See Pee Dee

In facial paralysis (Bells Palsy - LMN) of RIGHT CN7 which of the following is correct

Patient UNABLE to wrinkle right forehead and UNABLE to close RIGHT EYE Unilateral weakness of lower face suggest UMN lesion on contralateral side. The patient will be able to wrinkle his brow (frontalis) and close his eyes (orbicularis oculi). Weakness of upper and lower face suggest LMN lesion on ipsilateral side. Facial nerve - upper and lower motor neuron manifestation White portion is not paralyzed in upper motor neuron deficit The most common lower motor lesion is Bell's palsy

Auditory acuity is deminished in

Presbyascusis ( hearing loss with aging)

Acute Appendicitis signs

Posture -Fever (usually low grade) -Tenderness (Mc Burney's point) -Guarding -Rebound tenderness -Rovsing's sign - Psoas sign -Obturator sign -High rectal tenderness

Tests for DVT

Pratt and Homan

Aortic regurgitation

Present at Erbs point, and radiates to apex, right sternal border

Tricuspid regurgitatiton

Present at right sternum, xiphoid, left midclavicular area

young male with anemia, persistent erection, whats the cause!

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

SPLENOMEGALY

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

Acute Pancreatitis: Associated disorders

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

WHEEZES/RHONCHI

CONTINUOUS MUSICAL,PROLONG ED. WHEEZES-HIGH PITCHED RHONCHI-LOW PITCHED

CRACKLES OR RALES

DISCONTINUOS INTERMITTENT, N0N-MUSICAL ,BRIEF FINE COARSE

Acute Appendicitis: Differential Diagnosis Male/female:

Gastroenteritis. Inflammatory Bowel disease. Renal calculus . Nonspecific abdominal pain

Priapism:

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

Phimosis:

Prepuce cannot be retracted over glans

Primary Headaches

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

Acute Appendicitis: Differential Diagnosis for *YOUNG Women*

Urinary tract infection Ectopic pregnancy Pelvic inflammatory Disease. Ovarian cyst

Sensory Ataxic Gait

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

A 28-year-old woman, G2P2, is seen in the Emergency Department for pelvic pain that is not related to her menstrual cycle. Her LMP was two weeks ago, and she uses oral contraceptives. During the interview she appears very anxious. On examination, you note ecchymoses on her breasts and lower abdomen, some of which appear to be recent and a few appear to be almost resolved. Her abdominal and pelvic exams are otherwise normal. Once she is dressed, what is your most appropriate communication with her?

"Are there times that you feel unsafe at home?"

A 28-year-old business-woman, GO, is being seen for her annual gynecologic examination and renewal of oral contraceptives. Her LMP was one week ago. Following a normal speculum examination, the bimanual examination reveals a cystic mass in the midline just above the symphysis pubis. The uterus is difficult to palpate. There are no discrete adnexal masses. Your most appropriate words to the patient would be

"Did you empty your bladder recently?"

21 year old female with vagina discharge and complains of pain on urination. What the most suitable opening statement?

"I will ask you some questions that I ask of all my patients"

A 45-year-old woman has a 10-day history of a vaginal discharge that is becoming copious. Six days ago she developed pain during urination. A medical student is asked to take a sexual and gynecological history.

"I would like to ask you some questions that I ask all of my patients."

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

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

A 63-year-old previously healthy woman visits her family physician with complaints of fatigue and insomnia of 6 months duration. She lives with her husband of 28 years and has 2 adult children who lead independent lives. The gynecologic history reveals that she is 11 years post menopause. When asked about her sexual history she says that the last time that she had sex was about 3 months ago and that she is no longer interested in it. Which of the following responses by the physician is most appropriate at this stage of the interview?

"Tell me more about your lack of interest in sex."

Scrotal swellings

1. torsion of the testis - young, cord twisting, emergency 2. spermatocele - retention cyst of spermatic cord 3. epididymitis - painful swelling of epididymis -can be separated from testes 4. Orchitis - usually viral (mumps) 5. Varicocele - bag of worms, reduced fertility, multiple tortuous veins (more often on left) 6. hydrocele - accumulation of fluid in tunica vaginalis, painless, positive transillumination 7. Hernia (protrusion of peritoneum or viscera into inguinal or femoral canal (fingers CANNOT get above mass) -direct : weakness in posterior wall of inguinal canal at external ring (men over 40) -indirect : most common - originates at inguinal ligament internal ring priapism - random (secondary to leukemia, sickle cell, drugs) whereas peyronies is a fibrous plaque in CC

In labor a completely dialated CERVIX

10cm

Weber lateralizes to LEFT EAR. Rinne bone conduction is longer than air in left ear

Conduction hearing loss in LEFT ear

Optic atrophy: Consecutive-

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

Old man presents with four month history of unilateral non-tender large scrotal swelling and heaviness. The examinar is able to get fingers above the swelling. What is most likely present?

Hydrocele - positive transilumination test. Accumulation of fluid in tunica vaginalis, and painless.

hyperactive bowel sounds

Hyper active bowel sounds may also be heard in inflammatory conditions of the bowels such as Crohn's disease and ulcerative colitis.

Types of breathing

Hyperonea: Rapid Deep Breathing (hypoxia, anxiety, acidosis, exercise) Biot's Ataxic : unpredictable irregular breathing from damage at medulla Prolonged Expiration: COPD Cheyne Stokes - periods of breathing with apnea and hyperpnea

A 19-year-old football player has a syncopal attack ( Not getting enough pulse) during practice. He has a family history of a cardiac disease in a younger cousin. On examination there is a mid-systolic murmur in the right second intercostal space, parasternally, which is amplified by standing

Hypertrophic cardiomyopathy: Radiates to the left parasternal border and apex. -accentuated by standing

A young man presents to your office with a history of injury to face while playing soccer - during exam of eye you find blood in anterior chamber this is called

Hyphema (Stabismus = tropia, a constant misalignment of the visual axes of both eyes - they cannot point in the same direction).

Closed Angle Glaucoma -crescentic shdow

iris is normally flat and forms a wide angle with the cornea, no shadow is cast on shining the tangential light. -angle is narrowed by bowing of the iris forward, thus decreasing the space between the cornea and iris

Plummer-Vinson Syndrome

iron deficiency anemia, dysphagia (difficulty swallowing ) glossitis ( inflammation of tongue

Stye (hordeolum)

is an infection of the sebaceous glands of Zeis at the base of the eyelashes, or an infection of the apocrine sweat glands of Moll

Cullen's sign

is bluish discoloration of the umbilicus

The spastic gait

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

"Upper spares upper"

patient can wrinkle forehead on right but is not able to use any other muscles of facial expression - no response to corneal reflex testing on right side - UMN lesion of facial nerve on the left side

patient with addisons - what hormone will be elevated

patient will have craving for salt - and there will increase levels of ACTH

paroxysmal nocturnal dyspnea

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

A stamping gait is seen in

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

The obturator test is positive with a: ?

pelvic appendices

Hyperacusis

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

when should women perform a breast exam?

perform just after menses

50 yr old diabetic patient complains of pain, tingling, and numbness of his feet for the past 2 months. he has been having difficulty walking. on exam theres decrease touch, vibration, proprioception and pain - wheres lesion

peripheral nerve

Absent bowel sounds

peritonitis mesenteric thrombosis enterocolic ulceration Total Obstruction

A 45 year old drug user presents with fever, shortness of breath and palpitation. Examination of his hands reveal Osier's nodes

roth spots

Uveitits is associated with

sarcoidosis ankylosing spondylitis tuberculosis Lyme` disease and HIV

Seizures -

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

Glaucoma can cause :

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

tremor of the hands, lid retratction bilaterally, pretibial myxedema, and exopthalmost

signs of hyperthyroidism

Auscultatory Gap

silent interval between the systolic reading and the diastolic reading. This might lead to underestimation of the systolic blood pressure. This can be obviated by first determining the systolic pressure by palpation

60 year old man with pancoast tumor --> horner's symptoms what will be found in affected pupil?

small, reacts briskly to light and near reaction

SPASTICITY VS RIGIDITY

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

breast exam

start at 40 yearly (do it 10 years earlier if family member has breast cancer)

During examination of ears pulling outwards, backwards and upwards is for....

straightening of the canal

Chalazion is painless while...

styes are painful

Meniere's disease

sudden attack of vertigo preceded by tinnitus aural fullness and fluctuating hearing loss. The sensorineural hearing loss is usually in low frequency (125Hz to 1000 Hz).

high pitched tinkling sounds

suggest fluid and air under tension in a dilated bowel. Rushes of high pitched sounds coinciding with abdominal cramps suggest intestinal obstruction.

Correct way to examine patients RIGHT EYE

using right hand, right eye, and RIGHT index finger extended

Common findings in mouth

uvula deviation = CN10 tongue deviation = CN12 hard palate = Torus palatinus, a midline lump Swollen interdental papillae = gingivitis

The internal jugular vein lies deep to SCM and is visible only by its puslations -- what is characteristic of these

variable with inspiration (not palpable, change by position, multicomponent configuration)

35 yr old weight lifter -> develops sciatic nerve entrapment - shooting pain --> paresthetia, motor weakness, urinary incontinence, positive straight leg test --> what else will be seen?

weakness of ankle plantar flexion -tibial and common fibular is out ( Steppage Gait)

patient with a lesion of the frontal motor cortex

weakness/paralysis and spasticity and these will be located on the side opposite to the cortical lesion due to decussation of the descending tracts -deep tendon reflexes HYPERactive -superficial reflexes ABSENT -pathological reflexes PRESENT

Tophi

white small nodules on rim of auricle made from uric acid crystals (gout)

Lesion at L1-L2

will hurt KNEE reflex L2-L4 test motor myotomes. In the upper extremities: C5 is tested by abduction at the glenohumeral joint, C6 by flexion at the elbow joint, C7 by extension at the elbow, C8 by flexion at the finger joints and T1 by abduction and adduction of index, middle and ring fingers. In the lower extremity: L1 and L2 are tested by flexion of the hip, L2 L3 and L4 by extension of the knee, L5 and S2 by flexion of the knee, S1 and S2 by plantar flexion of the foot, and S2 and S3 by plantar flexion of the toes.

Lesion to peripheral nerve

will lose, touch, vibration, proprioception, and pain. -Injury at this level results in a lower motor neuron pattern of deficit and sensory loss in what is referred to as "glove and stocking distribution". The motor and sensory loss may be unequal.

urethritis

will see discharge, fever, pain, increase frequency -In men, painful urination without frequency or urgency suggests urethritis.

Thrombophlebitis of the communicating veins leads to

with destruction of the valves lead to venous insufficiency.

Jugular Venous Pressure Waves

a wave= right atrial systole (prior to s1) x descent = right atrial diastole v wave = venous filling of right atrium and ventricular systole y descent = right ventricular diastole (a and v wave produce a double pulsation seen at beside)

Keratitis

abrasion to the cornea causing inflammations is usually accompanied by eye pain, photophobia, foreign body sensation, tears, & blurred vision.

*Cholecystitis*

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

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

acute pancreatitis

optic nerve damaged -stimulus to brain is reduced thus when light is shown on the eye it dialates instead of constricts

afferent pupillary defect (Marcus Gunn pupil)

Cataracts

aging, downs, cretinism, hyperPARAthyroidism, diabetes, iritis

a positive jaw jerk indicates...

an UMN to CN 5

Rheumatoid arthritis - nodules

an example of a nodule is that due to rheumatoid arthritis. *Rheumatoid nodules are the most common cutaneous manifestation of rheumatoid arthritis*, occurring in 20% of such patients. The most common location is over *extensor surfaces near to joints such as over the ulnar border proximal to the elbow*. These nodules are usually painless. Complications of these nodules include erosion and infection.

Dacryocystitis

an inflammation of the lower lacrimal passages usually seen in infants and older individuals. It appears as a swelling between the lower eyelid and the nose. When acute it is painful, red and tender. The chronic form is associated with blockage of the nasolacrimal duct. Tearing is prominent.

Sacroilitis occurs in > 90% of patients with

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

headaches

Tension headaches are usually associated with occipital and neck pain. Frontal headaches are usually associated with sinusitis, and partial, pulsating headaches could be migraine.

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

Transition

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

Setting the agenda

Apneuistic breathing (apneuistic center in upper medulla)

-damage to pons AND upper medulla

A 67 year old male presents with an expressionless face and resting tremors for the past six months.

Festinant - shuffling - parkinsons

Causes of Conductive Hearing Loss

Buildup of cerumen Infection (otitis) Fluid in the middle ear Punctured ear drum Fixation of ossicles Tumors in middle ear Scarring

palpating pulse you note 2 peaks - only 1 heart beate for 2 waves what best describes this

pulsus Bisferins (biphasic)

Frontal headache worse when leaning forward and a postnasal drip -- what else is found

Tenderness over maxillary sinuses (Pain Nasal catarrh Post nasal drip Headache)

Pulmonic stenosis

radiates to left shoulder and neck

aortic stenosis

radiates to the carotids, left parasternal border and apex

Mitral regurgitation

radiates to the left axilla and sometimes the left parasternal border

Massive nose bleed

controlled by ligating or embolization of the *sphenopalatine artery*, which is the major supplier of blood to the nasal septum (Lower Anterior Nasal Septum)

An 18-year-old woman complains that she recently noticed a growth inside her mouth. It is not painful, but she is concerned because her uncle died from cancer of his throat a few years ago. On examination there is an oval swelling, 1.5x2.5 em diameter, and of bony consistency in the midline of the hard palate. The mucosa over the swelling is normal. The remainder of the examination, including palpation for cervical lymphadenopathy, is negative.

'This is harmless and needs no treatment".Torus palatinus is a benign midline bony swelling of the hard palate. Most palatal tori are less than 2 cm in diameter, but their size can change throughout life.

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

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

Lymph node that drains the scalp ?

(superficial cervical nodes

rotator cuff

(supraspinatus, infraspinatus, teres minor and subscapularis

A 56-year-old man has a 2 month history of pain in his left calf that is brought on by walking and relieved by a few minutes of rest. On examination his fingers are nicotine-stained. The left leg is cool to palpation. The dorsalis pedis and posterior tibial pulses are absent on the left and 1 + on the right. Which of the following tests is most appropriate in this patient?

* Buerger. * In a patient with significant peripheral arterial insufficiency, elevation of the lower extremity will result in pallor. The feet will become pale. The angle of elevation at which pallor occurs indicates the degree of insufficiency, the less the angle, the greater the insufficiency. *The angle at which pallor begins is termed the Buerger's angle.*

A 25-year-old woman presents to the clinic with a history of dysuria and right flank pain for the past 5 days. She also complains of nausea and fever. On examination which one of the following is most likely to be positive?

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

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

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

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

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

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

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

21-year-old medical student presents with severe right ear pain after swimming without ear plugs in the Grand Anse area, 2 days ago. On examination her temperature is 99°F, pulse rate 92/min and respiration 14/min. Examination of her right ear with an otoscope will most likely reveal:

*A Swollen Ear Canal* Otitis Externa - Smelly Discharge Otitis Externa (Swimmer's Ear) (bulging tympanic = otitis media Lack of mobility of tympanic membrane = scarring / block eustachian tube)

Superficial Reflexes

*Abdominal (T8-T12)* positive response is twitch with navel movement towards stroke *Cremasteric (L1-L2)* medial thigh - positive if rise of testicle *Anal Wink (S3-S5)* perianal skin stroke - positive is skin wrinkling around anus from external anal sphincter *Plantar Response (L5- S1)* lateral aspect of the sole of the foot is stroked, starting from the heel, to the base of the little toe. Stroking then continues across the ball of the foot at the base of the toes, starting at the little toe and ending at the base of the big toe Normal = Plantar Flexion, Abnormal = dorisflexion and abduction of toes

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

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

A 75-year-old woman is seen, accompanied by her daughter, who says that for the past 3 months, her mother is behaving oddly and that her 'memory is bad'. During the mental status examination you ask the patient "what do people mean when they say 'the squeaky wheel gets the grease?" Which one of the following mental status features are you testing?

*Abstract thinking*. similarity between objects and meaning of proverbs: Alternatively, ask the patient for similarities e.g. How are oranges and apples similar? How are children and dwarves similar?

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

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

Presence of pain on flexion of hip against against resistance

*Acute Appendicitis * this is PSOAS sign (he is PSO retro - retroperitoneal, retrocecal) -Obturator (Instruct the patient to bend his knee then flex the thigh on the right hip, directing the right knee towards his/her left shoulder. This maneuver flexes and internally rotates the thigh at the right hip.) The obturator test is positive with pelvic appendices. - DRE

45 year old chronic alcoholic admitted to hospital with 2 day history of vomiting and severe *epigastric pain which radiates to his back.*..the pain is exacerbated by lying down and improved by sitting up and leaning forward. Abdominal exam reveal painless *perilumbical ecchmyosis*

*Acute Pancreatitis* "Epigastric pain that is relieved by sitting up and leaning forwards may indicate acute pancreatitis." "Epigastric pain radiating to the back - is from pancreas" "Cullen's sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. = Pancreatitis"

Patient presents with painless, fluctuant swelling in right scrotum -transillumination test is positive

*Hydrocele* -Accumulation of fluid in the tunica vaginalis. -Painless - Fluctuant -Positive transillumination -fingers CAN get ABOVE mass

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

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

50 yr old with right IJV that has double pulsation each cardiac cycle (normal) with one wave seen just before carotid upstroke and 2nd wave seen just after carotid pulse - the JVP is 2cm above water -the jugular pulse waves described are

*Atrial pressure A and V * and obliterated by gentle pressure with fingers a wave is before 1st heart sound carotid pulse (it is atrial systole) v wave is venous filling and ventricular systole (a waves disappear in atrial fib, large v waves are tricuspid regurg)

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

*Axillary*

The mother of a 5-year-old girl complains that her daughter has not been arousable for 1/2 hour and has had a fever for the past 24 hours. The child is being treated for an ear infection for the past three days. On examination the child does not respond to commands but responds to tactile stimulation by moving her limbs and head in a purposeful manner. Her temperature is 102F. Nuchal rigidity and Kernig's sign are present. Tendon reflexes are normal. Which one of the following is most likely to be also present in this patient?

*BRUDZINSKI'S SIGN* - Flexing the patient's neck causes flexion of the patient's hips and knees.

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

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

Reflexes

*Biceps C5,6* (flex) *Brachioradialis C5,6* (flex) *Triceps C6,7* (ex) *Knee L2-L4* *Ankle S1-2* (achilles - Observe contraction of the gastrocnemius and resulting plantar flexion of the foot) *Cremasteric L1- L2* *Anal Wink S3-5* *Plantar Response (UMN Lesion L5-S1)* *Clonus* This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch *Jaw Jerk CN 5 sensory + motor* - An exaggerated bite down (snapping shut of the mouth) suggests an upper motor neuron lesion of CN V. *Hoffman Sign* flick DIP of index or middle finger look for flexion of thumb (UMN lesion median nerve)

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

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

. A 30-year-old woman presents with a three-month history of anxiety, restlessness, shaking of the hands and weight loss.Examination reveals: vital signs- BP 120/80mmHg, pulse 110/min and respiration of 18/min. Her skin is warm and moist. There is a fine tremor of the outstretched hands. In the neck, there is a diffuse swelling that moves up on swallowing. Which one of the following additional features will indicate that the neck mass is producing a hyper-metabolic state?

*Bruit over the mass*

a 40 yr old male smoker presents with a 2 month history of apin is his left calf which is brought on by walking and relieved by rest - left lower limb is pale, cool and all of the pulses are +1

*Buergers*

A 22-year-old college athlete presents with pain and swelling of his right knee for the past two days. On examination he has an antalgic gait that protects the right lower extremity. The right knee is swollen, warm to touch and somewhat tender. Which one of the following tests/signs will confirm a diagnosis of knee effusion?

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

A 40-year-old male presents with a 4-month history of intermittent swelling and pain in the area of the right lower jaw on eating. Inspection of the floor of the mouth reveals a swelling just distal to a small punctum located on the right side of ttie frenulum of the tongue. Palpation of this area reveals a small structure 0.5cm in diameter. Posterior to this mass and just posterior to the right lower incisor on the floor of the mouth and deep to the mandible, is a tender oval swelling of diameter 3cmx1.5cm. The most likely differential diagnosis of the anterior swelling is

*Calculus in Wharton's duct*: The submandibular duct (Wharton's) is about 5 cm long and originates from the deep portion of the gland, runs forward parallel to the tongue on the floor of the mouth, to open on the sublingual papilla on either side of the frenulum:

65 year old diabetic male presents with worsening vision over the past 3 years - on attempting opthalmoscopic examination the physician is unable to visualize the red light reflex bilaterally

*Cataracts* --> opacification. evaluate pupil for any reflected light, showing as grey or silver areas within each pupil. this may indicate cataract formation or in children a retinoblastoma

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

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

The aqueous humor is secreted by the ciliary body behind the iris. It drains through the pupil and then into the iridocorneal angle where it is reabsorbed into the Canal of Schlemm. If this drainage fails, glaucoma or increased intraocular pressure ensues and will cause retinal damage and blindness. *Acute glaucoma* occurs in *young persons *and is due to the *iridocorneal angle being too acute*

*Chronic glaucoma* occurs in the *elderly* and is due to *gradual loss of permeability of the Canal of Schlemm*. The *pressure rise is slow* and *insidious but blindness* that should be preventable is common due to this

A 35-year-old Guyanese woman complains of progressive swelling of her legs for the past 2 years. Three years ago she was treated for *several episodes of fever accompanied by painful swellings in both groins*. Examination reveals painless bilateral inguinal and femoral adenopathy, each node being 1-2cm in diameter and of firm consistency. There is non-pitting, non-tender edema of both feet, legs and thighs. Which of the following is the most likely cause of this edema?

*Chronic lymphedema* Secondary lymphedema • Radiation therapy • Surgery • Parasitic infection (e.g. Filariasis) • Surgical lymph node removal (radical mastectomy) • Malignant tumor invasion (metastases)

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

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

Primary Lymphedema

*Congenital lymphedema* generally presents at birth. An example of congenital lymphedema is Milroy's disease. *Lymphedema tarda* generally presents in adulthood (usually after the age of 35). An example of lymphedema tarda is Meige disease. *Lymphedema praecox* presents in early adulthood (before age 35). It is not clinically evident at birth.

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

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

A 45-year-old woman presents with chills, rigors and fever for the past 3 days. Her temperature varies between 100.1 F and 103.2 F degrees. Initially she had frequency of micturition. On examination there is costovertebral angle (CVA) tenderness

*Continuous* During a 24hr period the temperature is persistently above normal *Intermittent* (Diurnal variation) -The temperature fluctuates between normal and elevation during a 24hr period. e.g. malaria *Remittent* Abating and relapsing in cycles of over 1 degree change *Relapsing (recurrent)* Recurrent acute episodes of fever and defervescence of varying duration. There is spontaneous abatement and then recurrence of varying duration. The febrile episodes typically last 5-7days

Fever

*Continuous* During a 24hr period, the temperature is persistently above normal *Intermittent* Diurnal variation -The temperature fluctuates between normal and elevation during a 24hr period (or even to 72 hr). e.g. malaria *Remittent* o Abating and relapsing in cycles *Relapsing (recurrent)* Recurrent acute episodes of fever and defervescence of varying duration. There is spontaneous abatement and then recurrence of varying duration. The febrile episodes typically last 5-7days.

Breath Sounds

*Crackles - previously closed airways* pulmonary fibrosis (fine and late), bronchiectasis (coarse and biphasic - mid-inspiratory and expiratory), pulmonary edema (fine), pulmonary consolidation and chronic bronchitis (early), early congestive heart failure (late)* *Wheezing-vibration of walls from narrowed airways* (lower pitch=larger airway) High pitch means multiple airways like asthma - low pitch monophonic is foreign body/tumor in single large airway. *Stridor - narrowed airway near trachea, glottis, larynx* - high pitch monophonic. Stridor may be inspiratory (laryngeal), expiratory (tracheobronchial), or biphasic (glottic or subglottic).

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

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

A 44-year-old man presents with a 6-month history of palpitations and easy fatigability. His pulse is 104/min and respiratory rate 28/min. Auscultation reveals an early diastolic decrescendo murmur at Erb's point with the patient sitting up and leaning forward. Which of the following is likely to be present in this patient

*D. Collapsing pulse.* aka Corragans, water-hammer pulse: Greater amplitude; rapid rise normal plateau sudden decent Location. 2nd to 4th left interspaces Radiation. If loud, to the apex, perhaps to the right sternal border Intensity. Grade 1 to 3 Pitch. High. Use the diaphragm. Quality. Blowing; may be mistaken for breath sounds Aids. The murmur is heard best with the patient sitting, leaning forward, with breath held in exhalation *Early diastolic backflow across semilunar*

Dacryocystitis

*Dacryocystitis* is an inflammation of the lower lacrimal passages usually seen in infants and older individuals. *It appears as a swelling between the lower eyelid and the nose*. When acute it is painful, red and tender. The chronic form is associated with blockage of the nasolacrimal duct. *Tearing is prominent.*

45 year old woman is referred of stage 2 hypertension .. What describes criteria for stage 2 hypertension

*Diastolic of 105* Normal ( 120, 80) PreHyper (120-139, 80-89) Stage1 (140-159, 90-99) Stage 2 (160+, 100 +)

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

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

Fundoscopy with diabetes mellitus

*Dot/Blot Hemorrhages (flame too)* This is a leading cause of blindness in the USA and around the world and is directly related to the duration of the disease (present in most patients with duration over 25 years). Early changes (nonpropliferative) include capillary *microaneurysms (smooth borders and sharp round shape)*, dilatation and tortuosity of vessels and non perfusion of areas. Rupture of microaneurysms, capillaries and venules result in hemorrhages (flame-shaped or blot). *Exudates* (due to leaky capillaries) may appear in clusters, streaks or rings around the fovea. In later stages, *neovascularisation (new vessels)* develops on the disc and/or retina and these can lead to many complications (hemorrhage, retinal tears and detachment)

Lung signs

*Dullness* replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: *lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor*. Generalized *hyperresonance* may be heard over the *hyperinflated lungs* of *emphysema or asthma*, but it is not a reliable sign. *Unilateral hyperresonance* suggests a large pneumothorax or possibly a large air-filled bulla in the lung.

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

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

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

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

A 35-year-old athlete presents with pain in his right elbow for the past three days. There is no history of trauma, but he recently began his pre-season workouts. On examination there is tenderness at the lateral epicondyle of the right humerus. Which of the following movements against resistance is most likely to aggravate the pain in the right elbow?

*Extension of the wrist. * Lateral epicondylitis ("tennis elbow"): The pain is aggravated by activities that put the wrist in dorsiflexion, thus putting strain on the extensor tendons. These patients experience pain when opening a door or lifting a glass. *Cozen's test* - Place the elbow to be tested in 90 degrees of flexion.Have the patient pronate the forearm, make a fist, and radially deviate and extend (dorsiflex) the wrist. The other hand of the examiner applies pressure (resistance)

Glasgow Score 7 is bad

*Eyes* (spon 4, call 3, pain 2, absent 1) *Verbal* ( oriented 5, not or 4, inapprop speech 3, incomprehen 2, absent 1) *Motor* (obeys 6, localizes pain 5, withdraw flex from pain 4, decort rigidity 3, decerebrate rigid 2, absent 1)

Bells Palsy

*Facial nerve paralysis*- motor supply to the muscles of the face, forehead and eyelids- a) unable to whistle or puff his cheeks, b) close the eye (levator palpebrae superioris actions unopposed, c) sagging of the corner of the mouth, drooling and difficulty in chewing due to paralysis of orbicularis oris and buccinators, d) loss of taste to the anterior 2/3 of tongue via the chorda tympani branch innervates Stapedius and anterior 2/3 of tongue *Hyperacusis*

A 55-year-old man has a 6-month history of increasing weakness in his legs. For the past 3 months he has also had difficulty in buttoning his shirt, and his writing has deteriorated. On examination of his lower extremities there is grade 3/5 power, increased tone, hyperreflexia and Babinski reflexes. In the upper extremities, wasting and fasciculations are present in his forearm and hand muscles, tone is reduced and muscle power is grade 4/5. He is diagnosed with amyotrophic lateral sclerosis. In this patient which of the above physical signs is most specific for a lower motor neuron lesion?

*Fasciculations*- indicative of a lower motor neuron lesion such as a peripheral nerve lesion.

A previously healthy 66-year-old man has a 5 month history of increasing clumsiness in dressing himself and doing daily tasks. On examination his movements are slow, his face is expressionless and there is tremor of his fingers. Muscle tone is increased in the upper and lower limbs. Which of the following types of gait is most consistent with the above presentation?

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

A 18-year-old previously healthy woman has a 2-month history of a lump in her left breast that is not painful. On examination, her blood pressure is 110/72mm Hg, pulse 60/ min, regular, and respirations 16/min. The right breast is non-tender, without a palpable mass. In the left breast there is a firm, non-tender, and very mobile mass of approximately 1.5cm diameter in the upper outer quadrant. The most likely diagnosis is: A 18-year-old previously healthy woman has a 2-month history of a lump in her left breast that is not painful. On examination, her blood pressure is 110/72mm Hg, pulse 60/ min, regular, and respirations 16/min. The right breast is non-tender, without a palpable mass. In the left breast there is a firm, non-tender, and very mobile mass of approximately 1.5cm diameter in the upper outer quadrant. The most likely diagnosis is:

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

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

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

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

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

A 55-year-old man has a 2-month history of progressive shortness of breath that worsens if he lies flat at night. He also notices swelling of both legs for the past 2 weeks. He has had hypertension for 15 years. On examination his pulse is 120/min BP 180/130mmHg and respiratory rate of 22/min. His JVP is 5 cm H20. He has bilateral basal lung crepitations and 3+ pitting edema over both ankles. Which maneuver/position is most likely to cause a rise in his JVP?

*Firm pressure over the liver.* Jugular venous Pressure (JVP): This provides information on pressures in the right side of the heart and its inflow. Changes in the right side of the heart also frequently reflect changes in the venous system, blood volume, pulmonary circulation and left side of the heart hepato-jugular reflux:- apply firm continuous pressure with your fingers, in the abdomen, below the right costal margin in the mid-clavicular line, for more than 15 seconds. • In normal persons this test increases (by 1-3 cm water) the jugular venous pressure and this increase is not sustained > 10 secs. If the rise in jugular venous pressure is > 3cm and is sustained more than 10-15 secs, it is abnormal and is suggestive of right ventricular (or congestive cardiac) failure

A 36-year-old man presents with pain and tenderness in his right wrist after a fall on his outstretched hand 2 days ago. On examination there is tenderness on the lateral side of the wrist, just proximal to the base of the first metacarpal. Which is the most likely diagnosis?

*Fracture of the scaphoid* Tenderness over the "snuffbox" suggests a scaphoid fracture.

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

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

45 year old alcoholic with 2 month history of bilateral swelling in legs...tingling and numbness in feet, hands and around mouth for past few days. Pulse is 102, 16breaths, BP 120. *While taking his blood pressure by auscultation the cuff was inadvertently inflated to 170 causing a carpal spasm*

*HYPOCALCEMIA* CHVOSTEK'S SIGN - Tap on the face at a point just anterior to the ear and just below the zygomatic bone, over the facial nerve. TROUSSEAU‟S SIGN - Inflate a sphygmomanometer cuff on your patient‟s arm, above 20mmHg systolic blood pressure for several minutes. *Positive response: Carpopedal spasm*

A 65-year-old man complains of 'fluttering' in his chest and shortness of breath of 2 weeks duration. He also felt faint on two occasions today. On examination, his vital signs are: T 98°F, pulse 128/min, RR 22/min. His pulse is irregular in timing and of variable but symmetrical volume. S1 is of variable intensity. The lungs are clear. Which one of the following is the most likely additional physical finding?

*Heart rate of 172/min.* atrial Fibrilation: Irregular irregularity, Absent a wave

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

*Hemothorax.* PLEURAL EFFUSION *SIGNS* TRACHEA,APEX BEAT-DISPLACEDAWAY FROM MASSIVE EFFUSION EXPANSION- REDUCED PERCUSSION -STONY DULL BREATH SOUNDS-REDUCED OR ABSENT VOCAL RESONANCE-REDUCED

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

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

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

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

A 35-year-old man with a diagnosis of multiple sclerosis complains of frequent falling during the past 2 months. During the past month he also noticed shaking of his hands that is worse when he uses them. On examination his gait is very unsteady. The finger-nose and heel-knee-shin tests are abnormal. Dysdiadochokinesia is present. Which one of the following findings is most compatible with this presentation?

*Horizontal nystagmus.* Inability to maintain gaze fixation. There are involuntary uncoordinated rapid oscillations of the eyes when attempting to look at an object. A slow phase is followed by rapid saccadic correction. In cerebellar disease, the fast component is maximal toward the side of the lesion. It is most commonly gazed evoked but can also occur in a primary position. *The direction of nystagmus may be horizontal, vertical or rotary.*

A 75-year-old man presents with chronic cough and wheezing for the past 10 years. He has been a smoker for the past 50 years. On examination his chest is barrel-shaped and the trachea is central. Palpation reveals no tenderness but the antero-posterior diameter is more than the lateral diameter and expiratory wheezing is heard all over the lung fields.

*Hyperresonant* EMPHYSEMA SIGNS BARREL SHAPED CHEST PURSED LIP BREATHING USE OF ACCESORY RESPIRATORY MUSCLES PALPATION-REDUCED EXPANSION PERCUSSION-HYPERINFLATED BREATH SOUNDS-DECREASED SIGNS OF HEART FAILURE

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

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

Nonpitting Edema

*Hypothyroidism* *Lymphedema* occurs when there is a blockage to the transport of lymphatic fluid (as in nodal destruction or replacement and absence or destruction of lymphatic vessels). There is an accumulation of lymphatic fluid in the tissues. Lymphedema is non-pitting and tends to be unilateral and irreversible.

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

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

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

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

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

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

Ballotment

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

A 38-year-old woman complains of pain, redness and watering in her left eye for the past 2 days. She is now having difficulty reading. On examination of her left eye there is a mucoid discharge, the eye is red, the cornea is hazy and an abrasion is seen on the cornea. The pupil is normal. This is most likely:

*Keratitis* is a condition in which the eye's cornea, the front part of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves impaired eyesight

A 58-year-old man complains of low back pain that has been shooting down his left posterior thigh and leg for the past 4 days. He has 5-year history of similar pain that was previously treated with analgesics and physical therapy. On examination he has decreased sensation over his lateral foot, weak plantar flexion and inability to walk on his toes, all on the left. The left ankle reflex is absent. Which is the most likely site of disc herniation producing the above features?

*L5-S1.* Lasegue's or straight leg raising test - with the patient lying supine, as flat as possible, hold each leg by the ankle alternately and raise each straight leg, one at a time, passively to about 60 (30 to 70) degrees. *A patient with sciatic nerve root irritation, such as due to prolapsed intervertebral disc, or nerve root entrapment, will experience sharp pain in the back or buttocks that radiate down the thigh/leg along the L5 or S1 dermatome.*

. The mother of an 11-month-old girl complains that for the past day her child has had a cough, fever and runny nose. The child is dyspneic, and using accessory muscles of breathing. During her inspirations intercostal recession is seen and a high pitched noise is heard (stridor). Temperature is 101F, respirations 26/min, pulse 128/min, blood pressure 102/76 mmHg. Which of the following is the most likely diagnosis?

*Laryngotracheobronchitis* Stridor INSPIRATORY WHEEZING HEARD OVER NECK THAN CHEST. MEDICAL EMERGENCY DUE TO OBSTRUCTION IN LARYNX OR TRACHEA

When feeling your patients pulse you notice STRONG pulse with a week pule each time -- this is due to

*Left Ventricle Failure from long standing hypertension*

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

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

A 45-year-old ex-baseball player presents with white patches on his tongue that he first noticed 3 months ago. He has been chewing tobacco for the past 25 years. On examination 3 white slightly raised oval lesions 1-2cm in diameter are seen on the tongue and buccal mucosa. They cannot be removed with the tongue blade. The lesions are most likely:

*Leukoplakia.* Leukoplakia is a white patch that cannot be scraped off and can be premalignant. Smoking/chewing tobacco is also implicated in the causation of leukoplakia.

A 66-year-old man complains of severe cough and chest pain for the past 2 days. He looks ill and his temperature is 102F. On examination the trachea is central and tactile fremitus is increased. There is dullness to percussion at the right base, with bronchial breath sounds and egophony in the same area. Which of the following is the most likely diagnosis

*Lobar pneumonia* BRONCHOPNEUMONIA SIGNS EXPANSION -REDUCED TACTILE FREMITUS-INCREASED ON AFFECTED SIDE PERCUSSION-DULL BREATH SOUNDS-BRONCHIAL ADDITIONAL SOUNDS-RALES VOCAL RESONANCE-INCREASED ON AFFECTED SIDE PEURAL RUB MAY BE HEARD AEGOPHONY WHISPERING PECTORILOQUY

A 55-year-old man has been waking up at night repeatedly with breathlessness for the past 3 weeks. During these episodes he has been coughing up frothy sputum. He had a myocardial infarction 2 years ago. On examination he is sitting up in bed with a low volume pulse of 122/min, blood pressure 96/84mmHg and respirations 24/min.His extremities are cold and cyanotic. Which of the following is most consistent with his diagnosis of left ventricular failure?

*Lung rales.* • Rales (crepitations) on auscultation: basal rales may indicate congestive heart failure; diffuse rales may indicate the onset of pulmonary edema

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

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

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

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

68 yr old - deminishing vision he has been on treatment for diabetes mellitus for 15 years. He is noncompliant and losing lots of weight. Vitals are normal. What is present in his fundi

*Neovascularization -capillary microaneurysms -tortuous dilation of vessels -flame / blot hemorrhages* (Rest are Hypertension based) 1st stage: Copper wiring, Silver wiring 2nd stage: Arteriovenous nicking 3rd stage: Hemorrhages [flame shaped], Exudates that are hard or soft [cotton wool] 4th stage: Papilledema & Hemorrhages [flame shaped]

During her annual health screen, a 25-year-old woman expresses concern about her risk for ovarian cancer because her mother died of the disease. Which of the following is the most appropriate course of action?

*Obtain a more detailed family history of cancer.*

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

*Oculomotor*. innervates the Levator palpebrae superioris to elevate upper eyelid

a young female complains of pain and swelling in the back of the right elbow over past couple months. Rests elbows when studying. On exam there is a tender, soft swelling over the posterior elbow joint.

*Olecranon bursitis* - Swelling and inflammation of the olecranon bursa may result from trauma or may be associated with rheumatoid or gouty arthritis. The swelling is superficial to the olecranon process

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

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

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

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

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

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

A 57-year-old woman, GO, has been feeling full after small meals and thinks that she is gaining weight particularly in her abdomen, over the past 2 months. Her LMP was 5 years ago and she has never been on hormone replacement. On examination of the abdomen there is fullness in her flanks and shifting dullness. On pelvic examination, the vagina is atrophic, the uterus is small, atrophic, and there is no palpable adnexal mass. On rectovaginal examination, there is an irregular non-mobile 6 em mass in the right adnexa. The stool is negative for occult blood. Your most likely clinical diagnosis is cancer of the:

*Ovary* Causes of Ascites Malignancy (esp. Colon, ovary, pancreas, stomach)

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

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

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

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

A 65-year-old homeless woman is admitted with mental confusion and a temperature of 95°F. On examination she is obese and disoriented in time and place. There is a surgical scar over the anterior surface of her lower neck and loss of the lateral third of her eyebrows. Vitals are: Blood pressure 100/80mm/Hg, pulse 45/min and respirations 12/min. Which of the following findings is most consistent with the above presentation?

*Periorbital edema* Common symptoms include: Bradycardia Cold intolerance Weight gain Decreased appetite Loss or thinning of eyebrows Constipation Pale, dry skin Round, puffy face (myxedema) Hoarse voice Muscle aches Abdominal bloating Hair changes (thins, coarsens) Depression Decreased sex drive Slowed relaxation phase of deep tendon reflexes

an old man presents with a painless lesion in eye for past couple months. on exam - *yellowish triangular nodular lesion on the nasal side of left eye over the sclera close to the cornea*

*Pinguecula* is a whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjunctiva adjacent to the corneal-scleral junction (limbus). It does not grow unto the cornea.

How to localize the APex beat

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

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

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

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

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

old guy with left heart failure -sleeps on four pillows at night - frothy sputum - basal lung crepitations

*Pulsus alterans* = alternating weak and strong beats but normal rhythm --> *sign of left ventricular failure*

A 25-year- old woman complains of episodes of pallor, followed by bluish discoloration and redness of her hands for the past 6 months. The episodes usually occur in the winter , and sometimes when she is in air-conditioned rooms. She does not smoke. They do not occur if she is wearing warm undergarments and is not exposed to cold . Her younger sister has experienced similar episodes . General physical examination and examination of the hands reveal no abnormalities.. This is most likely due to

*Raynaud's disease* Causes of vasospasm include Raynaud's disease or phenomenon

Snellens Chart can be used to diagnose

*Refractive Error* (cannot focus light) -aging, hyperglycaemia of diabetes (due to reversible osmotic swelling of the lens). -Cataracts (or opacities in media) -retinal macular degen, scarring due to hemorrhage -diabetic retinopaathy, -optic nerve disorders (glucoma)

A 20-year-old man presents with a one day history of fever, and pain in the right lower quadrant. The pain started in the periumbilical area. On examination his temperature is 1000F, his blood pressure is 120/80 mmHg and pulse is 104/min. Examination of the abdomen reveals tenderness, guarding and rebound tenderness in the right lower quadrant and a positive psoas sign. Where is the affected organ located?

*Retrocecal.* The psoas test is positive when the appendix is located in a retroperitoneal retrocecal position

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

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

a 50 yr old male presents with fever, SOB, chest pain, for the past 6 days. low BP, high temp janeway lesions are seen on palms of both hands - cardiac exam reveals systolic murmur at the apex. - what will be found on opthalmoscopic findings?

*Roth spots*

A 25 yr old presents with lower right quadrant pain. started 24 hours ago in the *peri-umbilical region*- acute. vomiting for past 24 hours - on exam there is tenderness and *guarding in the right lower quadrant* - this patient has appendicitis - what are the 4 tests for appendicitis

*Rovsing's sign, psoas test* (The psoas test is positive when the appendix is located in a retroperitoneal retrocecal position.) *obturator sign* (The obturator test is positive with pelvic appendices.) *DRE*

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

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

Mr. B.W. age 58 years: "Doctor, I've been having difficulty passing urine for the last 2 weeks." Doctor: "Have you noticed anything else that's not normal?" Mr B.W.: "Yes, it's been burning me in the bottom of my belly when I pass it and I've been feverish since yesterday." Doctor: "Are there any other matters that you would like me to take care of during this visit?" Mr. B.W.: "No doctor, that is all"

*Setting the agenda.*

guy with liver cirrhosis - has palmar erythema, scleral icterus, and clubbing of fingers what test is positive?

*Shifting dullness*

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

*Skin marks of puritus.* Presentation & Symptoms: none weakness anorexia loss of weight abdominal distension jaundice itch Distension Everted umbilicus Ascites Abnormal liver span (small or large) Hepatic mass Splenomegaly

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

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

risk factors for Arterial disease vs Venous

*Smoking* • Hypertension • Diabetes • Hyperlipidemia *Obesity* • Coronary artery disease • cerebrovascular disease VENOUS is Immobilization/Bed rest Surgery on pelvic and long bones Pregnancy *Obesity Smoking* Oral contraceptives Fractures Hypercoagulability Malignancies Economy class syndrome - prolonged maintenance of the sitting position

A 13-year-old girl complains of a painful swelling on her rightupper eyelid for 3 days. On examination there is a swollen and erythematous area on the margin of the eyelid that points outwards. The most likely diagnosis is:

*Stye (hordeolum)* is red, swollen, and tender and has pus discharge

A 39-year-old man has a 2-day history of right shoulder pain that began after a game of tennis. On examination, active abduction of his right arm is relatively pain-free to 30, but further abduction/elevation is painful to 120, after which further elevation becomes less painful. There is tenderness over the shoulder-tip area. Which is the most likely diagnosis?

*Supraspinatus tendonitis= Painful arc syndrome* Pain 50-130 Shoulder impingement syndrome, also called painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder, is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder.

Marcus Gunn

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

What is the name given to palpable vibrations transmitted through the broncho-pulmonary system to the chest wall when the patient repeats 99?

*Tactile Fremetis * (*bronchophony* - sound should become less distinct laterally but in this becomes more loud laterally or in a specific area. *Whispered pectorliquy*- 99 whipser and sounds should NOT be heard, if they are its consolidation *Egophony* - EE repeated and listen for long muffled E - if hear higher pitch 'a' its consolidation)

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

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

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

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

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

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

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

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

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

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

Breathing

*Vesicular breathing*: soft and low pitched sounds heard over most of the lung fields. Inspiratory sounds are louder and longer than expiratory sounds and there is no gap between inspiration and expiration. *Bronchial sounds*: are loud, high pitched (harsh) and may be heard over the manubrium. Inspiratory sounds are shorter than expiratory sounds, both have about the same intensity and there is a gap between inspiration and expiration. Bronchial sounds are characteristically heard in consolidation and at the upper level of a pleural effusion. *Broncho-vesicular*: recognized by some authors, has midway characteristics between vesicular and bronchial. Both inspiratory and expiratory sounds are about equal in duration and there is no gap between inspiration and expiration.

12 year old boy presents with pain and swelling bilaterally around the angle of the mandible for the past 3 days. He complains of fever and inability to open his mouth fully. On exam diffuse swellings are seen on *either side of his face anterior to the pinna above the angles of the jaw*

*Viral parotitis usually occurs in children* Parotid lymph glands are located superficial and deep to the parotid fascia and within the gland. Other structures located in and around the parotid gland include the facial nerve, the retromandibular vein, the external carotid artery and the great auricular and auriculotemporal nerves (sensory supply to the parotid). *Swellings of the parotid gland are palpated at the angle of the mandible and usually lifts the pinna outwards.*

A 12-year-old boy presents with fever, pain and swelling of both sides of his jaw and inability to open his mouth fully for the past 3 days. On examination, swelling and tenderness are present on both sides of his face anterior to the tragus, above the angles of the jaw. Which one of the following is the most likely diagnosis?

*Viral parotitis.* Swellings of the parotid gland are palpated at the angle of the mandible and usually lifts the pinna outwards. Viral parotitis usually occurs in children. Mumps virus can also affect the pancreas and testis in males.

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

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

woman with anxiety and fluttering in chest for 2 months. Double vision for 3 weeks. PR = 112 BP = 135/90 Tremor in hands -whats a question to ask

*Weight Loss* other signs of hyperthyroid (1) Skin & Hair: Soft, warm, flushed, Excessive sweating, Fine & thin hair (2) GI: Hypermotility, Malabsorption, Diarrhea (3) Cardic: Palpitations, Tachycardia, Congestive heart failure [if aggravates preexisting disease], Fibrillation, Increased volume, Murmurs (4) Neuromuscular: Nervousness, Tremor, Irritability, 50% develop proximal muscle weakness (5) Ocular: Wide staring gaze, Lid lag, Exophthalmoses, Lid retraction, Extra-ocular weakness (6) Thyroid storm: Medical emergency (7) Reflex: Delayed relaxation phase of deep tendon reflexes, Pretibial myxedema

A 28-year-old man complains of fever, cough and shortness of breath for the past two days. On examination his temperature is 102°F, pulse rate is 110/min and respirations 30/min. His trachea is central. Chest expansion is reduced in the left lower chest. Which of the following findings in the lower zone of the left lung best supports the diagnosis of lobar pneumonia?

*Whispering pectoriloquy* *BRONCHOPNEUMONIA- SIGNS* EXPANSION -REDUCED TACTILE FREMITUS-INCREASED ON AFFECTED SIDE PERCUSSION-DULL BREATH SOUNDS-BRONCHIAL ADDITIONAL SOUNDS-RALES VOCAL RESONANCE-INCREASED ON AFFECTED SIDE PLURAL RUB MAY BE HEARD AEGOPHONY WHISPERING PECTORILOQUY

a 55 yr old women with hypothyroidism - described as weight gain, bradycardia, "worn out" constipated and cold - what other findings will be observed?

*abnormal deep tendon reflex's* - slow relaxation phase.

50 yr old man, chronic alcoholic, vomiting with severe epigastric pain thats made worse when lying down and is relieved when leaning forward. Exam reveals painless periumbilical ecchymosis

*acute pancreatitis* - this is a positive *cullen's sign*

a 60 yr old women in ER - two episodes of feeling faint - palpitations and SOB for past 5 weeks - low BP high pulse - timing and volume are irregular. whats diagnosis

*atrial fibrillation* Irregular irregularity - atrial dysrthytmia, such as AF. In atrial fibrillation, there is irregularity in rhythm and volume.

Tympanosclerosis

*calcified plaques* may be seen on the surface of the membrane and is usually due to *scar formation secondary to incomplete healing of otitis media*

Coloboma

*developmental abnormality* - hole in one of the structures of the eye, such as the iris, retina, choroid or optic disc. The hole is present from birth and can be caused when a *gap called the choroid fissure between two structures in the eye*. A well demarcated, moderate-sized to large, white oval of sclera is visible below the disc, often extending well beyond the limits of your examination. Its borders may be pigmented.

Causes of Senorineural Hearing Loss

*external* Ototoxic drugs such as amino glycosides, physical trauma (fracture of the temporal bone), infections such as suppurative labyrinthitis (inner ear infection), meningitis, mumps and measles and noised induced. *Internal* AGING is one of the main causes (presbycusis 4g-8g Hz), ischemia, perilymph fistula, acoustic neuroma, or tumor at cerebellopontine angle

Pyelonephritis

*flank pain*, *costo-vertebral tenderness*, fever, vomiting, nausea

a 50 year old male presents with weakness of the right lower limb and difficulty climbing stairs - trouble buttoning shirt - and knee reflexes are 4+ - what else will be found>

*hypertonia* -UMN lesion

baseball player - been chewing dip for 25 years - has patchy lesions on the tongue and buccal mucosa

*leukoplakia* Leukoplakia is a white patch that cannot be scraped off and can be premalignant. Smoking/chewing tobacco is also implicated in the causation of leukoplakia.

A 22-year-old woman presents to the eye clinic for her annual check. Her visual acuity is 20/30 in both eyes, on Snellen's chart.

*myopia * Difficulty with close work suggests hyperopia (farsightedness) or presbyopia (aging vision) Difficulty with distances, myopia (near-sightedness): In myopia, the light rays focus anterior to the retina;

Thrills in precordium

*palpable murmurs*, usually of grade 4/6 intensity or greater and resemble the purring of a cat

Buerger Test -lower limb arterial insufficiency

*return of color 10 seconds - venous filling 15 seconds* -both legs 60 degrees

28 yr old athlete healthy but on auscultation a split s2 is heard....

*splitting of NORMAL PULMONARY VALVE* (Left ventricular and aortic pressures are much higher than right ventricular and pulmonary artery pressures, causing left sided valve closures to be louder and occur slightly before the right. Pulmonary valve closure tends to be further delayed during inspiration, probably because of increased capacity of the pulmonary capillary bed during inspiration, which prolongs right ventricular ejection. This causes *physiologic splitting of S2, accentuated by inspiration, often best heard near the pulmonary area*)

a 30 yr old female presents with severe lower back pain radiating to the back of the thigh and the lower leg - this began after she lifted a heavy object - what test will show a positive result --> the test will identify a problem with the greater sciatic nerve --> test?

*straight leg raise* --> Lasegue's --> A patient with sciatic nerve root irritation, such as due to prolapsed intervertebral disc, or nerve root entrapment, will experience sharp pain in the back or buttocks that radiate down the thigh/leg along the L5 or S1 dermatome. - Bowstring

young boy presents with pain and swelling bilaterally around the angle of the mandible for the past 3 days, he also complains of fever and inability to open his mouth fully - exam there are diffuse swellings on EITHER side of his face anterior to the pinna and above the angles of the jaw.

*viral parotitis* Swellings of the parotid gland are palpated at the angle of the mandible and usually lifts the pinna outwards Other structures located in and around the parotid gland include the facial nerve, the retromandibular vein, the external carotid artery and the great auricular and auriculotemporal nerves (sensory supply to the parotid).

Sensorineural hearing loss

- LOUD NOISE EXPOSURE. -TUMORS. -TRAUMA. *Fracture of Temporal Bone* -CONGENITAL/FAMILIAL DISEASES. - TOXICITYASPIRIN, STREPTOMYCIN ,ALCOHOL. -AGING(PRESBYCUSIS) -MENIERE'S DISEASE.

Large a wave

- Pulmonary hypertension - Rt. heart failure - Tricuspid stenosis

Optic atrophy: Secondary

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

25yr male - crash. No seatbelt. Chest pain + shorntesess of breath the pain is right side of chest and hurts on inhalation. It is stabbing in nature. His BP 160/100. Resp = 25/min FAST and Shallow. No pallor Calm and alert Tender over 6th and 7th ribs with bruising Chest is stony dull on RIGHT Breath sounds + resonance and fremitus are all decreased on right side

-His chest pain may be pleuritic and maybe due to contusion or rib fracture -he has central cyanosis and should be given O2 -Right Side Pleural effusion stony dull = pleural efflusion

Positive Phalens Test associated with.... -median nerve compression

-Muscle atrophy (wasting) - of thenar eminence only (possible carpal tunnel syndrome -impaired opposition of thumb -hand pain radiating proximally -postive Tinel Test (not decreased ulnar nerve velocity)

40 yr old male presents with shortness of breath - worse when lying down at night - has been going on for 6 months - exam theres a loud s1 - murmur heard in mitral area - how can you maneuver patient to help determine the phase of the cardiac cycle the murmur is occurring in?

-Palpating the carotid pulse while auscultating the heart -With the bell over the mitral area, ask the patient to roll towards their left side (left lateral decubitus position) and continue to auscultate the mitral area for the mitral stenosis murmur or left ventricular S3 or S4.

Rheumatic Fever disease features

-arthritis -carditis -fever -chorea NOT retinitis Eye inflammation (conjunctivitis, uveitis, scleritis, episcleritis). Eye inflammation is one of the triad of signs seen in *Reactive arthritis*. Other components of the triad are arthritis of large joints and urethritis/cervicitis

Neck stiffness

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

Diabetes on fundus

-microaneurysms + ruptures -dilation and tortous vessels (nonperfusion) -flame-shaped / bot hemorrhages -exudates around fovea -neovascularization

Hypertensive fundus

-narrowing in arterioles -tortuous arteries -AV NICKING -Cotton Wool Exudates -Macular Star -Flame hemorrhages -EDEMA, Papilledema (malignant HS)

CN 7 UMN lesion -upper spares upper -remember bells palsy

-patient is able to raise both eyebrows! -patient can close both eyes! -patient has drop of corner of mouth on affected side -patient has no change in side perception on affected side (No stapedius problems)

Cerebellar Ataxia attributes

-unable to stand with feet together eyes open or closed (both) -tandem ataxia -dysdiadochokinesia -horizontal nystagmus (just eyes closed is Dorsal Column)

signs or portal hypertension

-venous hum over porta hepatis (veins are distended) -Hematemesis is often due to erosive gastritis, acid peptic disease or esophageal varices (portal hypertension). -ascites --> caput medusae -gynecomastia -The spleen and liver may be both enlarged in myelofibrosis, portal hypertension and chronic myeloid leukemia.

A 15-year-old girl is seen accompanied by her mother, who states that she wants her daughter to be on a contraceptive because she has become sexually active. During an interview with the patient alone, she reports that she has become sexually active with her boyfriend during the past 3 months; they use condoms consistently, and she is not interested in any other form of contraception at this time. Menarche was at the age of 12 years, and menses occur at regular 28-day intervals. She has had no symptoms of sexually transmitted diseases. Examination shows no abnormalities. In addition to counseling the patient about all contraceptive methods, which of the following is the most appropriate next step?

. Do not inform the mother that her daughter and her partner use condoms, but encourage the daughter to do so.

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

...

Glasgow Score

...

Jaundice is observed in the palpebral conjunctivia

...

Venous thrombosis.

...

What is a probable diagnosis in presence of papillaedema

...

put table on page 632 on white board

...

Failure rate of tubal ligation

1 in 200 times

Matching

1) Loss of Superficial Reflexes- LMN lesion 2) Decreased muscle tone + nystagmus - Cerebellar Lesion 3) Rigidity + mask facies = Parkinsons 4) Loss of Fine Touch = Dorsal Column Lesion 5) Significant Atropy + Fasciculations = UMN

What tests assess valvular competency in communicating veins of the leg?

1- Retrograde Filling Test (Manual Compression Test) 2- Tredenlenberg Test

Signs of venous insufficency

1. Edema 2. Stasis dermatitis 3. Ulcers - usually in the area of the medial malleolus 4. Varicose veins 5. Increase warmth due to associated cellulitis 6. Cords - thrombosed superficial vein • Pain - usually of a dull ache that may be relieved by elevation of the leg • Swelling and tightness of the leg • Erythema • Increased warmth of affected limb

In USA legal blindness

20/200

More Matching

20/200 = Legally Blind Lens Opacitiy = Cataracts Pupillary Constriction = Near Reaction ExOcular Movements = CN3,4, 6 Conjuntivitis = Red Eye

Fundoscropy Hypertension

1st stage: Copper wiring, Silver wiring 2nd stage: AV nicking 3rd stage: Hemorrhages [flame shaped], Exudates that are hard or soft [cotton wool] 4th stage: Papilledema & Hemorrhages [flame shaped

Name the vaginal end of the cervix

ectocervix

Eye chart numbers

20ft is Snellens (far vision) Rosenbaum is 14 inches (near vision better for 40+ yrs, or people using bifocals) Myopia refers to nearsightedness. Hyperopia refers to farsightedness. Presbyopia is the loss of ability to focus for near vision that occurs with increasing age. (Glaucoma can occur from anterior dislocation of lens)

60 year old female with shortness of breath - you examine her JVP and diagnose her with right sided heart failure - her JVP will most likely be

6cm (2-3cm is normal)

Normal Central Venous Pressure

7-8 cm above sternal angle of louis (patient 30-45 angle at trunk)

hinge joints

elbow, knee, interphalangeal joints

Posteriorly the tips of scapula is usually above which rib

7th rib

55 year male complains of shortness of breath and cough productive of frothy sputum for last 3 days. He sleeps on 4 pillows at night. On auscultation of his lungs there are creptitations on lung bases biltarally

ALTERNANS PULSE due to left ventricular failure

lesion to spinothalamic tract

loss of pain sensation

Cauda equina lesion will cause

loss of sensation to S2-S4

lesion to dorsal column

loss of touch, vibration and proprioception

the unhappy triad consist of tears of which combination of ligaments:

Anterior cruciate, medial collateral, medial meniscus

45-year-old man presents with increasing shortness of breath for the past week. *Two. weeks ago he had a flu-like illness that got better after six days*...on inspiration his pulse volume decreases markedly and his JVP increases.

A *paradoxical pulse* is found in pericardial tamponade, constrictive pericarditis (though less commonly), and obstructive lung disease

pinguecula vs pterygium pterygium invades into corneum and can blur vision the pinguin stays home and is harmless

A *pinguecula* is a whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjunctiva adjacent to the corneal-scleral junction (limbus). It does not grow unto the cornea. A *Pterygium* is in a similar location, is more vascular, begins at the medial canthus and extends beyond the corneal-scleral junction.

45 yr old male to the emergency room with acute shortness of breath and restlessness, he had a stab wound on the left side of his chest and tracheldeviation to the right. The shift is due to

A Large pneumothorax on the left

Pterygium

A Pterygium is in a similar location, is more vascular, begins at the medial canthus and extends beyond the corneal-scleral junction.

25yr lady with h(x) of rheumatic fever as a child presents with Hemiplegia....why

A cerebral embolus from left atrum -look for atrial fibrillation (pulse deficit)

Chalazion

A chalazion is cyst like and has *no acute signs of inflammation*. It is usually due to *inspissated secretions of the meibomian glands*.

staggering gait

A drunken person or someone with cerebellar dysfunction leads to a staggering gait. -medulloblastoma, floccular nodular lobe

Antalgic Gait

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

Pinguecula vs Pterygium

A pinguecula is a whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjunctiva adjacent to the corneal-scleral junction (limbus). It does not grow unto the cornea. A Pterygium is in a similar location, is more vascular, begins at the medial canthus and extends beyond the corneal-scleral junction.

A 45-year-old body builder presents with a swelling in the left groin for the past 6 weeks. He states that the *swelling increases in size when he coughs or sneezes*. He can see the swelling when he is standing and it disappears when he lies down. On examination a swelling is felt in the left groin when the patient is asked to cough. Which type of hernia is this patient likely to have?

A protrusion of peritoneum or viscera into the inguinal or femoral canal because of an inherent weakness in the abdominal wall.

lymphatic drainage of intercostal spaces

Anterior drainage is to the internal thoracic (parasternal) nodes. Posterior drainage is to the para-aortic nodes of the posterior mediastinum.

A double impulse indicates

mix AS and AI, left ventricular aneurysm

stamping gait (SENSORY)- seen in MS

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

STRIDOR

A wheeze (high pitch) that is entirely inspiratory -medical emergency -partial obstruction of LARYNX or trachea

malocclusion of the teeth

ACROMEGALY (pituitary tumor) -also for bitemporal heminopia

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

ACTIVE LISTENING -closely attending to what the patient is communicating, verbally and nonverbally including being aware of patients feelings

What is included in DVT assessment

Bulging veins, tenderness, edema (*Symptoms* of peripheral venous disease *Swelling* of feet and legs *Chronic ulcers* of the lower leg *Pain* in the calf area *Skin hyperpigmentation* and *thickening Prominent veins in the leg*)

Acute Pancreatitis

Distention + Cullens + Greys -bowel sounds present -tender upper abdomen with rebound tenderness Complications: hypocalcemia, fat necresis, shock + resp failure + diatbetes + pseudocyst

How do you diagnosis Glaucoma

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

a nosebleed that began 6 hours previously. On examination blood is coming from the right nostril. There is no blood in the naso- pharynx. Which of the following locations is the most likely source of bleeding?

Anterior nasal septum. The *lower anterior portion (littles area)* of the septum (where the patient's finger can reach) is a common source of epistaxis (nosebleed).

acute (bacterial) otitis media.

Distortion and redness of the tympanic membrane, obscured malleus, and bulging membrane with pus behind the membrane (or perforation with discharge)

Pain in left calf on walking - subsides at rest. Smokes cigs. Exam on left lower limb is Shiny, Pale, Thin. Nails are thickened. What other signs would you look for in vascular disease?

Absent Dorsalis Pedis pulse Other symptoms include - changes in the skin, hair loss on the distal leg, rest pain, non healing ulcers on tips of toes, numbness, tingling and weakness in the legs, impotence, thickened toenails, and pallor of the legs especially on elevation.

45 year old male with 2 year history fatigue, enlarging feet, jaw and hands. Weakness of his limbs. Phalen test is positive. X-ray reveals there is frontal bossing and enlarged jaw.

Acromegaly most commonly affects adults in middle age It most commonly it involves a GH-producing tumor called *pituitary adenoma* *Bitemporal Hemianopsia*

old man complains of increase in urinary frequency with a burning sensation. Difficulty passing urine. Suprapubic tenderness, no costo-vertebral angle, on exam reveals an enlarged nontender prostate.

Acute cystitis (prostatitis would be tender)

During her routine annual eye examination a 45-year--old woman is found to have unequal pupils, the left being larger than the right. The left pupil does not react to light and constricts slowly to accommodation. Her Achilles and patellar tendon reflexes are decreased bilaterally.

Adie's pupil. Dilated left which doesn't respond to light and then constricts slowly to accommodation

Breast Cyst

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

Coloboma

An iris coloboma is a notch or gap, usually inferior and bilateral, in the iris. It results from failure of fusion of tissues and is often part of choroidal coloboma which may also involve the retina

coloboma

An iris coloboma is a notch or gap, usually inferior and bilateral, in the iris. It results from failure of fusion of tissues and is often part of choroidal coloboma which may also involve the retina.

41 year old truck driving presents for routine exam - no history of surgery - no medications. He has been a smoker for many years. He does not use alcohol or illicit drugs. Family History is unremarkable. Right pupil is LARGER than left by .4mm. All else is normal. What is Diagnosis?

Anisocoria 10-20% of individuals have variation in size between the pupils (anisocoria). *Size difference of less than 1 mm with normal reaction to light and accommodation is termed physiologic (benign).*

downward "tugging" of the trachea

Aortic Aneursym

Leaning forward on exhalation

Aortic Regurg ( diastolic decrescendo murmur)

45 yr old male with 7 months of palpation and easy fatigue. BP = 148/50 PR= 104 Decrescendo murmur at ERBs point with patient sitting up and leaning forward -what else would you look for

Aortic Regurg so look for Collapsing Pulse or Pulsus Bisferins Collapsing = rapid upstroke sudden early descent (-*Pulsus Alternans*- LVF *Pulsus Parvus*-Slow carotid upstroke of Aortic Stenosis -*Pulsus Paradoxus* - drop of 15+mmHg on inspiration Cardiac Tamponade *Radio-femoral delay* - aortic coarc)

48-year-old man presents with shortness of breath while climbing stairs or walking up hill for the past 3 months. On examination the pulse is 96/min and bounding, the blood pressure is 160/64mmHg. There is an *early, grade 2/6, high pitched diastolic murmur * in the *second right intercostal space parasternally that radiates to the left third interspace parasternally*

Aortic Regurgitation - DiastolicMurmur, Backflow, s2 decresecendo +4 pulse

Wide Pulse Pressure

Aortice Regurgitation

Hutchinsons teeth associated with

Argyll Robertson Pupils

small, irregular and accommodates but does not react to light

Argyll robertson pupil

Tactile fremitus

Ask the patient to say "99" & feel for vibrations with ball [ulnar border] of your hand, i) Increased tactile fremitus: Consolidation ii) Decreased tactile or absent fremitus: Pleural effusion

Prolong expiratory phase of respiration suggests narrowing of the bronchioles in ...

Asthma

a 55 yr old diabetic complains of tingling and numbness of both feet for past 3 months - loss of T and V - whats the gait

Ataxic or broad-based gait -Acute cerebellar ataxia -Alcohol intoxication -Brain injury -Damage to nerve cells in the cerebellum of the brain (cerebellar degeneration) -Medications (phenytoin and other seizure medications) -Polyneuropathy (damage to many nerves, as occurs with diabetes) -Stroke

Pulse Defect

Atrial Fibrillation -difference in radial pulse and apical pulse

68 yr old racing heart and shortness of breath Her pulse is *irregular in timing* and of *variable but symmetrical volume*(irreg irreg) *Heart rate is also irregular* and approximately 150/min, and *S1 is of variable intensity*

Atrial Fibrillation (Absent a wave - atrial fibrillation) Types of irregularity: *Regular irregularity* - sinus arrhythmia (normal in the young), atrial extrasystole, ventricular extrasystole, heart block *Irregular irregularity* - atrial fibrillation, atrial flutter While palpating the radial artery, determine the rate and rhythm together with the amplitude. An irregular rhythm may be indicative of atrial fibrillation and a source of distal embolization.

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

B. saddle

A 55 year old male complains of shortness of breath which wakes him at night. He had a myocardial infarction 2 years ago. A diagnosis of left ventricular failure is made after physicalexamination. Which of the following would you expect to find in this patient?

BASAL RALES - late inspiratory basal rales as seen in patients with CHF - refer to whiteboard #2

bells palsy revisited

BELL's palsy (at the stylomastoid formina) -Drooping of outer corner of mouth and eyes result in saliva and tears running from mouth and eyes, corneal dehydration canresult -Loss of tone in the orbicularis oculi leading to eversion of lower eyelid Paralysis of the buccinators and orbicularis oculi results in food accumulating in the oral vestibule during chewing - Hyperacusis from Stapedius Muscle - loss of taste anterior 2/3rds of tongue

hernias inguinal - indirect or direct femoral

BEST examined when patient is asked to *cough*

48 yr old with 6mnth history of pain in left leg on walking. Improves if resting. Nails are nicotine stained. Left Left cool on touch compared to right. Left dorsalis pedis pulse and left tibial pulse absent - what test is postive?

BEURGER TEST (symptoms of arterial insufficency - pain on activity = intermittant claudication, rest pain (if SEVERE otherwise this is a venous symptom), paresthesia and numbness, cool temp,

Comatose patient ataxic (remember this is BIOTs) breathing suggests lesion at the level of....

BIOTS = medulla (notes say just medulla) or midbrain lesion Deep + Shallow + STOPS unpredicatable *Medullary rhythmicity"* center Quiet respiratory rhythm (base line) is set and controlled by this center. *Apneustic center* This center controls the depth of inspiration thus allowing response to increase demand for oxygen. *Pneumotaxic center* This center controls the rate of inspiration by exerting control over the duration of inspiration.

Consolidation produces

BRONCHIAL SOUNDS increased tactile fremitus and sounds

80 year old man with failing vision your attempt to examine retina using opthalmascope is unsuccessful this is explained by....

Bi-lateral Mature CATARACTS

MRI reveals tumor in sella turcica what visual field defect

Bitemporal Hemianopia

a 40 year old that has acromegaly - said that there was a positive phalen's test (carpal tunnel) and x ray revealed frontal bossing and enlarged jaw. What visual defect will be present?

Bitemporal heminopsia, mass effect from pituitary over the optic chiasm

Signs of meningeal irritation

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

Inflammed Lymph Nodes vs Malignant Lymph Nodes

Both Large HARD = Malignant, Soft Firm = Inflammed Only Tender in Inflammed Nonmobile= malignant Discrete = Inflammed, borders not defined in Malginant

important note on bowel sounds

Bowel sounds cannot be considered absent until the examiner has listened to the abdomen for at least 3 minutes. Ileus is failure of peristalsis and is a normal response of the bowel to laparotomy and peritonitis. Absent bowel sounds occur in adynamic ileus, ischemia of the bowel wall, inflammation of the bowel and in peritonitis. Adynamic ileus can also result from extraabdominal conditions such as pneumonia and uremia. Absent bowel sounds after a period of hyperactive bowel sounds may indicate intestinal perforation or strangulation and ischemia of the bowel wall.

48 yr old with fatigue, lethargy and cold intolerance over 6 months. She speaks slowly and her face appears puffy -with coarse hair. Thickening of the skin with nonpitting pretibial edema - What else would you be look for

Bradycardia (Look for hypothyroidism periorbital edema, coarse dry hair, weight gain, onycholysis, loss 1/3 eyebrow, yellow skin =hypercaroten, anemic pallor, myxedematous changes in skin)

60yr old lady complains of tiredness and weight gain - you believe its hypothyroidism What signs lead you to this...

Bradycardia Slow relaxation of reflexes Enlarged Thyroid Gland Loss of lateral 1/3 of eyebrows (not pretibial edema - specfic for graves)

Large pleural effusion on patients left chest which of the following is consistent with this finding -Listen for transmitted voice sounds - vocal fremitus (resonance), egophony ,whispered pectoriloquy

Breath Sounds: Decreased or Absent Percussion: Stony Dull Tactile Frem: Decreased to Absent but egophony present at upper limit Vocal Resonance: Decreased to absent

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

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

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

C6

Middle ear innervated by

CN 9 (glossopharyngeal)

Prolonged expiration (obstructive breathing)

COPD or asthma

Alternating peroids of fever and apryrevia lasting 5 days each

Cancer (relapsing fever = pel-ebstein)

McMurray is for :

Cartilaginous (medial and lateral menisci) injury

65 year old diabetic male presents with worseing vision over past 3 years -- on attempting ophthalmoscopic examination the physician is unable to visualize the red reflex bilaterally

Cataracts Opacification (cataract). Evaluate pupil for any reflected light, showing as grey or silver areas, within each pupil. This may indicate cataract formation or, in children, retinoblastoma Other causes of cataract include Down's syndrome and cretinism, ocular disease such as iritis, systemic diseases such as diabetes and hyperparathyroidism and penetrating eye wounds.

tympanosclerosis,

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

Dysdiadochokinesia is associated with

Cerebellar disease

chronic painless 1 cm mass in eye lid

Chalazion (A chalazion is cyst like and has *no acute signs of inflammation*. It is usually due to inspissated secretions of the *meibomian* glands.) *BLOCKAGE OF GLAND NOT INFECTION*

Comatose woman in ER. She has hypertension and medicated with anticoag for atrial fibrillation her pulse is 106/min and irregularly irregular. *Periods of breathing when there is NO breathing and changing to states of rapid and deep*

Cheyne Stokes - periods of breathing with apnea and hyperpnea -brain damage -heart failure -uremia -drug induced resp depression (opiates)

Hypertension--> stroke. What gait?

Circumductive Gait (Hemiplegic)

Clubbing of Fingers

Cirrhosis Lung Cancer Bacterial endocarditis Congenital Heart Disease Hyperthyroidism Inflammatory diseases (IBD) Fibrosing Alverolitis

What nerve damage causes diplopia?

Clinically, patients with lesions of the *IVth and VIth Cranial nerves* complain mostly of diplopia. Patients with IIIrd Cranial nerve paralysis do not have diplopia because they cannot open the affected eye.

Chronic Sniffling Nasal Congestion Nose Bleeds Septal Perforation

Cocaine Abuse

Murmur description

Collapsing Pulse (Waterson Hammer)= aortic regurg Radiating to neck (carotids) = Aortic Stenosis Radiating to left axilla = mitral regurg Raditing to R sternum, xyphoid, left mid clavicular = tricuspid regurg Raditing to left shoulder = pulmonary stenosis

Failure of the neuroectodermal tissue to wrap itself around the lens placode

Coloboma

Acute symptomatic seizures

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

Adie's (Tonic) Pupil

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

Middiastolic murmur

obstruction to flow across semilunar

Symmetrical with increased movement

paralysis of diaphragm (intercostal muscle contraction)

25-year-old woman complains of intermittent chest pain for the past 3 weeks. On examination her vital signs are normal. There is marked tenderness over the left parasternal area near the third and fourth ribs. Cardiac examination is normal.

Costochondritis = a temporary inflammation of the costal cartilage, which connects each rib to the sternum at the costosternal joint, and is a common cause of chest pain

'Lifting of Ear'

parotid gland enlargement

Cheyne Stokes Breathing

Damage to cerebral hemispheres (forebrain), Heart failure, Uremia, Drug induced respiratory depression

retrobulbar neuritis

Deep pain and pain on eye movement (retrobulbar neuritis).

Hypospadias:

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

stethescope

Diaphragm - high pitched sounds such as S2- 300Hz

Pulse deficit is

Difference between the *heart rate* by auscultation at the apex and the peripheral *pulse rate* by palpation (*rapid irregular rhythm = atrial fibrillation*)

hemorrhage symptoms

Diplopia or Double vision & headache

66 yr old with 1 year of worsening eye sight for past 17 years he had well controlled hypertension and type 2 diabetes. What changes will you find in his retina?

Dot - blot hemorrhage and neovascularization

Olivers Sign

Downward displacement of the cricoid cartilage with ventricular contraction AORTIC ARCH ANEURSYM

Which of the following is the most important to ensure patient comfort and good assessment during pelvic exam

Draping the patient

What is important to note while examining the lips and surrounding areas when patient is DEHYDRATED

Dryness and Cracking (also depressed frontalles)

waddle gait - myopathic gait -seen in pregnancy and muscular dystrophy

During ambulation, in a patient with weakness of the muscles in one hip girdle, a "waddle" gait will result (the hip tilts towards the weak side when the opposite foot is lifted off the ground). With bilateral weakness, the tilt will shift from side to side as the patient walks

Features of limb ataxia

Dysmetria, decomposition of movement, intention tremor, past pointing.

looking in ear of 16 year old girl which are the follow are normal/abnormal

Normal = see umbo, cone of light, cerumen over membrane and not see incus Abnormal = tympanic membrane convex or bulging

Lymph Nodes

Normal = small, mobile, firm, nontender, discrete Inflamed = large, mobile, soft/firm, *tender*, discrete Malignant = large, *nonmobile*, *hard*, nontender, *fixed-matted*

Dyspnea on exertion for 6 months....pursed lip breathing - increased AP diameter. We notice tactile fremitus - percussion with hyperresonance and deminished breath sounds

EMPHYSEMA Tactile fremitus (hand felt vibrations while patient says 99 may be normal, increased as in consolidation or decreased or absent as in pleural effusion and pneumothorax and COPD (chronic obstructive lung disease).

Filtration is non selective

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

diabetic retinopathy

Early changes (nonpropliferative) include capillary microaneurysms (smooth borders and sharp round shape), dilatation and tortuosity of vessels and non perfusion of areas. Rupture of microaneurysms, capillaries and venules result in hemorrhages (flame-shaped or blot). Exudates (due to leaky capillaries) may appear in clusters, streaks or rings around the fovea. In later stages, neovascularisation (new vessels) develops on the disc and/or retina and these can lead to many complications (hemorrhage, retinal tears and detachment).

Aortic Regurg

Early diastolic murmur with wide pulse pressure - and collapsing arterial pulse -Bisferans Pulsus + Water Hammer -Head nodding = deMussets -Femoral Bruit = Duroziers sign

more high pitched sounds

Early mechanical obstruction produces hyperactive peristaltic waves proximal to the obstruction. The bowel seeks to overcome the obstruction. These waves are increased in frequency and force and produce a concomitant increase in bowel sounds with characteristic "rushes".

HIGH PITCHED

Early obstruction produces hyperactive peristalsis proximal to the obstruction

Grey turner and Cullen's sign

Ecchymosis and bruising - Cullen's sign is bluish discoloration of the umbilicus and Grey Turner's sign is bluish discoloration of the flanks. The former tends to indicate intraperitoneal bleeding and the latter retroperitoneal bleeding as may occur in hemorrhagic pancreatitis.

Severe heart failure and bed ridden -- what would u find

Elevated JVP Positive Homans (DVT) Edema of Feet Hepatomegaly

a 68 year old male presents with SOB and a cough with productive clear mucoid sputum for 3 months. Cough and phlegm in the early morning - and complains of wheezing. Patient is sitting up in bed. exam reveals decreased breath sounds and hyper-resonance

Emphysema

Matching

Emphysematous Lungs = hyper-resonant Gastric Bubble = Tympany Healthy Lung = Resonance Heart Borders = Dullness Liver or Spleen = dullness Percussion over bowels distended with air will result in tympany. Percussion over solid organs, solid masses, or fluid will result in dullness. Resonance - loud, low pitch hollow sound of long duration Hyper-resonance - loud, low pitch booming sound of long duration Dullness - medium soft, with a thud-like sound Flat - soft, high pitched, with a short duration

Palpable Gall bladder

Enlarged: carcinoma of gall bladder Enlargement with jaundice : Cancer of head of pancreas

78 yr old man 3 year history of pain + irritation in both eye - worse on left. Immigrated from SE Asia recently - his left eye has red conjunctivia and is turned inwards toward cornea and sclera....

Entropion (- endotropion - aging and sagging of eyelid with a turn outward - tears. -dacryocystitis is an inflammation of the lower lacrimal passages of infants/elderly. Chronic = blockage. -Episcleritis is a benign noninfectious inflammatory process of the subconjuncitiva area

Entropion vs Ectro

Entropion -turning inwards of the lid margin. This can cause abrasion of the cornea. Ectropion - turning outwards (sagging) of the eye margin. It is often associated with aging. There is a constant flow of tears down the medial side of the face.

Medial epicondylitis ("golfer's elbow")

Examination for medial epicondylitis: Tenderness - palpate over the medial epicondyle Test - Ask the patient to flex his wrist while the examiner is providing resistance with one hand. Resulting pain is a positive test.

a 20 year old female tennis player presents with pain in the right elbow for the past three days. on exam there's tenderness over the lateral epicondyle.

Exension (dorsiflexion) of the wrist against resistance. -test for lateral epicondylitis = Cozen's test

Rapid deep - HYPERPNEA (hyperventilation)

Exercise o Anxiety o Metabolic acidosis o Midbrain or Pontine abnormalities - infection, hypoxia, hypoglycemia

Fasiculations

Fasciculations are muscle twitches due to contraction of a single motor unit, and is the second most common abnormal movement. These contractions, occurring randomly and involuntary, can be seen and felt, but does not result in joint movement. Fasciculation are often due to damage to the lower motor neuron Significant atrophy and fasciculations suggest lower motor neuron lesions. In lower motor neuron deficits, significant atrophy can start within 1 week of onset

When the examiner detects unusual coolness or temperature difference in the hands - should be next step in examination

Feel forearms with back of fingers

Otitis Externa is associated with a preforation of tympanic membrane

FALSE

an apagar score of 5/10 at 5 min indicates the baby is deceased

FALSE

frank blood in the stools is usually seen in UPPER GI bleeding

FALSE

the thomas test is always preformed on the affected leg

FALSE THIS MANEUVER IS FOR THE OPPOSITE HIP (Flex one hip to test other)

in chronic allergic rhinitis the mucous membrane looks pink in color

FALSE *Pale* boggy mucosa often indicates allergic rhinitis. Redness of the mucosa (together with a purulent discharge) may indicate a bacterial rhinitis.

both the afferent and efferent innervation of the jaw jerk is cranial nerve 7

FALSE CN 5

Conductive deaf

FOREIGN BODY IN AUDITORY CANAL. OTITIS MEDIA. PERFORATED EARDRUM. OTOSCLEROSIS OF OSSICLES. OTITIS EXTERNA.

CONDUCTIVE DEAFNESS

FOREIGN BODY IN AUDITORY CANAL./OTITIS MEDIA. /PERFORATED EARDRUM. /OTOSCLEROSIS OF OSSICLES/ OTITIS EXTERNA.

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

Facial nerve palsy with concominant hyperacusis d/t close proximity of nerve path --> BELLS PALSY is a LMN lesion

a 65 yr old male presents with tremors and an expressionless face for the past 6 months, on exam there is bradykinesia, rigidity and postural instability - what sort of gait will the patient have?

Festinant or Parkasonian gait - shuffling gait --> Patients with Parkinson disease have a characteristic gait. There is difficulty with initiating walking, short steps are taken but the gait is narrow based. Severe gait disturbance results in a propulsive gait, the patient appears to be chasing the center of gravity, shuffling and leaning forward, and may even fall at times.

Temperature

Fever This is defined as a core body temperature of over 99°F in adults and over 101°F in infants less than 3 months of age. Hypothermia This is defined as a core body temperature of under 95°F.

Unilateral nonpitting edema

Filarisis

Papilledema

Findings include blurring of the disc margin, loss of spontaneous venous pulsation, hyperemia hemorrhage and exudates on the disc. The commonest cause is due to raised intracranial pressure

Thyroid gland would be _____ in Hashimotos

Firm

Steppage Gait

Foot Drop usually LMN disease drag their feet or lift them high with knees flex and slap them onto floor appearing to walk upstairs. Unable to walk on heels.

Gait in conversion disorders/Helicopd gait

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

Common cause of airway obstruction

Foreign body Right bronchi is shorter and more straight

male, 50, alcoholic, pain in big toe, metatarso-phalangeal joint is swollen, red, tender, palpable nodules on extensor surface of right elbow and helix of right ear.

Gout --> Gout characteristically affects the MP joint of the great toe. That joint will be swollen, red and tender during acute attacks. -can also find nodules (tophi) in the helix of ear and elbow

45 yr old male presents with severe pain and swelling of his right big toe -- consumed lots of wine -- right metatarso-phalangeal joint is wollen and red and very tender. Nodules are palpable on the extensor surface of the right elbow and also on the helix of right ear

Gouty Arthritis

65yr w/ 2 years of large veins in right left that extend to thigh - right leg ulcer noted for last 4 months not responding to treatment. Large varicose veins on medial surface of right leg. Ulcer on medial aspect of lower third of leg Trendelenburg is reported as Negative Positive what is dysfunctional?

Great Saphenous Vein A report of negative - negative means that all valves are competent. A report of positive - negative means that the valves of the perforators are incompetent but those of the saphenous system are competent A report of positive - positive means that the valves of both areas (perforators and saphenous system) are incompetent Rapid filling of the superficial veins while the saphenous vein is occluded indicates incompetent valves in the communicating veins. Blood flows quickly in a retrograde direction from the deep to the saphenous system. Sudden additional filling of superficial veins after release of compression indicates incompetent valves in the saphenous vein. When both steps are abnormal, the test is positive-positive.

Chronic Liver Disease (Cirrhosis) includes

Gynecomastaisa Testicular Atrophy Spider Nevi Palmar (not koilonychia - iron def)

65 year old is admitted during winter in a comatose state with a body temp of 95F. On exam the patient is obese, with surgical scar in anterior aspect of neck and loss of the lateral 1/3 of her eyebrows.

HYPOTHYROIDISM -can cause *coarsening and dryness of the hair* -hypothermia (35C, 95C) General- Immobile and uninterested, weight gain *Eyes- Periorbital edema* Loss /thinning of lateral 1/3 o the eyebrows Hands- Pulse- bradycardia Temperature- decrease *Onycholysis* Skin- Coarse and dry Myxedematous changes in skin and subcutaneous tissues Yellow discoloration (hypercarotenaemia) Pallor (anemia)

. A 58-year-old man has a 6-month history of "pins and needles" in his feet. He is a painter who lives alone and for the past 18 years has regularly consumed about one quart of rum on weekends, often with his friends. He says that he has not spoken with any of his 5 children for about 10 years because they were critical of his drinking. Which of the following statements/questions would be most helpful in deciding whether the patient has alcoholism?

Have you ever had an early morning drink to steady your nerves?

Swollen tender occipital nodes

Head lice (look for superficial infection)

Presbycusis

Hearing loss associated with aging,

25 yr old African American with prolonged persistant erection - several episodes of abdominal, chest, and joint pain. Hemoglobin is 6gm/dl and his bilirubin level is slightly elevated

Hemochromatosis (look up)

a 50 yr old man with a 3 month history of loss of appetite and weight loss. Scleral icterus is present. Dark urine present, pruritis not mentioned, negative guaiac test.

Hepatoma or Hepatocellular carcinoma

A 20 year old woman presents with anxiety, loss of weight and increased appetite. On examination there is bilateral exophthalmos and a fine tremor of her fingers.

High Volume Pulse

Matching

Hypothyroid Neonate = Cretinism Autoimmune Thyroid = Hashimoto Midline Cystic Neck Mass = Thryro-glossal cyst Injury during Birth = Torticolis Embrolyogical mass near SCM = branchial cyst *Thyroid gland*- moves up and down with swallowing *Thyroglossal cyst* moves up on protrusion of the tongue *Branchial cyst* located anterior to upper 1/3 of the sternocleidomastoid muscle *Cystic hygroma* commonly found in babies (cystic degeneration of lymphatics *Submandibular gland*- arises from under the posterior mandible *Parotid gland*- Overlies the angle of the jaw Lymphadenopathy- infectious or malignant

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

Hypothyroidism

Clubbing HYPERTROPHY OF ANGLE - nail plate more CONVEX and DIP is round and bulbous BETWEEN NAIL BASE AND FINGER (Early) -BEAK SHAPED(Moderate) -DRUM STICK APPEARANCE(Severe)

INCREASE IN CURVATURE AND LIFTING OF NAIL BED Cirrhosis Chronic Hypoxia ----LUNGS DISEASES---- PYOGENIC BRANCOGENIC CARCINOMA FIBROSING ALVEOLITIS --HEART DISEASES-- CYANOTIC CONGENITAL HEART DISEASE SUBACUTE BACTERIAL ENDOCARDITIS --GASTROINTESTINAL DISORDERS INFLAMMATORY BOWEL DISEASES -iDIOPATHIC/CONGENITAL

Order of Approach

IPaPeA Inspection, Palpation, Percussion and Ascultation

Eye Deviation

If they appear misaligned, there will be typically one eye that fixates and the other eye will either deviate outward (exotropia), inward (esotropia) or upward (hypertropia).

Glaucoma

If this drainage fails, glaucoma or increased intraocular pressure ensues and will cause retinal damage and blindness. Acute glaucoma occurs in young persons and is due to the iridocorneal angle being too acute. When the pupil dilates widely, the physiologically thickened iris blocks the angle and the pressure rises very rapidly. This is a medical emergency and an emergency peripheral iridectomy should be performed as soon as possible. Chronic glaucoma occurs in the elderly and is due to gradual loss of permeability of the Canal of Schlemm. The pressure rise is slow and insidious but blindness that should be preventable is common due to this. All persons over the age of 60 years should have their intraocular pressure checked regularly.

Age of breast pathology presentations

Important to know ages

blepharitis

In blepharitis, the margin is red and irritated and covered with scales. -inflammation of lid

Radiofemoral Delay

In disease conditions with obstruction to the flow of blood to the lower extremities, the femoral pulse is delayed in arriving, e.g. Leriche's syndrome (isolated aorto-iliac disease) and post subclavian coarctation of the aorta

Cholesteatoma

In healing perforations, epithelium of mucus membrane and squamous epithelium cover area forming cholesteatoma

Thomas's test

In the absence of abnormalities, the left pelvis is forced to tilt, the hip becomes extended and the knees will remain in contact with the couch. If there is a fixed contracture in the lift hip, this procedure will result in flexion at the knee with the posterior knee loosing contact with the couch (positive Thomas test)

45 yr old w/ 1 week history of fever and cough w/ yellow sputum Reduced expansion of right chest -what would help confirm right lobar pneumonia

Increased Tactile Fremitus (increased as in consolidation- pneuomnia or malignant, or decreased or absent as in pleural effusion and pneumothorax and COPD)

Iritis

Inflammation predominantly located in iris. More correctly classified as anterior uveitis. Ciliary body can also be inflamed and is called iridocyclitis.

steppage gait - spondylithesis, guillian barre, deep fibular nerve injury, MS, polio

Injury to the common fibular nerve results in a foot drop. During walking, the patient lifts the affected leg high in the air to clear the foot off the ground (Steppage gait). In a normal stride, the heel of the leading foot strikes the ground first. In patients with a foot drop, the toes of the affected side, strikes the ground first.

35- year- old man who recently emigrated from Africa presents with fever, chills and rigors for the past 4 days. His temperature varies between 98.6°F and 102.2°F during the day

Intermittant Fever - diurnal variation

Arterial Insufficiency

Intermittant claudication decreased or absent pulses Gangrene Thin, Shint, Atrophic skin (not edema)

HYPERACTIVE

Irritable Bowel Diarrhea Early Partial intestinal Obstruction Obstruction

Hyperactive bowel sounds

Irritable Bowel Diarrhea Early Partial intestinal Obstruction Obstruction ( TOTAL obstruction is ABSENT sounds)

If patients eyes are symmetrical but bulging / prominent - you would ask....

Is there any undue sweating and weight loss? (Hyperthyroid) -Restlessness, agitation, weight loss -lid lag, opthalmoplegia, diplopia, chemosis -Palmar erythema, increased temp - Clubbing (Thyroid Acropachy) -Onycholysis (sep from nail bed) -Vitigo, warm moist skin -Pretibial Myxedema (graves dermopathy) -hypertension + muscle weakness

38 year old woman comes to clinic complaining of pain and redness in her eye the past 2 days. She has been having difficulty reading and her left eye has excess tearing. On exam her left eye has mucoid discharge and the cornea is hazy w/ some abrasion. The pupil is normal

KERATITIS - impaired eyesight + pain Keratitis is inflammation of the cornea. It is often accompanied by conjunctival hyperemia, tearing and photophobia.

keratitis

Keratitis is inflammation of the cornea. It is often accompanied by conjunctival hyperemia, tearing and photophobia.

45 year old male presents with severe headache, fever, and neck pain for past 2 days. He has had left ear pain and difficulty hearing on the left side. On exam his temp is 101F. He has tenderness with pressure on the mastoid process -- his neck is stiff.

Kernig's Sign Meningeal Irratation BRUDZINSKI‟S SIGN - Flexing the patient‟s neck causes flexion of the patient‟s hips and knees. - KERNIG‟S SIGN - Flexing the patient‟s hip 90 degrees then extending the patient‟s knee causes pain.

Umbilicus

L3 -L4 intervertebral spaces

Most important site oral cancer

LIP

65yr man with flaccid paralysis + atrophy + fasciculations and hyporeflexia

LMN lesion

Deviations of eye

Latteral deviation, Ptosis, Dilated pupil = CN3 palsy Inability to look down - Trochlear nerve [CN 4] palsy Medial deviation of the eyeball -> CN 6 palsy Strabismus (tropia): Condition in which a person can't align both eyes simultaneously Exotropia: Divergent eyeballs

Causes of generalized lymphadenopathy include

Leukemia Lymphoma Infections (viral, bacterial and protozoa) Connective tissue diseases Drugs

Thickened white patches that are hard to remove on tongue and buccal mucosal

Leukoplakia

What should you feel in the normal abdomen (dont lift hand)

Liver Edge 2cm below costal margin a pregnant uterus a full bladder -part of RIGHT kidney (can be a sign of malignancy, hydronephrosis, cysts - if bilateral PCKD) -maybe transverse colon, aorta, descendinc colon, sigmoid

Right hypochondrium differential - pathology

Liver, gallbladder, hepatic flexure, transverse colon, right kidney

Teenager comes in with Glasgow coma score E4 V4 M5

Normal chance of recovery E4 - opens eyes spontaneously V4- not oriented but speech intact M5 - localizes pain

mitral regurgitation

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

Sensory ATAXIC gait is associated with

Loss of position of sense in the legs -dorsal column

Fasciculations in calf muscles. is a sign of

Lower motor neuron injury

lymphatic drainage of vulva and vagina

Lymphatic Drainage: The vulva and lower vagina drain into inguinal lymph nodes. The uterus, ovaries, tubes and upper vagina drain into internal iliac and paraortic lymphatics.

Lymph Nodes of the Breast lateral breast

Majority of lymph drains into ipsilateral (same side) axillary nodes along a chain which starts at ANTERIOR AXILLARY (PECTORAL) nodes and continues into CENTRAL nodes and then APICAL (Subclavian / Infraclavicular )Nodes, and later Supraclavicular Further drainage is into Subscapular (posterior axillary) and Interpectoral nodes

A 17 year old high-school football player gets hit on the lateral side of his right knee while playing. He presents with severe pain and restricted movement of the right knee and is diagnosed as having a medial meniscal tear.

McMurray - lateral or medial meniscus

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

McMurray: Cartilaginous (medial and lateral menisci) injury

Acute Appendicitis: Differential Diagnosis Child

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

Malar Flush

Mitral Stenosis

Lateral Decubitis

Mitral stenosis (S3- atrial filling, S4 atrial contraction are accenuated)

Homan test

Muscle irritability due to inflamed or thrombosed veins running through them (posterior leg muscles), results in a positive Homan's sign. -Resistance to dorsiflexion by the patient, or incomplete dorsiflexion, is a positive Homan's sign -*The test is performed with the knee flexed, to avoid a false positive test which may occur in instances where there exists injury to the gastronemius muscles. Flexion of the knee relaxes the gastronemius muscle thus removing its effect on the test*

45- year-old man presents with severe retro-sternal chest pain radiating to the left arm for the past hour. He also complains of dyspnea on exertion. On examination there is a *left ventricular S3 gallop rhythm* and crackles are present over the lung bases

Myocardial infarction

24- year-old man presents with sharp retrosternal pain for the past 2 days that worsens whenever he changes position in bed. He has been having a flu-like illness for one week, with fever and tachycardia. On examination the *heart sounds are muffled and the internal and external jugular veins are distended*

Myocarditis Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent with a recent viral infection, including fever, rash, diarrhea, joint pains, and easy fatigueability. Myocarditis is often associated with pericarditis,

Dialated veins in abdominal wall are indicative of

Portal vein obstruction IVC obstruction Cirrhosis of Liver Portal Hypertension (not embolus in SMV)

Ulcers on sole of foot (plantar surface) only occur if

Neuropathic + Arterial disease -look for DIABETIC NEUROPATHY

Argyll Robertson Pupil (ARP) (look for this w/ hutchinson teeth)

Neurosyphilius Pupils are small and frequently irregular in shape Both pupils are usually involved but the degree may be asymmetrical. There is virtually no response to light but brisk response to near reaction. Dilate poorly in response to mydriatics. Vision in the affected eye is normal, hence the patient is asymptomatic

Palpation Order for the breast

Nipple Areola Breast Axilla Lymph nodes

Cover uncover test - tests this

Nonparalytic strabismus is caused by an *imbalance in ocular muscle tone*. It has many causes, may be hereditary, and usually appears early in childhood

venous thrombosis what is it and what leads to it:

Obstruction to flow & Acute Pulmonary Embolism

Symmetrical w/ decreased movement

Old Age Emphysema

Marathon - guy feels unwell, why?

Orthostatic Hypotension

evaluation of pulses

Osler's maneuver • Elevate the BP cuff to obliterate the radial pulse • If the radial artery is still palpable and rigid, this is a positive Osler's sign

Degenerative arthritis

Osteoarthritis - Heberden node (DIP) and Bouchard node (PIP) - remember that in RA the DIP joint is spared

Bulging erythematous tympanic membrane w/ loss of landmarks

Otitis Media (chronic goes to mastoiditis --> infection in mastoid air cells)

Golfer's elbow - i am super stressed about golf game

Overuse, especially when associated with valgus stress on the medial elbow, results in injury.

50 year old male with painless lesion in his eye which has been there for 3 months. On exam there is *yellowish triangular lesion on the nasal side of his left eye over the sclera close to the cornea*

PINGUECULA (a whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjunctiva adjacent to the corneal-scleral junction (limbus). It does not grow unto the cornea. )

Arterial Disease

Pain - initially on activity and relieved by rest (intermittent claudication) due to muscle hypoxia • Rest pain - progression of disease but not generally a feature • Paresthesia and numbness • Cool or cold extremity • Skin color changes - pallor (hypoxia),black means gangrene • Ulcers • Pallor • Decrease skin temperature • Loss of hair distally • Loss of muscle mass • Decrease to absent pulses • Distal ulceration (tips of digit) • Peripheral neuropathy • Gangrene

Signs and symptoms of deep vein thrombosis

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

Sacroiliac stress test

Pain experienced in the stressed joint during this maneuver, is indicative of an inflammatory process such as sacroiliitis. This test is not very sensitive and imaging is more diagnostic for suspected sacroiliitis

antalgic gait

Pain in one lower limb will result in an antalgic gait (not putting full weight on the affected limb). This may be due to pain in the affected foot, knee or hip

What symptom accompanies arterial insufficiency besides *postural color changes*?

Pain on Walking (veinous would be pain all the time)

35 year old male with loud mitral murmur If you hear a murmur and need to determine the phase of the cardiac cycle it occurs in this is beset done byy

Palpating the Carotid Pulse while auscultating the heart (not sure on this one) If mitral stenosis: With the bell over the mitral area, ask the patient to roll towards their left side (left lateral decubitus position) and continue to auscultate the mitral area for the mitral stenosis murmur or left ventricular S3 or S4.

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

Palpating the carotid pulse while auscultating the heart.

A 55 year old male hypertensive patient who presents to the ED with severe occipital headache of 1 day duration. There is also a history of progressive shortness of breath. His blood pressure is 240/120 mmHg and his pulse rate is 110/min. Basal rales are heard on auscultations. Funduscopy is performed. What finding on funduscopy that will enable the physician to make a diagnosis of malignant hypertension?

Papilledema -hypertensive retinopathy

All test done to determine

Patency of Radial artery Patency of Ulnar Artery Collateral circulation in hand

Radiofemoral delay due to

Post - subclavian coarctation of the aorta

Quadriceps Gait

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

*Shuffling or Festinant Gait*

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

60 year old women is admitted with low body temp, cold intolerance, loss of lateral 1/3 of eyebrows. - patient has hypothyroidism - what else may be present?

Periorbital puffiness

Diabetic w/ tingling and numbness in feet for past 2 months. He has difficulty walking. Exam shows decreased pain, touch, vibration along with decreased proprioception in a stocking distrubtion this is due to

Peripheral Neuropathy

Pathophys of venous

Peripheral venous disease results from: • Valvular incompetence (venous insufficiency) • Obstruction to flow - venous thrombosis Thrombophlebitis of the communicating veins with destruction of the valves lead to venous insufficiency.

Pratt test

Place both hands around the calf with the thumbs together and resting over the anterior tibia and the fingers overlying the posterior muscles (soleus and gastronemius). Using the pads of the fingers, apply gentle pressure in an antero-posterior direction by bringing the fingers towards the thumbs. Do not massage the calf. Pain felt by the patient during compression may indicate the presence of deep vein thrombosis.

cozen's test

Place the elbow to be tested in 90 degrees of flexion. The thumb of one hand of the examiner is placed over the lateral epicondyle of the flexed elbow. Have the patient pronate the forearm, make a fist, and radially deviate and extend (dorsiflex) the wrist. The other hand of the examiner applies pressure (resistance) to the patient's proximal hand, during active extension, in an attempt to palmar flex the wrist.

Unilateral decrease in chest expansion

Pleural Efflusion Pnuemonia Rib Fracture Pneumothorax

A 24-yr-old 2 week history of shortness of breath, cough and fever. He was treated for a respiratory infection 7 days ago. BP 110/60 mmHg, pulse 102/min, respirations 20/min T 102° F Chest expansion and tactile fremitus are reduced on the left side. Percussion note is *stony dull* and *breath sounds are decreased over the left chest*

Pleural Effusion PLEURAL EFFUSION: PERCUSSION -STONY DULL & BREATH SOUNDS-REDUCED OR ABSENT & VOCAL RESONANCE-REDUCED Asymmetric chest movement may be a clue to a space-occupying lesion, such as pleural effusion, hemothorax, or intrathoracic mass.

45 year old male was brought tot he emergency room after being stabbed on the left chest - short of breath - x ray shows tracheal deviation to the right - tracheal shift to the right is most likely due to.

Pneumothorax on the left - spontaneous

a 65 year old male presents with inability to maintain his balance and walking for the past 2 months - past history insignificant - he is not hypertensive what is most appropriate test?

Proprioception and cerebellar function.

Ptosis

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

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

Pulmonary edema.

Splitting S2

Pulmonary valve closure tends to be further delayed during inspiration, probably because of increased capacity of the pulmonary capillary bed during inspiration, which prolongs right ventricular ejection. This causes physiologic splitting of S2, accentuated by inspiration, often best heard near the pulmonary area.

Left Ventricular Failure Pulse

Pulsus Alterans

55 yr old frothy sputum with shortness of breath on exertion and a cough of frothy sputum - sleeps on 3 pillow and 3 previous hospitalizations with an MI 2 years ago. -Dyspnea -Resp 26 min -pulse 110 reg BP 90/58 What type of pulse is found

Pulsus Alternans - LEFT VENTRICULAR FAILURE -regular rythym with alternating amplitude

In normal person systolic BP falls less than 5mmHg during inspiration due to reduced pul inflow on left side of heart - if this exceeds 10mmHg consider a pericardial effusion and it is called...

Pulsus Paradoxus

Hypertensive Retinopathy With Macular Star

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

Blind eye (amaurotic):

Pupils are equal in size. Neither pupil reacts when the defective eye is stimulated. Both pupils react when the contralateral eye is stimulated. Near reflex is normal.

these may elevate JVP

RHF Constrictive pericarditis Tricuspid stenosis SVC obstruction (not aortic regurg)

Difficulty walking + resistance throughout the range of passive motion

RIGIDITY

Breathing weirdness

Rales /crepitis : opening of alveoli Rhonchi : secretions in bronchial airway Wheeze : asthma Egophony : lumbar pneumonia

Dorsalis pedis pulse in a 40 year old asymptomatic male without other physical findings

Raynaud's Disease vasospasm(most likely - followed by atherosclerosis or trauma)

Transillumination of the sinuses is a test used to reveal thickened mucosa or secretions in sinus - if light is placed through front sinus what is observed?

Red Glow above the eye

A 24 male laborer presents with pain in the right elbow area and right hand. On examination there is a red streak in the right forearm and a tender swelling anterior and slightly superior to the medial epicondyle of the right elbow. The swelling is discrete, about 1cm in circumference and not attached to surrounding structures. Where will you examine in the right upper extremity to determine the cause of the swelling?

Red streak = lymphatic spread --> path -examine the * right hand* to determine the site of origin

Rhythm - irregular --> regular, irregular

Regular irregularity - (repetitive pattern) premature atrial or ventricular contraction

following an illness of 1 week with bloody stools + severe abdominal cramps - your patient develops redness and irration in both eyes and painful inflammatory arthritis of left shoulder - right knee and both ankles - he also notices a discharge from his penis

Reiters Syndrome (Reactive arthritis) (2nd Reiters Question) URETHRITIS ARTHRITIS CONJUNCTIVITIS

Triad of urethritits, conjunctivitis and arthritis

Reiters Syndrome (reactive arthritis)

Associated with Parkinsons

Resting tremor Mask Fask Shuffling Gait Rigidity Asym Resting Tremor (not intention tremor - cerebellar)

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

Sensorineural deafness.

differential of nodules on elbow or ear (tophi)

Rheumatoid arthritis --> rheumatoid arthritis is usually polyarticular, bilateral, symmetrical affecting small (sometimes large) joints, on right and left sides of the body.

Alcoholics tend to get aspiration pneumonia in....

Right UPPER lobe (posterior portion)

Parasternal Heave

Right ventricular hypertrophy

41yr male treated for severe duodenal ulcer - now presents with marked abdominal pain, severe pallor, tachycardia and hypotension. You suspect perforated ulcer and peritonitis. What would you find

Rigidity in abdominal wall Abdominal Distention Thoracic Respiration (not abdominal) Rebound Tenderness (not marked increase in abdominal sounds)

a 50 yr old diabetic female presents with tingling and numbness in lower extremities - high HbA1c - loss of vibration and proprioception - what other test will be positive?

Romberg test -->Wide base gait where feet strike the ground heavily as strength required is not precise due to lack of coordination & lack of propioception. Conditions that impair sensory nerves and receptors of propioception can cause sensory ataxia: Subacute combined degeneration.

Bacterial Endocarditis signs

Roth Spots Janeway Lesions Oslers Nodes Splinter Hemorrhages (not heberdens)

roth spots

Roth spots using ophthalmoscope (hemorrhage in the retina with a central pallor).

Signs for acute appendicitis

Rovsings Obturator Rebound Tenderness Tenderness in right iliac fossa (not boas sign = cholescystitis)

Matching

S1 - closure of mitral valve/tricuspid S2 - closure of aortic valve/pulmonary SPLIT - Aortic Valve S3 - occurs after mitral valve opens during *rapid ventricular filling* (normal in kids) S4 - Atrial Contraction (normal in kids) Gallop Rhythym - S3/S4 w/ CHF tachycardia

A 68-year-old man presents with a *three month dyspnea and chest pain.* On examination the apex beat is of increased amplitude and is in the fifth left interspace 1em outside the midclavicular line. There is a grade 4/6 *crescendo-decrescendo murmur in the second right interspace parasternally* that is *synchronous with the carotid pulse*

SLOW UPSTROKE *Pulsus Parvus*-Slow carotid upstroke of Aortic Stenosis Harsh late-peaking crescendo- decrescendo systolic murmur Heard best- left 2nd ICS Radiation to the carotids

Sign of an UPPER airway upstruction?

STRIDOR

MASTALGIA

SYMPTOM : BREAST TENDERNESS &PAIN • Cyclic Changes in Reproductive age females • Increased tenderness premenstrual (Increased Estrogen & Progesterone) • Fibrocystic Change • Pregnancy

Choreiform gait

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

On *inspection* of posterior thorax what is observed

Shape, Symmetry, Deformities

Criterion visual acuity using Snellens Chart

Smallest line of print that is read correctly

the liver

Span: 6-12 cm right lobe 4-8 cm left lobe Protected by ribs Palpable at right costal margin , just beneath ribs ; moves toward the examiner's fingers with deep inspiration

a 60 yr old male is brought to clinic with weakness of the right upper and lower limbs. on exam of motor system there is a *clasp-knife resistance* on the right side and the deep tendon reflexes are exaggerated on the same side. the resistance to passive motion.

Spasticity. An increase of tone may be *spastic (clasp-knife)* or rigid ("lead pipe"). In spasticity, caused by upper motor neuron disruption, there is significant resistance to movement initially; such resistance then decreases over the remaining range of motion. In *rigidity, caused by extrapyramidal disruption, there is increase resistance throughout the full range of passive motion*

Matching

Spider Nevi - Inspection Liver Span - Percussion Renal Artery - Auscultate Kidney Ballotment - Palpatation Costo-vertebral tenderness- Palpatation

Valsalva maneuver (and standing) - decrease cardiac output effects what murmur *** Compared to Release phase of valsalva maneuver (squatting) -

Standing = Murmur of stenosis softer. Release= increase cardiac output. Murmur of stenosis louder

Chronic venous insufficency

Stasis Dermatitis Brownish Discoloration of limbs Ulcer on medial ankle Edema of limb (not rubor and decreased pulses - this is arterial)

When doing a cover uncover test you note the response is abormal this is due to

Strabismus or Phoria; extraocular muscle tone

Sty

Stye (hordeolum) is red, swollen, and tender and has pus discharge.

"Now let me make sure I have the full story...you have a cough for 3 days, that is really bad at night and you started to bring up yellow sputum....and now you have a fever"

Summarization

While interviewing his patient, a family physician says, "Now let me know if I've got this right. You said you have had heavy periods with lots of clots for about 8 months and that you've been tired and exhausted for the past two months. For the past 2 weeks your usual activities have been making you short of breath. Is that all correct?" This is an example of:

Summarization.

A patient comes to the clinic for her regular visit. You are seeing her for the first time because her regular doctor is ill. During the interview she is very talkative. Which one of the following will help to improve the effectiveness of the interview?

Summarize the first few minutes of history and ask her to focus on one aspect.

Palpation of abdomen

Superficial (light) palpation is used to assess tenderness, rigidity and guarding. Deep palpation is used to assess organ size and the presence of abnormal abdominal masses. (side note - Bruit confined to systole may be heard without pathology. Bruit heard in systole and diastole often indicates turbulent blood flow due to partial stenosis. A continuous bruit may indicate an arteriovenous fistula (penetrating trauma)

Iritis

Symptoms include severe pain, photophobia, lacrimation, decreased vision.

Tensor Tympani muscle is supplied by the 5th cranial nerve

TRUE

the trachea divides at the level of the 4th thoracic vertebra

TRUE

Motor of Cranial Nerve 5

Tensor Tympani Masseter Temporalis Medial Pterygoid (not buccinator)

Trigeminal Nerve The middle ear contains three ossicles, malleus, incus and stapes, and two muscles, tensor tympani (attached to handle of malleus), innervated by the trigeminal nerve (CN V) mandibular division, and the stapedius innervated by the facial nerve (CN V11).

Tensor Tympani Masseters Temporalis Medial Pterygoid (not buccinator) The Trigeminal nerve is the somatic sensory innervation to the entire face, eyes, nasal passages and oral cavity, and its motor branch, via the mandibular branch, is the somatic motor to the muscles of mastication, tensor tympani and tensor palatine muscles of mastication are: *Paired temporalis and Masseter *muscles - function in jaw closure Medial Pterygoid - closes the jaw and moves it from side to side The lateral Pterygoid - with the help of some muscles of the upper neck, open the jaw accompanied with a downward and opposing inward motion

The rectal exam normal rectum is non tender , and a wide vault . • Stool may be palpable . • The rectal walls should be smooth • A mass may feel like an elevation , irregular , usually not very hard

The Rectal Examination Place the patient in lateral Sims position : lying on left side; flex right knee upon the thigh. With gloved hands, separate the buttocks and inspect the sacroccygeal and perianal ares . • Place lubricated forefinger on the anal verge Ask patient to strain down. Instruct patient that he/she will feel pressure similar to a bowel movement . • Gently insert your finger, full length ; rotate your finger to palpate all walls • Upon removing finger , place stool on occult blood ( giuiac ) testing card • Dry the patient's anal area , and redrape him/her

Sacroiliac joint

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

hepatosplenomegaly

The spleen and liver may be both enlarged in myelofibrosis, portal hypertension and chronic myeloid leukemia.

Normal Fundus of an Older Person

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

Spleen

The spleen is protected by the lower rib cage (ribs 9, 10, and 11. Its axis is in line with the 10 th rib. The spleen lies in Traube's space which is defined superiorly be the 6 th rib, laterally by the anterior axillary line and inferiorly by the left costal margin. -With the patient supine, percuss the lowest interspace (10 th) in the anterior axillary line. This should be tympanic. Dullness indicates splenomegaly. If tympanic, ask the patient to take a deep breath. In the absence of splenomegaly tympany should remain. Splenomegaly will result in dullness on deep inspiration.

lesion to pyramidal tract (corticospinal tract)

The corticospinal pathway is responsible for decisional voluntary skeletal muscle contraction. A lesion here will lead to weakness or paralysis. -either UMN or LMN lesion

Optic atrophy: Primary -

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

white optic disc

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

Optic atrophy: Temporal pallor -

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

Adie's (Tonic) pupil:

The lesion is in the ciliary ganglion (and sphincter is affected) It is mostly unilateral, affecting women (usually young adults) more than men. When unilateral (80%), there is no response to either direct or consensual light reflex. *Near reflex is normal.* There is internal opthalmoplegia with loss of sphincter function and accommodation. *Accommodation is very sluggish and there is impaired pupillary response* The affected pupil is relatively dilated in bright light and relatively constricted in dim light. A dilute (0.05-0.125%) solution of pilocarpine causes the abnormal pupil to contract vigorously but with only minimal effect on good pupil. *A number of patients have reduction in the knee jerk reflex*

lymphatic drainage of the breast

The lymphatic drainage of the breast is into the ipsilateral (same side) anterior axillary (pectoral) lymph nodes, then superiorly into the central axillary and apical lymph nodes. The medial breast drains into the internal mammary nodes.

BELL's palsy Drooping of outer corner of mouth and eyes result in saliva and tears running from mouth and eyes, corneal dehydration can result Loss of tone in the orbicularis oculi leading to eversion of lower eyelid Paralysis of the buccinators and orbicularis oculi results in food accumulating in the oral vestibule during chewing requiring

The most common infranuclear pathology. A lesion of the facial motor nucleus or facial nerve (lower motor neuron), will affect the muscles of both upper and lower face on the ipsilateral side.

*Nephrolithiasis* :

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

*Acute Pancreatitis*

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

Vision is noted to 20/30

The patient sees at 20 feet what is normally seen at 30 feet

Waddling Gait aka Myopathic gait.

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

*Pronator drift* with a tremor

The tremor of Parkinson disease, extrapyramidal disease, is a resting tremor and is usually asymmetric. In essential tremor, the tremor is worst on sustained posture as in testing for pronator drift (see muscle strength).

classical symptoms of appendicitis

The typical patient requiring these tests complains of abdominal pain which starts in the area of the umbilicus, then moves to the right lower quadrant. There is often nausea, vomiting and anorexia. An elevated temperature is often present.

Optic atrophy: Glaucomatous -

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

Afferent Pupillary Defect (APD): "Marcus Gunn" pupil.

This diagnostic phenomenon is one of "pupillary escape". This is caused by defect in optic nerve conduction. When the affected eye is stimulated by light, it behaves as though the light is dimmer. The affected eye constricts less and redilates more than a normal eye. The normal eye has a greater direct response than consensual; the affected eye has a greater consensual response than direct. When the light stimulus is brought from the good eye to the affected eye, the affected pupil dilates instead of constrict. Diagnosis is made using the "swinging flashlight" test.

Weber Test:

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

Argyll Robertson Pupil

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

Cuff

Too short or too narrow a cuff will result in a false elevation of the blood pressure (10-50mmHg) o The length of the bladder in the cuff should be 80% of the circumference of the upper arm (or of the part being used to measure the blood pressure) 15 o The width of the bladder should be 40% of the circumference of the arm (or of the part being used to measure the blood pressure) Orthostatic Hypertension - fall of 20mmHg systolic and/or 10mmHg diastolic on standing for 3 minutes after recumbency

Positive Drawer Sign

Torn anterior cruciate ligament

Causes of Ascites: transudates vs. Excudates

Transudates Cardiac failure Constrictive pericarditis Budd-Chiari Meig's Syndrome Nephrotic syndrome Excudates Malignancy (esp. Colon, ovary, pancreas, stomach) Tuberculosis

posterior triangle boundries

Trapezius [posterior], SCM [anterior], Clavicle [inferior] Inferior belly of the omohyoid muscle splits this into to two triangles

tests for venous insufficiency

Trendelenburg and manual compression

varicose veins on right leg -- what test should you do

Trendenlenburg for Venous Insufficiency of Communicating and sapheonous veins

Positive sign for tetany?

Troussau Sign Chvostek Sign

Most common cause of lung collapse

Tuberculosis

Special position for Mitral stenosis of LV S3/S4

With the bell over the mitral area, ask the patient to roll towards their left side (left lateral decubitus position) and continue to auscultate the mitral area for the mitral stenosis murmur or left ventricular S3 or S4.

signs of peripheral venous disease

Ulcers of the leg - the most common location is anterior and superior to the medial malleolus. This area contains the greatest concentration of communicating veins between the deep and the superficial systems. These ulcers tend to be large and shallow with a sloping edge. -Ulcers may occasionally occur in the vicinity of the lateral malleolus due to venous disease of the small saphenous vein.

*urethritis*

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

Acute cystitis

Vesical pain: Arising from the bladder. Discomfort in the suprapubic area. Usually associated with frequency and urgency. E.g. urinary tract infection, cystitis -Pus in urine (will also be seen in pyelonephritis)

Accomidation reflex includes

Visual Axis Convergence Contraction of Ciliary Muscles (relax ligaments and curve and THICKEN lens) Thickening of lens INCREASED refraction of light (not pupillary dialation)

Asthma

WHEEZING -TACHYPNOEA -TACHYCARDIA -PROLONGED EXPIRATION - PROLONGED FORCED EXPIRATORY TIME(PEAK FLOWRATE&FEV DECREASED) -USE OF ACCESSORY MUSCLES OF RESPIRATION -HYPERINFLATED CHEST

arcus senilis

WHITE / grey / blue ring *normal finding in patients over 40 years*. *In patients under 40 years it may be a sign of hypercholesterolemia*.

circumduction gait (hemiplegic)

Weakness in one limb when combined with spasticity results in the weak limb being dragged around the body in a circumduction gait. VERY COMMON IN STROKE

True fact about second heart sound

When split it may be increased by inspiration Delay closing of pulmonary valve - by inspiration. Fixed - ASD Wide - RV Bundle Paradoxical - LV Bundle Block Given the lower vascular resistance of the pulmonary artery, during inspiration, the pulmonary artery is able to tolerate more volume of blood before the pressure above the valve increases. Additionally, during inspiration, more blood fills the right ventricle leading to a slightly longer ejection time, adding to the delayed pulmonic valve closure.

Pulse pressure wider than normal on all but

Wider: Fever, Anemia, Advanced age, aortic incompetence Narrower: Hypothyroidism

discrete, waxy, yellowish deposit on the medial aspect of the lid.

Xanthelasma -high cholesterol correlating with atherosclerosis

25 yr old with 6 month history of fever, fatigue, night sweats, weight loss. Unprotected sex, multi partners - oral candidasis and taking anti-retrovirals. Firm, nontender LEFT POSTERIOR CERVICAL LYMPH NODES. Chest has dulness to percussion and egophony above left clavicle. What is the diagnosis?

answer is Pulmonary Tuberculosis (Submental and submandibular nodes- oral or dental infection Preauricular nodes- viral illness, lymphoma, or cat-scratch fever *Posterior auricular nodes*- toxoplasmosis or measles *Occipital nodes*- HIV infection *Posterior cervical* HIV, scalp infection, seborrheic dermatitis *Tonsillar nodes* are often enlarged in Strep throat. *Superficial cervical*- upper respiratory infection *Deep cervical* lymphoma, metastatic malignancy, tuberculosis, actinomycosis Supraclavicular- metastatic disease

In the refractive error of myopia light focuses ....

anterior to the retina

decreased bowel sounds

are normal in character but occur at reduced frequency, tone or loudness. Reduced bowel sounds can occur following general or spinal anesthesia.

untreated hypertension

arteriolar narrowing in fundus exam

Physical exam is valuable to assess for

assessing severity of illness detecting valvular heart disease detecting testicular mass appreciating respiratory diseases (not defining the size of intracranial mass)

Corrigans Pulse

associated with increased stroke volume of the left ventricle and decrease in the peripheral resistance leading to the widened pulse pressure of *aortic regurgitation* (possible PDA)

Self Breast Exam

at the end of menstraution

cerbellar abnormalities

ataxia, dysmetria intention tremor, hypotonia, dysarthria, nystagmus and head tilt, nausea and vomiting without warning

pivot

atlas, axis, radioulnar joint

30 yr old athlete has pain in left knee with swelling for past couple of days - on exam the left knee is swollen, tender and medial hollow is obliterated. what test will help with diagnosis with knee effusion?

ballotment sign (patellar tap) - Continued pushing will result in the patella colliding with the femoral condyles, thus producing a palpable impact (palpable tap).

Scissors Gait

bilateral spastic paresis of legs (UMN lesion) -stiff gait each leg advanced slowly and thighs tend to cross forward on each steup - steps are short and patient appears to be walking through water

normal size, does not react to light or accommodation

blind eye

Inner Ear

bony labyrinth containing perilymph. The receptors in the utricle responds to centrifugal and vertical acceleration and those in the saccule respond to linear acceleration.

Beurgers

both feet at 90 degrees for 60s Observe for return of color (10 seconds) and venous filling (15 seconds)

A 28 year old athlete presents with pain and swelling of the right knee for the past 3 days after falling on it.

bulge sign

gliding joint

patello-femoral joint

normal bowel sounds

consist of intermittent, low pitch, chuckling (clicks and gurgles) sounds at intervals of 5 to 34 per minute. One may also hear borborygmi (prolonged gurgles of hyper- peristalsis). Normal peristalsis produces bowel sounds when gas, fluid and food are passed through the intestinal lumen

boundries of anterior triangle

calvicle, midline of neck and anterior border of sternomastoid

condyloid joint

carpometacarpal joint of the fingers radiocarpal joint temporomandibular joint (also a hinge joint)

saddle joint

carpometacarpal joint of thumb

Absence of red reflex

cataracts or retinoblastoma (not seen in opacities)

Exertional dyspnea

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

55 year old male presents with tremors in his hands for past 2 months. The tremors are pronounced in his hands. Finger-nose and heel-knee-shin are positive. Also has dysdiadochokinesia

cerebellar disease Patients with cerebellar lesions will have dysmetria (past pointing) and an intention tremor. Inspect the eye for *horizontal nystagmus*

dysdiadochonkinesia indicates a lesion in the

cerebellum

Rhinophyma

chronic alcoholics increase in size of lower nose due to increase in sweat glands

A 45 year old hypertensive suffered a stroke eight months ago. His left arm and left leg are spastic.

circumductive

tests for DVT

circumference, homan, pratt

Arterial Insuffiency lower limbs

cold white foot thickening of nails on foot loss of dorsalis pedis pulse loss of hair on dorsum great toe

Untreated symphilis assocatied with

complaining of falling over when he closes his eyes Sensory ataxia is distinguished from cerebellar ataxia by the presence of near-normal coordination when the movement in question is visually observed by the patient, but marked worsening of coordination when the eyes are shut

chalazion

cyst like and has no acute signs of inflammation. It is usually due to inspissated secretions of the meibomian glands

Chalazion

cyst like structure that has no acute signs of inflammation. It is usually due to *inspissated secretions of the meibomian glands*

Orthopnea

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

Cheyene- Stokes

damage to CEREBRAL HEMISPHERES -o Brain damage (Both sides of cerebral hemisphere) o Heart failure o Uremia o Drug induced respiratory depression

Gag reflex

dependent on CN 9 and CN10

Campbells Sign

down displacement of THYROID cartilage during INSPIRATION seen in patients with COPD

MEDIAL BREAST

drains into Internal Thoracic and Mediastinal (Internal Mammary) nodes

anterior cruciate ligament and medial cruciate ligament

drawer's sign (anterior and posterior)

Orthostatic Hypertension is caused by

drugs loss of blood dehydration prolonged bed rest (not regular exercise)

Cornea

first and MOST powerful lens of the eye

4 yr old with headache, fever, and now altered conciousness what is true

flexion of the neck may cause flexion at the hips

Dullness replaces resonance in the lungs when:

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

A 70 yr old male alcoholic with spider angiomas and gynecomastia has worsening shortness of breath - what other test will be positive

fluid wave - ascites from portal hypertension -shifting dullness -bulging flanks and dullness

The upper outer quadrants of the breast are most common for

for fibrocystic changes and malignancies

McMurray test

for medial and lateral menisci --> In a severe tear of the meniscus, a fragment of the meniscus may become trapped between the tibia and femur, locking the knee and preventing full extension at the knee.

Crepitus over nasal bone

fracture of nasal bone

"please tell me what happens during you dizzy spells"

guided questioning

Roth Spots

have a clear white center surrounded by hemorrhage. Seen in infective endocarditis, HIV retinitis and leukemia.

Special test for abnormalities of the hip joint Fixed flexion contracture of hip

have the patient lie flat on his/her back with both legs straight. One hand of the examiner is placed under the patient's lower back to ensure that the normal lumbar lordosis in the erect position is no longer present. Ask the patient to fully flex the right knee. The examiner then fully flexes the right hip until the right thigh is firmly in contact with the anterior abdominal wall. This maneuver assesses the left hip. In the absence of abnormalities, the left pelvis is forced to tilt, the hip becomes extended and the knees will remain in contact with the couch. If there is a fixed contracture in the lift hip, this procedure will result in flexion at the knee with the posterior knee loosing contact with the couch (positive Thomas test).

DeMussets

head bobbing of aortic regurg

patent ductus

heard at the left clavicle

Systolic Murmurs

heard between S1 and S2 (S3, S4 )

The arm level of patient after applying the sphygmomanometer .....

heart (4th rib)

ball and socket

hip joint (deep cup) and shoulder (shallow cup)

loss of bowel sounds

in late intestinal obstruction there may be loss of all bowel sounds due to loss of peristaltic activity due to vascular compromise of the bowels

dysdiadochokinesia

inability to perform rapid alternating movement

• Sit up, lean forward, (hold breath in expiration),listen at base : Increase what murmur

increase intensity of aortic incompetence murmurs

hypothyroidism

hoarse voice, muscle aches, *round puffy face d/t myxedema* abdominal bloating, hair changes (thinning, coarsens), depression, decreased libido, slowed relaxation phase of deep tendon reflexes, -*bradycardia*, cold intolerance, *weight gain*, decreased appetite, *thinning of eyebrows*, constipation, pale dry skin.

old man with intention tremor for past 2 months - tremors more pronounced with use of hands, there is dysdiadochokinesia, heel-shin positive --> whats another finding?

horizontal nystagmus

Tension pneumothorax

hyper-resonance (not dullness) to percussion decreased or absent breath sounds decreased excursion decreased tactile fremitis -deviation of trachea to opposite side

Presence of the external urethral meatus on the ventral aspect of penis suggests

hypospadias

Hypothyroidism

immobile, uninterested Periorbital edema and loss of 1/3 eyebrow -bradycardia, decreased temp -oncholysis -coarse dry skin, myxedema -hypercartonemia (yellow skin) -anemia (pallor) -Delayed relax of deep tendon reflexs

Kussmaul breathing

increase in rate and depth -fast and deep

Left lateral decubitus (apex closer to the chest wall), listen at apex -

increase intensity of murmur of mitral stenosis, better appreciation of S3, S4 Gallop rhythms.

Scleritis

indicative of a systemic disorder such as a connective tissue disorder (IBD, RA)

Bowstring maneuver

indicative of sciatic entrapment because pain was elicited on straight leg test - The bowstring maneuver - Recurrence of the above pain on dorsiflexion is confirmatory evidence of sciatic nerve root irritation or entrapment.

Failure of the development of the iridocorneal angle and/or the Canal of Schlemm

infantile glaucoma or buphthalmos (large eye)

Secondary Headaches are d/t

infection, brain tumor or metastatic growth in brain, hemorrhage

What lymph node drains the feet?

inguinal nodes

Uterus ,ovaries , tubes and drain into

internal iliac and paraortic lymphatics

Grey-turner and cullens

intra or extraperitoneal hemorrhage - blue ecchymoses, cullen is periumbilical and grey-turner is flank

A 45-year-old woman complains of hearing loss which followed a 5 week history of ringinging in her left ear. Otoscopic examination reveals cerumen bilaterally and neither tympanic membrane is visualized clearly. On whisper test she has a marked decrease in hearing on the left. Weber test lateralizes to the right ear and Rinne's test indicates that air conduction is better than bone conduction. The cranial nerves are intact. Which one of the following is the likely diagnosis in this patient?

its sensorineural defect - but cranial nervers are intact - probably meniere's disease - other choices were conductive hearing loss (not correct) and acoustic neuroma (schwannoma) - which would damage the CN.

Ulcers on tips of toes

just arterial

old guy with an ear infection that turns into meningitis - whats the test used to help in diagnosis?

kernig's test - flexed hip with knee at 90 degrees then slowly begin to extend leg, while observing patient for pain.

Right ventricular hypertrophy produces a....

left parasternal heave that can be palpated in these patients.

hypertrophic cardiomyopathy

left sternal border and apex

Spastic Gait (hemiparesis)

lesion in corticospinal traction (stroke) -one arm is immobile and to the side with elbow wrist and fingers flexed. The leg is extended with plantar flexion of foot. On walking patient drags the foot scraping the toe or circles outward

direct hernia

less common, seen in men >40, d/t weakness of post. wall of inguinal canal at external ring

anatomical terms of eye

limbus = j(x) sclera and cornea canthi = junction of eyelids (corners)

rectal temperature (3 min)

lubricate thermometer and insert 3-4cm up into rectum with the patient lying on side with hip flexed.

Rectal Temperature

lying on side with hip flexed

Tests for venous insufficiency

manual compression and trendelenburg

A 35 year old software engineer complains of pain and tingling in the lateral fingers of the right hand for the past 3 weeks. She is concerned about her job as she is unable to use the computer. On examination there is a loss of sensation in the lateral three and a half fingers of her right hand. Tinnel's sign is positive

median nerve - test dorsum of hand first 1web (thenar eminence, thumb, pointer, index, 1/2 ring)

A 50 year old diabetic of 18 yrs duration complaining of failing vision for the past year

microaneurysm - check with dani and harris

the sphincter muscle which is under parasympathetic innervation when contracted causes

miosis

Mitral Regurg

murmur best heard at apex and radiates to axilla -dialated atria common, and atrial fib

Cholecystitis

murphys and boas

A 50 year old man has a 3 yr history of failing eysesight. He has had diabetes mellitus for 25 years but has not complied with medications and has never seen an opthalmologist. His vital signs are BP 110/80mmHg, pulse 78/min, respiratory rate 18/min, temperature 98 °F. Glycosylated hemoglobin (AIC) is very elevated. Which one of the following is most likely seen on fundoscopy.

neovascularization seen in proliferative retinopathy

Old guy has weakness in RIGHT LOWER LIMB after fall. Hyperreflexes shown (4+)

no atrophy (unless disuse) no fasiculations increased tone, increased reflexs ANKLE clonus will be present

A 75 year old male complaining of slowly progressive loss of vision for the past 5 years. Eye examination shows a grey/white appearance through each pupil.

no red light reflex --> Gradual painless loss of vision (usually bilateral). Causes include cataract, advanced glaucoma and retinopathy.

Neuropathic ulcers - complications of diabetes

occurs at the tips of digits, *plantar surface of the feet*, over bony prominences, and the posterior heal area. Look also between the toes for maceration and ulceration. *Ulcers on the plantar surface are termed neuropathic ulcers* and result from a combination of vascular insufficiency and peripheral neuropathy. Arterial ulcers tend to be deep with a punched out appearance. The base tends to be pale and may contain a small portion of slough.

Cross Eyes -a 'phoria' is a latent deviation held in check by fusion.

one eye that fixates and the other eye will either deviate outward (exotropia), inward (esotropia) or upward (hypertropia). In situations where the eyes appear aligned, one eye is covered for 20 seconds and the cover then removed. The covered eye should maintain its position, but if there is weakness of one or more extraocular muscles on that side, the covered eye would have drifted in (esophoria) or out (esophoria)

inguinal hernia

originates above inguinal ligament at the internal ring - most common - all ages - men>women

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

osteoarthritis

exacerbation of ear pain upon moving the auricle is suggestive of

otitis externa

Chronic Pancreatitis

pain so thehy squat to realive

Pancreatic carcinoma:

pain, obstructive jaundice, palpable gallbladder (courvoisers law)

Thrill

palpable murmur - turbulence of blood flow

How do you perform a pratt test?

palpate the posterior calf gently - the other test for DVT is the homan test which involves dorsiflexion of the foot and observing for resistance.

Testicular Cancer

para-aortic nodes enlarged

A 5 year old uncircumcised boy was brought to the Emergency Department with swelling and pain in the penis for the past 3 hours. On examination there is a ring of swollen edematous tissue proximal to the glans penis with some swelling of the glans penis. The area is very tender on palpation. The foreskin is not retractable.

phimosis! - if the foreskin was forcibly retracted then answer would be paraphimosis

a 55 yr old man with acromegaly - what other test will be positive?

positive phalen test - this allows physician to assess the median nerve through the carpal tunnel. the other special test for carpal tunnel syndrome is tinel's test

Fluid in left knee what do u do?

preform a ballotement of affected knee looking for pellta taping against femoral condyles -or BULGE SIGN (medial upwards, lateral downwards looking for medial side refilling)

venous hum

present in the 1st and 2nd interspaces

neovascularization

proliferative retinopathy

hernias

protrusion of peritoneum into inguinal or femoral canal because of an inherent weakness in abdominal wall

dilator muscle, which is under sympathetic innervation

resulting in mydriasis

Greenish yellow rings on cornea

results from copper deposition in Descemet's membrane of the peripheral cornea.

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

rheumatoid

Stokes- Adams

syncopy related to CVD (seizures) - remember there are no ABNORMAL finding upon waking

crescendo-decresendo systolic murmur radiating to the neck (carotids)

systolic murmurs = aortic stenosis and mitral regurgitation

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

the eyes "look away" from the affected hemisphere.

Eye Facts -The choroid nourishes the retina; the ciliary body produces the aqueous humor. -The iris and every part of the eye posterior to this structure with the exception of the lens, originates in the neuro-ectodermal layer of the embryo. The lens and all of the structures of the eye anterior to the iris originates in the embryonic ectodermal layer.

the sphincter muscle which is under parasympathetic innervation (resulting in miosis) and the dilator muscle, which is under sympathetic -Inflammation of the iris is called iritis, that of the ciliary body is called cyclitis and of the choroid is choroiditis (posterior uveitis). Combination often occurs such as uveitis, iridocyclitis (anterior uveitisinnervation (resulting in mydriasis).

A 60 year old man presents with a 9 month history of a non productive cough and weight loss of 30 pounds. 24 hours ago, on two occassions, he coughed up small clots of blood. He has a 50 pack year smoking history. There is no history of chills or fever. On examination his right eyelid is drooping and his right pupil is smaller than the left. Which one of the following findings is most likely to be observed in this patient?

this guy has a pancoast tumor - resulting in horner syndrome --> thus will find *dull percussive note above the right clavicle*

50 yr old man with hx of bilateral swelling of legs. Complains of tingling and numbness in his extremities, increase pulse, normal resp. normal bp. On exam - when inflating the cuff far above systolic, carpal spasm occurred.

this is due to *hypocalemia* Trousseau's sign (carpo-pedal spasm) refers to spasm of the hands (carpo) and feet (pedal). Described above is carpal spasm. There will be similar motions in the corresponding joints of the feet

Adies Pupil

three hallmark symptoms, namely at least one abnormally dilated pupil (mydriasis) which does not constrict in response to light, loss of deep tendon reflexes, and abnormalities of sweating -ciliary damage

Raccoon eyes

to basilar (frontal) skull fracture. It is usually accompanied by lateral subconjunctival hemorrhage

Hard painless midline lesion in the hard palate

torus palatinus

parietal examinations

two point discrimination, point localization, dyspgraphia, visual, hearing

Shifting Dullness

unless ascites is massive, a boat shaped area of tympany is mapped out on each side that includes the area around the umbilicus. This is due to the fact that gas filled bowels will float on top the ascites. Mark the areas where dullness and tympany meet. Have the patient turn on one side. Percuss the abdomen from the upper to the lower (most dependent) part and determine the new division lines between dullness and tympany. If ascites is present, the line of dullness in the most dependent part "shifts" towards the umbilicus, including areas that were previously tympanic. There must be a minimum of 500 cc of fluid in the abdomen to demonstrate shifting dullness.

Sensory Ataxia -dysfunction of the dorsal columns of the spinal cord due to a variety of disorders: infectious, auto-immune, metabolic, toxic, vascular and hereditary diseases

unsteady wide based gait -throw feet forward and outward and bring them town bringing them down on heel and then toe - have to watch ground. - Positive Romberg *B12 def, Tabelis Dorsalis (Neurosphylus), GPID, Vit E*

What are the characteristics of NORMAL INFLAMED MALIGNANT Lymph nodes

yep

Rheumatoid arthritis

• Arthritis can be classified as inflammatory (rheumatoid) and degenerative (osteoarthritis) • Inflammatory arthritis can be further subdivided based upon the nature of joint aspirate - crystal or non crystal

Retroperitoneal structures

• Pancreas • Lymph Nodes • Kidney , ureters • Adrenal • Aorta

Secondary Lymphedemas

• Radiation therapy • Surgery • Parasitic infection (e.g. Filariasis) • Surgical lymph node removal (radical mastectomy) • Malignant tumor invasion (metastases)

TAKING BLOOD PRESSURE

• The *length* of the bladder in the cuff should be *80% of the circumference* of the upper arm (or of the part used) • The *width* of the bladder should be *40% of the circumference* of the arm (or other body part used).

Fibroadenoma

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

Apex beat description:

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

55 year old man with drooping of his right eyelid for past week -- long time smoker. Pulse is 88bpm, BO is 146/86, and resp 18bm. Mild ptosis of the Right eye and his forehead is dry on same side...what would you find in right pupil

♦ *Small (miosis ,) reacts briskly to light and near reaction* ♦ Horners Syndrome: miosis, ptosis, anhidrosis and apparent enophthalmos. ♦ Anisocoria(unequal pupil size) is more marked in dim light: the ptosis is mild: the decreased sweating occurs on the ipsilateral side. ♦ There is increased accommodation response due to unopposed action of the parasympathetic. ♦ Pupillary response to light and near is normal. ♦ The lesion could be preganglionic or postganglionic. ♦ 1% hydroxyamphetamine solution instilled in both eyes will cause a pupil with a preganglionic lesion (and the normal pupil) to dilate but not one due to a postganglionic pathology.