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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 __________.
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 _______.
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 _________.
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 ________.
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.
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
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.
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?
Pt has conjunctivitis, sneezing, serious rhinorrhea, and swelling of the nasal mucous membranes. Diagnosis is _______.
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?
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?
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 _____.
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?
Pt has loss of laterial eyebrow hair (Queen Anne's sign), coarsening of features, enlarged tongue, and delayed reflexes. Diagnosis is _________.
Pt has enlarged tongue, diffuse non-pitting edema of upper extremeties and face, and elevated jugular venous pressure. Dx is _____.
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 ___.
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 ______.
Transplant pt taking cyclospirine A gets diffuse thickening and enlargment of the ______ as a side effect
Pt has purulent material at base of teeth, tartar and calculus at gingiva/tooth interface, swelling, and mild bleeding of gums. Dx is ______.
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 ______.
Pt has white papules and plaques that look like curdled milk on mucosa, pharynx, tongue, and gingiv Dx is ______.
Pt shows up with disrupted tooth enamel and brown/black discoloration where gums meet teeth. Dx is _____.
Pt comes in with a dry mouth following chemo therapy. You should advise him that he is at increased risk of ______.
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
A benign, non-tender nodule in the hard palate covered with mucosa is known as _______.
Pt comes in with cervical lymph node enlargement, runny nose, serous otitis media, and erythema and swelling of tonsils and post. pharynx. Diagnosis is ____.
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 ______.
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 _____.
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 _________.
As women get older, __________ tissue gives way to __________ tissue in the breast.
Tanner Staging is from ____ (least developed) to _____ (most developed) and shows breast maturation
What is the best method of examining a breast?
Vertical method, then concentric circles, then spokes of wheel method (worst)
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
serosanguinous discharge and non-tender, small, subareiolar nodules are present in ________.
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?
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
Pt comes in with blisters / pustules on his skin in a dermatomeric distribution. What disease does she have?
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)
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
Late inspiratory crackles are high pitched, sound like velcro, and suggest ___________.
fibrosis OR pneumonia OR CHF OR Alveolar hemorrhage
Ronchis are low-pitched and continuous expiratory sounds. They suggest the presence of ___________
neoplasms (vibration of solid tissue is what you hear)
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?
How can you distinguish crackles from pleural friction rubs?
Pleural friction rubs also have an expiratory component
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?
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?
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)
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 __________.
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?
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.
Regarding specificity and sensitivity, percussion has good ______ but poor ______ for detection of LARGE pleural effisions
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
How can you differentiate stridor from a wheeze?
Stridor is ONLY inspiratory (while wheezes are both inspiratory and expiratory)
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
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
Neoplastic nodes are usually described as _________ while necrosis and bacterial lymphadenitis causes nodes to feel ________.
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.
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
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
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?
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
You read a pt's arterial pulse and notice a slow rate of rise. What does this suggest?
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?
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 normal upstroke (not delayed) suggests _________.
Mitral stenosis or cardiomyopathy (decreased contraction or filling)
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.
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 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.
Double or triple (Triple ripple) systolic apical impulses suggest _________.
hypertrophic obstructive cardiomyopathy
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 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 ________.
An early ejection sound (pulmonic or aortic) shows up during auscultation as a ________
S1 split at the base
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)
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
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)
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)
S3 is a powerful predictor of clinical severity for many conditions; the most important of these is ______.
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
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 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)
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 are the three components of pericardial friction rub? M
Mid-systolic, early-diastolic, and late-diastolic
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
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)
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
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
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
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.
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)
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
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
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
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
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?
A localized bulge in the epigrastric area suggests __________.
Large pericardial effusion (Auenbrugger's sign)
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?
If your pt's abdomen doesn't move at all while he is breathing, you might suspect _______.
IVC obstruction shows up on the _____ abdominal wall while SVC shows up on the ______ abdominal wall.
Abnormal venous networks radiating from the belly button and seen in portal hypertension are known as __________.
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.
Between the stomach, SI, and LI, which organs produce the most bowel sounds?
Stomach, then LI, then SI
Murmurs in the abdomen that are not continuous (as with bruits) are usually ________ (systolic or diastolic)?
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 _____.
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
Between spleen and liver palpation, which is specific for organomegaly?
Spleen (note: sensitivity is LOW), using a scale of 0-5
Malet-Guy's sign helps us screen for _______ by percussion of the thoracolumbar spine or palpation of the LU
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)
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)
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)
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)
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.
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 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
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
Besides Tinel's test, which other test is used to measure for peripheral nerve entrapment?
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 Bullas, pustules, and vesicles, which is filled with pus?
Pustules; Bullas are fluid filled and vesicles are clear-fluid filled
Herpes simplex involves clusters of ____ while chickenpox involves clusters of ______.
Pt comes in with bruises due to anticoagulants. How would you describe them?
Purpura (also can be due to vasculitis)
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)
A type of allopecia that is autoimmune-related and due to thyroid-disease, causing patches of hair loss, is known as _____.
Decreased hearing on affected side, sense of fullness in ear, swelling, erythema, serous discharge
Smooth nodule or mass in the posterior pharynx ajacent to a tonsil
Quinsy (due to streptococcal abscess)
Coarsening of features, macroglossia, Queen Anne's sign, delayed relaxation phase or reflexes
Nontender, yellow papules on the helix and antihelix are called what and associated with what condition
Auricular tophi, gout
A marked loss of structure and function of the auricle due to trauma or infection of the auricle is called
Dullness, prominence of landmarks, speckled type of light reflection, arifluid levels behind the tympanic membrane, and sense of ear fullnees
Serous otitis media
Manifests as a hole in the membrane itself with loss of cone of light relex, and a dull membran
Perforation of TM
Periorbital ecchymosis (racoon's eyes), with Battle's Sign, and hematotympanum
Basilar skull fracture
Tender erythematous swelling in anterior nexk, esp submental area with possible airway compromise and stridor
Diffuse tender swelling, tartar, and calculus at gingive/tooth interface and mild bleeding
Mucosa covered, bony benign nodules, usually on lingual side of the mandible are called
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)
Red patches of denuded tongue epithelium, surrounded by rims of white and areas of normal epi, changes daily
Enlargement of Sister Mary Joseph's node
Intrapelvic or intraabdominal cancer (usually gastric or ovarian)
Medial Knee Structures
MCL, medial meniscus, hamstrings (semimembranosis and semitendinosis), ACL attachment
Gentle pushing downward on patella- feel fluid/see bulging of fluid
Ballotable patella (and thus also bulge sign)
Positive test that is indicator of worse knee injury
Positive Anterior Drawer (requires an unstable knee)
Which collateral ligament of the knee has it's fibers intimately assoc with the underlying meniscus
Pain and tenderness over medial knee distal to joint line and pain increased with hamstring squeeze test
Pes anserine bursitis
Pain in flexion is maximal posteriorly, pain in extension is maximal anteriorly
Positive Tenderness displacement test for 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
Fluctuant swelling over the olecranon process without significant limitation to ROM
Trauma related pain in lateral elbow forearm to anatomic snuffbox with squeeze sign
Radial head fracture
The summation of the contributions that muscles provide about a joint in order to maintain baseline position is called
To confirm a Reflex score of 0 perform what maneuver
Jendrassik's maneuver (clasp hands and squeeze)
Deficit of CN10 rsults in
loss of oculocardiac reflex and difficulty stating "K", hard "C", or "Q" sounds due to soft palate dysfunction
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
Thickened yellow nailplate beginning distal, lateral, and medial progressing proximally
Local alopecia esp in lower extremities with Brown pigment, mild atrophy and mild edema
Venous Stasis dermatitis alopecia
Purple nonblanching purpuric lesions on the plantar aspect of feet or palms of hands
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
Warm red rash with discernable edges, may be tender and mildly pruritic with fever common
Superficial bright red quite warm, non-tender, non-pruritic, progressively, and rapily expanding patch-like rash, often on face
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)
Exanthems assoc with parvovirus B19 and slapped cheek appearance
Erythema infectiosum or Fifth disease
Rapid increase in number, size, and distribution of seborrheic keratosis referred to as ____ and worried about what ______
Leser-Trelat sign; internal adenocarcinoma
Superficial or deep ulcers, usually lower extremities, normal pulses, local hair loss, increased pigment, non-pitting edema, etc
Venous stasis ulcers
Presence of a rim of white btw upper lid and upper limbus while asked to follow figure downward
Weaknes to one or both eyes during active convergence is seen in early exophthalmos and is called
Red patches and plaques on the anterior tibial surfaces is called ______ and see in ________
Pretibial myxedema, Grave's disease
Important physical exams in a diabetic patient
Foot exam, Derm exam, Eye exam, Vascular exam, and sensory exam
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
Nipple retraction is related to an underlying breast cancer if it has what characteristic
of recent onset or is progressive
Breast cancer as opposed to benign processes tends to manifest as
Hard fixed nodule, irrigular in consistency
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
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)
Manifestations of Vitamin B12 deficiency
Atrophic glossitis, stocking-glove neuropathy, pancytopenia
Guaiac positive stool, melena, constipation, and tenesmus are manifestions of what cancer
Painless jaundice, clay-colored stool, darkened urine, Virchow's node, Sister Mary Joseph's nodule are manifestations of what type of cancer
Nipple retraction, bloody nipple discharge, hard and fixed axillary nodes, enlarged supraclavicular node, are manifestations of what type of cancer
Cough, weight loss, post-obstructive pneumonia, SVC syndrome, hard and fixed LNs are manifestations of what type of cancer
Orthostatic parameters should be performed on all patients with
Dizziness, syncope, concern for volume depletion from GI fluid/blood loss, or sign. bleeding
A patient that is receiving diuretics or fluids should have what measured
Daily weights, I's and O's (inputs and outputs)
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