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JMC Physical Diagnosis Part 2

Everything else
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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)