia (dilated small blood vessels under nose) and increased nose size. What is the diagnosis?
Rhinophyma
Pt has conjunctivitis, sneezing, serious rhinorrhea, and swelling of the nasal mucous membranes. Diagnosis is _______.
Allergic rhinitis
Pt has non-exudative pharyngitis, nonproductive cough, swelling and congestion, sneezing, conjunctivitis, and nasal discharge that is at different times clear, white, and yellow. What is the diagnosis?
Viral rhinitis
Pt recently had has nose broken. Pt feels pain and nose has discrete, purple colored swelling in the septal are Both nares are effected. What is the diagnosis?
Septal hematoma
Pt comes into office with a nose ring. Examination of her nasal canals reveals soft, red, pedunculated nodules hanging from the septum. These are known as _____.
Nasal Polyps
What symptoms are consistent with nasal fracture?
painful, swollen, echhymotic, and disfigured nose with anterior epistaxis (bleeding)
Pt has periorbital plaque-like ecchymosis, enlarged tongue, and right heart failure (hepatomegaly, peripheral pitting edema, etc). This is consistent with what facial problem?
Amyloidosis
Pt has loss of laterial eyebrow hair (Queen Anne's sign), coarsening of features, enlarged tongue, and delayed reflexes. Diagnosis is _________.
Myxedema
Pt has enlarged tongue, diffuse non-pitting edema of upper extremeties and face, and elevated jugular venous pressure. Dx is _____.
SVC syndrome
A basilar skull fracture can result in symptoms including __________.
periorbital ecchymosis, decreased consciousness, hematotympanum, and battle's sign (ecchymosis over mastoid processes)
pt comes in with green nasal discharge, tenderness to percussion over affected sinus, and decreased transillumination in the affected sinus. Dx is ___.
sinusitis
Pt's thyroid is enlarged and manifests as large mass in anterior neck. Dx is ______.
Goiter
in cervical lymph node enlargement, nodules in the neck can be due to hard stony nodules (due to _______), rubbery nodes (due to ______), or tender swollen nodes (due to ______).
metatstatic disease; lymphoma, infection
Pt develops difficulty breathing and stridor (high pitched sound) after manifestation of tender erythematous swelling in anterior neck under chin. Dx is ______.
Ludwig's angina
Parotid gland enlargement usually manifests as swelling on which part of the neck?
Lateral
Transplant pt taking cyclospirine A gets diffuse thickening and enlargment of the ______ as a side effect
gingeva
Pt has purulent material at base of teeth, tartar and calculus at gingiva/tooth interface, swelling, and mild bleeding of gums. Dx is ______.
Gingivitis vulgaris
Herpes simplex stomatitis results in the following symptoms: __________.
painful erosions and ulcers on gingiva, mucosa, lips, and skin
Pt works at daycare center and comes in with rashes on palms and soles of feet. Pt has diffuse vasicles that become painful erosions and ulcers on gingiva, mocusa, lip, and posterior pharynx (but stay within lip). Dx is ______.
Coxsachie stomatitis
Pt has white papules and plaques that look like curdled milk on mucosa, pharynx, tongue, and gingiv Dx is ______.
Thrush
Pt shows up with disrupted tooth enamel and brown/black discoloration where gums meet teeth. Dx is _____.
Caries
Pt comes in with a dry mouth following chemo therapy. You should advise him that he is at increased risk of ______.
Tooth decay
Pt has smooth tongue with no papillae in dorsom. Diagnosis is ______.
Atrophic glossitis, due to vit B deficiency (or folate deficiency)
Pt comes in with painless red or white, firm exophytic (grows outward) papule and plaque that ulcerates on tongue. What should you immediately be worried about?
Squamous cell carcinoma
Are submental varices usually a problem?
No.
Sublingual varices suggest _________.
long-term elevated right-sided pressures
A benign, non-tender nodule in the hard palate covered with mucosa is known as _______.
Torus oakatubys
Pt comes in with cervical lymph node enlargement, runny nose, serous otitis media, and erythema and swelling of tonsils and post. pharynx. Diagnosis is ____.
non-exudative pharyngitis
Pt has swelling, erythema, and white foamy substance on surface of posterior pharynx and uvul Diagnosis is _________. If due to strep, which lymph nodes would be concurrently enlarged? If due to mono, which areas would be concurrently enlarged?
exudative pharyngitis; jugulodigastric nodes for strep; diffuse lymphadenopathy and splenomegaly for mono.
Pt comes in with a life-threatening smooth nodule or mass (collection of abscesses) in posterior pharynx adjacent to a tonsil. This nodule is a complication of a previous case of strep throat and can obstruct the patient's airway. Diagnosis is ______.
Quinsy
Pt comes in feeling cold, constipated, depressed, and fat. Measurement shows the patient has indeed gained weight. Pt loses a lot of hair all over body (especially over lateral eye brows), has delayed relaxation of reflexes, bradycardia, thick / doughy skin, proximal muscle weakness, and a goiter. Pt has _____.
hypothyroidism
pt loses lots of weight, feels really hot all the time, and poops a lot. Pt has a goiter and shows brisk deep tendon reflexes, tremor, thin skin, proximal muscle weakness, oncholysis, plummer's nails, and tachycardi Pt is also diagnosed with Graves disease and myxedem Underlying cause is _________.
hyperthyroidism
As women get older, __________ tissue gives way to __________ tissue in the breast.
glandular; adipose
Tanner Staging is from ____ (least developed) to _____ (most developed) and shows breast maturation
1, 5
Breasts become firmer and glandular tissue becomes enlarged during the week before _______.
Periods
The shape of breast tissue is _________.
Rectangular
How many levels of palpation should be applied?
3
What is the best method of examining a breast?
Vertical method, then concentric circles, then spokes of wheel method (worst)
The inframammary ridge is at which rib?
6th
5 sets of lymph nodes in the breasts are ____________.
Central axillary, lateral axilla, pectoral, supraclavicular, and infraclavicular
Which quadrant is the most common site of breast cancer manifestation? Which area is second most common?
upper outer; nipple
multicolored discharge is present in _________.
ductal ectasia
serosanguinous discharge and non-tender, small, subareiolar nodules are present in ________.
Intraductal Papilloma
Pt comes in with warm, indurated, tender, erythmatous rash; Dx is ______.
Mastitis
Nipple retraction can be indicative of ___________.
Breast Cancer
erythmatous, scaly rash is known as ___________.
eczema
A movable, well demarcated nontender mass in the breast is known as ____________.
fibroadenoma
Breast abscesses are usually in locations with concurrent _________.
Mastitis
Pt comes in with unilateral erythmatous rash confined to the areol It is later determined that the pt has a subareolar duct carcinoma there. What is the diagnosis?
Paget's disease
What does a horizontal rib slope suggest?
emphysema
Pigeon chest is also known as ________, and invoves the sternum and ribs sticking out, while funnel chest is also known as ________ and involves sternum and ribs pushed inward
Pectus Carinatum, pectus excavitum (which might impinge on the heart and cause mitral valve prolapse)
What are two disorderes linked to shallow respirations during physical exam?
Cheyne-Stokes and Biot's
What is the most common cause of SVC syndrome?
Neoplastic obstruction
Pt comes in with blisters / pustules on his skin in a dermatomeric distribution. What disease does she have?
Herpes Zoster
In Scleroderma, what physical finding regarding skin should you notice?
Tightening of skin
If the trachae is deviated ipsilaterally, you should suspect ____________. If the trachea is deviated contralaterally, you can expect ________.
atelectasis (alveolar collapse); pneumothorax/effusion
What does oliver's sign show us?
If the trachea shifts downward during systole, then the aortic arch is dilated (aneurysm)
Sternal pain suggests two possible diseases. What are they?
CML and Xiphoid-sternal arthritis
What is vocal fremitus
a palpable vibration during speech
What are the various results of percussion of the chest?
Resonant = normal lung; Hyperresonant = emphysema; Dull = atelectasis, pneumonia, hemorrhage; flat = pleural effusion
Tubular breath sounds in the chest are abnormal. They indicate __________.
consolidation; loss of alveolar air (alveolar collapse, edema, pneumonia) either by alveolar collapse or filling
Amphoric breathing suggests ______________.
Cavernous breathing (cavitary disease like TB)
All breathing sounds but ______________ have full inspiratory and expiratory duration.
Vesicular
Early inspiratory crackles are low pitched and suggest ___________.
bronchitis
Mid-inspiratory crackles suggest __________.
bronchiectasis
Late inspiratory crackles are high pitched, sound like velcro, and suggest ___________.
fibrosis OR pneumonia OR CHF OR Alveolar hemorrhage
What percent of diagnosed asthmatics actually have vocal cord dysfunction?
33%
Ronchis are low-pitched and continuous expiratory sounds. They suggest the presence of ___________
neoplasms (vibration of solid tissue is what you hear)
Do all wheezes suggest asthma?
No
Wheezes are continuous, high-pitched sounds during exhalation. They indicate fluttering of the bronchial wal. Do they correlate well with the degree of airway obstruction?
No
How can you distinguish crackles from pleural friction rubs?
Pleural friction rubs also have an expiratory component
A late inspiratory squeak with crackles suggests __________
inflammation of the small airways
A tubular sounds and crackling sound at the same time suggests ____________.
alveolar fluid filling
Pt breathes with pursed lips during lung examination. In order to breathe, pt has to lean forward and rest elbows on knees. This produces Dahl's sign (hyperpigmented callouses above knees). What does this suggest?
COPD
During paradoxical respiration, the abdomenal wall contracts while the chest expands due to asynchronious movement of which two muscles?
Diaphragm and intercostals; diaphragm is paralyzed bilaterally; paradoxical respiration is a good indicator of respiratory failure
Pt is rocking in one direction, then rocking in another direction, while breathing. You notice that the pt is alternating between using the intercostals and diaphragm. What is your diagnosis?
Respiratory Alternans
Pt's RLQ of abdominal wall remains still while breathing. This is suggestive of ____________.
Peritonitis (specifically appendicitis in this case0
You ask your pt to take a deep breath. You notice that the chest doesn't uniformly expand (there is local lagging). What does this suggest?
Protracted lung collapse
What two methods help determine severity of scoliosis in pts?
Cobb angle and chest radiography (cobb angle greater than 100 is severe)
A doctor describes a patient as Gibbus. What does this mean?
Hunchback; kyphosis
Pt comes in and the slope of his ribs are measured. What is a normal slope? What does a horizontalized slope suggest?
45 degrees; emphysema, bronchitis, or asthma, aging
Pt displays hoover's sign. What symptoms does he show?
Lower rib cage moves inward during breathing because diaphragm is flattened. Happens during inspiration in COPD
Insufficient ventilation shows up as ____________ while ineffective oxygenation shows up as __________.
Cyanosis; pallor
Expiratory bulging can suggest ________ if focal and _________ if diffuse.
pneumothorax; obstructive disease
A physician places his fingers on a pt's thyroid cartilage. He does this to measure if there is a tracheal descent with inspiration, which is correlated with airflow obstruction. What sign is this?
Campbell's sign
A physician places his hands on each side of a pt's chest to measure the vibrations made by the pt when the pt is asked to repeat numbers or letters. Symmetry is measured. What test is this?
VCT (vocal tactile fremitus)
Does pneumonia increase or decrease VCT?
Depends; if it is alveolar then it increases VCT; if alveolar AND bronchiolar, then it decreases VCT
Regarding specificity and sensitivity, percussion has good _________ but poor ________ for detection of pneumothorax, consolidation, atelectasis, and pleural effision.
Specificity; sensitivity
Regarding specificity and sensitivity, percussion has good ______ but poor ______ for detection of LARGE pleural effisions
Sensitivity; specificity
With chest percussion, bilateral hyperresonance suggests _________.
Airflow obstruction
Which conditions does Fremitus decrease in?
status asthmaticus, pleural effusion, and emphysema
Which conditions does Fremitus increase in?
pneumonia, hemorrhage, fibrosis, and atelectasis
The preferential frequency band in humans is ____________.
1000-5000 Hz
How can you tell early-inspiratory crackles from late-inspiratory crackles?
Early-inspiratory crackles may clear with coughing
Late inspiratory crackles where the breath sound remains vesicular are usually caused by _________ while late-inspiratory crackles where the breath sound is bronchial are caused by _________.
Fibrosis (in posterior base of lung); interstitial fluid
Bronchial breath sounds with no crackles indicate _________.
Collapsed alveoli
How can you differentiate stridor from a wheeze?
Stridor is ONLY inspiratory (while wheezes are both inspiratory and expiratory)
Can you include cardiac asthma (left ventricular failure) in the differential for wheezing?
Yes
Wheezes are ____ pitched while rhonchi are _____ pitched.
High; low
Grating, creaky, and rubbing sounds present in both inspiration and expiration, non-continuous (noise), and present over the chest are known as ________.
Pleural Friction Rub
Pleural Friction Rubs present in _________.
Collagen vascular diseases and bacterial pneumonias
Whispered pectoriliquy is a transmitted voice sound that suggests _______.
a small consolidation
Late inspiratory squeaks are characterized by short, high-pitched, vesicular sounds which are often accompanied by late inspiratory crackles. They are diagnostic of _________.
fibrosis, bronchiolitis, allergic alveolitis;
Though the general rule is that lymph nodes greater than 1 cm are possibly pathologic, we can be certain that nodes > _____ cm are always neoplastic
5
Neoplastic nodes are usually described as _________ while necrosis and bacterial lymphadenitis causes nodes to feel ________.
Hard; fluctuant
Tenderness of lymph nodes usually suggests ________.
Inflammation, though sometimes it can mean malignancy too.
Matting (or fusion) of lymph nodes suggests _________.
Malginancy, though sometimes this happens in inflammatory processes too.
For which lymph nodes does a size of less than 1 cm still suggest malignancy?
preauricular
Hard, fixed, matted lymph nodes in the axilary region suggest __________.
Spready from malignancy (lung or breast)
During a lymph node exam, you notice an enlarged epitrochlear lymph node. What could this mean?
IV drug use, systemic illness, inflammation in hand/forearm
Which are more important: Inguinal or Femoral nodes?
Inguinal (which are more lateral)
An enlarged node is found in the paraumbilical region. What is this nodule called?
Sister Mary Joseph's nodule; suggests metastasis of stomach or ovarian malignancy
Asymmetric pulses mean suggest ________ in younger patients and ________ in older patients.
coarctation; atherosclerosis or dissection
What is the triple response of Raynaud's?
Pallor (white), Cyanosis (blue), and rubro (red); rubro causes the most numbness and pain
A pt comes in and demonstrate's Raynaud's syndrome after immersion of her hand in a bucket of ice water. What should you be worried about?
Systemic diseases, blood disorders, etc; eventual gangrene and necrosis
Which test measures radial and ulnar artery proficiency?
Allen Test
Both Dosalis Pedis and Tibialis posterior pulses are absent in _____ % of patients
2%
What is the major cause of peripheral vascular disease?
Atherosclerosis
What are the major symptoms of PVD?
Claudication (limping), poor healing of sores/ulcerations, muscle weakness, paresthesia
What are four major physical findings of PVD?
Absent pulses, atrophic foot changes, vascular bruits (femoral), increased venous filling time, and unilateral cool limb
A 70 y/o pt walks into the office and immediately shows signs of limping. You get no foot pulses on him. You measure his venous filling time and it is greater than 20 seconds. What do you suspect?
Severe PVD
You examine your pts legs by elevating them to 90 degrees for 2 minutes and then lowering them at a 90 degree angle for 2 minutes. You note pallor during the first part of the test and then redness during the second part. What test are you performing?
Buerger's test (for arterial perfusion in the leg)
Two predisposing factors for "the diabetic foot" are ________.
peripheral neuropathy and atherosclerotic arterial disease
The test used to identify peripheral neuropathy in diabetic pts is known as _____________
Semmes-Weinstein (SW) monofilament test
A patient comes in with an ulcer on the inside of his ankle, skin thickening in his foot, and brown hyperpigmentation of his skin. He feels no pain due to the ulcer and doesn't suffer from gangrene. What type of ulcer is this?
An ulcer due to chronic venous stasis
How can you tell neuropathic ulcers from ischemic ones?
Neuropathic ulcers are surrounded by callouses, are painless, and have little gangrene. Both types will usually be on the toes or other trauma sites.
What symptoms are present in Charcot's foot?
neuropathic osteoarthropathy due to sensory and motor loss. This manifests as a convex foot with rocker-bottom appearance and unnoticed fractures/bone deformities
Which three arteries are suitable for arterial waveform examination?
carotid, brachial, and femoral arteries (all central)
Which factors cause limitations to arterial analysis to determine left ventricular outflow obstruction?
Hypertension and atherosclerosis
What does an abnormal carotid pulse suggest?
aortic regurgitation
You read a pt's arterial pulse and notice a slow rate of rise. What does this suggest?
Aortic Stenosis
You read a pt's arterial pulse and notice a fast rate of rise. The time between systolic and diastolic sounds is normal. What does this suggest?
ventricular septal defect (right ventricle issue) or mitral regurgitation (left atrium issue), or hypertrophic obstructive cardiomyopathy
You read a pt's arterial pulse and notice a fast rate of rise. The time between systolic and diastolic sounds is longer than normal. What does this suggest?
Aortic regurgitation
You take a pt's arterial pulse. You notice two peaks in systole, both with high amplitudes. What is this called and what does it suggest?
Pulsus bisferiens. Severe Aortic regurgitation
You take a pt's arterial pulse and notice two peaks in systole. The first has a high amplitude and is brisk. The second is weaker. What is this called and what does it suggest?
Bifid Pulse; severe obstructive cardiomyopathy
A pulse with low amplitude and slow upstroke suggests _______.
aortic stenosis
A pulse with low amplitude and normal upstroke (not delayed) suggests _________.
Mitral stenosis or cardiomyopathy (decreased contraction or filling)
A pulse with a high amplitude and high upstroke suggests _________.
Aortic or mitral regurgitation
Corrigan's pulse and water-hammer pulse are both associated with __________.
Aortic regurgitation
Which side of the heart does venous pressure (jugular pulse) evaluate?
Right side (right Internal Jugular Vein is better for inpspection)
True or False: Pts with more severe medical conditions have CVPs that are more difficult to read.
True
Where is the internal jugular vein located?
Between the two SCM muscles (deep to them)
Can you palpate the IJV?
No (it dies when you touch it)
How can you distinguish venous pulses from carotid pulses?
venous pulses are bifid and have a slower upward deflection, vary with position of the pt, respiration, and abdominal pressure, and are not palpable.
Which peaks and troughs from the wigger diagram are visible in physical examination?
A (atrial contraction) and V (early ventricular diastole, apex of carotid pulse); X1 (right atrial relaxation) and Y (right atrial emptying, S3)
How do inspiration and expiration affect jugular venous pulse?
Inspiration causes X and Y descents to be more visible (and jugular pulse too) but decreases jugular venous pressure); Expiration causes A to decrease and V to become more visible (but pressure rises).
What does an elevated CVP (above 7cm) tell us?
hypervolemia or problems with right-sided filling
What does a decreased CVP tell us?
GI or urinary losses
What does a positive abdominojugular reflux test tell us?
JVC > 4mm; this means that right heart chambers can't handle increased venous return; also predicts left ventricular failure
An increase in size and/or force of the apical impulse suggests ________.
Left ventricular hypertrophy
A sustained apical impulse and a shift of the impulse down and a shift of the impulse up and to the right suggest a _________ load.
Pressure; seen in hypertensive pts
A large, non-sustained apical impluse or a shift of an apical impulse down and to the left suggests a ________ load.
Volume
Double or triple (Triple ripple) systolic apical impulses suggest _________.
hypertrophic obstructive cardiomyopathy
A hypokinetic apical impulse is seen in pts with ____________.
Congestive Cardiomyopathy
Which is longer: diastole or systole?
Diastole
What do S4, S1, and S2 mean?
S4: atrial contraction (final sqeezing of atrium to fill ventricle); S1: closure of AV valves; S2: closure of semilunar valves
What is systole in terms of S1-S4?
Systole is the time between S1 and S2
If S2 is louder than S1, this suggests __________.
Pulmonary or Systemic (Aortic) hypertension
What do an abnormally loud and soft S1 mean?
Loud: hyperkinetic heart syndrome, heart valves are farther apart, increased contractility, mitral stenosis; Soft: CHF usually due to rheumatic fever, heart valves are closer together, decreased contractility, aortic regurgitation
Thicker leaflets make S1 _________ while hardened and calcified leaflets make S1 ________.
Harder; softer
Which valve is more dominant and closes first (mitral or tricuspid)?
Mitral
An early ejection sound (pulmonic or aortic) shows up during auscultation as a ________
S1 split at the base
A widely split S1 heard at the apex suggests
Delayed closure of the tricuspid valve
Which semilunar valve closes first (aortic or pulmonic)?
Aortic
Regarding splitting and sound intensity, which is more important for readings of S1 and which is most important for S2 readings?
Splitting for S2 and Intensity for S1
What are two causes of physiologic splitting (widening of gap between Aortic and Pulmonic closure)?
Increased RV filling (making pulmonic valve close earlier) or decreased LV filling (making aortic valve close earlier); note: splitting decreases with aging; PHYSIOLOGIC SPLITTING IS ONLY DURING INSPIRATION
What does expiration do for S2 sounds (how does it change the gap between A2 and P2)?
It narrows the gap (while inspiration widens it)
Does lying in a supine position increase or decrease physiologic splitting of S2?
Increase; sitting up decreases it
What causes late closure of the pulmonic valve?
Right bundle branch block (decreased contractility), impedences to right ventricular emptying (pulmonary stenosis, etc)
What causes premature closure of the aortic valve?
Rapid filling of LV (mitral regurg, Ventricular Septal Defect)
What is the most common pathologic condition associated with a fixed S2 split
Atrial Septal Defect
A pt is refered to you by another physician. His file says he has fixed S2 splitting. What should you hear upon auscultation?
late systolic click (heard best at apex) and early diastolic extra sound (either S3 or opening snap of mitral stenosis; also consider a tumor or pericarditis) (so, a click right before S2 and another sound right after S2)
Regarding S2 splitting, when during the breathing cycle do phyiosogical, fixed, and paradoxical splitting occur?
Physio: inspiration; paradoxic: expiration; fixed: both
What is happening during paradoxical splitting of S2?
A2 is after P2 (instead of before, due to LV bundle branch problem, LV blockage, or myocardial ischemia); also, inspiration now narrows the gap between P2 and A2 while expiration widens it.
What causes single splitting (apparently normal S2 that is actually split)?
aging, emphysema, paradoxical splitting, pulmonary hypertension, hardening of semilunar valves
If P2 precedes A2, is it a right or left bundle branch block?
Left
Normally you hear a physiologic split of S2 at the base (where P2 is measured); what does it mean if you can hear a split at the apex?
pulmonary hypertension (which causes P2 to be way louder)
What causes the intensity of S2 to increase?
pulmonary or systemic hypertension
What does it mean if S2 is softer than S1?
Pulmonary or Aortic Stenosis
Pt comes in with a loud and ringing S2 with overtones. What does this suggest?
dilation of the aorta (aortic disection or aneurysm)
If P2 is louder than A2, what is happening?
either pulmonary hypertension (increasing P2) or aortic stenosis (decreasing A2)
A pt comes in with calcified semilunar valves and low pulmonic and systemic blood pressure. He is a long time smoker who you suspect has emphysem What will S2 sound like?
Both A2 and P2 will be softened so S2 will be softer as well
How do you hear S3 and S4 (both of which are pathologic)?
Using the bell, at the apex; you can also palpate S4 and sometimes S3 too; exercise increasing intracardiac blood flow can make it more audible too
What produces the S3 and S4 sounds?
S3 is rapid/passive filing of ventricles (80% of ventricular fililng) while S4 is the late/active squirt (20% of filling) into ventricles
A patient asks you if a gallop is a bad thing. What do you say?
Yes, you are screwed. There are two major gallops (S3 gallop is ventricular gallop and S4 gallop is atrial gallop) and there is 1 summation gallop (both atrial and ventricular, seen with tachycardia; shortens diastole)
A child comes in to your office, and you notice an S3 gallop. The child plays a lot of sports and exercises regularly. When she sits up, her S3 gallop goes away. What does this suggest?
Physiologic gallop (healthy in kids/pregnant women; unhealthy if pt is above 40)
Pathologic S3 is usually due to _______.
increased ventricular preload or poor systolic function (reduced ventricular contraction)
You diagnose mitral regurg in ________ but you assess severity in ________.
systole; diastole (S3)
S3 is a powerful predictor of clinical severity for many conditions; the most important of these is ______.
CHF
Diastolic overload can cause S3. Which conditions lead to diastolic overload?
PDA, VSD (NOT atrial septal defects), mitral regurgitation (causes louder S3, w/ opening snap)
A pt comes in with aortic regurgitation and you also notice an S3. What does this mean?
High chance of LV failure
Is aortic stenosis associated with S3 or S4?
S4
What is the Carvallo maneuver?
Tells you if S3 is right-sided or left-sided; R is louder with inspiration and causes parasternal lift while L is louder with expiration
Is stenosis often present during S3?
NO!
What is more common: S3 or S4?
S4; and it is always pathologic, especially when palpable
What causes S4?
Aging can cause S4 which decreases ventricular compliance (hypertrophy, fibrosis)
What generates S4?
Mostly L Atrial systole but sometimes R too
Is S4 more indicative of diastolic or systolic dysfunction?
Diastolic; more blood is actively squirted into a non-compliant ventricle due to decreased passive filling
In cases of ventricular dysfunction, what happens to an S4 sound as the ventrical becomes more and more dysfunctional?
It disappears and is replaced by an S3 sound (S4 is the early warning)
What diseases cause S4?
Anything that causes the ventricle to be so thick that extra effort is needed for atrial contraction (hypertrophic cardiomyopathy, hypertension, aortic stenosis, coarctation of the aorta)
Is S4 associated with MI?
Yes
What pathology do mid-to-late systolic clicks suggest?
Mitral Valve Prolapse (when heard with murmors they also imply regurgitation); sound is due to billowing of leaflet and chordal snap
What causes early-systolic clicks?
ejection sounds
What are the three components of pericardial friction rub? M
Mid-systolic, early-diastolic, and late-diastolic
Are rubs palpable?
Yes
What makes a rub louder?
sitting up and leaning forward; inspiring with a deep and held breath
How can you tell a pericardial from a pleural rub?
Pt should inspire and then expire. Pleural rub will not persist but pericardial rub will.
You listen to a pt and hear pericardial rubs. What diseaes do you suspect?
pericarditis, acute MI, neoplasm, pericardial effusion
What is Erb's point used for?
Detection of murmurs
Generally, systolic murmers are ____ while diastolic murmers are ____.
benign; bad (diastolic = diabolical); note: continuous murmers are pathologic too
How can volume of a murmer help you tell if it is benign or not?
Murmers that are louder are generally more harmful (3/6 or lower is usually benign)
How do grade a thrill?
A thrill must be at least a 4/6 on the murmer scale and is thus pathological
What are two characteristics that turbulence (the source of sound in murmurs) is based on?
narrowing of vessels and velocity
Do continuous murmurs originate within the heart chambers?
No (and they have "train-in-tunnel" sound)
What is more common: a systolic murmur or a diastolic murmur?
Systolic Murmur (and exercise has more of an effect on this than it does on diastolic murmur)
Which systolic murmurs can be pathologic?
Late-systolic and holosystolic (since they extend to S2, which suggests AV regurgitation)
Early diastolic murmurs indicate ______ while mid-to-late diastolic murmurs suggest ______.
semilunar regurgitation AV stenosis
The name of the system that grades murmurs from 1-6 is the ______.
Levine System
A murmer that is generated by a low pressure gradient suggests ________.
Mitral stenosis (high pressure gradients that cause murmurs may suggest Aortic regurgitation); note: mitral regurgitation murmurs have a more musical quality while aortic stenosis murmurs are often rough and harsh)
What does valsalva do for murmurs that are due to hypertrophic obstructive cardiomyopathy and mitral valve prolapse?
Increases intensity of HOCM and increases duration of MVP
How does deep inspiration affect a holosystolic murmer caused by tricuspid regurgitation?
It increases its intensity (use this to differentiate between trcuspid and mitral regurg)
What does sitting and standing do for HOCM and MVP murmurs?
It decreases their intensity / duration respectively; if you squat for 30 seconds then immediately stand, it increases intensity/duration respectively
An isometric hand grip helps identify ______.
Mitral regurgitation
Increasing diastolic pause (with premature beats) can help identify ______
Aortic Stenosis from mitral regurgitation
The main guide for a clinician when judging the pathology of a murmur is ______.
S2 (when it is obliterated or incorporated into murmurs); note: a soft S2 usually means obstruction while a loud S2 means stenosis
Are functional murmurs harmful?
No. By definition they are benign. They are common in children
What are two causes of systolic murmers?
Ejection and regurgitation
An apical-carotid and/or brachio-radial delay can help diagnose which type of murmur?
Aortic Stenosis (note: intensity of a murmur can also be diagnostic but only in children)
What is the Bernheim phenomenon and how does it relate to Aortic Stenosis?
Something that happens on one side of the heart has an effect on the other side (ie: aortic stenosis causes left ventricular hypertrophy which causes pulmonary hypertension and thus compresses the right ventricle)
What are predictors of severity/outcome of Aortic Stenosis?
murmur intensity / lateness in diastole, presence of a single S2, delayed/smaller carotid pulse
Radiological tests for a pt reveal thickened IV septum, which causes the mitral valve to obstruct flow during systole. What is this condition called?
HOCM (with a murmur heard loudest at the apex)
When in systole does an HOCM murmur start and what is the carotid pulse like?
Mid to Late; bifid pulse
In a bedside exam, how can you increase LV volume to diagnose HOCM?
leg raising and standing to squatting exercises.
What other condition is HOCM often associated with?
Mitral regurgitation
Regurgitant murmurs start _______, extend into S2, and have a musical quality.
early in systole
What are two causes of MR?
Valve dysfunction and alterations of LV (dilation and dysfunction)
A murmur is holosystolic, has normal S2 intensity, is loudest at the apex, radiates to the left axilla, and is high-pitched. What do you suspect?
MR (with good sensitivity and specificity)
What aspects of a MR murmur make it more severe?
intensity, length; LV size increase; S3 at the same time; S2 splitting; in most MR cases, PMI is displaced down and out and pulse is brisk and single
What causes MR murmurs to be louder?
exhalation (opposite of TR murmurs), squatting/vasopressors/handgrips, and standing (only for MR due to MVP and not for MR due to dialated LVs)
What is the most common valve disorder on the planet?
MVP syndrome (which is more common in women)
What accompanies MVP?
mid-to-late systolic click, LV ballooning during systole
How does increasing LV size affect MVP murmurs?
It delays and decreases the intensity of the click sound and the murmur
What can increase the click and murmur intensity in MVP?
inspiration, tachycardia, squatting then standing, valsalva
90% of TR pts will have _______ plus ________.
distended neck veins; peripheral edema and/or ascites
A diastolic murmur can be caused by what two things?
forward flow through AV valve and backward flow through semilunar valve
Early diastolic murmurs suggest _______ while mid-to-late diastolic murmurs suggest _______.
Semilunar Regurgitation; AV stenosis
AR is responsible for ___ % of heart valve disease.
10
In the US, AR is mostly caused by _____ while in the rest of the world, it is caused by ______.
leaky valves; rheumatic fever / syphillis; note: hypertension can also contribute to AR
Can AR be caused by enlargement or shrinking of the aorta?
Enlargement (dilation)
A pt's physical exam and further testing suggest that his left ventricle is facing a volume overload. This overload has over time decreased left ventricular function and is causing an rise in pressure in other ventricles as well. It is apparent that blood is flowing backwards from the aorta and forwards from the mitral valve so that the LV is ballooning up. What condition do you suspect?
AR (which is usually asymptomatic)
What are three cardinal signs of AR?
Widening of gap between systolic and diastolic BP (systolic goes up, diastolic goes down), brisk/tall pulse, enlarged apical beat that is displaced down and out
What type of murmur is present in AR?
Early diastolic murmur (starts RIGHT after S2) that tapers, heard over Erb's point or Apex
Austin Flint murmurs are present in which pathologic condition?
AR
What conditions are responsible for continuous murmurs?
PDA, increased vascular flow (in arteries OR veins)
You hear lots of noise in both the systolic and diastolic phases. What do you suspect?
3 options: AR + systolic flow murmur, PDA murmur (continuous), pericardial friction rub
Eisenmenger's syndrome is cyanosis due to pulmonary hypertension resulting from ____.
PDA
When is aortic regurgitation diagnosed? When is severity assessed?
Diastole; systole
You do a superficial exam of a pt's abdomen and notice a central dimple resembling cupid's bow near the umbilicis. What do you suspect?
acute pancreatitis
A localized bulge in the epigrastric area suggests __________.
Large pericardial effusion (Auenbrugger's sign)
A bulge in the hypogastric area suggest ____.
full bladder
A bulge over the two upper quadrants of the abdomen might be ______.
Hepatosplenomegaly
How can you distinguish small bowel obstruction from large bowel in a superficial abdominal exam?
ladder appearance: small bowel; inverted U pattern: large bowel
Three reasons why your belly button can evert are:
1) mass in abdomen, 2) fluid, and 3) obesity/lax abdominal wall
You notice a protuberance at a pt's umbilicis. What should you be worried about?
Sister Joseph's nodule (metastatic cancer with primary origin in stomach or ovaries). Pt has 1 year to live.
You notice Cullen's sign (periumbilical ecchymosis - purple color) and Grey Turner's sign (bilateral reddish/purple discoloration) around your pt's belly button. What are you worried about?
Acute hemorrhagic pancreatitis (note: low sensitivity and specificity)
If the belly button is displaced downward, it suggests _______; upward displacement means either ______ or _____.
ascites or hepato-splenomegaly (downward is more common); pregnancy or pelvic tumor
You notice that your patient's chest and abdomen don't rise and fall at the same time while breathing. This creates a rocky motion in his chest. You believe that this means the diaphragm is weak or paralyzed. What does this predict with high sensitivity and good specificity? What is this called?
Respiratory Failure; abdominal paradox
Your pt's abdomen seems to rock back and forth from side to side as he breathes. It seems he is alternating between using intercostal muscles and his diaphragm to breathe. What is his condition called?
Respiratory Alternans
If your pt's abdomen doesn't move at all while he is breathing, you might suspect _______.
peritonitis
Cushing's syndrome may show up on the abdomen as _______.
Purple striae (stretch marks)
IVC obstruction shows up on the _____ abdominal wall while SVC shows up on the ______ abdominal wall.
lateral, upper
Abnormal venous networks radiating from the belly button and seen in portal hypertension are known as __________.
Caput medusae
How can you distinguish an intra-adbominal tumor from an intramural tumor?
Raise pt's head to increase intra-abdominal pressure and make intra-abdominal masses disappear (but not intramural masses)
The AAA exam looks for horizontal expansion of the aorta and measures for an expansile mass greater than 3cm. It is highly specific and _______ sensitive for small expansion but _______ sensitive for large expansion.
not; very
Between the stomach, SI, and LI, which organs produce the most bowel sounds?
Stomach, then LI, then SI
Bowel sounds have ______ sensitivity and _____ specificity for SI obstruction.
poor; poor
Murmurs in the abdomen that are not continuous (as with bruits) are usually ________ (systolic or diastolic)?
Systolic
Murmurs heard in the epigastrum are usually benign and systolic; in contrast murmurs from the RUQ are generally bruits and are malignant tumors such as _____.
Hepatomas
What are three pathologies associated with LUQ bruits/murmurs?
Pancreatic cancer, splenic vascular issues, aneurysm
A continuous murmur heard in the umbilical (epigastric) area and accompanied by a thrill is known as a venous hum. Which tree conditions are accompanied by this murmur?
hepatic cirrhosis, portal hyertension, and caput medusae; this murmur is known as Cruveilhier-Baumgarten murmur.
You examine a pt's RUQ and notice a rub. What do you suspect?
Liver cancer (if it were the LUQ, you'd suspect pancreatic cancer)
Two conditions associated with pulsatile liver (which is sensitive, not specific) are:
tricuspid regurgitation and constrictive pericarditis
The abdomino-jugular reflex must cause at least 4cm of distension of neck veins and is 100% specific but moderately to highly sensitive for what pathologies?
CHF, murmurs, or tricuspid regurgitation (test method is known as Rivera-Carvallo maneuver)
Between bruits (arterial) and hums (venous), which is primarily systolic and which is also heard in diastole?
bruits are mostly systolic; hums are heard in both phases
Presence of a rub AND a bruit in hepatic exam strongly suggests ______.
neoplasia
Between spleen and liver palpation, which is specific for organomegaly?
Spleen (note: sensitivity is LOW), using a scale of 0-5
Kehr's sign (referred pain in the left shoulder) helps tell us what?
Pt may have splenic rupture
A cheap and useful test for detection of splenomegaly is ______.
Ultrasonography
Malet-Guy's sign helps us screen for _______ by percussion of the thoracolumbar spine or palpation of the LU
pancreatic findings
Of all of the kidney murmurs, which are the most important?
Anterior continuous bruits for determining renovascular disease
Grading of power (strength of muscle groups about a joint) is via a scale from
0-5 (5 is normal, 3 means only can perform against gravity, 1 is twitch, 0 is absent )
How do you define paresis, plegia, fasciculations and pseudohypertrophy for the power exam?
paresis (1-4); plegia (0); fasciculations (1, twitching); pseudohypertrophy (0 but muscle is larger)
What muscles/nerves do you assess in the power exam?
Deltoid (abduct humorous, C5 axillary nerve), Biceps (flex elbow, C5 and C6 musculocutaneous nerve), Iliopsoas (flex hip, L2/L3 roots), Quadraceps (Extend Knee, L4 root femoral nerve)
Increased tone and spastic (claspknife) paralysis on the contralateral side is due to ______ damage while increased tone on the ipsilateral side and cogwheel rigidity is due to ______ damage
UMN; basal ganglia (ie: Parkinsons)
Which muscle groups and nerves are testing in reflex examination?
Biceps (C5/C6), Triceps (C7), Quads-patellar (L4), Plantar/Gastrocnemius (S1)
How are reflexes graded?
0-4; 0 is absent, 2 is normal, 4 is clonus; Jendrassik's maneuver helps get a 1 out of a 0; 0 is plegia and 1 is paresis
You do a facial nerve exam on a pt and notice ipsilateral whole face is weak and frontalis muscle is weak too. What does this suggest?
Bell's palsy (LMN problem)
An UMN lesion to the facial nerve is assessed via _______.
smile / growl or LOWER FACE (contralateral)
Swallowing and the uvula test CN _____.
9 and 10
Testing for winged scapula and shoulder shrugging assess what CN?
11
In CN 12 damage, the tongue deviates to which side?
Side of damage (due to LMN problem)
A pt just had a stroke and you are assessing her gait. What would you expect?
UMN problems, so spastic gait. On CL side to stroke, narrow-based, arms are supinated and against body, legs cross over with each stop and are dragged, and hyperreflexia/paresis are present)
A pt with a cerebellar issue will have what kind of gait?
Ataxic gait (wide-based, unsteady, no arm swinging, less sensation in feet)
How do you examine CN5 motor function?
Masseters (bite down, left then right)
Parkinson's disease manifests as which type of gait?
Shuffling gait (slow movement, tremor, narrow-based, hunched over, elbow flexion, difficulty starting and stopping)
A positive Romberg Test suggests ______ while a negative test might mean ______.
Sensory ataxia; cerebellar ataxia (test involves closing eyes and standing with feet together)
The semmes-weinstein monfilament and 256-HZ tuning fork are used to measure what?
Sensation for peripheral neuropathy, stocking-glove neuropathy
What are three manifestations of cerebellar dysfunction that can be tested?
Dysmetria (finger-to-finger for depth perception), diadochokinesia (supination-pronation, ability to perform rapid and alternating activities), and asynergia (heels up and down against leg, graceful, gliding movements tested)
During the knee ROM test, flexion is up to ____ degrees and extension is up to ___ degrees.
150; -5
Two ways to check for effusion in the knee are _____ and _____.
Ballotable patella (push downward) and fluid displacement (lateral, fluid goes to other side)
For assessment of ACL sprains, which test is best?
Lachman test (at 25 degrees, much more sensitive than anterior drawer test)
What do you palpate to check for hamstring injury?
Semimembranosis/semitendinosis
Varus stress (lateral pain) means LCL sprain
Valgus stress (medial pain) means MCL sprain; both are at 25 degrees
What nerves are tested with arm / forearm gestures?
C5: arm abduction; C5/C6: elbow flexion; C7: Elbow extension; C8: Fist; T1: Finger Abduction
The apley scratch test for rotator cuff muscles can expose limits from above which mean _____ injury or below, meaning _____ injury.
infraspinatous; subscapularis
What does Yergason's test determine?
Bicipital tendonitis (via elbow flexion and supination)
Cozen's test measures if a pt has tennis elbow. This is an evaluation of pain in the _________.
Lateral epicondyle; note: medial epicondyle pain is known as bowler's/ golfer's/ rock climber's elbow
True or False: we can pronate our forearms more than we can supinate?
True (pronation is up to 80 degrees and supination is 75)
The forearm squeeze test assesses which two nerves?
Radial and Ulnar
The hand neurologic exam tests for which nerves with the 1)okay sign, 2)fingers spread, 3)thenar eminens sensation, 4)hypothenar sensation, and 5)snuffbox sensation respectively?
1) median, 2) ulnar, 3) median, 4) ulnar, 5) radial
The Allen test assesses the patency of the _____ nerves.
Ulnar and Radial
Tinel's test measures peripheral nerve entrapment sites by tapping fingers at a site repeatedly, which tests for which pathologies?
Ulnar Tunnel and Carpel Tunnel
The Finkelstein Test measures for pain in the ________
Snuff Box and Palmar Wrist
Besides Tinel's test, which other test is used to measure for peripheral nerve entrapment?
Phalen's Test
What is the difference between petechiae, purpura, and ecchymosis in size and which are palpable?
Only purpura are palpable; petechiae are 1-2mm; purpura are 2-10 mm; Ecchymosis are 1cm or more
You notice a nevus mole (not palpable) on a pt that is less than 1 cm in size. What is this called?
a macule; note: papules are the same size but are palpable
Of Plaques and Patches, which is palpable?
Plaques (both are > 1cm)
Are nodules (furuncles, abscess, etc) palpable?
Yes
Of Bullas, pustules, and vesicles, which is filled with pus?
Pustules; Bullas are fluid filled and vesicles are clear-fluid filled
Excorations are scratches that indicate _______.
Pruritis
Herpes simplex involves clusters of ____ while chickenpox involves clusters of ______.
vesicles; pustules
Pt comes in with bruises due to anticoagulants. How would you describe them?
Purpura (also can be due to vasculitis)
Platelet dysfunction can cause what kind of bruising?
Petechiae
Pt has red, puritic papules and plaques. Lips are swolen. What condition is this?
Urticaria
Cratching urticaria lesions can cause ______ formation
Wheal and flare
Rashes that stay wtihin a dermitome might be due to _______.
Varicella zoster virus
Psoriasis has an _______ rash pattern while dermatitis has a _______ rash pattern.
Extensor, flexor
Pt comes in with a rash that developed over a previous surgical scar. What is this sign called?
Koebner's sign (may be due to psoriasis)
Endocarditis can manifest on the nails as _______.
Splinter hemorrhages (longitudinal purple-black lines)
Schamroth's sign tests for what dermatological finding?
Clubbing
Temporal and occipital allopecia are mainly due to ________.
Androgen issues
A type of allopecia that is autoimmune-related and due to thyroid-disease, causing patches of hair loss, is known as _____.
Allopecia Areata
HEENT
HEENT
Only structure of auricle not cartilage
Ear lobe
Structures of auricle
Helix, antihelix, tragus, canal, lobe
Structures seen on tympanic membrane
umbo, light reflex, pars flaccida, pars tensa
Diffuse, erythematous tender swelling of entire auricle
Otitis externa maligna
Otitis externa maligna is infection caused by
Pseudomonas
People at risk for otitis externa maligna
Diabetics, immunocompromised
Decrease hearing on one side, sense of fullness in ear
Cerumen impaction
Otitis externa also called
Swimmer's ear
Decreased hearing on affected side, sense of fullness in ear, swelling, erythema, serous discharge
Otitis externa
Painless ulcer on the ear may be
Squamous Cell carcinoma
Enlargement of Posterior auricular node
Squamous cell carcinoma of auricle
During Otoscopy pull which direction on the ear
Upward and backward
Bulging TM, diffuse erythema, purulent, loss of landmarks
Purulent Otitis media
Used for draining Otitis media
tympanoplasty tube
Swollen, deformed nose with epistaxis
Nasal fracture
Painless enlarged red nose with telangiectasia and enlarged sabecous glands
Rhinophyma
Swollen nasal mucosa with rhinorrhea
Rhinitis
Tenderness to percussion over sinuses, decreased transillumination, green nasal discharge
Sinusitis
Loss of tooth substance with brown/black discoloration
Caries
Recession of gingiva "long of tooth"
Gingivitis (severe)
Nontender nodule/exostosis in palate of mouth (normal varient)
Torus palatinus
Sublingual varices may indicate long term what
Elevated right side pressures
Loss of papillae except circumvallate papillae is called
Atrophic glossitis
Abnormal taste
Dysgousia
White or red ulcerating, firm mass usually on lateral base of tongue
Squamous cell carcinoma
Erythema and swelling of tonsils and posterior pharynx
Non-exudative pharyngitis
Serous Rhinorrhea and serous otitis media often accompany
Non-exudative pharyngitis
Diffuse cervical lymph node enlargement found in
Non-exudative pharyngitis
Swelling, erythema and exudates on posterior pharynx and uvula
Exudative pharyngitis
Enlarged tender jugulodigastric lymph nodes found in
Exudative pharyngitis (Streptococcus)
Smooth nodule or mass in the posterior pharynx ajacent to a tonsil
Quinsy (due to streptococcal abscess)
Edema in face and upper limb with elvated jugular venous pressure and macroglossia
SVC syndrome
Coarsening of features, macroglossia, Queen Anne's sign, delayed relaxation phase or reflexes
Myxedema
External canal of the ear is lined by
Stratified squamous epithelium
The evagination of the malleus on the tympanic membrance is called
Umbo
Nontender, yellow papules on the helix and antihelix are called what and associated with what condition
Auricular tophi, gout
Soft, nontender nodules in the ear lob due to trauma
Ear lobe keloids
Palpable preauricular nodes are due to infection where
Periorbital structures
A marked loss of structure and function of the auricle due to trauma or infection of the auricle is called
Cauliflower ear
Dullness, prominence of landmarks, speckled type of light reflection, arifluid levels behind the tympanic membrane, and sense of ear fullnees
Serous otitis media
Serous otitis media is caused by
Viral or atopic process
Purulent otitis media is caused by
Bacterial infection
Organisms that often cause purulent otitis media
S. pneumo, H. influenza, Moraxella catarrhalis
Manifests as a hole in the membrane itself with loss of cone of light relex, and a dull membran
Perforation of TM
Which turbinates are visible on inspection
Middle and Inferior Turbinates
Discrete purple colored swelling in the nasal septum
Septal hematoma
Complications of a nasal fracture
Septal hematoma and septal deviaton
Soft, red, pedunculated nodules in the nasal canals
Nasal polyps
Nasal polyps can be due to
Atopic rhinitis or foreign bodies
Periorbital plaque-like ecchymosis, macroglossia, finderings of right heart failure
Amyloidosis
Periorbital ecchymosis (racoon's eyes), with Battle's Sign, and hematotympanum
Basilar skull fracture
Bruising behind the eyes is called
Battle's sign
Visible and palpable mass in the anterior neck
Goiter
Goiter can be associated with
Hyper, hypo, or euthyroid
Cervical LN enlargement due to mets
Hard, stoney nodes
Cervical LN enlargement due to lymphoma
Rubbery nodes
Cervical LN enlargement due to infection
Tender swollen nodes
Tender erythematous swelling in anterior nexk, esp submental area with possible airway compromise and stridor
Ludwig's angina
Lateral neck swelling is a manifestion of
Parotid gland enlargement
Parotid glands can be enlarged due to
Mumps, bulimia, or sialolithiasis
Gingival hypertrophy is often due to
AE of meds like phenytoin or cyclosporine A
Diffuse tender swelling, tartar, and calculus at gingive/tooth interface and mild bleeding
Gingivitis vulgaris
Diffuse gingival hypertrophy can be caused by
Acute non-lymphocytic leukemia M5 subtype
Hypertrophic interdental papilla is called
Epulis
Epulis is caused by
Irritation due to flossing of 3rd trimester pregnancy
Mucosa covered, bony benign nodules, usually on lingual side of the mandible are called
Torus mandibularis
Clusters of vesicles that become painful erosions and ulcers on gingiva, mucosa, lip, and skin outside the vermillion border
Herpes Simplex stomatitis
Diffuse vesicles that become painful erosions and ulcers on gingiva, mucosa, lip, posterior pharynx, and does not cross the vermillion border
Coxsachie stomatitis (herpangina)
White papules and plaques in the mouth
Thrush
Tender erosions on buccal mucosa
Aphthous stomatitis
Wearing down of incisural surfaces of teeth
Tooth attrition
Transverse fissures in the lip
Cheilitis
Crusty fissures on the angles of the mouth
Cheilosis
Cheilosis is due to
Candida or iron deficiency
Atopic glossitis is seen is what conditions
B12 or folate deficiency
A black tongue can be due to bismuth, charcoal, or
Aspergillus niger colonization
Purple vessels of the sublingual surface
Sublingual varicosities
Red patches of denuded tongue epithelium, surrounded by rims of white and areas of normal epi, changes daily
Geographic tongue
Lymph and Extremities
Lymph and Extremities
Lymph nodes are significant at what size
> 1 cm
Rock hard LNs
Neoplastic
Fluctuant LNs
Necrosis and bacterial lymphadenitis
LNs that fistulize and form open sinuses are called
bubos
Mass like conglomerates of LNs called
Matting
Matting is usually a sign of
Malignancy
Tenderness is usually a sign of
Inflammation
Cervical lymphadenitis called
Scrofula
Sister Mary Joseph's node
Periumbilical node
Hard, fixed, or matted axillary nodes
Spread from lung or breast cancer
Enlargement is common in childhood infections but not in adults
Occipital LNs
Enlargement of preauricular nodes
lymphoma or conjunctivitis
High posterior cervical nodes
nasopharyngeal tumor
Enlarged Submental and submandibular nodes
cancer of nose, tip, ant. tongue, ant. floor of mouth
Midjugular nodes
Cancer of base of tongue or larynx
Lower jugular nodes
Cancer of thyroid or cervical esophagus
Anterior cervical lymphadenopathy
URI
Posterior cervical lymphadenopahty
Otitis media
Cluster of prelaryngeal LNs on the thyrohyoid membrane called
Delphian nodes
Enlarged Delphian nodes indicative of
Thyroid disease
Sentinel node
Left supraclavicular node
Palpable supraclavicular node
Metastatic breast or lung cancer
Enlargement of sentinel node
deep-sited carcinoma
Palpable left supraclavicular node also called
Troisier's node
Palpable left supraclavicular node due to gastric metastasis called
Virchow's node
Valsalva maneuver will help in palpating what LN
Superclavicular LNs
Enlarged epitrochlear node
Inflammation of hand or forearm
Enlargement of Sister Mary Joseph's node
Intrapelvic or intraabdominal cancer (usually gastric or ovarian)
Usual sequence in Raynaud's Phenomenon
pallor, cyanosis, rubro (white, blue, red)
Numbness or pain found in Raynaud's Phenomenon during which stage
Rubro (reprofusion)
Excess sensitivity of hands and fingers to cold
Raynaud's Phenomenon (wide differential diagnosis)
Test that assesses patency of radial and ulnar arteries
Allen's test
Delay in refilling in Allen's test is
> 5 seconds
Absence of both pedal pulses suggests
PVD
Claudication affects buttocks, thigh, and calf
PVD of distal aorta
Claudication primarily affects the calf
PVD of femoropopliteal distribution
Claudication of foot
PVD of peroneotibial distribution
PVD of peroneotibial distribution is rare except in
Diabetics
Intermittent limb pain, usually triggered by activity
Claudication
Classic Sx of PVD
Claudication (and arterial insufficiency Sx)
Increased venous filling time as measured in leg
> 20 seconds
Buerger's test is a sign of what characterisitc of PVD
Distribution
An assessment of distribution of PVD is
Buerger's test
Essential to guide arterial puncture and cannulation
Allen's test
Standard for testing diabetic neuropathy
Semmes-Weinstein (SW) monofilament test
Inability to sense a 5.07 SW filament is predictor for
Risk of foot ulceration
Positive SW monofilament test
Loss of sensation in 4/10 sites, or over 3rd and 5th metatarsal head
Other findings in a diabetic foot
Hypertropic calluses, brittle nails, hammer toes, fissures
Neuropathic osteroarthropathy with sensory and motor loss
Charcot's foot
Charcot's foot seen in which diseases
Diabetes, Tertiary syphilis, Charcot-Marie-Tooth
Swelling of a limb caused by accumulation of fluid
edema
Accumulation of serum
venous edema
Accumulation of lymph
lymphedema
Accumulation of fat
lipedema
Formation of a well defined depression in soft tissue following pressure
pitting edema
Pitting edema is graded on what scale
1-4 (4 is highest)
Bilateral lymphedema, more common in women, before age 40
Primary lymphedema
Unilateral lymphedema following infection, surgery, etc.
Secondary lymphedema
Neck vein distension when upright suggests
Right or bi-ventricular failure
Test for functionality of leg vein valves
Trendelenburg's test
Trendelenburg test will have false negative with
arterial insufficiency
Common Sx of DVT
leg pain and swelling
Physical exam for what diagnose is not good
DVT
Musculoskeletal
Musculoskeletal
Medial Knee Structures
MCL, medial meniscus, hamstrings (semimembranosis and semitendinosis), ACL attachment
Lateral Knee Structures
LCL, ITB, lateral meniscus, hamstrings (biceps femoris)
Anterior Knee Structures
Quadriceps tendon, patellar tendon, ACL
Posterior Knee Structures
Hamstrings, Popliteal fossa, PCL
ROM Knee Flexion
150 degrees
ROM Knee Extension
negative 5 degrees
Bow-legged
Varus
Knock-kneed
Valgus
Gentle pushing downward on patella- feel fluid/see bulging of fluid
Ballotable patella (and thus also bulge sign)
Transmission of fluid in knee to other side
Fluid displacement
Common muscular cause of knee problems
Hamstrings
W hand configuation for what test
Varus/Valgus
Medial pain/laxity with valgus stress
MCL or lateral meniscus
Lateral pain/laxity with varus stress
LCL or medial meniscus
Classic test for ACL sprains
Lachman's test
Knee at 25 degrees and place P/A stress on tibia
Lachman's test
Positive Lachman's test
Anterior movement of tibia
Anterior drawer identical to Lachman's except
Knee at 90 degrees
Positive test that is indicator of worse knee injury
Positive Anterior Drawer (requires an unstable knee)
Clear the shoulder joint by performing
Passive Crank Test
Muscle: Abduction of the shoulder
Supraspinatus
Muscle: External rotation of the shoulder
Infraspinatus
Muscle: Internal rotation of the shoulder
Subscapularis
Test active ROM of shoulder
Active Crank Test
Test nerve roots C5,C6
Active flexion at elbow
Test nerve root C5
Active shoulder abduction
Test nerve root C6
Active supination at elbow
Test nerve root C7
Active extention at elbow
Test nerve root C8
Active finger flexion (making a fist)
Test nerve root T1
Active abduction and adduction of fingers
ROM flexion of arm
170 degrees
ROM Extension of arm
45 degrees
ROM Internal rotation of arm
80 degrees
ROM External rotation of arm
85 degrees
ROM Adduction of arm
40 degrees
ROM Abduction of arm
170 degrees
Limited Apley Scratch test from above
Infraspinatus
Limited Apley Scratch test from below
Subscapularis
Good test for rotator cuff function
Apley Scratch test
Test active flexion at elbow and supination of forearm
Yergason's test
Yergason's Test is good for what
Bicipital tendonitis
Origin of flexors and pronator of forearm
Medial epicondyle
Origin of extensors and supinator of forearm
Lateral epicondyle
Ulner nerve enters forearm through
Cubital tunnel
Passive ROM Flexion Ulnar/Humeral joint
160 degrees
Passive ROM Extension Ulnar/Humeral joint
5 degrees
Passive ROM Supination Radial/Ulner joint
75 degrees
Passive ROM Pronation Radial/Ulner joint
80 degrees
Pain in wrist or elbow with Forearm Squeeze Sign
Assess further
Examiner squeezes mid-forearm (radius and ulna) together
Forearm Squeeze Sign
Lateral epicondylitis
Tennis elbow
Medial epicondylitis
Bowler's, golfer's, rock-climber's elbow
Extensor compartments of the anatomic snuffbox (#)
1,3
Bone deep in the anatomic snuffbox
Scaphoid bone
Nerve in the carpel tunnel
Median nerve
Active extension of wrist tests which nerve
Radial nerve
Active OK sign tests which nerve
Median nerve
Active abduction/adduction of fingers test which nerve
Ulnar
Sensation on thenar eminence
Median nerve
Sensation on hypothenar eminence
Ulnar nerve
Sensation on snuffbox
Radial nerve
Test to for assess peripheral nerve entrapment
Tinel's test
Follow-up test to Tinel's test
Phalen's test
Test to assess problem at anatomic snuffbox
Finkelstein's test
Pain in palmar wrist with Finkelstein's test
Scaphoid problem
Pain in snuffbox with Finkelstein's test
Inflammation of extensors- deQuervains
Patient makes fist with fingers flexed over thumb
Finkelstein's test
Muscle: extension of the knee
Quadriceps
Largest of the 4 heads of the Quadriceps
Vastus Obliqus Medialis (VOM)
Muscles inserted on the pes anserine
Sartorius, Gracilis, and Semitendinosis (SGT)
Contents of the popliteal fossa
Tibial nerve and popliteal artery
Which collateral ligament of the knee has it's fibers intimately assoc with the underlying meniscus
MCL
Mass in posterior knee that upon transillumination diffusely lights up
Baker's cyst
Pulsatile mass in posterior knee, nontrnsilluminable, and has a bruit
Popliteal artery aneurysm
Swelling and edema of lower extremity
DVT
Diffuse, doughy swelling superior to patella
Suprapatellar bursitis
Discrete swelling at the point of the patella
Prepatellar bursitis
Swelling and tenderness adjacent and deep to patellar ligament
Infrapatellar bursitis
Semimembranosis strain is often an acute injury due to
Running
Pain and tenderness over medial knee distal to joint line and pain increased with hamstring squeeze test
Pes anserine bursitis
Pes anserine bursitis often due to
Running with flat shoes, hyperpronating, or pes planus
Medial pain with a varus stress test
Bohler's sign (medial meniscal tear)
Pain in flexion is maximal posteriorly, pain in extension is maximal anteriorly
Positive Tenderness displacement test for meniscal tear
Grinding of tibia against femur elicits click or thud
McMurray's maneuver (for meniscal tears)
Lateral pain with a valgus stress test
Bohler's sign (lateral meniscal tear)
Point tenderness of lateral fibula and positive squeeze of fibular and tibia together 15 cm distal to the knee
Fibular neck fracture
5 cardinal HPI features of acute cruciate ligament sprains
Acute swelling, sever pain, audible pop, inability to walk or bear weight, clinched fist upon exam
The carrying angle of the elbow normally is slightly
Valgus
Pain with active action of lateral epicondyle muscles
Positive Cozen's maneuver
Pain with active action of medial epicondyle muscles
Positive Reverse Cozen's maneuver
Tingling and numbness to tapping over area
Positive Tinel's test
Put hands together and hold for 30 seconds
Phalen's test
Classic mechanism for bilateral cubital tunnel
Fowler's position due to chronic severe orthopnea
Fluctuant swelling over the olecranon process without significant limitation to ROM
Olecranon bursitis
Firm, nontender nodules with a gritty feel
Tophi
Subcutaneous, firm nodules on extensor surfaces
Rheumatoid nodules
Entrapement of the radial nerve in the brachioradialis
Wartenberg's syndrome
Trauma related pain in lateral elbow forearm to anatomic snuffbox with squeeze sign
Radial head fracture
Only rotator cuff that inserts on less tuberosity
Subscapularis
Innervation of Supraspinatus
Suprascapular nerve
Innervation of Infraspinatus
Infrascapular nerve
Innervation of Tere Minor
Axillary nerve
Innervation of Subscapularis
Infrascapular nerve
Landmark of the anterior shoulder
Coracoid process
Space between the rotator cuff and the deltoid
Subacromial bursa
Muscle: Elevation or shrugging of the scapula
Trapezius and Levator scapulae
Muscle: Scapular retraction
Rhomboids
Muscle: internal rotation and arm extension
Teres Major and Latissimus dorsi
Innervation of Teres Major
Subscapular nerve
Innervation of Latissimus dorsi
Thoracodorsal nerve
Innervation of Rhomboids
Dorsal Scapular nerve
Innervation of Levator scapulae (nerve roots
C2-C4 nerve roots
Neurology
Neurology
Strength of muscles about a joint is called
Power
Power test- Normal power
5
Power test- Movement against gravity alone
3
Power test- Muscle twitch
1
Power test- Nothing happens
0
Power test- Movement against gravity and two fingers
4
Power test- Movement seen
2
Grading of Power good to assess what muscles
Proximal muscles
Weakness (1-4)
Paresis
Paralysis (0)
Plegia
Twitch of a motor unit
Fasiculation
Loss of muscle tissue
Atrophy
Paradoxic increase in size of muscle with severe paresis
Pesudohypertrophy
Active abduction of humerus
Deltoid
C5 (only) nerve root (which nerve)
Axillary nerve
Innervation of Deltoid
Axillary nerve
Active flexion at elbow
Biceps brachii
C5,C6 nerve root
Musculocutaneous nerve
Innervation of Biceps
Musculocutaneous nerve
Active flexion at hip
Iliopsoas muscle
Innervation of Iliopsoas (nerve roots)
L2, L3
Active extension at knee
Quadriceps mm
L4 root
Femoral nerve
Innervation of Quadriceps
Femoral nerve
Afferent of Reflexes
Stretch receptors to spinal cord
Efferent of Reflexes
LMN to muscle
Grade of absent reflex
0
Grade of reflex barely present
1+
Grade of baseline/normal reflex
2+
Grade of increased reflex (brisk)
3+
Grade of increased reflex with clonus
4+
Grade of Hyperreflexia
3,4
Grade of Hyporeflexia
1
Rhythmic beating of muscles
Clonus
Grades of reflexes considered normal
1,2,3
Grade of reflexes considered abnormal
0,4
Reflexes can't be elicited in
Cold muscles
Biceps Reflex nerve root(s)
C5,C6
Triceps Reflex nerve root(s)
C7
Quadriceps Reflex nerve root(s)
L4
Angle of knee for Quadriceps reflex
20 degree flexion
Plantar Reflex nerve root(s)
S1
Examination of eye movements test which cranial nerves
CN3,4,6
Muscles innervated by CN3
MR,SR,IR,IO
Muscle innervated by CN4
SO
Muscle innervated by CN6
LR
All recti mm move eye (blank direction) except (blank muscle)
out, MR
Olique recti move the eye (blank direction)
inward, and opposite of name sup/inf
Patient bites on tongue blade and then pull to assess power test which CN
CN5
Sensory of V1,V2,V3 respectively
forehead, cheek, mandible (CN5)
Weakness of all facial muscles on one side
Ipsilateral LMN lesion- Bell's palsy
Weakness of lower facial muscles only
Contralateral UMN lesion
Patient with a peripheral CN7 lesion cannot do what
Close eyes tightly or wrinkly forehead
Examine swallowing and movement of uvula to test which CN
CN9,10
Active shrugging of shoulders tests which CN
CN11 (trapezius)
Two muscles that can be used to test CN11
SCM, trapezius
Active tongue protusion tests which CN
CN12
LMN lesion of CN12 is indicated by what on tongue protrusion
ipsilateral deviation of tongue
Normal gait is where feet are beneath what
ASIS
Spastic hemiparetic gait caused by
Contralateral UMN deficit
Wide-based, unsteady gait with decreased or absent arm swinging
Ataxic Gait
Ataxic gait due to
Cerebellum dysfunction or decreased sensation in feet
Patient stands in anatomic position, then places feet together
Stance
Stance with arms forward and eyes closed is what test
Romberg
Finger to Finger test is looking for what
Metria/Dysmetria
Dysmetria indicates what type of problem
Cerebellar
Testing ability to perform rapidly alternating activites is looking for what
Diadochokinesia
Diadochokinesia indicates what type of problem
Ipsilateral cerebellar
What measures the ability to perform a graceful, gliding type action
Synergia
Asynergia indicates what type of problem
Ipsilateral cerebellar
Problems saying K or hard C; problem moving heel up tibia
Asynergia
Sensory examination is very important for what disease
Diabetes
Stocking-glove neuropathy
Diabetes (distal to proxmial)
Active extension at hip
Gluteal muscles
The distal muscles are best graded as
Absent, weak, or normal
The summation of the contributions that muscles provide about a joint in order to maintain baseline position is called
Tone
UMN damage manifests with ____ tone
Increased (contralateral to side of damage)
Increased tone in UMN damage is
Spastic
Basal ganglia damage manifests with ____ tone
Increased (ipsilateral to side of damage)
Increased tone in basal ganglia damage is
Rigid
Cerebellar damage manifests with _____ tone
Decreased (ipsilateral to side of damage)
Fundamental to DTRs is
complete relaxation of the joint
Pectoralis Major Reflex nerve root
C7
Achilles Reflex nerve root
S1
To confirm a Reflex score of 0 perform what maneuver
Jendrassik's maneuver (clasp hands and squeeze)
UMN damage manifests with
Hyperreflexia (3+ or 4+)
LMN damage or primary muscle problems manifest with
Hyporeflexia (1+ or 0)
If relex is present after Jendrassik's maneuver score is
1+
Function of CN1
Smell
Unilateral, ipsilateral loss of smell can be caused by
Unilateral frontal lobe tumor
Function of CN2
Vision
Deficits of CN3,4,or 6 result in
Strabismus
Deficit of CN3 results in
Exotropia (eye is down and out) and ptosis
Deficit of CN4 results in
Paralysis/weakness to medial and inf eye movements
Deficit of CN6 results in
Entropia (crosseye paralysis/weakness) to lateral movements
CN5 innervates which muscles
Ipsilateral Temporalis, masseter and pterygoid muscles
CN7 innervates which muscles
Ipsilateral Facial muscles
Function of CN8
Auditory
CN9 innervates which muscle
Glossopharyngeal muscle
CN10 innervates which muscle (in neuro exam)
Tensor palatini
Deficit of CN10 rsults in
loss of oculocardiac reflex and difficulty stating "K", hard "C", or "Q" sounds due to soft palate dysfunction
CN11 innervates which muscles
Trapezius and SCM
CN12 innervates which muscle
Tongue muscles
Gait in which feet are placed medial to ASIS
Narrow based gait
Gait in which feet are placed lateral to ASIS
Wide based gait
Proximal muscle weakness manifests as what type gait
Waddling gait
UMN damage manifests as what type of gait
Spastic, hemiparetic gait
Parkinson's disease manifests as what type of gait
Shuffling type gait
Cerebellar dysfunciton manifests as what type of gait
Ataxic gait
Deep fibular nerve damage manifests as what type gait
Steppage type gait
Ankylosing spondylosis manifests as what type of gait
Poker gait
Acute confusional state that mandates aggressive acute evaluation
Delirium
Insidious, chronic confusional state
Dementia
Fine touch measures competence of (nerve?tract?)
Peripherial nerves and anterior spinothalmic tracts
Superficial pain measures competence of (nerve,tract)
Peripherial nerves and lateral spinothalmic tracts
Vibration measures competence of
Peripherial nerves and dorsal columns
Dermatology
Dermatology
Lesion < 1 cm, non-palpable
Macule
Lesion < 1 cm, palpable
Papule
Lesion > 1 cm, non-palable
Patch
Lesion > 1 cm, palable
Plaque
Nevus (mole)
Macule
Pustule or Zit
Papule
Café au lait spots
Patch
Psoriasis
Plaque
Lesion > 1 cm, palpable, subcutaneous
Nodule
Scratch marks
Excoriations
Several lesions groups together
Clusters (herpes)
Lesions < 1 cm, clear-fluid filled
Vesicles
Lesions < 1 cm, pus filled
Pustules
Lesions > 1 cm, fluid filled
Bulla (blister)
Furuncle, lipoma, lymph node example of
Nodule
Exoriations may indicate what
Pruritis
Herpes simplex, poison ivy
Vesicles
Chickenpox, acne
Pustules
Lesion 1-2 mm purple, non-palpable
Petechiae
Lesion 2-10 mm purple, palpable/non-palpable
Purpura
Lesion > 1 cm purple, non-palpable
Ecchymosis
Turns white when pressure is applied
None of them
Platelet dysfunction causes
Petechiae
Anticoagulants, vasculitis cause
Purpura
Trauma-related, black and blue
Ecchymosis (Bruise)
Red, Pruritic papules and plagues found in
Urticaria
Angioedema, anaphylaxis, and dermatographism associated with
Urticaria
Rash usually on flexor surfaces
Eczema
Rash usually on extensor surfaces
Psoriasis
Rash in one dermatome
Shingles
Observation of a rash that develops in a site of trauma or surgical scar
Koebner's Sign
Koebner's sign indicates what type of rash
Psoriasis (3 other uncommon ones)
A nail finding in the plate itself and can be due to trauma or psoriasis
Nail pitting or thickening
Fungal infection of nail (onychomycosis) causes
Nail thickening
Flakes of superficial skin
Scales
Superficial or deep crevices in skin
Cracks/fissures
Dried fluid in and about a lesion
Crust
Ring-shaped lesions
Annular
Scales are associated with
Psorisis and Seborrhea
Crusting and fissure/cracking are
nonspecific
Annular rashes are associated with
Tinea corporis and Erythema multiforme
Thickened yellow nailplate beginning distal, lateral, and medial progressing proximally
Onychomycosis
Nail pitting with destruction beginning proximal and progressing distally
Psoriasis
Ram's horn configuration on thickened nails
Onychograposis
Temporal and occipital loss of hair
Androgen-mediated alopecia
Local alopecia
Arterial insufficiency alopecia
Local alopecia esp in lower extremities with Brown pigment, mild atrophy and mild edema
Venous Stasis dermatitis alopecia
Patches of hair los, esp on the head
Alopecia areata
Dilated vessels in the skin
Telangiectasia
Red-purple papules, nontender, nonblanching
Cherry hemangioma
Purple stain-like nonblanching patch
Port wine stain (nevus flammus)
V1 Port wine stain, seizures, and intracranial calcifications
Sturge-Weber
Purple nonblanching purpuric lesions on the plantar aspect of feet or palms of hands
Janeway lesions
Nontender easily fragile, friable palpable purpura
Kaposi's sarcoma
Non-blanching ecchymosis on the flank due to a retroperitoneal bleed
Grey Turner's sign (often due to coagulopathy)
Telangiectasias in skin of nose, fingers, tongue, with anemia and guaiac pos. stool
Osler-Weber-Rendu syndrome
Tinea cruris, corporis, pedis locations
Groin, body, feet
Warm red rash with discernable edges, may be tender and mildly pruritic with fever common
Cellulitis
Superficial bright red quite warm, non-tender, non-pruritic, progressively, and rapily expanding patch-like rash, often on face
Erysipelas
Red rash on face bilaterally focused on nose
Rosacea
Malar rash with erythematous papules and patches, spares nasolabial folds
Discoid lupus
Types of dermatitis
Contact, atopic, drug-induced, photodermatitis- sunburn, seborrheic, venous statsis
Purple red tender nodules in the skin, esp on extensor surfaces of legs
Erythema nodosum (assoc with sarcoidosis)
Target lesions, may have central bulla, mucous membrane involvement
Erythema multiforme
Annular rash assoc. with rheumatic fever
Erythema Marginatum
Annular rash assoc. with tick bite
Erythema Chronicum Migrans (Lyme disease)
Red an pink lesions with concurrent fever, cough, sore throat, fatigue and rhinorrhea are
Exanthems
Exanthems assoc with parvovirus B19 and slapped cheek appearance
Erythema infectiosum or Fifth disease
Exanthem assoc. with rubella
Third disease
Exanthem assoc. with rubeola
First disease
Color, painless umbilicated papules with central cheesy material
Molluscum contagiosum
HPV assoc. warts
Condylomata acuminata
Skin nodule with ulceration
Squamous cell carcinoma
Solitary papule, trnaslucent, pearly margin
Basal cell carcinoma
Hyperkeratotic area on skin that is normally thickly keratinized
Callus (tyloma)
Hyperkeratotic area that is normally on thinly keratinized skin
Corn (heloma)
Pigmented lesion with a stuck-on appearance
Seborrheic keratosis
Rapid increase in number, size, and distribution of seborrheic keratosis referred to as ____ and worried about what ______
Leser-Trelat sign; internal adenocarcinoma
Loss of all epidermal layers
Ulcer
Loss of some epidermal layers
Erosion
Deep ulcers, often painful, with a loss of pulses
Arterial insufficiency ulcers
Superficial or deep ulcers, usually lower extremities, normal pulses, local hair loss, increased pigment, non-pitting edema, etc
Venous stasis ulcers
Superficial or deep ulcers over sites of pressure
Decubital ulcers
Pigmented patches on hands and arms in older individuals
Lentinges ("liver spots")
Medical term for freckles
Epheldies
Oval reddish scaly patches on trunk, back, and chest
Pityriasis rosea
Yellow plaques in periorbital skin
Xanthelasma
Pruritic plaques with silver scales on extensor surfaces
Psoriasis
Cluster of vesicles that cross the vermilion border of the lip
Herpes labialis ("cold sore")
Painful clusters of vesicles on the vulva/penis
Herpes genitalis
Set of clusters in a single dermatome unilaterally
Herpes zoster
Groups of vesicles with multiple crops with fever and cough
Varicella/chickenpox
Fragile, flaccid bulla, erosions
Pemphigus vulgaris
Pustule in and around hair follicles
Folliculitis
Tender, fluctuant nodule in subcutaneous tissue
Furuncle
Multiple furuncles, usually on posterior neck or buttocks
Carbuncle
Endocrine
Endocrine
Sx: Feeling cold
Hypothyroid
Sx: Constipation
Hypothyroid
Sx: Weight gain
Hypothyroid
Sx: Feeling tired
Hypothyroid
Sx: Depression
Hypothyroid
Sign: Diffuse alopecia or alopecia areata
Hypothyroid or Hyperthyroid
Sign: Coarse, thick hair
Hypothyroid
Sign: Queen Anne's sign
Hypothyroid
Myxedema can be seen in severe _______
Hypothyroidism
Severe hypothyroidism can manifest as
Myxedema, hypothermia and/or bradycardia
Sign: Decreased power to proximal muscles
Hypothyroid or Hyperthyroid
Sign: Decreased deep tendon reflexes
Hypothyroid
Sign: Delay in relaxtion phase of DTR
Hypothyroid
Loss of lateral eyebrows is called
Queen Anne's sign
Sx: Feeling warm
Hyperthyroid
Sx: Weight loss
Hyperthyroid
Sx: Palpitations
Hyperthyroid
Sx: Hyperdefecation
Hyperthyroid
Sign: Fine, thin hair
Hyperthyroid
Sign: Slight tachycardia
Hyperthyroid
Atrial fibrillation may be seen in
Hyperthyroidism
Distal onycholysis in the nailplates is called
Plummer's nails
Plummer's nails may been seen in
Hyperthyroidism
Sign: Fine tremor in the hands
Hyperthyroid
Sign: Increased deep tendon reflexes
Hyperthyroid
Sign: Lid lag
Hyperthyroidism (specific)
Presence of a rim of white btw upper lid and upper limbus while asked to follow figure downward
Lid lag
Diffuse goiter often with a bruit is found in
Grave's disease
Exophthalmos (proptosis) is found in
Grave's disease
Weaknes to one or both eyes during active convergence is seen in early exophthalmos and is called
Moebius sign
Red patches and plaques on the anterior tibial surfaces is called ______ and see in ________
Pretibial myxedema, Grave's disease
Manifestions of hypoglycemia
Tachycardia, diaphoresis, tremor, confusion
Most reproducivle acute mnaifestation of hypoglycemia is
Confusion
Acute hypoglycemia is seen when glucose < _____
60 mg/dl
Acute hyperglycemia is seen when glucose > ______
300 mg/dl
Manifestions of hyperglycemia
Changes in vision, polyuria, polydipsia
Is Kussmaul's respiration seen in regular/pure hyperglycemia?
No (only in DKA)
Best test to test sensation in a diabetic patient
Monofilament test
Important physical exams in a diabetic patient
Foot exam, Derm exam, Eye exam, Vascular exam, and sensory exam
Neuropathic joint is also called
Charcot joint
Anterior tibial rash seen in diabetic patients
Necrobiosis lipoidica diabetica
From superior to inferior the anatomy of the neck that is palpated to palpate the thyroid
Hyoid,, thyroid cartilage, cricoid cartilage, tracheal rings, thyroid with isthmus across the trachea
Lateral lobes of the thyroid are partially covered by
SCM
What action by the patient will help with palpation of the thyroid
Have the patient swollow
Breast and Rectal
Breast and Rectal
Breasts of fully developed women consist of
Predominantly glandular and fibrous CT, less adipose
Breasts of postmenopausal women consist of
Predominantly adipose tissue and less glandular tissue
Tanner: Breast buds- elevation of nipple only
Tanner Stage 1
Tanner: Elevation of breast and nipple, elargement of areola
Tanner Stage 2
Tanner: More elevation of breast and areola as one contour
Tanner Stage 3
Tanner: Projection of areola and nipple as a secondary mound
Tanner Stage 4
Tanner: Projection of nipple only
Tanner Stage 5
Week before menses the breast glandular tissue and texture becomes
enlarged, firmer respectively
The breast extends to what rib inferiorly
6th rib
The "tail" of breast tissue extending to the axilla is called
Tail of Spence
When evaluating the breast it is important to evaluate for what
symmetry
There is no data to support that inspection increases detection of lumps: T/F
TRUE
The breaset should be palpated with what kind of motions
circular
Palpation of the breast includes how many levels of pressure
3: light, medium, and deep
What tissues should be palpated during the breast exam
glandualr, fibrous, and adipose tissue
What are the 3 patterns of palpation
Concentric circles, Wdge/spokes, Vertical strip method
What is the palpation pattern of choice
Vertical strip method
What is important during palpation to make sure areas are not missed
overlapping of rows
What should else should be palpated during the breast exam
axilla and supra/infraclavicular LNs
Skin dimpling of the breast is called
Peau d'orange
Peau d'orange is usually seen in what stage of breast cancer
late stages
Peau d'orange is due to tumor compression of what
Cooper's ligaments
Nipple retraction is related to an underlying breast cancer if it has what characteristic
of recent onset or is progressive
Persistent unilateral erythematous scaling rash of the breast is seen in
Paget's disease
Paget's disease is what type of cancer
subareolar duct carcinoma
Sx: Erythematous rash that is indurated, warm, and tender on palpation
Mastitis
Breast cancer as opposed to benign processes tends to manifest as
Hard fixed nodule, irrigular in consistency
Bilateral whitish nipple dischage with no palpable lesion is called
Galactorrhea
Most common cause of galactorrhea
Pregnancy
Sx: Serosanguinous discharge with nontender small subareolar nodule
Intraductal Papilloma
Sx: Multicolored nipple discharge which is unilateral or bilateral
Ductal Ectasia
Positions of the rectal exam
Standing or lateral decubitus
Are the seminal vesicles usually palpable on rectal exam
No
Tarry color of stool on color after rectal exam indicates
Bleeding proximal to ligament of Teitz
Blood in stool after rectal exam indicates
Rectal or anal source
Skin lesions that may be detected perianally during rectal exam
Viruses (HPV), parasitic (pinworms), or Fungi (Candida)
Small, rubbery prostate with symmetric and smooth lobes and a well demarcated median cleft
Normal Prostate
Firm prostate gland suggests
Malignancy or chronic prostatitis
A prostate fixed to the pelvis or palpable seminal glands suggests
Extension of a Prostate tumor
What lobe of the prostate do tumors often arise in
Posterior lobe
Tenderness of the prostate usually indicates
Prostatic infection
______ in the prostate should always be caused suspicious until proven otherwise
Nodule
The normal size of the prostate
A walnut
Rectal exam is a _______ test for prostate cancer
Specific
Fecal occult blood testing (FOBT) has high _______
Specificity
Serum acid prostatic phosphatase will increase after a rectal exam in what condition
Prostate cancer (not BPH)
T/F: Routine screening for prostate cancer via rectal exam or PSA level is recommended
False (neither a recommendation for or against)
Hematology and Renal
Hematology and Renal
Appearance of mucous membranes in anemia
Pale conjunctive, pale gingiva
Appearance of palmar creases and nails in anemia
Pale
Hemoglobin that corresponds to physical findings of paleness
< 10 grams
Manifestations of iron deficiency anemia
Nail spooning, Chelosis, Pica
Peripheral blood smear in iron deficiency anemia
Microcytic, hypochromic RBCs
Manifestations of Vitamin B12 deficiency
Atrophic glossitis, stocking-glove neuropathy, pancytopenia
Peripheral blood smear in B12 deficiency
Macrocytic RBCs, Hypersegmented PMNs
Manifestation of B12 deficiency that is irreversible
Loss of vibratory sensation
The "B" Symptoms
Unintentional weight loss, fevers, night sweats
Non B Symptoms of Hodgkins Lymphoma
Severe pruritis, pain in LNs after alcohol
Peripheral blood smear in Multiple Myeloma
Rouleaux, anemia, maybe neutropenia and thrombocytopenia
Ecchymoses, purpura, petechia and bleeding are seen in what type of AML
M3 type
Hyperplasia of gingiva is seen in what type of AML
M5 type
Colon cancer metastasizes where first
Liver
Rectal cancer matastasizes where first
Lung
Guaiac positive stool, melena, constipation, and tenesmus are manifestions of what cancer
Colon carcinoma
Painless jaundice, clay-colored stool, darkened urine, Virchow's node, Sister Mary Joseph's nodule are manifestations of what type of cancer
Pancreatic carcinoma
Nipple retraction, bloody nipple discharge, hard and fixed axillary nodes, enlarged supraclavicular node, are manifestations of what type of cancer
Breast carcinoma
Cough, weight loss, post-obstructive pneumonia, SVC syndrome, hard and fixed LNs are manifestations of what type of cancer
Lung carcinoma
Orthostatic parameters
Systolic BP >10, HR >10%, Sx of dizziness
Relative contraindications to orthostatics
Hypotension, HR >110, profound dizziness
False results of orthostatics in
Autonomic neuropathy and B-blocker usage
Best site to assess edema in a supine patient
Presacral site
Best site to assess edema in an ambulatory pt
Feet, legs
Generalize pitting edema is called
Anasarca
Practical way of reporting pitting edema
State the height of the edema
Orthostatic parameters should be performed on all patients with
Dizziness, syncope, concern for volume depletion from GI fluid/blood loss, or sign. bleeding
Best place to assess moistness of mucous membranes
Lower buccal or lingual mucosa, deep in sulcus
What measurement is of extreme importance in assessing volume status and should go w/ VS
Weight
Accumulation of fluid outside the vascular and extravascular tissues is called
Third spacing
Can a patient be intravascularly depleted and have third spacing
Yes
Common sites of third spacing
Pleural spaces, pericardial space, peritoneum
T/F: Axillary sweat is only a moderately important sign of volume status
TRUE
A patient that is receiving diuretics or fluids should have what measured
Daily weights, I's and O's (inputs and outputs)
As part of a volume status examine look for
CHF, ascites, pleural effusion (third spacing)