CPD from class
Raised JVP, normal waveform
*Right heart failure* • Tricuspid regurgitation • Conduction block and arrhythmias • Fluid overload
Risk factors for developing atherosclerosis
*Smoking* ( overlaps with risk factors for DVT) hypertension Diabetes Hyperlipidemia *obesity* ( overlaps with risk factors for DVT) Coronary artery disease cerebrovascular disease
Eyes For peripheral signs of CVD
*pallor* (under lower eyelid) *jaundice* (especially under upper eyelids) *corneal arcus* (creamy yellow discoloration at junction of iris and cornea due to deposition of cholesterol crystals), *funduscopic evidence of hypertensive and diabetic retinopathy* *Nicotine staining on teeth*
Masses
"Fat" • "Flatus" • "Feces" • "Fluid" • "Fetus"
UBIQUITY
"I have to ask everyone this" Questions commonly asked for all patients in a similar situation. "In situations like this, there are a set of questions that I ask of all patients
Define Afferent Pupillary Defect (AKA Marcus Gunn pupil)
"Pupillary escape" Defect in optic nerve conduction Pupillary response normal when shined in normal eye Pupillary response weaker when shined in abnormal eye Diagnose using "swinging flashlight" test
DISPLACEMENT
"dont worry, most ppl feel like this" Emotions, ideas or wishes of patients shifted from their original object to a more acceptable substitute that is less anxiety producing. A patient who seems uncomfortable discussing his feelings can be put at ease. "Many people in this situation would have some strong feelings."
Koilonychia what are the causes
("spoon-shaped" nail) - iron deficiency
SEVENTH-CRANIAL NERVE
(FACIAL) Sensory to Tongue (anterior 2/3) Motor - Muscles of Facial Expression TEST: Smile Frown Whistle Blow
Bruits in the thyroid gland indicates
(Indicates congestion)
What is S2
(closure of aortic and pulmonary valve) after the carotid upstroke --> Pulmonary is the slower valve, due to pulmonary hypertension
What is S1
(closure of the AV valve) occurs just before the carotid upstroke
tearing PAIN
(dissecting aneurysm)
Prinzmetal angina
(due to coronary spasm) - pain at rest
Leukonychia, what are the causes
(one or more non-uniform, white lines or spots, occurring in random distribution) - albumin deficiency May be due to trauma to nail chemotherapy
What is significant weight loss?
5% or more within 6 months or 10% or more over 1 year
What is tachypnea? What can cause it?
>24bpm - rapid shallow Seen in ->restrictive lung disease, ->pleuritic chest pain, ->elevated diaphragm due to increased intra-abdominal pressure
Rinne test
AC>BC is normal when AC is 2x BC
Cause of acute DYSPNOEA
ACUTE-PULMONARY EMBOLISM -PULMONARY EDEMA -PNEUMOTHORAX
Define Graves dermopathy
AKA Pretibial myxedema Plaques or nodules on the lateral and anterior aspects of the leg or at sites of previous trauma. Bilateral, but asymmetric, firm, non-pitting and pink to purple brown in color.
What is a remittent fever?
Abating and relapsing in cycles (but always stays above normal)
What are the accessory muscles of expiration?
Abdominals and intercostals
How do we test T1?
Abduction and adduction of index, middle and ring fingers
How do we test C5?
Abduction at the glenohumeral joint
Define kyphosis
Abnormal curvature that is convex posteriorly (thoracic) Causes: osteoporosis, compression fractures, hunch back Slows up as a restrictive pattern on pulmonary function tests
Continuous temperature
Abnormal through out they day fluctuating less than 1 F ex lobar pneumonia
Why is position/size of ears important?
Abnormality can indicate a chromosomal defect
Apnea
Absence of breath = cardiac arrest
What are causes of CN 8 associated hearing loss?
Acoustic neuroma Meningioma Tumor at cerebellopontine angel
What does APGAR stand for?
Activity Pulse Grimace Appearance Respiration
What causes pain in the right upper quadrant?
Acute cholecystitis
ice cold extremely
Acute ischemic infarct ( embolisation)
Define Dysphonia
Alteration in volume, quality and pitch of the voice
Relapsing (pel-ebstein)
Alternative periods of Fever and Apyrexia lasting 5-7 days each -> Normally seen in cancer
What is the cardiac output? What is it dependent on?
Amount of blood moved with each heart beat Dependent on: - Blood volume - Water/sodium intake - water/sodium loss
Clicker Question: Most likely location!!
Answer is 4
A 16year old student had examination of her eyes to obtain new glasses. The exam was facilitated by dilating the pupils. Two days later the right eye became red and the patient complains of a foreign body sensation in the eye.
Answer: conjunctivitis
What nerves provide sensation to the tongue?
Anterior 2/3s - CN V3 Anterior 1/3 - CN IX
What nerves provide taste sensation to the tongue?
Anterior 2/3s - CN7 (chorda tympani) Posterior 1/3 - CN 9
What happens below the belly button
Aorta bifurcates below
What is found in the midline of the abdomen?
Aorta, uterus if enlarged, bladder if distended
That thoracic landmark is at level: T12?
Aortic hiatus
What can cause a pulse amplitude of 4?
Aortic regurgitation
Anteriorly, what is the upper border of the lung?
Apex rises about 2-4cm above the inner (medial) third of the clavicle
Describe secondary ophthalmoscopic classification
Architecture of the nerve is lost Disc is grey with poorly defined margins Drusen and tortuous veins Progressive contraction of the visual fields Due to papilledema
Pupillary abnormalities
Argyll Robertson, Adie-Holmes, Horner, Marcus Gunn
DDx. of a neck lump: Submandibular gland
Arises from under the posterior mandible
What is the description of circumvallate papillae?
Arranged in a V shape at the junction of anterior 2/3 and posterior 1/3
What causes transverse ridges?
Arrest in temporary tooth development. i.e. malnutrition
What do the baroreceptors monitor?
Arterial blood pressure
Define systole
Arterial or ventricular contraction
Define diastole
Arterial or ventricular relaxation
What can cause asterixis?
Encephalopathy secondary to renal and liver failure Other causes: CO2 narcosis, drug overdose with barbiturate, phenytoin and electrolyte disturbances
Lymphnode (Cancerous)
Enlarged, Hard, Non Tender, Matted, Adherent to the Surrounding Structures -> May be inflamed due to secondary infection.
That thoracic landmark is at level: T10?
Esophageal hiatus
What do the muscles of the lateral compartment do?
Evert the foot
The Umbilicus: differentials for everted belly button
Everted ? Hernia ? Scars ( Laparoscopic, hernia , jewelry) Tumor ( Sister Joseph Nodule ) Vascular pattern ( Caput Medusa )
EMPHYSEMA
BARREL SHAPED CHEST PURSED LIP BREATHING USE OF ACCESORY RESPIRATORY MUSCLES PALPATION-REDUCED EXPANSION PERCUSSION-HYPERINFLATED BREATH SOUNDS-DECREASED SIGNS OF HEART FAILURE
Last thing to change in kids in SHOCK
BP
What is the last vital sign to change when a child is in shock?
BP - don't assume if the BP is okay that the patient is OK
radicular
Back pain from a sciatic injury similar to an atalgic gait-> gets up by pushing on the arms still back, flat lumbar curvature avoid putting wight on the painful leg
How is whispered pectoriloquay heard in pleural fluid or overinflation?
Barely percieved or absent
That thoracic landmark is at level: T3?
Base of scapular spine Top of aortic arch
Where do you check the heart rate in a newborn?
Base of the umbilical cord
Where do you find the oblique fissure?
Begins on the anterior chest at the level of the 6th rib MCL and extends laterally upward Crosses the 5th rib in the MAL Crosses the 4th rib and 4th interspace Ends at the spinous process of T4
Describe a Pulsus Bisferiens. What can cause it?
Biphasic pulse Has 2 main peaks 2 strong systolic beats separated by a mid systolic dip Seen in aortic regurgitation with or w/o stenosis
When taking a child's blood pressure, what are the dimensions of the cuff?
Bladder covers 2/3 of the upper arm Bladder is 1/2 width of upper arm Cuff goes all the way around
Define epistaxis
Bleeding from the nose
malignant hypertension from uncontrolled hypertension
Blood pressure of 210/140 = uncontrolled hypertension Just this is maligant hypertension BUT this same value with papilledema that is malignant
Cullen's
Blue color at umbilicus secondary to hemoperitoneum
What is acrocyanosis? What can cause it?
Blue extremities Normal for first several hours If it doesn't resolve, consider heart disease
Define Grey Turner's sign
Blush discoloration of the flanks
What are the boundaries of the triangle of auscultation? What is it over?
Bounded by the trapezius, latissimus dorsi and medial border of the scapula Found over the inferior lobe of the corresponding lung
What is the arterial supply of the scalp?
Branches of the internal carotid (supratrochlear and supraorbital) External carotid (superficial temporal, posterior auricular and occipital)
What is the blood supply of the palate?
Branches of the maxillary artery (greater palatine, lesser palatine) and facial artery (ascending palatine)
Sighing Respiration
Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome—a common cause of dyspnea and dizziness. Occasional sighs are normal
What are causes of conductive hearing loss?
Build up of cerumen Infection (otitis) Fluid in the middle ear Punctured ear drum Fixation of ossicles Tumors of the middle ear Scarring
What are the special tests for joint effusion of the knee?
Bulge sign Ballotment sign (patellar tap)
What are the special tests for ascites?
Bulging at the flanks Fluid wave Shifting dullness
When do the posterior fontanelles close?
By about 2 months
List 5 nerves that innervate the scalp.
CN V1 (ophthalmic) CN V2 (maxillary) CN V3 (mandibular) C2 C3
What cranial nerves come off the top of the brainstem?
CN1, CN2
What are the signs of tympanoclerosis?
Calcified plaques seen on the surface of the membrane Usually due to scar formation secondary to incomplete healing of otitis media Generally asymptomatic, unless they protrude into the tympanic cavity, causing conductive deafness
Tracheal tug sign in which there is downward displacement of the thyroid cartilage during inspiration
Campbell's sign - COPD
Enlargment of the gall bladder with jaundice= Courvoisier's sign
Cancer of head of pancreas
PULSE-PULSUS PARADOXUS
Cardiac tamponade and Asthma
Cardiovascular chest pain is usually due to
Cardiovascular chest pain is usually due to myocardial ischemia, pericarditis or dissecting aneurysm
What is found in the right lower quadrant?
Cecum, appendix, ascending colon, ureter
What is found in the right iliac/inguinal region?
Cecum, appendix, ileum, ascending colon, right ovary
Where do metastesis of lip carcinoma go?
Central - submental Lateral - submandibular Then to jugulo-omohyoid nodes
Spider Angioma
Central body , sometimes raised ,surrounded by erythema , and radiating legs very small to 2 cm Distribution : face , neck, arms, upper trunk • Causes : Liver disease , pregnancy, VitB deficiency
Phasia
Central control of speaking
What secretes ear wax?
Cerumenous glands
Describe the superficial cervical LNs
Chain of nodes along the external jugular vein on teh superficial surface of the SCM. Drains the psoterio-lateral and posterior regions of the scalp via the mastoid and occipital nodes. Drains into the deep cervical nodes.
a subacute nontender nodule involving a meibomian gland. A beady nodule in an otherwise normal lid, it is usually painless. Occasionally a chalazion becomes acutely inflamed but, unlike a sty, usually points inside the lid rather than on the lid margin.
Chalazion
Basal motor nuclei
Choreiform gait
What are the special tests for hypocalcemia?
Chvostek's sign Troosseau's sign
Define anterior uveitis
Combined iritis and cyslitis
Neuromuscular= Foot drop gait
Common radial nerve injury with paralysis of dorsiflexion. Patent jerks the knee high and thus flipping the foot up in dorsiflexion and then slaps the foot down... ( CANT WALK ON THE TOES)
DDx. of a neck lump: Cystic hygroma
Commonly found in babies (cystic degeneration of lymphatics)
What is the complication with hemo or pneumothorax?
Compression of the parenchyma tissues of the lung resulting in respiratory distress
What types of joints does a TMJ function as?
Condyloid joint Gliding joint Hinge joint
Milroy's disease
Congenital lymphedema
What cause Hutchinson's incissor?
Congenital syphilis
What does the Apneustic center regulate?
Controls the *depth* of inspiration, ->allowing response to an increased demand for O2
Moon Facies
Cushings
Unequal Blood pressures
D/t stenosis arteriosclerosis
Two arthritits
DIP -> Osteoarthritis & Psoriatic ( Rash and HLA b27 & pitting of the nails)
Veinous Ulcerations are to
DUE to Venous hypertension and Incompetent communicating veins between the Deep and the superficial veins = medial malleolus
What causes secondary lymphedema?
Damage to the lymphatic system Secondary to radiation or surgery
What can cause intrinsic hair cell damage?
Deafness genes Aging (presbycusis - loss is in the 4000-8000Hz range) Vascular ischemia Perilymph fistula Idiopathic
What are the pathophysiological causes of diarrhea?
Decreased mucosal transport or secretory dysfunction Increase osmotic load Malabsoprtion Excessive exudates Altered bowel motility
What is Cheyne-stokes breathing? What can cause it?
Deep alternating with periods of apnea Seen in brain damage (both sides of cerebral hemisphere), heart failure, uremia, drug induced respiratory depression
Describe a large, bounding pulse. What can cause it?
Defined as 3+ Does not fade out with pressure - not easily obliterated Seen in hyperdynamic circulation (i.e. hyperthyroidism)
What can cause tachycardia in a child?
Dehydration, SVT or other cardiac abnormality, poisoning, shock, anemia, medications, thyroid disease
What can cause pretibial myxedema?
Deposition of mucin (GAGs) in the dermis of the skin
What is a pulse deficit? What can cause it?
Difference between the heart rate by auscultation at the apex and the peripheral pulse rate by palpation Seen in atrial fibrillation, rapid irregular rhythms
What causes generalized abdominal pain?
Diffuse abdominal involvment, such as peritonitis, secondary to ruptured viscus
Define mydriasis
Dilatation of the pupil Under sympathetic innervation
Adie-Holmes (tonic)
Dilated pupil, absent light reflex, accommodation present (of near reaction). Argyll and adie both have absent light reflex
Define telengiectasis
Dilated venules Located in the intradermal area 1mm in diameter
What are the special tests for peritonitis?
Direct tenderness Guarding (voluntary) Rigidity (involuntary) Rebound tenderness
Explain Palmar grasp
Disappears by 3-4 months Persistence indicates cerebral dysfunction
Describe primary ophthalmoscopic classification
Disc is chalky white, sharply demarcated, and with normal retinal vessels Optic nerve degenerates in an orderly fashion Causes: pituitary tumor, optic nerve tumor, traumtic optic neuropathy and MS
Define otorrhea
Discharge from ear
Define Xanthelasma
Discrete, waxy, yellowish deposit on the medial aspect of the lid
Define Dysarthria
Disease of the muscles involved in formulating words (lips, tongue, pharynx or palate)
What abdominal parts are hindgut derivatives? Where is the pain felt?
Distal colon and genitourinary tract ->Lower abdomen
What are the signs of acute (bacterial) otitis media?
Distortion and redness of the tympanic membrane Obscured malleus Bludging of the membrane with pus behind the membrane (or perforation with discharge)
What is an intermittent fever?
Diurnal variation - the temperature fluctuates between normal and elevation during a 24hr period (i.e. Malaria)
Intermittent temperature
Diurnal variation e.g Malaria Temperature elevation is present only for a certain period, later cycling back to normal. Patter then repeats itself. Malaria
Temperature has what type of variation
Diurnal variation makes sure to measure the same time each day.
Describe the deep cervical LNs
Divided into an upper and lower group by the intermediate tendon of the omohyoid muscle and form a chain of nodes along the internal jugular vein. Deep to the SCM.
Define vertigo
Dizziness
What position is best for examining the child?
Do what you can while the child is being held by a parent - Child will be less frightened - Your exam will be more accurate Do procedures in a position of safety
What do the muscles of the legs anterior compartment do?
Dorsiflex and invert the foot, invert and extend the toes
What can cause abnormal respiration?
Emotions (i.e. anxiety, fear) Pain Exercise Smoking Environment (i.e. temperature, altitude) Medication (narcotics depress respiration, stimulating increase respiration) Medical conditions
What is found in the right lumbar region?
Tip of the right lobe of liver, ascending colon, right kidney, ileum
What are the features of an Arterial ulcer?
Tips of digits, heel and plantar surface of foot Tend to be small Cool Reduced to absent pulses Painful Punched out, no attempt at healing Absent granulation tissue Dry Base is pale and flat, may contain some necrotic tissue
Dupuytren's contracture what are the causes
This contracture results in the inability to extend these joints. This deformity is seen in alcoholic cirrhosis.
anterior chamber
clarity - hyphema (blood), hypopyon (pus) depth - iris is normally flat and and forms a wide angle with the cornea. Decrease in the angle (by bowing of the iris forward) results in shadowing on examination and may result in acute narrow angle glaucoma (blockage) to drainage of aqueous humor.
Filiform papillae fx
cleansing and rasping (scraping) actions in the mouth
Blinking
close eyes to bright light -absence indicate blindless
Anterior frontallen
closes 4-26 months -open soft and fat bulging = ICP or meningitis Sunken = dehydration measure head each visit
conjunctivitis and subconjunctival hemorrhage
conjunctivitis - d/t dilated vessels subconjunctival hemorrhage - blood outside the vessel, secondary to trauma or bleeding disorder or sudden increase in venous pressure. -two causes: local cause or intracranial bleeding --> fracture of floor of anterior fossa, will see subconjunctival hemorrhage
Tympanosclerosis
deposition of chalky white patch containing hyaline within layers of tympanic membrane
Which part of the stethoscope is used to detect high pitch sounds?
diaphragm
Diffus Rales (crepitations) on auscultation
diffuse rales may indicate the onset of pulmonary edema
70% of pt's with crebral palsy will have
diplegic gait (scissors)
MI Description
discomfort, pressure, crushing, aching, burning, fullness, squeezing
Galants Reflex
dissapears at 2 months -absent in *transverse* spinal cord lesion
What is the circulation of aqueous humor?
drains through the pupil, then into the iridocorneal angle where it is reabsorbed into the Canal of Schlemm
Ptosis
drooping eyelid
Steppage d/t
due to foot drop
waddling (Trendelenberg)-
due to hip girdle muscle weakness,-> ON the good leg the hip falls toward the BAD side
absent cone of light
either poor technique or perforation that healed - so no longer shiny
Palmar Erythema where is the colour the deepest?
erythema ) deepest over hypothenar eminence ,less pronounced thenar eminence ,and digital segments of fingers=
Describe the ulcers seen in peripheral arterial disease
Tips of digits, plantar surface of fee, over bony prominence, and posterior heal area Neuropathic ulcers - combination of vascular insufficiency and peripheral neuropathy Tend to be deep with a punched out appearance Base is pale (Granulation tissue) and may contain a small portion of slough
Define entropion
Turning inward of the lid margin. This can cause abrasion of the cornea.
Sound of percussion over air outside the bowel in the abdomen?
Tympanic (there is no hypertympany) These areas are normally dull
What are the signs of otitis media?
Tympanic membrane is red, bulging and dull, pus may be visualized. However, crying may cause redness of the TM
Lung percussion
Typanic sound
What area is drained by: superficial cervical nodes?
Upper respiratory infection
Investigation for a pulmonary embolism
VENOGRAM
That thoracic landmark is at level: T8/9 disc?
Vena caval hiatus
What area is drained by: Preauricular nodes?
Viral illness, lymphoma, cat-scratch fever
Define varicose veins
Visible and palpable Subcutaneous tissue Over 3mm in diameter
Define reticular veins
Visible, but not palpable Subdermal area Between 1-3mm in diameter
Explain pulsus differens
Volume differences between two different pulses Seen in local stenosis or compression of the paths of the vessel with the weaker pulse
*WIIPEEP mnemonic
Wash hands Introduce yourself Identify the patient Permission to examine Explain the task ahead Expose the area to be examined Position the patient
Cachexia What % of the body weight must you loose over 6-12 months
Weight loss of 5% of body weight over 6-12 months should prompt evaluation
What duct drains the submandibular gland?
Wharton's duct - opens on the sublingula papilla on either side of the frenulum
Informed consent
What is the following: A process of communication between a patient and physician that results int eh patients authorization or agreement to undergo a specific medical intervention.
What does the vitreous humor do?
Exerts pressure to maintain the shape of the eye
Draping for the abdomen male vs. female patient
Expose below breasts in the female , nipple line in male • Expose to iliac crests , covering genitalia
CLUES
Expression or behavior that imply, but not explicitly state the patient's ideas, concerns and expectation
Where do you find the horizontal fissure?
Extends form the fourth rib at the sternal border Follows the contour of the costal cartilage of the 4th rib Crosses the foruth interspace and ends at the oblique fissue, after crossing the 5th rib in the MAL
How do we test C7?
Extension at the elbow
How do we test L3, L4?
Extension of the knee
What are the three layers of the eyeball?
External - sclera and cornea Intermediate - anterior (iris and ciliary body) and posterior (choroid) Internal - retina
What landmarks can be identified from the back of the skull?
External occipital protuberance The mastoid processes
What does CN 3 control?
Eye adduction (medial rectus) Elevation (Superior rectus) Depression (inferior rectus) Elevation of the eyelid (levator palpebrae superioris) Parasympathetics for the pupil
What is the clinical presentation of a CN3 palsy?
Eye is turned out and slightly down, with ptosis and a mydriatic pupil
Define proptosis
Eye protrusion beyond the level of the supraorbital ridge Non-endocrine mediated issues - Cavernous hemangioma, lymphagiomas, lymphomas and Wegener granulomatosis In children - orbital cellulitis (unilateral), neuroblastoma and leukemia (bilateral)
What hormones drive the development of the breast?
FSH and LH ->activates primordial ovarian follicles ->and estrogen secretion, ->which stimulates breast development; estrogen stimulates the connective tissue and vascular supply. progesterone is required for lobular development. ->Insulin, ->cortisol, ->thyroxine, ->prolactin, ->growth hormone.
What causes infantile glaucoma or buphthalmos?
Failure of the development of the iridocorneal angel and/or the Canal of Schlemm
What causes a coloboma?
Failure of the neuro-ectodermal tissue to wrap around the lens placode and fuse in a double layer inferiorly
What does a too small cuff do to BP?
Falsely elevates BP
What does a too large cuff do to BP?
Falsely lowers BP
What are the 9 Fs of protuberance?
Fat Fluid Feces Flatus Fetus Fibroid Full bladder False pregnancy Fatal tumor
What symptoms are seen when a temperature is rising?
Feeling cold and shivering
What is Durozie's sign? What does it indicate?
Femoral bruit ("pistol shot") Normally a bruit is only heard in systole. Durozie's is seen in both systole and diastole (two phase bruit), heard over the peripheral arteries (i.e. femoral). Rapid "back and forth" flow of blood - as seen in aortic insufficiency
What blood vessels are effected in diabetics?
Femoral-iliac Small vessel occlusion
BROCHIECTASIS Symptoms
Fever, cachexia, sinusitis clubbing and cyanosis sputum = voluminous ( FOUL SMELLING ) Coarse inspiratory crepitations
What are the jugular venous pressure waves?
a (upstroke) x (descent) v (upstroke) y (descent)
Passive Splenomegaly congestion due to
abnormal splenic blood flow or portal hypertension , ie cirrhosis , echinococcus, schistosomiasis , congestive heart failure , splenic vascular abnormalities ( artery aneurysm , venous obstruction )
What are the factors that can affect blood pressure?
Force of the heart's pumping action Amount of resistance in the blood vessels Amount of blood in the blood vessels Pain, emotion Age, disease, obesity Drugs/medication Physical fitness Trauma
Athria
Formulating the words
Pain (OSA)-Onset - sudden; after drinking alcohol
Gout!!!
VSD is what Intensity of murmur
Grade 6
What are children's jobs? What do you expect them to do?
Grow Develop Learn Explore
BRONCHOGENIC CARCINOMA
HAEMOPTYSIS CLUBBING PNEUMONIA PLEURAL EFFUSION FIXED RESPIRATORY WHEEZE TENDER RIBS MEDIASTINAL COMPRESSION LYMPHADNOPATHY
Enlarged posterior cervical nodes (3)
HIV scalp infection seborrheic dermatitis
Enlarged occipital nodes
HIV infection
What area is drained by: Occipital nodes?
HIV infection
What area is drained by: posterior cervical nodes?
HIV, scalp infection, seborrheic dermatitis
X ray straight sign ( horizontal liquid air interface) indicates
HYDROPNEUMOTHORAX
CLUBBING-GRADING
HYPERTROPHY OF ANGLE BETWEEN NAIL BASE AND FINGER (Early) BEAK SHAPED(Moderate) DRUM STICK APPEARANCE(Severe)
Define Argyll Roberston Pupil
Hallmark of neurosyphilis Effects the pupils Vision is normal
What do you see when looking into the ear?
Handle of the malleus, umbo and cone of light
Rheumatoid nodule
Hard nodule - not painful, also will see joint inflammations
Tophi
Hard nodule on helix, when squeezed - chalky white precipitate - uric acid crystals - and associated with joint pains
Large hands and feet
acromegaly
What is special about CN1?
Has direct access to cerebral cortex without going through the thalamus
Nervous innervation of the ear
external ear = sensory is vagus and and trigeminal, and glossopharyngeal
Entropion
eyelid turned in causing irritation of conjunctiva
DDx. of a neck lump: Thyroiditis?
Hashimotos, De-Quervains
What is de Mussett's sign? What does it indicate?
Head nodding coinciding with the carotid pulse Seen in aortic regurgitation
What can cause a pulse amplitude of 1?
Heart failure
Score a baby on APGAR
Heart rate resipiration muscle tone irritability color
Compassion
feeling of deep sympathy and sorrow for another who is strsicken by misfortune, accompanied by the strong desire to alleviate the uffering
What can cause pain in the thyroid gland?
Inflammatory disease Acute bacterial - tenderness, warmth and redness
What does the cardiac center effect?
Influences heart rate and myocardial contractility
What does the vasomotor center effect?
Influences systemic vascular resistance
What causes primary lymphedema?
Inherited or congenital disorder with the lymphatic channels
Where does Stensen's duct open?
Inside of the cheek at the level of the second upper molar.
What is the hemodynamic effect of respiration?
Inspiration ->increases (prolongs) right heart ->shortens (decreases) left heart activities Expiration ->increases (prolongs) left heart ->shortens (decreases) right heart activities
What do you observe for?
Interactions with parents Play/explore? Does the child look sick? (too quiet, too cooperative, unable to speak?) Remember, children change rapidly.
What are the symptoms of blood vessel occlusions?
Intermittent claudication Changes in the skin Hair loss on the distal leg Rest pain Non-healing ulcers Numbness Tingling and weakness in the legs Impotence thickened toenails Pallor of the legs, especially on elevation
Pupil
allows light to pass, appears black due to absorbing pigments in the retina
What abnormality of a blood vessel can be detected by using a stethoscope?
aneurysm or stenosis *turbulence of flow gives a swishing noise
Limping
antalgic gait = stance foot is shortened ! -> Can be due to damage ANYWHERE ON THE LEG
What do normal bowel sounds, sound like?
Intermittent, low pitch, chuckling (clicks and gurgles) at intervals of 5-34/min Borborygmi (prolonged gurgles of hyper-peristalsis) Normal peristalsis produces bowel sounds when gas, fluid and food are passed though the instestinal lumen
In the Bronchial what is the intensity, pitch, I:E ratio Description and normal location
Intnesity = loud Pitch= high *I:E ration 1:3* Description= tubular Normal location: malnuibrium
In the vescicular what is the intensity, pitch, I:E ratio Description and normal location
Intnesity = soft Pitch= low *I:E ration 3:1* Description= Gentle Rustling Normal location: most of the peripheral lung
In the trachea what is the intensity, pitch, I:E ratio Description and normal location
Intnesity = very loud Pitch= very high I:E ration 1:1 Description Harsh Normal location: extrathoracic trachea
DDx. of a thyroid goiter: Simple goiter?
Iodine deficiency
Describe the parotid gland
Irregular, lobulated yellowish structure, located on the side of the face, anterior and inferior to the pinna. Largest of the paired salivary glands. It is wedged between the ramus of the mandible and the mastoid process with its superior limit being the zygomatic arch.
What are the signs of hypertensive retinopathy?
Irregularities in arteriolar size (narrowing) Tortuosity of arteries Changes in arteriovenous crossing (a-v nicking) Cotton wool exudates Macular exudates Macular star Flamed-shaped hemorrhages Retinal edema Papilledema
HYPERACTIVE
Irritable Bowel Diarrhea Early Partial intestinal Obstruction Obstruction
cornea
first and most powerful refractory lens element of the eye, with the lens allows production of a sharp image
Midsystolic murmurs
flow through semilunar
Patients Present detailed information about how you feel Ask questions if desired information is not provided Check your understanding of provided information Express any concerns about recommended treatment
Is the PACE system of communication/education for patients or physicians? What does PACE stand for?
What are the boundaries of the posterior triangle of the neck?
apex: union of the SCM and trapezius muscle anterior: posterior border of the SCM posterior: anterior border of the trapezius base: middle 1/3 of the clavicle
Palpatations Leaping
arrthymias
Diabetes = what is wrong
arterial system defects and neuronal prob.
Hepato-jugular reflux
JVP rises with hepatic compression, then falls (in less than 5 secs) even with continued pressure. Sustained rise in right heart failure ( if Positive the the heart cannot adjust to the increase in blood)
Define diarthrosis (synovial) joints?
Joints that are freely moveable Articulating portion of each bone is covered iwth a thing layer of articular (hyaline) cartilage Allows free, low-friction, painless gliding of bones on each other Separated by a fluid containing cavity
That thoracic landmark is at level: T2?
Jugular notch
Describe the lower cervical deep LNs
Jugulo-omohyoid node is the highest of the lower deep nodes and drains the tongue. Drains all of the other LNs.
What three joins have fibrocartilagnious discs (menisci) between the articulating bones?
Knee Temporomandibular Ulna-carpal joints
Sensory ataxia ( secondary to tabes dorsalis)
Knee raise high, foot slaps down, places them irrgeularly in a broad base
Hypothermia
Less then 95F or 45 C - hypothyroidism
CHRONIC BRONCHITIS
Look for someone who is bluish palpitations- hyperinflation of the chest with reduced expansion Percussion resonance and HYPERRESONANCE Wheezing/ inspiratory crackles and right heart failure
Define Anosmia. What can cause it?
Loss of sensation of smell Nasal disease, head trauma, cocaine abuse
Define Aphonia
Loss of the voice, due to larynx or its nerve supply
Define bronchial sounds
Loud, high pitched (harsh) May be heard over the manubrium Inspiratory sounds are shorter than expiratory sounds Both have the same intensity There is a gap between inspiration and expiration Characteristically heard in consolidation and the upper level of the pleural effusion
When do you hear hyper-resonance?
Loud, low pitch booming sound of long duration Emphysema
When do you hear resonance?
Loud, low pitch hollow sound of long duration Normal
What type of sound is the Bell of the stethoscope used for?
Low frequency sound (with light pressure)
Sound of percussion over normal lungs?
Low pitch and high amplitude Resonant
HYPOACTIVE/ Decreased also can be Ileus
following anesthesia abdominal-pelvic surgery
What are the characteristics of a condyloid joint?
Morphology: One articulating surface is convex and the other is concave. Allows no rotation Biaxial - flexion/extension; adduction/abduction Ex: Carpometacarpal join of the fingers, radiocarpal joint, temporomandibular joint (which is also a hinge joint)
Synovial (diarthrosis)
Most common : freely movable and most apparent. Comprises the largest sub grouping of joints (knee, shoulder)
What describes the ulcers in peripheral venous disease?
Most common location - anterior and superior to the medial malleolus Tend to be large and shallow with a sloping edge
Describe the upper cervical deep LNs
Most superior of the deep cervical nodes is the jugulo-digastric (tonsillar). Drains the tonsils and tonsillar regions.
How do you take a child's history?
Most will be obtained from the parents Beware of bias in the history Ask: how many words can the child say? what can she do in her own environment? Ask: eating, sleeping, behavior? Ask: concerns?
What is the range of motion for a multiaxial joint?
Moves in multiple directions
What is the range of motion for a uniaxial joint?
Moves in one plane, two opposite directions
What is the range of motion for a biaxial joint?
Moves in two planes at right angles to each other
Where does the iris and posterior structures of the eye (with the exception of the lens) originate from?
Neuro-ectodermal layers
Describe the mastoid superficial LNs
Nodes are posterior to the ears near the attachment of the sternocleidomastoid muscle to the mastoid process. Drains the posterolateral half of the scalp.
Describe the submental superficial LNs
Nodes located inferior and posterior to the chin. drain the ventral lower lip, chin, floor of the mouth, tip of the tongue and lower incisor teeth.
What causes leukonychia?
Non-uniform, white lines or spots, occurring in a random distribution Albumin deficiency
What is a regular pulse rhythm?
Normal
What is the normal slope of the ribs? When is there a change?
Normal angle of insertion of the ribs to the spine and costal cartilages (costochondral junction) is 45 degrees. In COPD there is elevation of the ribs, with a loss of normal slope
What is a radio-femoral delay? What can cause it to be abnormal?
Normal transmission of a pulse wave is 75ms (radial artery) and 70ms (femoral artery) Longer when there is obstruction to the flow of blood Seen in Leriche's syndrome (isolated aortic-iliac disease), post-subclavian coarctation of the aorta
Radio-Femoral Delay what are the normal valves
Normal transmission of pulse wave to the radial artery is 75ms and to the femoral artery 70ms.
Pain came on suddenly, minutes?
fracture.
How do the internal intercostal muscles run?
Obliquely posteriorly and inferiorly in the intercostal spaces deep to, and at right angles, to the external intercostals
Define synostosis
Obliteration of sutures by bone
BUERGER'S TEST What are the final results
Observe for return of color (10 seconds) and venous filling (15 seconds)
What do you do first with a child?
Observe from a distance
What can cause a pulse amplitude of 0?
Obstruction or shock
What are the 6 superficial lymph nodes of the neck?
Occipital Mastoid (post-auricular) Pre-auricular and parotid Submandibular Submental Superficial cervical
When Does the Kussmaul Sign occur
Occurs in conditions of pericardial effusion, constrictive pericarditis, cardiac tamponade
Define paroxysmal nocturnal dyspnea
Occurs suddenly, 1-2 hours after falling asleep Symptom of left ventricular failure (pulmonary edema), caused in part by the gradual re-absorption of significant amounts of edema fluid (From the legs) into the circulation during recumbency The increase in blood volume causes pulmonary edema, which awakens the patient with dyspnea, sometimes accompanied by cough and frothy sputum
Describe lymphedema
Occurs when there is a blockage to the transport of lymphatic fluid Accumulation of lymphatic fluid in the tissues Non-pitting edema Unilateral Irreversible
Tracheal tug sign in which there is downward displacement of the cricoid cartilage with ventricular contraction
Oliver's sign - aortic arch aneurysm
Relationship building with a difficult patient
PEARLS • Partnership • Empathy • Apology • Respect • Legitimization • Support
PERCUSSION NOTES: FLATNESS
PEURAL EFFUSION
Define otalgia
Pain in ear
DDx. of a neck lump: Thyroid carcinoma?
Papillary > follicular > anaplastic > medullary
What is found in the left lumbar region?
Part of the transverse colon, descending colon, left kidney, jejunum
What is found in the left lower quadrant?
Parts of the descending colon, sigmoid colon, ovaries, ureter
When does jaundice peak? How do we treat it? What are potential complications?
Peaks on 3-4th day of life Treated with phototherapy Failure to treat can result in kernicterus
extra abdominal sign of hypoproteinemia
Pedal edema
Congenital lymphedema
generally presents at birth. An example of congenital lymphedema is Milroy's disease
If a patent is STILL what type of pain does that indicate
Peritonitis because you dont want any movement
What cause mucosal pigmentation?
Peutz Jegher's syndrome
A yellowish, somewhat triangular nodule in the bulbar conjunctiva on either side of the iris, a pinguecula is harmless. Pingueculae appear frequently with aging, first on the nasal and then on the temporal side
Pinguecula
Conjunctival growths over the nasal aspect
Pinguecula - does not cross the corneal-scleral junction Pterygium - May encroach the pupil, does cross the corneal-scleral junction - can cause blurred vision and is seen in the tropics bc its thought to be due to UV from sun.
facture of temporal bone
bluish discoloration by mastoid process - Raccoon sign
Enlarged Gall Bladder
carcinoma of gall bladder
Crying
causes redness in tympanic membrane
Xanthelasma
cholesterol deposit, slightly raised, well defined plaques, located at the nasal portion of one or both eyelids
How do we test S1, S2?
Plantar flexion of the toes
What do the muscles of the posterior compartment do?
Plantarflex the foot Flexes the lateral four toes Flexes the great toe Laterally rotates the femur on a fixed tibia Plantarflexes the foot
Define Aphasia
Problems producing or understanding language
What are the functions of the palatine muscles?
Protect the nasopharnyx (closes it off) during swallowing
Review global assessment chart.
Pruritis: unpleasant sensation that provokes the desire to scratch.
What does the Medullary Rhythmicity center regulate?
Quiet respiratory rhythm (baseline) set and controlled
What do you do first when you start to assess the patient?
Quiet things - like auscultate Do painful/frightful things last
Constitutional - malaise, fatigue - inflammatory arthritis
RA, Psoriatic , SLE; fever e.g. septic arthritis , gout (low-grade fever )
What is the BP if you can paplate a radial pulse? Femoral pulse? Carotid pulse?
Radial - 80mmHg Femoral - 70mmHg Carotid - 60mmHg
What is an irregular irregularity pulse?
Random irregular pattern Seen in atrial dysthytmia (i.e. atrial fibrillation)
What is a relapsing (recurrent) fever?
Recurrent, acute episodes of fever and defervescence of varying duration. There is spontaneous abatement and then recurrence of varying duration. Febrile episodes typically last 5-7 days.
Define vermilion border
Red zone that separates the skin zone from the mucosal zone in the lips
What can cause Palmar erythema?
Reddening of the palms involving the thenar and hypothenar eminences Causes: liver cirrhosis, rheumatoid arthritis, thyrotoxicosis, diabetes mellitus
What is the hormonal regulation of blood pressure?
Renin-Angiotensin-Aldosterone syndrome
What is a regular irregularity pulse?
Repetitive irregular pattern Seen in premature atrial or ventricular contraction
What does lack of mobility of the ear drum indicate?
Scarring Blocked eustachian tube
What are the signs of chronic ear infection?
Scarring with retraction of the membrane
Argyll Robertson
Small irregular pupil accomodates but NO light reflex - seen with syphillis and diabetes. Normal vision in affected eye. Both eyes.
Describe a normal LN
Small, moveable, discrete, non-tender Referred to as "shotty"
Define the glands of montgomery?
Small, raised areas on the areola, transitional between sweat and lactiferous glands They lubricate the nipple
Define thyroid acropachy
Soft tissue swelling (clubbing of toes and fingers) and periosteal proliferation of the shaft of phalanges and other distal long bones. Occurs in the presence of pretibial myxedema and eye changes.
Define white lesions of the retina
Soft, cotton-wool or dense Seen with diabetes and hypertension
What are some causes of neck stiffness?
Spasm of the cervical muscles leading to tension headaches. Meningeal irritations in meningitis.
pull external ear upwards and backwards away from the head
Speculum examination
Where doe the sphenoidal sinuses drain?
Spheno-ethmoidal recess superior to the superior concha
How is vocal fremitus heard in consolidation?
Spoken words are loud and clear
Under normal circumstances, what controls the heart rate?
Sponatneous rhythmic disrachge of the sino-atrial node 100-110 beats/minute Can be modified by the ANS - Vagus nerve (PSNS - decreases HR) - SNS - stimulates
What causes koilonychia?
Spoon-shaped nail ->*Iron deficiency*
Define antalgic (Trendelenberg) gait?
Stance phase of gait is abnormally shortened compared to the swing phase on the affected side More rapid transfer of weight form one foot (affected side) to the other (opposite) side Associated with pain on weight bearing side
Facial nerve supplies what muscle of the ear
Stapedes = hyperacutosis
Explain the blinking reflex
Startle reflex - eyes close in response to bright lights Disappears by one year Absence my indicate blindness
Where do you feel pain from acute appendicitis?
Starts in the periumbilical area (visceral midgut) Shifts of the lower right quadrant (location of the appendix)
Bilateral Foot drop
Steppage Gait
That thoracic landmark is at level: T4?
Sternal angle (manubriosternal junction) Second costal cartilage Tracheal bifurcation Upper end of the ascending aorta Beginning of descending aorta Arch of azygos vein and its entrance into the superior VC Fusion of right and left mediastinal pleura in anterior midline
Where do the posterior ethmoidal cells drain?
Superior nasal meatus
What is APGAR?
Systemic way to assess newborns Scored at 1 and 5 minutes (longer is low) 1 minute score does NOT indicate a poor prognosis if 5 minute score is normal Good score do not guarantee a good outcome
When is the "Click" heard
Systole ( S1-s2)
Describe the steronocostal hiatuses?
T10 Superior epigastric vessels
Describe the aortic hiatus
T12 Azygos vein, thoracic duct, lymph vessels NOT the aorta - it runs posterior the the median arcuate ligament and anterior to the 12th rib
Describe the vena caval hiatus
T8/9 disc Inferior vena cava and branches of the right phrenic nerve
Ulcers in arterial insufficiency
TIPS of the digets !! or on the bottoms on the foot
What are some basic concepts when examining a child?
Take/make the time Be calm, be patient Be age appropriate
What is prolonged expiration? What can cause it?
Takes a long time to breath out Seen in obstructive lung disease (i.e. asthma, COPD)
Ectropion
Tearing constantly
BRONCHOPNEUMONIA signs
Temperature for 3 days Expansion is reduced Tactile fremitius is increased percussion is dull breath sounds are bronchial additional sounds are Rales VOCAL RESONANCE-INCREASED ON AFFECTED SIDE PEURAL RUB MAY BE HEARD AEGOPHONY ( ee is heard as aa) WHISPERING PECTORILOQUY
Vital signs - what are the age appropriate norms?
Temperature is the only constant HR and RR are higher in younger children BP are lower in younger children HR, RR and BP can be elevated by fear, crying and fever
What are the two muscles of the inner ear? What innervates them? What is their role?
Tensor tympani (CN V) Stapedius (CN VII) To dampen sound
Thrombophlebitis
Test for DVT ( Pratt and Homan)
Define the lower anterior part of the skull
The facial skeleton Composed of paired bones: nasal, palatine, lacrimal, zygomatic, maxillae, inferior nasal conchae Unpaired: vomer
Define the limbus
The junction between the sclera and the cornea
Placement of Cuff (for the arm)
The lower border of the cuff should lie about 2cm above the antecubital fossa
Enlarged submental and submandiblar nodes
oral or dental infection
tympanic membrane (ear drum)
outer part of ear drum supplied by vagus and inner part of ear drum supplied by glossopharyngeal
Causes of syncope
outflow obstruction and conduction defects: aortic stenosis, bradycardia, heart block, ventricular arrhythmias(Stokes -Adams)
X ray with meniscus shaped fluid accumulation
pleural effusion
Too small head
premature closure of sutures -metabolic problem -chromosomal abnormal
Lymphedema tarda
presents in adulthood (usually after the age of 35). An example of lymphedema tarda is Meige disease.
When making a fist, all the fingers should point to which bone?
scaphoid
Ortolani Teste -leg flex at 90
sensation of gliding of femoral head in and out of acetabulum -reduction of dislocated femoral head
Cartilaginous (amphiarthrosis)
slightly moveable (vertebral bodies of the spine)
External ear infection
small amount of discharge, narrowed space
Flat -
soft, high pitched, with a short duration
Enlarged tonsillar nodes
strep throat
Facial nerve Foramen
styleomastoid foramen = damage in bells palsy = Ipsilateral paralysis
Allen Test, tests :
superficial ( Ulnar) and deep (radial) *palmar arches* receive connections from the radial and ulnar arteries.
Fibrous cyst that forms from a persistent thyroglossal duct
thyroglossal cyst
heel drop gait
tibial nerve injury with inability to plantar flex - ( CANT WALK ON HEEL)
How will a left UMN lesion of CN XII present?
tongue deviation to the right
Pleural effusion
trachea apex beat, --> displaced away from the massive effusion expansion reduced percussion- stony dull breath sounds -reduced or absent vocal resonance - reduced
Danger area of the face
trauma to nose
Tenderness "Tug Test"
tug test - by pulling external ear up or down and pressing tragus - pain indicates otitis externa. Whereas pressing on mastoid - pain suggests otitis media.
What is the normal percussion note of the abdomen?
tympanic
Pivot
uniaxial e.g. atlantoaxial , proximal radio-ulnar. Usually with a rotatory component Gliding - allows uniaxial movement e.g. patello-femoral
Enlarged superficial cervical nodes
upper respiratory tract infection
S4 (just before S1-apex beat):
ventricular compliance. Low pitched
Diabetes
hemorrhages dot-blot, microaneurysm, exudate, neovascularization
Up out and back
how to pull ear during exam tympanic should be pink/gray -> light reflex no bulge
too large head
hydrocephaly, brain tumor, subdural hematoma -measure head each visit -weigh undressed -less the 5th percentile = failure to thrive -BMI over 95% = obese (BMI = kg/m^2)
" STARING" distinctive
hyperthyroidism
0ver several hours or 1-2 days?
infectious, crystals deposition, inflammatory arthropathy.
What are the 2 major arteries that supply the layers of the scalp?
internal carotid artery - supratrochlear artery - supraorbital artery external carotid artery - superficial temporal artery - posterior auricular artery - occipital artery
anterior segment
iris, cornea, pupil, anterior chamber and posterior chamber
Parietal Cortex
is the higher level of thought
Submandibular gland nodes structures
lateral lip
Transudate defined as
less then 30g of protein
Hyper-resonance -
loud, low pitch booming sound of long duration
Resonance
loud, low pitch hollow sound of long duration
Enlarged deep cervical nodes (4)
lymphoma metastatic malignancy tuberculosis actinomycosis
How will the tongue present in acromegaly and amyloidosis?
macroglossia (large)
Where is the opening of the parotid duct located?
opposite the second molar (upper) - Stenson's duct
Difficulty breathing
nasal flaring retratctions -stridor = whistle on inhalation -wheezing = whistle on exhalation Peroidic breathing (cheyne) is normal
70 yr patient complains of nasal obstruction and anosmia
nasal polyp
Exostoses
non-tender swelling in ear canal
What is the appearance of accessory lymphoid tissue in the mouth that may indicate allergies?
"Cobble-stone" appearance
Fifth - Cranial Nerve
A) Motor to Muscles of Mastication Temporalis Masseter Pterygoids ( Lateral and medial)
Define a breast cyst
->Tender, ->feels like a soft small balloon like mass Can be a poorly defined fluid filled structure
What are the major factors affecting arterial blood pressure?
1) Left ventricular stroke volume 2) Elasticity of the aorta and major arteries 3) Peripheral arteriolar tone 4) Circulating fluid volume
What are the major functions of the musculoskeletal system?
1) Locomotion 2) Activities of daily living 3) Provide structure and form for soft tissue 4) Protect vital organs 5) Hematopoesis 6) Storage reservoir for calcium and phosphorus
What are the functions of the nasal cavities?
1) Smell 2) Temperature and humidity of inspired air 3) Trap and remove particulate mater 4) Add resonance to laryngeal sound
Biomedical task
2 Fs - finding the problem (diagnosis) and fixing the problem (treatment)
Milestones
2 months smile 4- hold rattle - roll over 6 - sit 9 - understand but ignore, NO
Sinus Tachycardia ( what is the pulse)
100 -180
What are the symptoms of acute ischemia?
5Ps and 1C Pallor, Pulseless, Pain, Paralysis, Paresthesia, Cold
How far can ligaments stretch before they snap?
6%
when does the maxilla grow to elongate the face?
6-12yo
What is a normal heart rate?
60-100 bpm (140 in infants)
Tip of the scapular is at which rib
7th rib !
What is the average heart rate for 10-14 years?
85 (55-115)
What is the average heart rate for 6-10 years?
95 (65-125)
When do you hear absent bowel sounds?
Adynamic ileus Ischemia of the bowel wall Inflammation of bowel Peritonitis
Meige disease.
An example of lymphedema tarda
TACTILE FREMITUS-
Ask patient to say99 and feel for vibrations on chest wall with ball of hand. Tactile fremitus is increased in consolidation and decreased in pleural effusion.
Irregular Irregularity
Atrial fibrillation
What are the ectopic locations of the thyroid gland?
Behind the sternum At the base of the tongue
What is found in the left iliac/inguinal region?
Descending colon, sigmoid, jejunum, left ovary
Frequency
Desire to pass urine more often, with no volume increase Decreased capacity of the bladder
What are tonsillar "stones"? What do they cause?
Desquamated cells, food and other debris that accumulate in the crypts forming tonsillar "stones." Can cause scratchy throat and halitosis
Fruity Odor
Diabetes ketoacidosis
Flapping tremor (Asterixis) what are the causes
Flapping tremors are *not* symmetrical on both sides. *The most common causes* of asterixis are *encephalopathy* secondary to renal and *liver failure*. Other causes include respiratory failure causing CO2 narcosis, drug overdose with barbiturates and phenytoin and electrolyte disturbances (hypo glycemia, hypokalaemia and hypomagnesaemia). Palmar crease pigment
how do you describe the Shape of the abdomen
Flat ( scaphoid ) , obese, distended,
Define Kernig's sign?
Flex the hip, then extend the knee - pain For meningitis
How do synovial joints move? What are some examples?
Freely movable Knee, shoulder
PERCUSSION NOTES: TYMPANY
GASTRIC AIR BUBBLE, LARGE PNEUMOTHORAX
Where do you see supernumery teeth?
Gardner syndrome (multiple colon polyps)
Define red lesions of the retina
Hemorrhages (round, linear or flame-shaped)
What impact does Herpes simplex infection cause on the eye?
Herpes simplex ulcers are a common cause of corneal related blindness (usually unilateral)
What do you use the diaphragm for?
High pitch sounds
Explain Galant's reflex
How the baby prone in your hand - stroke one side of the back with your hand. The trunk should curve to that side. Disappears at 2 months. Absent in transverse spinal cord lesions.
What are the named perforators of the lower extremities?
Hunterian (proximal thigh) Dodd (distal thigh) Boyd's (below the knee) Lockett's (between the posterior arch vein and deep veins of the leg - three)
Paradoxical Pulse.
If you have noted that the pulse varies in amplitude with respiration or if you suspect pericardial tamponade (because of increased jugular venous pressure, a rapid and diminished pulse, and dyspnea, for example), The difference between these two levels is normally no greater than 3 or 4 mm Hg.
Explain the Rooting reflex
If you stroke the cheek, it will turn and suckle to that side Disappears by 3-4 months Absence indicates CNS disease
Radio-Femoral Delay
In obstruction to flow to the lower extremities there is delay in femoral - Measure upper and lower extremity blood pressure in supine position.
venous insufficiency
Incompetent veins allow flow in opposite direction • Manual compression • Trendelenberg
Define a Barrel chest
Increase in the AP diameter of the chest with teh AP diameter approximating that of the transverse diameter Caused by COPD
What can cause symmetrical enlargement of the thyroid?
Increased secretion of pituitary TSH secondary to deficiency in thyroid hormone biosynthesis. I.e. Grave's disease, subacute thyroiditis
How do you interpret Tactile fremitus?
Increases in volume with consolidation Decrease in volume with pleural effusion, pneumothroax, COPD
What can cause a perforated ear drum?
Infection (Acute otitis media) Secondary to trauma (foreign body or slap over outer ear)
What can cause angular chelitis?
Infection (i.e. candida albicans) Nutritional deficiency (i.e. Vit B12) Overclosure of jaws due to loss of tooth structure
DDx. of a neck lump: Lymphadenopathy
Infectious or malignant
That thoracic landmark is at level: T7?
Inferior angle of scapula
What are muco-cutaneous diseases of the mouth?
Lichen planus Pemphigus vulgaris
Patient presents with bulging eyes with sclera above the iris.
Lid retraction (hyperthyroidism)
What is the blood supply of the tongue?
Lingual artery
Where is HHV type 1 located?
Lips - limited to keratinized mucosa
Uremic odor
Liver failure
What can cause gynaecomastia?
Liver failure High circulating estrogen
Long limbs
Marfan's syndrome
What area is drained by: supraclavicular nodes?
Metastatic disease
What can movement of one side of the chest be do to in respiration?
One side moving more laterally (aletlectasis, subphrenic abscess) One side moving more medially (intercostal muscle paralysis, pleural effusion, tension peneumothroax)
"beefy" red ulcer with granulation tissue
Only seen in venous ulcers, because granulation tissue is from arteries and fibrin ( these are absent in Arterial insufficiency)
Which kidney can be palpated?
Only the lower pole of the right and only some times
Respiration *tend* to affect the What sided Hear mumurs ( if it affects the left it has the opposite effect)
Respiration tend to affect the right side of the heart rather than the left • Inspiration - increase intensity of right sided murmurs inc • Expiration - reduces intensity:
Tremor Most common of all the movement disorders Rhythmic movement of body part with constant frequency (and variable amplitude)
Rest Postural Action (including kinetic and isometric)
Systolic murmur d/t
Restrictions to forward flow
Define black lesions of the retina
Shaped like bone spicules that are associated with retinitis pigmentosa
What are the characteristics of somatic pain?
Sharp, constant Well localized; clearly described; usually unilateral Sensitive to pressure on abdominal wall, friction, burning, jarring, deep inspiration, inflammation Seldom has accompanying symptoms
Sound of percussion over fluid in the abdomen?
Short, dull note
What is the appropriate appearance of fontanelles? What are other signs?
Should be open, soft and flat (AFOSF) Bulging - increase ICP, meningitis (or crying) Sunken - dehydration
Scleral icterus is most likely d/t ___ because :
The Sclera has a particular affinity for bilirubin due to elastin content bilirubin 3mg/dl (normal 0.1-1 mg/dl )
Palmar erythema what are the causes
The causes are numerous and include liver cirrhosis (23%), rheumatoid arthritis (60%), thyrotoxicosis (18%) and diabetes mellitus (4.1%). High circulating estrogens are implicated in the etiology when cirrhosis is present.
Describe temporal pallor ophthalmoscopic classification
The disc is pale (more pronounced on the temporal side) Clear, demarcated margins Vessels are normal Seen in traumatic or nutritional optic atrophy, most often seen in MS
Describe consecutive optic ophthalmoscopic classification
The disc is waxy pale with normal disc margin Arteries are markedly attenuated Causes: retinitis pigmentosa, myopia, central retinal artery occlusion
What is Wharton's duct?
The duct of the submandibular gland, which is located on the posterior surface of the tongue.
Prolonged courses of steroids?
infection or osteonecrosis of the bone.
Describe the Stensen's duct
The parotid duct is thick walled, 5cm long and runs horizontally forward from the upper anterior edge of the gland. Passes anteriorly across the masseter muscles and then turns medially, piercing the buccinator muscle and opens in the vestibule.
What can be identified on the skull by looking from the side?
The zygomatic arch External acoustic meatus Mandible Pterion
What happens, anatomically, during expiration?
There is elastic recoil of the lung The relaxed diaphragm moves upward Decreases the vertical diameter of the chest Increases the intrathroacic pressure - pushing air out
Is there Swelling in chronic arterial disease...?
There is no swelling in chronic arterial disease only in acute infarction !
What is the description of filiform papillae?
They are hairlike keratinized structures containing taste buds.
How do fibrous joints move? What are some examples?
They are immovable Skull sutures
What are the peripheral chemoreceptors? How do they impact respiration?
They are located in the carotid and aortic bodies They are responsive to PPO2 in the arterial blood - triggered when O2 drops less than 60mmHg Afferent of carotid body is the glossopharyngeal nerve; Aortic body - Vagus nerve
What are the skin changes in peripheral venous disease?
Thickening of skin Hyperpigmentation (usually brown) Scaliness Erythema may indicate cellulitis or phlebitis
flexion contracture of hip joint
Thomas
Special tests - hip and spine
Thomas - for fixed flexion contracture of hip joint. • Sacroiliac stress - for sacroilitis • Straight leg raising and bowstring - for sciatica. Please also perform neurologic testing for evidence of nerve compression
What is found in the umbilical region?
Transverse colon, jejunum, ileum, stomach, pancreas, right and left kidneys with ureter
What causes painful hematuria?
Trauma Renal Stones UTI
Define mucocele
Trauma to salivary glands of the lower lip
What can cause paradoxical sternal movement?
Trauma with multiple rib fractures
Parkinsons
Tremor at rest, FLEXED posture rises and walks slowly with short steps
What are the special tests for the hip and gluteal muscles?
Trendelenburg sign Thomas' test (fixed flexion contracture)
Large v wave ( in the JVP)
Tricuspid regurgitation
What is the nerve supply of the scalp?
Trigeminal nerve and C2, C3 from the cervical plexus
What are the skin changes seen in chronic interruption of blood flow?
Trophic changes - thinning, shiny, loss of hair, thickened nails, dependent rubor in severe obstruction, black - gangrene
The prognosis.
When delivering bad news should the diagnosis or prognosis be delivered first?
diastolic murmur d/t
When there is back flow
Otosclerosis
a fixation of the ossicles by bony overgrowth - restricted movements, congenital, infectious, traumatic.
Functional problem
a patient presents with symptoms
what tends to kill pt's with alzheimers
aspiration pneumonia and malnutrition
which conditions predispose you to Respiratory variation
asthma, emphysema and cardiac tamponade there is a drop of greater than 10mm during inspiration. This is referred to as pulsus paradoxus
Early diastolic
backflow across semilunar
Which part of the stethoscope is used to detect low pitch sounds?
bell
Saddle
biaxial movement thumb, wrist
Posterior segment
contains vitreous humor (stagnant) - pieces break off and are called floaters in the eye. No circulation
List the 5 characteristics of the skull to observe.
contour size shape deformities suture lines
lens and ciliary body function
controls fine focusing of light, muscles of the ciliary body control the curvature of the lens
Malleus, incus and stapes
controls vibration/ oscillation of the tympanic membrane via tensor tympani and stapedius - if they are paralyzed will get tinnitus "ringing of the ear"
Hypertensive changes
copper wiring, silver wiring, A/V nicking, hemorrhages (flame), exudate - hard or soft (cotton wool), papilledema
What 2 lymph nodes can be involved in thyroid cancer?
deep cervical supraclavicular
All lymph from the head and neck ultimately drain into which group of nodes?
deep cervical group of nodes
Osler maneuver is to determine
if there is thickening of the vessel dt atherosclerosis
Inspiration
increase intensity of right sided murmurs inc
Leriche's syndrome
isolated aortoiliac disease and post subclavian coarctation of aorta
What is the intensity of a very "tight"/ severe stenosis
it will actually be a lower grade (softer murmur) because so little blood is getting out
inflammation of cornea
keratitis
Dacryocystitis
lacrimal sac inflammation
Patient presents with enlarged, hard, matted, non-tender, and non-mobile lymph nodes.
malignant nodes
Enlarged supraclavicular nodes
metastatic disease
What is the arterial blood supply to the calvarium?
middle meningeal artery
Malar flush
mitral stenosis
Excudate Defined as
more then 30 g of protein
A late systolic
murmur-mitral valve prolapse
Tender lymph nodes
palpable pre and post auricular LN suggest external infection
What skill is used to feel for signs?
palpation
Which 2 skills are used to assess blood pressure?
palpation auscultation
Conjunctiva
palpebral (eyelids) and bulbar (over sclera). can get chemosis (swelling - fluid in episcleral space)
Tinnitus
paralysis of tensor tympani and stapedius, also seen in patients with high bp
Horners
partial ptosis, small pupil, anhidrosis
Barlow Test
passive dislocation
What skill is used to tap for signs?
percussion
How do the eyes present in Myasthenia gravis?
ptosis
What is the description of fungiform papillae?
they are interspersed between filiform papillae and contain 1+ taste buds
Causes of generalized lymphadenopathy
• Leukemia • Lymphoma • Infections • Connective tissue disorders • Drugs
Grey Turner description
• Massive non-traumatic ecchymosis ( bruising ) on abdomen , and flank from infiltration of extraperitoneal tissue
CLOSE ENDED QUESTIONS
A form of question, which normally can be answered with a simple "Yes/no" or a specific simple piece of information. Choices are given by the physician This limits or bias patient's information responses Reduce the willingness of the patients to share ideas, concerns and expectation. Used to determine the precise sequence of symptoms development. "What started first", "Then what", "Finally what" Use simple English. Avoid jargon (medical) One question at a time. Avoid multiple choice questions; avoid rapid fire, closed questions. If possible make question visual. Ask patient to point and show. Avoid leading questions e.g. "Is the pain sharp or dull?
OPEN ENDED QUESTIONS
A question that cannot be answered with a simple "Yes/no". It allows the patient to give information in their own words. Define or limit the range of response to an area of interest. Choices made by the patient. Should address the cardinal manifestations of disease. 1. Symptom description - (quality, intensity, location) "Tell me about you pain." 2. Story line (onset, setting, frequency, duration) "Can you describe what's happening with your pain since it first started." 3. Modifying factors (aggravating, relieving, treatment attempted) "What have you done or tried that has made your symptoms better or worse." 4. Associated symptoms "What other changes have you noticed in how you feel and what you are able to do."
VALIDATION, ACKNOWLEDGEMENT, LEGITIMIZATION
An acknowledgement that the patient's opinions and emotions are justified, whether or not the listener agrees with the content
4. stupor
Arousable for Short Periods Slow Responses
ACTIVE LISTENING
Closely attend to what the patient is communicating, verbally and non-verbally including being aware of the patient's feelings
Delirium
Confusion with Disordered Perceptions and Decreased Attention Span Marked Anxiety with Motor and Sensory Excitement Inappropriate Reactions to Stimuli --> Alcohol<--
Lethargy
Drowsy, falls asleep quickly Once aroused, responds appropriately
ROOT CAUSES OF SEIZURE (?only 3?)
Epilepsy Provoked ->alcohol Non-Epileptic Seizures -> no abnormal electrical activity -> may be responsive
PARTNERING
Make explicit your desire to work with the patient in an ongoing way Offer to work with patient in solving the issues. "Let's work on this together" "You do seem sad. Would you like help with this
MIRRORING
Matching the physician's position to that of the patient. The paralanguage of the patient can also be matched: - qualities of speech such as pacing, tone and volume
5.Coma.
Neither Awake nor Aware De-cerebrate Posturing to Painful Stimuli. (Extensor response)
HYPOTHESIS FORMULATION
Postulating a possible explanation of a patients non-verbal feelings. E.g. "I suspect you must be very angry. Am I right?" Used when emotions are implied but not expressed.
ECHOING
Repetition of the patient's last words. Encourage patients to express themselves, factual details and feelings
Types of Seizure
Simple Partial Seizure Complex Partial Seizure Generalized Seizure -> Absence (petit mal seizure) -> Generalized tonic-clonic (grand mal seizure -> Clonic -> Myoclonic -> Atonic (drop seizure)
SUMMARIES
Summary of data collected. Main areas. Serve primarily to confirm what you believe you heard Often lead to corrections or to additions of critical information Indicate that you value what the patient has said Alerts you to elements not included in the cardinal manifestations of disease
CONTINUERS
Technique of eliciting information without providing direction or topic. Verbal e.g. "Go on", "Tell me more", "What else". Non-verbal - nod of the head, leaning forward, eye contact
Trachea deviates to opposite side in
Tumor Pleural effusion Pneumothorax
Segues (Transitions):
Verbal road map that signal the transition from one line of question to another "Now, I am going to ask about your social history
ANTICIPATORY SILENCE
Wait expectantly in silence. Any strong feeling the patient has are likely to surface
Define fibrocystic changes
*Upper outer quadrants* may be denser ->with slight irregularity in contour, ->but a firm mass is not identifiable
Pulse deficit
- Difference between the heart rate by auscultation and *peripheral rate* by palpation (rapid irregular rhythm e.g. AF)
Methods: Calgary-Cambridge Guide
- Initiate the Session - Gather Information for the Session - Provide Structure for the Session - Build the Relationship - Explain and Plan - Close the Session
Tools: Follow-Up • Medical Care
- Monitor health parameters (BP, Blood Sugar, Weight, etc.) - Document medical compliance/adherence (Medications, Labs, Referrals, Weight Loss/Gain, etc.) - One of the best ways to STAY OUT OF LEGAL TROUBLE
What factors can influence SV?
- Preload (volume of fluid flowing into the right atrium) - Afterload (pressure generated by the LV that will be required to pump blood into the aorta) - Intropy (degree of ventricular contractility)
Methods: P.A.C.E. System (for pt's to use)
- Present detailed information about how you feel - Ask questions if desired information is not provided - Check your understanding of provided information - Express any concerns about recommended treatment
Tools: Follow-Up • Education (The "Re" 's)
- Re address sensitive topics and areas of disagreement - Re check understanding and reassess goals and objectives - Re inforce knowledge and encourage compliance - Re iterate the action plan and review results - Re educate as needed
Regular/Irregular
- Sinus Arrhythmia - Atrial or Nodal - VPC - Ventricular Premature Beat
At what level should the blood pressure cuff be places
- Support the arm at the level of the patient's heart (4th interspace at the sternum
Splenomegaly due to Hyperplasia or hypertrophy
- increased demand on splenic function : ie anemias, thalessemias - immune response to systemic infection , ie mononucleosis , bacterial endocarditis
What are the accessory muscles of respiration?
->Intercostals, ->SCM, ->levator scapulae, ->scalene muscles, ->erector spinae
What are the characteristics of ductal carcinomas?
->Irregular, ->firm to hard, ->asymmetric, ->non-tender masses, varying sizes ->Average - 2cm ->Early - 1cm
What hormones are needed for milk secretion is dependent on?
->Progesterone, ->placental Lactogen, ->Cortisol, ->Estrogen, ->Prolactin, ->Insulin
What are the tests for appendicitis?
->Signs of peritonitis ->Rovsing's sign (pressure to right side) ->Psoas sign (flex left hip to left shoulder) - retroperoteneal retrocecal ->Obturator sign (flex left hip to right shoulder) - pelvic appendices ->DRE
Clubbing what are the Abdominal causes
-causes include chronic inflammatory bowel diseases like ulcerative colitis, GI lymphoma, *cirrhosis of the liver* ( mentioned in class as well), malabsorption conditions like celiac disease, pulmonary diseases, congenital heart disease
Signs of venous insufficiency
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
History taking steps
1. INTRODUCTION + BIODATA - NAME 2. CHIEF COMPLAINT 3. HISTORY PRESENTING ILLNESS 4. PAST MEDICAL HISTORY 5. FAMILY HISTORY 6. SOCIAL HISTORY 7. OBGYN/SEXUAL HISTORY 8. REVIEW OF SYSTEMS 9. CLOSING THE INTERVIEW
Strenght of the ligament depends on two factors ( knee relys on these)
1. the amount of collagen 2. if it crosses ( it is stronger then up and down)
- Atrial Flutter ( what is the pulse)
100-175
What is the average heart rate for 2-6 years?
103 (68-138)
Describe the esophageal hiatus
10th rib Esophagus, anterior and posterior vagus nerve, esophageal branches of the left gastric vessels
At what age do breasts begin to develop?
10yo
What is the average heart rate for 1-2 years?
110 (70-150)
Ventricular Tachycardia ( what is the pulse)
110-250
What is the average heart rate for 6-12 months?
115 (75-155)
What is the average heart rate for 1-6 months?
130 (80-180)
What is a normal rate for breathing?
14-20bpm (up to 44 for children)
What is the average heart rate for at birth?
140 (90-190)
What is the normal ratio of AP diameter/transverse diameter?
1:2 5:7 From PAL to AAL From AAL to AAL
Describe a Pulsus Bigeminal. What can cause it?
2 beats in rapid succession Normal beat plus premature beat The two beast vary in amplitude due to the reduced stroke volume of the second beat Seen in premature ventricular contraction
# of teeth
2 incisors 1 canine 2 pre-molars 3 molars
What is the arrangement of teeth?
2 incisors, 1 canine, 2 premolars, 3 molars
The slow of the lower borders of the lung run....?
2 ribs above the plerual reflection Lower border crosses the 6th rib at the MCL and T10 in MSL
Meniere's disease
20-50yrs, vertigo, tinnitus, and hearing loss, nausea, vomiting, dilation of semicircular canals and increased endolymph
at 1 year visual acuity of child
20/200
What is the maximum achievable heart rate?
220 - age in years = # bpm
Sternal angle (angle of Louis):
2nd rib (interspace)
Rooting Reflex
3-4 month disappear negative indicates CNS disease -stoke side of mouth -turns toward to suck
Clicker Question
3. peripheral arterial disease
At what angle
30-45 degree angle at trunk
2° AV Block ( what is the pulse)
30-60
What is the scale for amplitude of pulse?
4 - bounding 3 - full and increased 2 - normal 1 - diminished, barely palpable, thready 0 - absent, not palpable
Communication task
4 Es - engage, empathize, educate, enlist
Normal time for expiration
4s if longer consider COPD
What are the lower borders of the costal pleura?
8th rib - MCL 10th rib - MAL 12th rib - neck
What is bradycardia?
< 60 bpm
What is bradypnea? What can cause it?
<10bpm Seen in ->CNS diseases, ->metabolic disorders, ->raised intracranial pressure
Bradycardia ( what is the pulse)
<60
What is tachycardia?
> 100 bpm
Isolated Systolic Hypertension
>140 Systolic Diastolic is normal (
What is hyperpnea? What can cause it?
>24bpm - rapid deep Seen in ->exercise, ->anxiety, ->metabolic acidosis, ->midbrain/pontine abnormalities ~infection, ~hypoxia, ~hypoglycemia
Define leukoplaki
A white patch that cannot be scraped off and can be premalignant. Associated with smoking/chewing tobacco
Describe a Water Hammer Pulse. What can cause it?
AKA Corrigan pulse, Collapsing pulse Greater amplitude, rapid rise/upstroke, normal summit, sudden descent Due to a blackflow through the aortic valve Seen in aortic regurgitation and patent ductus arteriosus
Define a stye
AKA hordeolum Red, swollen and tender Pus discharge
Define pectus excavatum (AKA funnel chest)
AP diameter of the chest is decreased, primary in the mediastinum Structures in the midline of the thorax get displaced Becomes systematic with exertion (Decreased stamina, endurance, easy fatigability and tachycardia)
Remittent temperature
Abating and relapsing in cycles Infective endocarditis.. Remains elevated throughout the day but with fluctuations more than 1 F.
Define microtia
Abnormalities of ear development ranging from subtle deviations in size, shape and location to absence of the pinna and ear canal
What is the pupillary response in Adie's pupil?
Accommodation is sluggish Impaired impaired pupillary response Affected pupil is dilated in bright light and relatively constricted in dim light Contracts vigorously with pilocarpine (minimal effect on good pupil)
What causes palmar crease pigmentation?
Addison's disease
Marcus Gunn
Afferent defect in light perception. The affected eye constricts less to light and redilates more more to dim light than the normal pupil
What are risk factors for the development of peripheral arterial disease?
Age (over 50) Smoking Family history of dyslipidemia Diabetes Hypertension Hyperlipidemia History of heart disease Obesity
Describe a Pulsus alterans. What can cause it?
Alternating weak and strong beat with ah normal rhythm. Usually associated with a left-sided S3. Seen in left ventricular failure
Auscultatory Gap
An auscultatory gap is a 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
Clicker question:
Answer is 2
Where does the trachea bifurcate?
Anteriorly - level of the sternal angle Posteriorly - T4 spinous process
Describe the gait of older age?
Associated with aging Speed, balance and agility decrease with aging Steps become short, uncertain and shuffling Legs may be flexed at hips and knees Cane can bolster lost confidence
Describe parkinsonian gait
Associated with basal ganglia defects of Parkinson's disease Posture is stooped Head and neck forward and hips/knees slightly flexed Arms are flexed at elbows/wrists Slow in getting started Steps are short and shuffling Decreased arm swinging Patient turns around stiffly "All in one piece"
Describe scissors gait
Associated with bilateral spastic paresis of the legs Gait is stiff Legs advance slowly, thighs cross forward on each other Steps are short Patient appears to be walking in water
Describe cerebellar ataxia gait
Associated with disease of the cerebellum or associated tracts Gait is staggering, unsteady, wide based Exaggerated difficulty on the turns Double failure on the Romberg
Describe steppage gait
Associated with foot drops, secondary to LMN disease Patients drag their feet or lift them high, with knees flexed Bring them down with a slap onto the floor Appears to be walking up stairs Unable to walk on their heels
Grey Turner is associated with
Associated with hemorrhagic pancreatitis , • Retroperitoneal hematoma • Also strangulated bowel
Describe spastic hemipareisis gait
Associated with lesions in the Corticospinal tract (i.e. stroke) One arm immobile and close to side (elbow, wrist, IP joints flexed) Leg extended, plantar flexion of the foot When walking, patient drags the foot (scraping the toe) or circles it stiffly outward and forward (circumduction)
Describe sensory ataxia gait
Associated with loss of proprioception Gait is unsteady and wide based Patients throw feet forward and outward and bring them down First on the heels and then on the toes - double tapping sounds Watch the ground for guidance Positive Romberg sign Staggering gait worsens with eyes closed
What can cause wheezes through out the chest?
Asthma, chronic bronchitis, COPD, congestive heart failure
How can you safely access the pericaridal sac?
At the *left parasternal* area, between costal cartilages *4 and 6* Can be entered without piercing the pleural space and lungs
Where is the right hemidiaphragm located?
At the level of the 5th rib anteriorly T9 posteriorly
Define "pillars of the fauces"
At the oropharyngeal junction, the lateral walls of the facues are formed by two arches - anterior (palatoglossal) and posterior (palatopharyngeal)
What is Biot's breathing? What can cause it?
Ataxic breathing - unpredictable irregularity May be ->shallow, ->deep or ->cease for a short period Seen in *respiratory depression* and midbrain damage at the *medulla*
(Biot's Breathing) Ataxic breathing
Ataxic breathing is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include respiratory depression and brain damage, typically at the medullary level.
Ataxic Breathing (Biot's Breathing)
Ataxic breathing is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include respiratory depression and brain damage, typically at the medullary level.
Hyperthyroidism leads to what type of pulse ( described as a chest flutter)
Atrial fib. =Irregular Irregularity
What is the a wave indicative of?
Atrial systolie Occurs just prior to the first heart sound and the carotid pulse
Define actinic damage
Atrophy with erythema or leukoplakia with marked thickening. Both can occur congrously.
Explain the Hering-Breuer reflex
Based on peripheral stretch receptors located in teh smooth muscle of the bronchi and bonchioles They act during labored breathing triggered by increased demand for O2 (exercising, mountain climbing) Protective reflexes, mediated by the Vagus nerve, that prevents over inflation (expansion) of the lungs by terminating inspiration
When does the frontal suture close? The others?
Begins during infancy (up to two years) Completes by 6 years The rest fuse by middle age.
When do the anterior fontanelles close?
Between 4-26 months
What is the vitreous chamber of the eye?
Between lens and retina Filled with vitreous humor
What is the anterior chamber of the eye?
Between the cornea and iris Filled with aqueous humor
What is the posterior chamber of the eye?
Between the iris, zonule fibers and lens Filled with aqueous humor
Essential
Bilateral postural or kinetic tremor of the hands and forearms (usually 4-6 Hz) or isolated head tremor without evidence of dystonia. Absence of other neurologic signs or recent trauma. MOST COMMON NEUROLOGIC DISORDER THAT CAUSES POSTURAL/ACTION TREMORS. (5% OF WORLD)
Define Cullen's sign
Bluish discoloration of the umbillicus
NON-VERBAL CUES
Body Language: Facial expression; eye contact; leaning forward; posture; head position; movement such as nodding; placement of arms and legs (crossed, neutral, open
Where do you check the heart rate in infant/toddler?
Brachial or femoral artery
Causes of chronic dyspnoea
CHRONIC-COPD -ANEMIA -FIBROSING ALVEOLITIS
Condyloid - biaxial movement
CMJ, carpometacarpal, temporo-mandibular; wrist Flexion&extension & adduction &abduction
Levator palpebrae superioris innervation
CN 3 (oculomotor nerve)
What is the nerve supply of the palate?
CN 9 EXCEPTION - Tensor veli palatinin CN ?
What cranial nerves come from the midbrain?
CN3, CN4
What is the only CN that crosses the midline?
CN4
What cranial nerves come from the pons?
CN5-8
What cranial nerves from from the medulla?
CN9-12
What do the chemoreceptors monitor?
CO2 and O2
Dependent Pitting bilateral edema
CVD edema
What causes painless hematuria?
Caner Glomerulonephritis BPH
What is the c wave?
Cannot be seen clincally Present on right artiral pressure recordings
What is Quinke's sign? What does it indicate?
Capillary pulsation in the nail bed Manifests as alternating flushing and blanching of the nail bed due to pulsations in the subpapillary arteriolar and venous plexuses Seen in aortic insufficiency
Pain in the wirst with tingling and numbness that radiates into the index finger
Carpal Tunnel Syndrome 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.
What can the absence/abnormality of a red reflex indicate?
Cataracts, retinopathy of prematurity or retinoblastoma
Define exertional dyspnea
Caused by failure of the left ventricular output to rise with exercise, resulting in increased pulmonary venous pressure and reduced lung compliance
What is the y descent?
Caused by right ventricular diastole which reduces right ventricular pressure and opens the tricuspid valve
Most common cause of jaundice
Causes : Liver disease Hemolysis ( less often )
Bowel Sounds • ABSENT= Ileus : Inhibition of peristalsis
Causes : peritonitis mesenteric thrombosis enterocolic ulceration Total Obstruction post surgical
What is the clinical presentation of a CN4 palsy?
Causes the eye to be slightly up and out Patient will tilt their head toward the opposite shoulder to minimize the diplopia
If someone comes to you with these problems: • Coronary artery disease • cerebrovascular disease Then consider
Checking the arterial system for dysfunciton
How do children control their cardiac output?
Children control their CO almost exclusively by increasing their heart rate
What are GIT causes of clubbing?
Chronic inflammatory bowel disease (i.e. ulcerative colitis) GI lymphoma Cirrhosis of the liver Malabsorption condition (celiac disease) Pulmonary disease Congenital heart disease
What secretes aqueous humor? Where is is located?
Ciliary body behind the iris
Define Waldeyer ring?
Circle of lymphoids that drains the mouth
Define Roth's spots
Clear white center surrounded by hemorrhage Seen in endocarditis, HIV retinitis and leukemia
Trachea deviates to same side in
Collapse of lungs.
Define Posterior uveitis
Combined cyslitis and choroiditis
Define miosis
Constriction of the pupil Under parasympathetic innervation
What causes Dupuytren's contracture?
Contraction of the palmar fascia with gradual pulling the metacarpophalangeal joints and proximal interphalangeal joints of the little and ring fingers in flexion. Results in the inability to extend these joints. Seen in alcoholic cirrhosis.
What does the Pneumotaxic center regulate?
Controls the *rate* of inspiration ->by controlling the *duration* of inspiration
What qualifies as hypothermia?
Core body temperature of under 95oF Seen in exposure to cold, hypothyroidism
Define Keratoconus. What is Munson's sign?
Cornea protrudes as a cone, with the apex becoming thin and scarred. Bilateral but asymmetrical. Presents with slow deterioration of vision Looking downwards makes the cone more obvious - Munson's sign
Why do some cough when cleaning the ear?
Cough precipitated due to stimulation of the vagus nerve.
What are the special tests for the elbow?
Cozen's test (Lateral epicondylitis - "tennis elbow") Medial epicondylitis - "golfer's elbow"
What are the adventitious sounds?
Crackles Wheezes Rhonchi Stridor Pleural rub
What are the cranial structures from the top of the head?
Cranial sutures Bregma Lambda
Define a chalazion
Cyst like No acute signs of inflammation Due to inspissated secretions of the mibomian glands
Define tophi
Deposition of uric acid crystals
What is the diameter of the apex beat
Diameter - normally one interspace and less than 2.5 cm
What happens, anatomically, during inspiration?
Diaphragm contracts, lowers its dome (flattens), descends and there is an increase in the vertical diameter of the thoracic cavity Elevation of the ribs increases the transverse and antero-posterior diameter of the chest This decreases the intrathoracic pressure - drawing air in
When is S3 and S4 heard?
Diastole, S3 and S4 normally indicates cardiac failure
How can you prevent peripheral arterial disease?
Dietary modification - reduction of fat, cholesterol and simple carbohydrates Treatment of dyslipidemia Weight reduction Smoking cessation Exercise Good control of DM and HTN
What are causes of cataracts?
Down's syndrome Cretinism Ocular diseases, such as iritis Systemic disease (Diabetes, hyperparathyroidism) Penetrating eye wounds
Cruciate ligaments: test
Drawer sign, anterior and posterior
Define ptosis. What can cause it?
Drooping of the eyelid. CN III nerve palsy, sympathetic dysfunction (Horner's), neuromuscular disease (Myasthenia Gravis)
Define Xerostomia
Dryness of the mouth
What are the symptoms of Sjogren's syndrome? What is the cause?
Dryness of the mouth and eyes Due to inflammation of the salivary and lacrimal glands
Define a waddling gait?
Duck like walk Proximal muscle weakness of the hip Seen in congenital hip dislocation
When do you hear high pitched wheezes?
Due to multiple distal airway obstruction heard in asthma
What are the characteristics of visceral pain?
Dull, aching, crampy, intermittent Poorly localized; perceived in the midline, difficult to describe Sensitive to stretch, spasm, distention, ischemia, inflammation, traction Accompanied by - nausea, vomiting, sweating, pallor, referral to cutaneous structures
Sound of percussion over reduction of air or increase of fluid?
Dull, short note
What is a continuous fever?
During a 24hr period, the temperature is persistently above normal
Define hemiplegic breath movements?
During normal breathing, the affected side moves more than the unaffected side, but moves less during forced breathing
PERCUSSION NOTES:HYPERRESONANCE
EMPHYSEMA, PNEUMOTHORAX
PNEUMOTHORAX
EXPANSION-REDUCED ON AFFECTED SIDE *PERCUSSION-HYPER RESONANCE* BREATH SOUNDS-REDUCED OR ABSENT SUBCUTANEOUS EMPHYSEMA
keloid
Ear - hard nodule - inject steroids to reduce size
• HIGH PITCHED
Early obstruction produces hyperactive peristalsis proximal to the obstruction
What are the signs of diabetic retinopathy?
Early: nonproliferative - Capillary microaneurysms - Dilated and torturous vessels - Non-perfusion or areas - Rupture of microaneurysms, capillaries and venules results in hemorrhages (flame-shaped or blot) - Exudates (Due to leaky capillaries) as clusters, streaks or rings around the fovea Later: proliferative - Neovascularisation (new vessels) - Hemorhage, retinal tears and detachment
Define Fordyce granules
Ectopic sebaceous glands on the lip - whitish-yellow papules
What are signs of peripheral venous disease?
Edema/swelling Stasis dermatitis, thickening of the skin, lipodermatosclerosis Ulcers varicosities Venous cords Calf tenderness (thrombophlebitis)
What is the nucleus for CN2?
Edinger-Westphal
Hinge - allows uniaxial movement
Elbow is one of the most stable joints
Massive embolism
Elevated JVP
Define sebaceous cyts
Elevations with a punctum indicating a blocked sebaceous gland
Where does the lens and all the structures anterior to the iris originate from?
Embyonic ectodermal layer
What can cause bradycardia in a child?
Endocrine abnormality, poisoning, head trauma, cardiac disease, thyroid gland
Physiologic
Enhanced physiologic tremor. High frequency 10-12 Hz, not visible unless enhanced by ->adrenergic medications, ->fright /anxiety, ->thyrotoxicosis, ->other drugs by unknown means, and others. MOST COMMON CAUSE OF POSTURAL/ACTION TREMORS IS ENHANCED PHYSIOLOGIC TREMOR. (NOT EXCLUSIVELY NEUROLOGIC; 100% OF WORLD)
Describe a malignant lymph node
Enlarged Hard Non-tender Borders not clearly defined Little to no mobility (fixed to surrounding tissue)
Describe an inflamed lymph node
Enlarged Soft to firm Tender Discrete Mobile, but may be slightly reduced
Lymph nodes (Inflammed)
Enlarged, Soft to Firm, Tender, Discrete, Red on the surface
Describe an inflamed LN
Enlarged, discrete, mobile, tender, soft
Describe a malignant LN
Enlarged, hard, matted, non-tender and non-mobile
Episcleritis is a localized ocular redness from inflammation of the episcleral vessels. In natural light, vessels appear salmon pink and are movable over the scleral surface. Usually benign and self-limited, episcleritis may be nodular, as shown here, or may show only redness and dilated vessels.
Episcleritis
Describe a Pulsus Paradoxus. What can cause it?
Exaggeration of the normal fall in amplitude of the pulse during inspiration Decreased is determined by changes in the systolic blood pressure Normal - 10mmHg fall during inspiration If a fall is greater than 12-15mmHg, indicative of Pulsus Paradoxus Seen in severe obstructive lung disease, pericadial tamponande, constrictive pericarditis
What is the facial blood supply?
Facial artery Superficial temporal Transverse facial
Define ileus
Failure of peristalsis and is a normal response of bowel to laparotomy and peritonitis
B) Sensory to Face and Cornea Test for Pain, Touch & Temperature Corneal Reflex Jaw Reflex
Fifth - Cranial Nerve
Define a fibroadenoma
Firm, well circumscribed, mobile mass varying size ->a few millimeters ->to a few centimeters. Single or multiple Non-tender Younger women
What are the tests for pyelonephritis?
Fist percussion
Define Brudzinski's sign?
Flexing the patient's neck causes flexion of the hips and knees For meningitis
Spastic hemiplegic
Flexion at the elbow & wrist with their fingers closed walking they will circumduct ( semi circle with the leg) the Damaged leg
How do we test C6?
Flexion at the elbow joint
How do we test C8?
Flexion at the finger joints
How do we test L1, L2?
Flexion of the hip
How do we test L5, S2?
Flexion of the knee
Define the base of the skull
Floor of the cranial cavity Parts of the sphenoid, temporal and occipital bones
What causes high pitched tinkling sounds in the abdomen?
Fluid and air under tension in a dilated bowel Intestinal obstruction
What are the cells of the thyroid?
Follicular cells which concentrate and organify iodine and involved in thyroid hormone synthesis Parafollicular (C cells) which secrete calcitonin which has a minor role in serum calcium ocncentration
DDx. of a neck lump: Thyroid adenoma?
Follicular commonest
When do you hear decreased bowel sounds?
Following general or spinal anesthesia
What are the cranial structures from the bottom of the skull?
Foramen magnum Maxilla Hard palate
PULMONARY EMBOLISM
GENARAL-TACHYCARDIA,TACHYPNOEA,FEVER LUNGS-PLEURAL FRICTION RUB Right ventricle gallop and Heave increased pulmonary component of the 2nd heart sound tricuspid regurgitation MURMUR
What are factors affecting temperature?
Gender Recent activity Food and fluid consumption Time of day Stage of menstrual cycle
List the components of the general survey.
General state of health (healthy, acutely ill, chronically ill) Height, Weight, and Build Posture Gait Involuntary movements (tremors, tics) Eye contact, Grooming, Personal hygiene, Odors Facial expression and Facies Manner of speaking (phonia, arthria: articulate, phasia) State of awareness
Phonia
Generating the sounds
What are the four extrinsic muscles of the tongue? What do they do?
Genioglossus, hyoglossus, styloglossus, palato-glossus Move the tongue
What causes of aqueous humor drainage fails?
Glaucoma Increased intraocular pressure Can cause retinal damage and blindness
Order of the Physical Examination of the Abdomen
Global Assessment • Inspection • ASCULTATION • Palpation • Percussion
Define Kayser-Fleisher ring
Greenish-yellow rings in the cornea Seen in Wilson's disease - copper deposition in Descemet's membrane of the peripheral cornea
What are sensori-neural causes of hearing loss?
Hair cell damage CN 8 problems Brain (rare) Meniere's disease Cochlear otosclerosis
Define broncho-vesicular breathing
Has midway characteristics between vesicular and bronchial breathing Both inspiratory and expiratory sounds are equal in duration and there is no gap between inspiration and expiration
What can lead to speech delays?
Hearing loss
What do you examine using auscultation?
Heart Lung Abdomen Blood vessels
What types of sound is the Diaphragm of the stethoscope used for?
High pitched sounds (i.e. 300hz)
Ball and socket
Hip = stable joint Shoulder = unstable joint
Clicker Question: " most appropriate"
Homan!! = most appropriate
The affected pupil, though small, reacts briskly to light and near effort. Ptosis of the eyelid is present, perhaps with loss of sweating on the forehead of the same side. In congenital Horner's syndrome, the involved iris is lighter in color than its fellow (heterochromia).
Horner's Syndrome
What symptoms are seen when a temperature is falling?
Hot and sweating
Ask them to explain to you what they are going to tell their loved ones or others about what was discussed.
How can we elicit our patients understanding of the discussion you had with them?
Empathy and partnering
How can you deal with a patient with anxiety/fear?
By having a strong knowledge, and ability to use, the different types of communication skills Empathy, validation, active listening, partnering, and understanding.
How is physician anxiety overcome? What skills can be, and are often used, to overcome physician anxiety?
What is the effect of hyperthyroidism on hair? Hypothyroidism?
Hyper - thin and sparse Hypo - coarsening and dryness
Affect on hearing in Belys palasy
Hyperaucusis
What can cause a pulse amplitude of 3?
Hyperdynamic circulation (hyperthyroidism)
Sound of percussion over hyperinflation of the lung?
Hyperresonant
What nerves supply the muscles of the tongue?
Hypoglossal nerve EXCEPTION - palato-glossus (vagus nerve)
Low JVP
Hypovolemia - blood loss, dehydration
TACTILE FREMITUS increased in and decreased in:
INCREASED IN PNEUMONIA(CONSOLIDATION) DECREASED IN PLEURAL EFFUSION PNEUMOTHORAX FIBROSIS/ATELECTASIS
Explain Barlow's test
Identifies a hip that can be passively dislocated. Hip is flexed and thigh is adducted while pushing posteriorly, causing femoral head to dislocated posteriorly Dislocation is palpable as femoral head slips out of acetabulum
What blood vessels are effect in non-diabetics?
Ileal-femoral occlusion
What does intercostal retraction signify?
Imbalance between negative intrathoracic pressure generated and the ability of the lungs to expand during inspiration Retraction may be generalized (inspiratory obstruction), focal (bronchial obstruction, fail chest, constrictive pericadritis). Unilateral loss of retraction (pleural effusion, pnuemothorax and consolidation)
This will be a question *Risk factors* for the development of deep vein thrombosis
Immobilization/Bed rest Surgery - pelvic and long bones Pregnancy *Obesity* ( also Risk factor for Atherosclerosis) *Smoking*(also Risk factor for Atherosclerosis) Oral contraceptives Fractures Hypercoagulability Malignancies Economy class syndrome
Obstructive Breathing
In *obstructive lung disease*, *expiration is prolonged* because narrowed airways increase the resistance to air flow. Causes include *asthma, chronic bronchitis, and COPD*
Confusion:
Inappropriate response to questions Decreased attention span and memory
Where does the nasolacrimal duct open into?
Inferior meatus of the nose
A swelling between the lower eyelid and nose suggests inflammation of the lacrimal sac. An acute inflammation (illustrated) is painful, red, and tender. Chronic inflammation is associated with obstruction of the nasolacrimal duct. Tearing is prominent, and pressure on the sac produces regurgitation of material through the puncta of the eyelids.
Inflammation of the Lacrimal Sac (Dacryocystitis)
Define choroiditis
Inflammation of the choroid
Define cyclitis
Inflammation of the ciliary body
Define keratitis
Inflammation of the cornea Symptoms include conjunctival hyperemia, tearing, photophobia
Define iritis
Inflammation of the iris
In the Bronchovescicular what is the intensity, pitch, I:E ratio Description and normal location
Intnesity = moderate Pitch= moderate I:E ration 1:1 Description= Rustling but tubular Normal location: over main stem bronchi
Define amphiarthrosis (fibrocartilaginous) joints?
Joints connected by fibrocartilage with no joint cavity between them Joints are slightly moveable Vetebral joints, symphysis pubis, ascroiliac joints, costochondral junction
Define canthi refer
Junction between the upper and lower eyelids
Immunizations
KNow these HepB1 @ birth HepB2@ 1-4 months, 3 @6months
Where do you do a spinal puncture?
L3/L4 or L4/L5
Antalgic
LIMPING of weight bearing placed down gingerly with little weight placed on it, wincing and hunched shoulders
PERCUSSION NOTES: DULLNESS
LOBAR PNEUMONIA
CLUBBING
LUNGS DISEASES (PYOGENIC BRANCOGENIC CARCINOMA FIBROSING ALVEOLITIS) HEART DISEASES (CYANOTIC CONGENITAL HEART DISEASE & SUBACUTE BACTERIAL ENDOCARDITIS) GASTROINTESTINAL DISORDERS INFLAMMATORY BOWEL DISEASES (chrones) IDIOPATHIC/CONGENITAL
What are the functions of the breast?
Lactation Sexual pleasure Female beauty and self-image
Middle ear infection
Large amount of discharge, pus
What causes epigastric depression with inspiration?
Large pericardial effusion
What causes unilateral bulging of the apex?
Large pleural effusion (lungs floating on fluid)
What are the special tests for sciatic nerve root irritation or entrapment?
Lasegue's or straight leg raising tests Bowstring maneuver
Define scoliosis
Lateral curvature (often accompanied by a rotary deformity) Thoracic spine Restricts rib movement, placing the respiratory muscles at a mechanical disadvantage and displaces the organs of the thoracic cavity Chest wall and lung compliance decreases
What does CN6 control?
Lateral rectus for eye abduction
What layer of the scalp do arteries lie in? What layer to branches penetrate?
Layer 2 Layer 4
Varicocele more common in
Left
Pink frothy sputum
Left Ventricular failure with pulmonary edema
Define Adie's (Tonic) pupil
Lesion in the ciliary ganglion - sphincter and the ciliary muscles are affected (pupils and accommodation) Unilateral Women, young adults Random association - reduction in the knee jerk reflex
What are causes of generalized lymphadenopathy?
Leukemia Lymphoma Infection (Viral, bacterial and protozoa) Connective tissue disease Drugs
What are the palatine muscles? What do they do?
Levator veli palatini (elevation) Tensor veli palatini (tensor) Palatoglossal (elevator of the tongue - draws the soft palate down to close the oropharyngeal isthmus) Palatopharyngeus (tenses the soft palate and pulls the walls of the pharynx upward, forward and medially during swallowing) Musculus uvulae (assists in closing of teh nasopharynx during swallowing)
What is found in the right upper quadrant?
Liver, gallbladder, duodenum, right kidney and adrenals, head of pancreas, parts of the ascending and transverse colon, ureter
What is found in the right hypochondrium region?
Liver, gallbladder, hepatic flexure, transverse colon, right kidney
What is found in the epigastric region?
Liver, stomach, right and left kidney with adrenals, transverse colon, pancreas, jejunum
What can cause neck pain?
Local pathology. Referred pain from angia or myocardial infarction.
Describe the pre-auricular and parotid superficial LNs
Located anterior and antero-inferior to the tragus Drains the anterior surface of the auricle, antero-lateral scalp, upper half of the face, eyelids and cheeks.
DDx. of a neck lump: Branchial cyst
Located anterior to upper 1/3 of the SCM muscle
What are the central chemoreceptors? How do they impact respiration?
Located in the interstitial space outside of the BBB They respond to PCO and pH within the CSF When pH drops - respiration increases
Describe the occipital superficial LNs
Located near the attachment of the trapezius to the skull in the are of the occiput. They drain the posterior scalp and neck.
Explain Ortalani's test
Looking for dislocation of the hip. Palpable sensation of the gliding of the formal head in and out of the acetabulum Reduction of a dislocation of femoral head
What are the signs of serous otitis media?
Loss of luster of the drum with visible effusions behind it Handle of the malleus is horizontal Results from blockage of the eustachian tube with a fall in the pressure in the tympanic cavity
What do you use the bell for?
Low pitch sounds
When does the trachea deviate to the same side of the injury?
Lung fibrosis Post pneumonectomy "Being pulled"
What do you examine using percussion?
Lungs Heart Abdomen
What area is drained by: deep cervical nodes?
Lymphoma, metastatic malignancy, TB, actinomycosis
Differentials for chest pain
MI or pulmonary embolism
What does the medial longitudinal fasciculus do?
MLF Connects the 6th nerve nucleus to the 3rd nerve nucleus to conjugate movement
pendulum nystagmus (not slow then rapid)
MS
there might be a link between EBV and which CNS disease?
MS
Define angular chelitis
Maceration and cracking at the corner of the mouth.
What is the clinical presentation of carcinoma in situ?
Mammorgraphic findings not palpable
Optic disc
Margin (sharp) and rounded (shape), yellow-orange = normal color white = dead optic nerve
Define blepharitis
Margin is red and irritated Covered with scales
Describe glacomatous ophthalmoscopic classification
Marked cupping of the disc Bayonetting and nasal shifting of the retinal vessels Splinter hemorrhages may be observed at the disc margin
What are the functions of the tongue?
Mastication Articulation Cleansing of the mouth
Torn menisci-
McMurray sign- Listen fo ra click or a look for a lock
What are the special tests for cartilaginous injury of the knee?
McMurray's test Medial meniscus - Fouche's sign
What causes Koplik spots?
Measles
What are the special tests for ligament integrity of the knee?
Medial ligament Lateral ligament Anterior draw sign Posterior draw sign
When do you hear dullness?
Medium soft, with a thud-like sound Lobar pneumonia
Where do the anterior and middle ethmoidal cells drain?
Middle meatus
What is the main artery supply to the calvarium?
Middle meningial arteries Some additional - pericranial vessels and branches of the arteries of the scalp
Where does the maxillary sinus drain?
Middle nasal meatus
Where do the frontal sinuses drain?
Middle nasal meatus via the frontonasal ducts
What are partial, pulsating headaches associated with?
Migraine
Pain (OSA)-Onset - sudden; after rheumatic fever
Migratory arthritis
What are the characteristics of lobular carcinomas?
Mimic fibrocystic change Feels like thickening of breast tissue
What are the features of Horner's syndrome?
Miosis Ptosis Anhidrosis Apparent enophthalmos
What is a systolic murmur over Mitral vs. the aorta
Mitral murmur - d/t regurgitation Systole murmur -d/t stenosis
What is malar flush associated with?
Mitral stenosis
Parkinson's
Mixture of rest and action tremors; occasionally action tremor alone. Leg or foot tremor more common than with essential tremor, usually does not produce head tremor. Frequency 4-6 Hz. MOST COMMON CAUSE OF RESTING TREMOR.
Define stridor
Monophonic, high pitch sounds produced by tubulent airfolw in narrowed airway at the level of the supraglottis, glottis, subglottis and/or trachea Can be harsh, musical or breathy Can be inspiratory (laryngeal), expiratory (tracheobronchial) or biphasic (glottic or subglottic) Usually affects infants and children
What are the characteristics of a pivot joint?
Morphology: bony pivot with an osteoligamentous ring. Allows circular rotation Uniaxial - head nodding, supination, pronation Ex: Atlas and axis, proximal radioulnar joint
What are the characteristics of a hinge joint?
Morphology: configuration of the opposing articular surfaces, the presence of strong collateral ligaments, restricts motion Uniaxial - flexion and extension Ex: elbow, knee, interphalangeal joints of the fingers
What are the characteristics of a gliding joint?
Morphology: flat articular surface allows gliding over eachother Uniaxial - moves in flexion and extension Ex: Patello-femoral joint
What are the characteristics of a ball and socket joint?
Morphology: one articulating surface is a hemispheric head and the other surface is cup shaped Multiaxial - flexion/extension, adduction/abduction, external rotation/internal rotation, circumduction Ex: Hip joint (deep cup) and shoulder (shallow cup)
What are the characteristics of a saddle joint?
Morphology: surface of both bones are convex in one direction and concave in the other direction Biaxial - flexion, extension, adduction, abduction Ex: carpometacarpal join of the thumb
Dx. of a neck lump: Thyroid gland
Moves up and down with swallowing
DDx. of a neck lump: Thyroglossal cyst
Moves up on protrusion of the tongue
What causes parotitis? What are the associated complications?
Mumps virus Also infect the pancreas and testis
What do you hear well at Erb's point?
Murmur of aortic insufficiency and pulmonary valve sounds
Valsalva maneuver (and standing) - decrease cardiac output.
Murmur of stenosis softer. ( and murmur of hypertrophy louder)
What are the tests for cholecystitis?
Murphy's sign Boa's sign
What causes paradoxical abdominal muscle movement?
Muscles move out during expiration Caused by paralyzed diaphragm, respiratory failure, exercise fatigue during exacerbation of COPD
Subconjunctival hemorrhage @ birth
NORMAL
PERCUSSION NOTES:RESONANCE
NORMAL LUNG CHRONIC BRONCHITIS
Describe the appearance of lid lag.
Normally, the eye lid and eye ball move together in unison. In lid lag, the eye goes down, and the sclera is exposed because of the loss of the normal coordination.
Optic atrophy
Note the chalky white disc with discrete margins. Optic atrophy is a late finding with increased intracranial pressure -diminished vision
What veinous insufficiency looks like
Notice the shiny skin, swollen and loss of hair on the big temp
What does the aqueous humor do?
Nourishes the cornea and lens
How do the external intercostal muscles run?
Obliquely anteriorly and inferiorly in the intercostal spaces
What are tension headaches associated with?
Occipital and neck pain
Define orthopnea
Occurs immediately with recumbency Caused 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
What do you hear in mitral stenosis?
Opening snap of the AV and semi-lunar valves
Where does the sublingual gland drain?
Opens into the floor of the mouth through 10-12 ducts
Temperature
Oral - 37° C - 98.6° F ( Morning 96.4, Evening 99.1) - Rectal - ·4° - ·5°C · 7°- ·9° F ↑oral - Axillary 1° Lower than oral
What area is drained by: submental and submandibular nodes?
Oral or dental infection
is there no constitutional symptoms
Osteoarthritis
What can cause external hair cell damage?
Ototoxic drugs such as amino glycosides Physical trauma (fracture of the temporal bone) Infections such as suppurative labyrinthetis, meningitis, mumps, measles Noise induction (starts in the high frequency - 4000Hz)
What is the normal movement of of the abdomen during breathing?
Outward during inspiration Inward during expiration
What qualifies as a fever?
Over 99oF in adults Over 101oF in infants less than 3 months old Seen in infection, trauma, drug reaction, hyperdynamic state
What does a tracheal tug indicate?
Over inflation of the lungs Thoracic aneurysm
What are causes of lip carcinoma?
Overexposure to the sun (i.e. farmers) Chronic irritation from pipe smoking (tobacco tar)
DDx. of a neck lump: Parotid gland
Overlies the angel of the jaw
STRIDOR what is due to
PARTIAL OBSTRUCTION OF LARYNX OR TRACHEA It is louder in the neck then over the chest wall it is a medical emergency
What symptoms do you have with sinus problems?
Pain Nasal catarrh Post nasal drip Headache
What can limit active range of motion?
Pain (bursitis, arthritis) Swelling Reduction of forces acting on the joint (muscle weakness) Structural changes in the soft tissue (ligaments, muscles) Changes in the boy compartment Muscle bulk
PAIN that is brought on by walking and relieved by rest is what type of vessel insufficency?
Pain - initially on activity and relieved by rest (intermittent claudication) due to muscle hypoxia= arterial insufficiency
Where do do you feel pain when you have parotid problems?
Pain in the pinna, eternal acoustic meatus, the temple and temporomandibular joint. Referred via the auriculotemporal nerve.
Define intermittent claudication
Pain on walking varying distances and relieved by rest
Strangury
Painful urge to pass urine while there is no urine in the bladder
Define Priapism. What can cause it?
Painful, prolonged erection Secondary to leukemia, sickle cell disease, drugs
Tenth: Motor
Palate & Larynx Sensory- Pharynx - Larynx Test: a) Say "Ah" b) Gag Reflex
What are the signs of allergic reaction of the eye?
Pale, boggy swelling of all four eyelids
What is the normal appearance of accessory lymphoid tissue in the mouth?
Pale, irregular mucosal papules
What do you think of when a alcoholic is having abdominal problems?
Pancreatitis Hepatitis Gastritis
Kussmaul sign
Paradoxical JVP with inspiration, - JVP increases with inspiration (JVP normally decreases with inspiration)
Injury of the hypoglossal results in...
Paralysis and eventual atrophy on THAT side of the tongue Therefore, when protruded, it will point to the injured side
Mask like face
Parkinsons
3 EXTRA-abdominal signs of liver disease
Parotid Gland enlargement ( cirrhosis ) • Gynecomastia in male ( cirrhosis ) • Testicular atrophy ( cirrhosis )
What are the structures surrounding the parotid gland?
Parotid LN (superifical and deep to the fascia) Facial nerve Retromandibular vein External carotid artery Greater auricular and auriculotemporal nerve (sensory supply)
Left heart failure has what type of dyspnea
Paroxysmal nocturnal dyspnea (PND)-- patients typically are awaken from sleep with difficulty breathing in the early hours of the morning. Standing upright brings
Define lid retraction
Patient will have wide eyed starring appearance. Superior sclera is visible on opening of the eyes fully.
Who experiences cardiac based dyspnea?
Patients who are in cardiac failure, whose pulmonary blood volume and extra cellular fluid volume are increased due to sodium retention.
Should percussion begin in areas of resonance or dullness?
Percussion is performed from areas of resonance or tympany to areas of dullness.
Cheyne-Stokes Breathing
Periods of deep breathing alternate with periods of apnea (no breathing). Children and aging people normally may show this pattern in sleep. Other causes include heart failure, uremia, drug-induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or diencephalon).
What are the special tests for carpal tunnel syndrome?
Phalen's test Tinel's test
What drug may cause hypertrophy to the gums?
Phenytoin
Define a peural rub (AKA Crackles)
Pleura is inflamed - friction and resistance to movement on the passing, during respiration Grating or creaking sounds during both phases of respiration Tends to be localized
When does the trachea deviate to the opposite side of the injury?
Pleural effusion Penumothroax "Being pushed"
What are the disease processes involving the pleural lining?
Pleuritis Pleural adhesion Pneumothorax Hemothorax Pleural exudates/effusion Empeyma (pyothorax) Chylothorax
What can cause asymmetrical movement?
Pneumonia, large pleural effusion, pneumothorax, rib fracture
What are causes of subcutaneous emphysema?
Pneumothorax secondary to rib fracture Ruptured bronchus (penetrating injury, deep biopsy) Ruptured esophagus (forceful vomiting, penetrating injury) Fracture of the facial bones invovling the sinuses Positive pressure ventilation
What do you need to educate patients about who have nose problems?
Pollutants Environmental and pet allergy Allergy desensitization Proper cleaning of ears Excessive noise protection and avoidance Drug side effects Nosebleed first aid
Where are the neurogenic respiratory centers located? What influences them?
Pons and medulla Limbic system
What are the complications of peripheral arterial disease?
Poor wound healing Incapacitating leg and foot pain Gangrene Amputation Stroke Heart attack
Explain the Babinski reflex
Positive - up going toes Normal until 2 years
Classic causes of clubbing and description
Proximal nail fold increases to 180 degrees or more , and feels spongy or floating • Causes : chronic hypoxia lung cancer cirrhosis ( mechanism unclear : may be humoral substance which dilates blood vessels )
Skin Rash & arthritis
Psoriatic (*seen in picture* remember) , SLE(often photosensitive) Rheumatic fever, Juvenile RA
What is the sensory innervation of the palate?
Pterygopalatine ganglion branches: - Greater palatine - Lesser palatine - Nasopalatine
What is the pupillary response in blindness?
Pupils are equal in size Defective eye stimulation - no response Normal eye stimulation - both respond Near reflex is normal
What is the pupillary response in Argyll Robertson Pupil?
Pupils are small and irregular in shape Bilateral, asymmetrical No response to light Brisk response to near reaction Dilate poorly in response to mydriatics
Define Anisocoria
Pupils of unequal sizes
How do you test full range of motion in the shoulder
Put your hand behind your head!
Where do you check the heart rate in older child/adult?
Radial, carotid or femoral artery
Secondary lymphedema
Radiation therapy • Surgery • Parasitic infection (e.g. Filariasis) • Surgical lymph node removal (radical mastectomy) • Malignant tumor invasion (metastases
Rapid Deep Breathing (Hyperpnea, Hyperventilation)
Rapid deep breathing has several causes, including exercise, anxiety, and metabolic acidosis. In the comatose patient, consider infarction, hypoxia, or hypoglycemia affecting the midbrain or pons. Kussmaul breathing is deep breathing due to metabolic acidosis. It may be fast, normal in rate, or slow.
Rapid Shallow Breathing (Tachypnea)
Rapid shallow breathing has a number of causes, including restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.
What impact does pseudomonas infections tend to cause on the eye?
Rapidly progressive, leading to perforation
Cerebellar axtais
Reeling stance and gait If ask to stand with feet together will cause them to fall
Eye symptoms ( episcleritis) & Arthritis
Reiter's(redness, pain), Sjogren's (grittiness, stickiness)
Partership Empathy Apology Respect Legitimization Support
Relationship building with a difficult patient requires PEARLS. What are these?
Describe crackles
Results from opening of previously closed aiway Inspiratory, discontinuous, intermittent, nonmusical and brief sounds The coarser the crackles the larger the airways of origin (bronchiectasis) The later they occur in the inspiratory cycle, the more distal the site of origin (pulmonary fibrosis)
Describe wheezing
Results from vibration of the walls, as air passes through, narrowed, almost closed airways. Characterized by continuous, musical sounds, the lower the pitch, the larger the obstructed airways
Clicker question: about anxious women having trouble swallowing
Retro sternal goiter
Disorders
Rhinitis, polyps, epistaxis, anosomia
What does an EKG measure?
Rhythm
Bowlegs
Rickets
What is the x descent?
Right artrial diastole Immediately followed by a trough
How do you determine S1
Right carotid pulse (lower neck) - used in identifying S1. Assess volume and contour (upstroke, plateau and down stroke)
Aspiration pneumonia occurs most often in which lobe
Right upper lobe
Where are the three places the pleura extends below the costal margins
Right xiphisternal angerl Right and left costovertebral angles
What does a positive Osler maneuver mean?
Rigid wall is indicative of atherosclerotic disease of the blood vessel
Define tinnitus
Ringing in ear
What do you hear when a patient is in CHF?
S3 and/or S4 as components of a gallop rhythm Tachycardia
What do you think of when an IV drug user is having abdominal problems?
SBE Septic embolization to the gut
What is the minimum systolic BP for children 1-10 years old?
SBP (5%) = 70 + (age in years X 2)
Causes of Short dyspnoea
SHORT-PULMONARY EDEMA -ASTHMA
Pleural effusion
SLE
Setting: Set up int einterview in a private and comfortable place. Patient: Assess the patients understanding and expectations. Invitation: Invite them to receive some or all of the information. Knowledge: Provide the information in gradual steps. Empathy: Empathize with your patient. Strategy/Summary: Show partnering, schedule follow up visits and summarize the meeting to ensure the patient understood everything.
SPIKES is a method of delivering bad news. What does SPIKES stand for?
Raised JVP absent pulsation
SVC blockage(Thrombus, lung cancer)
What is the special test for sacroiliac joint?
Sacroiliac joint stress maneuver
for sacroilitis
Sacroiliac stress
What systemic diseases are associated with uveitis?
Sarcoidosis Ankylosing spondylitis Tuberculosis Lyme's disease HIV
Prognathism
Seen in acromegaly, the upper and lower jaws dont match leading to malocclusion
Define onycholysis
Separation of the nail plate from the underlying and lateral supporting structures. Nails are firm, smooth and without inflammation.
What are the symptoms of eye inflammation?
Severe pain, photophobia, lacrimation, decreased vision Adhesion between iris and cornea, and iris and lens can lead to glaucoma
What is found in the suprapubic/hypogastrium region?
Sigmoid colon, rectum, ileum, urinary bladder, right and left ureter, right and left ovaries
Define pterygium
Similar in location to a pinguecula, but more vascular. Begins at the medial canthus and extends beyond the corneal-scleral junction
Define rhonchi
Similar to wheezing but they are low pitched Due to secretions in the larger airways with airway narrowing Often clear after coughing
What are frontal headaches associated with?
Sinusitis
What are the 5 layers of the scalp?
Skin Connective tissue (dense, well-vascularized, innervated) Aponeurosis (muscles) Loose connective tissue (spreading of infections) Periosteum
What are the soft tissue layers of the abdomen?
Skin Subcutaneous tissue Muscle Fascia Parietal peritoneum
What are the five layers of the scalp?
Skin (thick, sweat glands and sebaceous glands) Connective tissue (well vascularized, innervated) Aponeurosis epicranialis (galea aponeurotica) (strong and membranous, contains frontal and occipital muscle bellies) Loose connective tissue (area that things can travel through) Pericranium (periosteum)
Review characteristics to inspect.
Skin is often overlooked. 3
How do cartilaginous joints move? What are some examples?
Slightly moveable (symphysis) Vertebral bodies of the spine
Fetor Hepaticus= ANOMIA
Slightly sweet aromatic odor in patients with liver failure
Define vesicular breathing
Slow 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
Slow Breathing (Bradypnea)
Slow breathing may be secondary to such causes as diabetic coma, druginduced respiratory depression, and increased intracranial pressure.
Describe a normal lymph node
Small Firm Non-tender Discrete Mobile
What abdominal parts are midgut derivatives? Where is the pain felt?
Small bowel, proximal colon, appendix Periumbilical area
When do you hear flat?
Soft, high pitched, with a short duration Pleural effusion
What can cause nodular enlargement of the thyroid?
Solitary nodule in normal gland - malignancy Solitary nodule in abnormal gland - less likely to be malignant
What abdominal parts are foregut derivatives? Where is the pain felt?
Stomach, duodenum, liver and pancreas Upper abdomen
What is found in the left upper quadrant?
Stomach, spleen, body and tail of pancreas, splenic flexure of the colon, parts of the transverse and descending color, left kidney and adrenals, ureter
What is found in the left hypochondrium region?
Stomach, transverse colon, splenic flexure, part of descending colon, pancreas (tail), spleen, left kidney, ileum
for sciatica
Straight leg raising and bowstring
What area is drained by: tonsillar nodes?
Strep throat
Urgency
Strong urge to pass urine, even though the bladder is not full
A painful, tender, red infection in a gland at the margin of the eyelid, a sty looks like a pimple or boil pointing on the lid margin.
Sty (Acute Hordeolum)
What is normal in the eyes of a newborn?
Subconjunctival hemorrhages are common immediately after birth. Red reflex should be visible in both eyes At 1 year - visual acuity is 20/200
Syncope
Sudden and transient loss of consciousness. There is a transient reduction in cerebral perfusion with resulting hypoxia
Define Meniere's disease
Sudden attacks of vertigo preceeded by tinnitus aural fullness and fluctuating hearing loss. Loss is in the low frequency range (125hz-1000hz)
What are the features of a Venous ulcer?
Superior and anterior to the medial malleolus Tend to be large Warm Pulses are present Painless or very mild Edges are sloping with attempt at healing Granulation tissue is exuberant Wet with large amounts of exudates Base is made of granulation tissue covered with slough
What are the four intrinsic muscles of the tongue? What do they do?
Superior longitudinal (curls the tongue up) Inferior longitudinal (curls tongue down) Transverse (narrows and increases height of the tongue) Vertical (flattens and broadens the tongue) They alter the shape
What does CN 4 control?
Superior oblique muscle, which is important to looking down and in (Toward the midline)
Define the suspensory ligaments of cooper?
Support for the breast
What are the risk factors for developing DVT?
Surgery Obesity Pregnancy Immobilization/bed rest Smoking Drugs (OC, steroids) Injury to soft tissues of the legs Fractures of the tibia, fibula, femur and hip Hypercoagulability Malignancies
What causes Fetor hepaticus?
Sweet fecal smell Due to liver disease
Define Chemosis
Swelling Fluid in the episcleral space
What are the symptoms of peripheral venous disease?
Swelling of feet and legs Chronic ulcers of the lower legs Pain in the calf area Skin hyperpigmentation and thickening Prominent veins in the leg
Define Papilledema
Swelling of the optic disk blurring of the disc margin, loss of spontaneous venous pulsation, hyperemia hemorrhgage and exudates of the disc Due to raise ICP
What are the structures that pass through the diaphragm without a specific hiatus?
Sympathetic trunk Thoracic splanhnic nerves Hemiazygos vein Branches of the phrenic nerves
What is pulse pressure?
Systolic pressure minus diastolic pressure
PLEURAL EFFUSION
TRACHEA,APEX BEAT- DISPLACEDAWAY FROM MASSIVE EFFUSION EXPANSION- REDUCED *PERCUSSION -STONY DULL* BREATH SOUNDS-REDUCED OR ABSENT VOCAL RESONANCE-REDUCED
TENSION PNEUMOTHORAX SIGNS
Tachypnoeic, cyanosed, hypotensive, trachea, apex beat - Displaced always from the affected side *EXPANSION*- reduced *PERCUSSION* - hyper resonant *BREATH SOUNDS* - absent *VR*- reduced
What is hyperpyrexia? What can cause it?
Temperature over 106oF Seen in septicemia
What causes bulging interspace during inspiration?
Tension pneumothorax, large pleural effusion, emphysema, reactive airway disease
Define Pectus carnatum (AKA pigeon breast)
The AP diameter of the chest is increased - overgrowth and buckling onto the sternum of the anterior costal cartilages. Results in a ridged chest - fixed in a position of near full inspiration during respiration, there is heavy relance on the accessory muscles of respiration Has a restrictive pattern
Iliotibial tract
The Fascia and skin provide stability
What is the difference between a comprehensive and focused physical examination?
The comprehensive physical examination is detailed and covers all the systems. The focused physical examination is problem-oriented and confined to the area(s) dictated by the presenting complaint(s)--it is often used in follow-up.
Describe the appearance of the nails in peripheral artery disease.
The nails thicken because of the loss of blood flow. Normally, blood flow is necessary for the efficient turnaround of the nail.
With percussion, which finger is on the surface?
The pleximeter finger
With percussion, which finger does the tapping?
The plexor finger
Define the tail of spence
The portion of the breast that projects laterally into the axilla
What determines the stability of a synovial joint?
The shape and depth of the articulating surface Ligaments Associated muscles and muscle tone
Joint stability what are the big factors
The shape of the bone! DEEP bone of the hip is very stable The shoulder is very shallow!
What are the special tests for the rotator cuff tears?
The shoulder drop test
Define that calvarium
The upper domed part of the cranium
plantar (sole) ulcer
This is a combination neuropathic + Arterial Ulcer
Pain relieved by elevation
This is a sign for Venous insufficiency ( arterial it is made worse b/c it is already ischemic )
If you are asked to exam an area that might have nerve compression remember to
To Screen neurological distribuation
What area is drained by: Posterior auricular nodes?
Toxoplasmosis or measles
LUNG COLLAPSE
Tuberculosis is the most common cause of lung collapse TRACHEA-DISPLACED TO COLLAPSED SIDE EXPANSION-REDUCED PERCUSSION-DULL BREATH SOUNDS-REDUCED
Define ectropion
Turning outward (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.
Define synarhrosis (firbous) joints?
Two bones connected by fibrous tissue that are immovable Skull, hard palate
Sound of percussion over the anterior abdomen where the is air in the bowel loops?
Tympanic
Weakness w/o atrophy
UMN
How does carcinoma of the lip manifest?
Ulcerated or indurate lesions commonly found in the central portion of the lip. Hard submental nodes.
What impact does pneumococcal infection have on the eye?
Ulceration
List 4 things physicians inspect/palpate for.
Unusual pulsations Venous and arterial pulsations Midline structures, deviation and curvature Swellings, enlargement
Define hypospadias
Urethral opening is on the VENTRAL side of the penis
How can you image the brain of a newborn?
Using US through the fontanelle
How do you treat a congenital hip dislocation?
Usually requires a harness/brace If untreated, can lead to longer-term joint problems
What is the v wave?
Venous filling of the right atrium while the tricuspid valve is closed during ventricular systole Occurs right after the carotid pulse
Is the venous hum accentuation during systolic or diastolic? and where is it best heard?
Venous hum with systolic accentuation heard below xiphoid , over epigastric surface of liver
Which nustagmus is a big problem
Vertical
23 yr old presents with a history of sudden unilateral sensorineural hearing loss what is the probable cause?
Viral infection
What cause atrophic glossitis?
Vit B12 Iron deficiency
What does WIIPEEP stand for?
Wash hands Introduce yourself Identify the patient Permission to examine Explain the task ahead Expose the area to be examined Position the patient
Waddle gait
Weakness of the proximal muscles of the shoulder hip and back Preganant patient near to term
What can cause lymphadenopathy?
Wegener granulomatosis Non-TB mycobacterium Sarcoidosis
List 2 granulomatous diseases that can cause lymphadenopathy.
Wegener's granulomatosis sarcoidosis
Informed consent No
What is an example of shared decision making? Do we have to provide a patient with all of the information if they do not want it?
Ask the patient about their knowledge of a condition, tell the patient about the condition, then ask them to teach it back to you. Typically 40-80% of medical information given to a patient is immediately forgotten and of the information retained about 50% of it is incorrect.
What is the ASK-TELL-ASK method of patient education? Why is this important?
Physician anxiety. Death and dying
What is the following: Medical encounters in which the patient's mannerisms, physical and mental condition or environment of the encounter elicits uncomfortable feelings in the physician. What is a common topic that causes physician anxiety?
Domestic violence It usually escalates in frequency and intensity "Do you feel safe at home?"
What is the following: Repeated pattern of abusive behavior How does this abuse/violence change over time? What is a good question to open up the discussion about abuse?
When do you hear low pitched wheezes?
When a single large airways becomes blocked I.e. tumor or aspirated foreign body
1. With enough advanced time for the patient to reflect and gather additional information 2. Before they happen 3. At annual visits and any time for at risk patients 4. At annual visits and any time for at risk patients 5. Prior to or during an annual history and physical exam 6. At every visit
When should the following patient education technique be implemented? 1. Informed consent 2. Prevention of accidents 3. Prevention of diabetes 4. Prevention of heart disease 5. Self examination and awareness 6. Education about health hazards like smoking and drinking
What are fontanelles?
Where the major suture lines of the head intersect The "soft spot"
Define arcus senilis
White ring in the cornea Normal >40yo < 40yo is a sign of hypercholesterolemia
Define exopthalmos
Whiteness of sclera visible below the iris Due to Grave's disease
Define pinguecula
Whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjuctiva adjacent to the corneal-scleral junction (limbus) Does NOT invade the cornea
Slightly raised, yellowish, well-circumscribed plaques in the skin, xanthelasmas appear along the nasal portions of one or both eyelids. They may accompany lipid disorders (e.g., hypercholesterolemia), but may also occur independently.
Xanthelasma
That thoracic landmark is at level: T9?
Xiphoid process
Can you palpate the dorsalis pedis in a diabetic with gangrene of the foot?
YES! because diabetes is a disease of the Microvascular system and therefore the dorsalis pedis would be spared
Define hypercarotenemia
Yellow discoloration of the skin
Otitis media (Acute)
acute - URT infections, small eustachian tube in children, on exam will see red tympanic membrane, loss of landmark, pus, if effusion present will see bulging of tympanic membrane
Normal pulse in adults Normal in children
adults = 60-100 Children= 60 -140
Pt with ureter pain is (eg renal calculi)
agitated, cant get comfortable (vs appendicitis)
Rhinitis
allergic (perennial or seasonal) nonallergic, and vasomotor rhinitis.
Decrease chest expansion & Arthritis
ankylosing spondylitis
Pansystolic murmurs
backflow through AV valve
Red eye differential
bacterial conjunctivitis, scleritis, acute closed angle glaucoma, acute anterior uveitis
Basal Rales (crepitations) on auscultation:
basal rales may indicate congestive heart failure
chalazion
blockage of a gland, occur in eyelid proper, subacute, painless nodule of lower eyelid. Points inside as opposed to a sty at the lid margin. Originate in a meibomian gland. Not a infection, inflammation
Closed angle glaucoma
blockage to the flow of vitreous humor through the canal of schlemm
Differentials for jaundice
carotenoderma - excessive carotene intake ; spares sclera & is on palms, soles, forehead , nasolabial folds ) Quinacrine - discolors skin and sclera
Submental nodes structures (3)
central lip floor of the mouth tip of the tongue
posterior frontellale
closes at 2 months
List 7 characteristics of the gums and teeth to observe.
color bleeding hyperplasia (visible in patients taking certain anti-psychotics, tetracyclines, and doxycycline) number of teeth caries & fillings abscess tenderness
List 5 characteristics of the buccal mucosa to observe.
color pallor ulcers leukoplakia: associated with chewing tobacco swellings
List 5 characteristics of the skin to observe.
color texture thickness inflammation any other lesions
List 6 characteristics of the lips to observe.
color: usually pink dryness ulcers lumps cracks leukoplakia
Describe the following characteristics of cancerous lymph nodes: size texture mobility tenderness discreteness
enlarged hard non-motile non-tender matted (adherent to surrounding structures)
Describe the following characteristics of inflamed lymph nodes: size texture mobility tenderness discreteness
enlarged soft to firm mobile tender discrete - red on surface (erythematous)
conductive deafness
foreign body, otitis media, perforated eardrum, otosclerosis of ossicles, otitis externa
hyperpyrexia
greater then 106f or 41C= septicemia
List 6 characteristics of the scalp to observe.
hair distribution texture: coarse hair in hypothyroidism and thinning out in hyperthyroidism presence or absence of nits (eggs of lice) or lice dandruff and scaliness swellings hematoma
Musty order of the breath in paitents with
hepatic encephalopathy
Respiratory variation
high negative intra pleural pressure during inspiration may be up to 10mmHg difference between inspiration and expiration
A localized systolic or continuous bruit may be heard in
hyperthyroidism.
Puff face and absent lateral eyebrow of
hypothyroidism
What thyroid disorder is associated with delayed ankle reflex relaxation?
hypothyroidism
a. ODIPARA - This is for every symptom
i. Onset: What were you doing when the problem started? ii. Duration: How long did it last? iii. Intensity: Was it mild, moderate, or severe? iv. Progression: Since it (whatever it may be) has started, has it been getting worse, better, or is it the same? v. Associated symptoms: Did you notice any other symptom? vi. Relieving and aggravating factors: Have you noticed anything to make it worse or better? vii. Anything else? : Is there is anything else you want to tell me?
b. SOCRATES - This is for pain, ANY kind of pain
i. Site: Where is the pain? ii. Onset: What were you doing when the problem started? iii. Character: Can you describe the pain? iv. Radiation: Does the pain move anywhere? v. Associations: Is the pain accompanied by any other features? vi. Time course/Timing: When did you last feel well? vii. Exacerbating and Relieving factors: Does anything (position/eating/drinking) make it better or worse? viii. Severity: How sever is it on a scale of 1 to 10?
Fibrous (synarthrosis)-
immovable (skull sutures)
Cholesteatoma
in healing perforations, epithelium of mucous membrane and squamous epithelium cover damaged area
Describe the submandibular superficial LNs
in the submandibular triangle inferior to the body of the mandible. Drains the path of the facial artery, encompassing the forehead, gingivae, teeth and tongue.
Otitis externa
infection, swollen, edematous, painful when pushing on tragus or pulling on helix - post and preauricular LN are palpable
Myringitis
inflammation of tympanic membrane due to viral infection. Bullous myringitis is a viral infection characterized by painful hemorrhagic vesicles that appear on the tympanic membrane, the ear canal, or both. Symptoms include earache, blood-tinged discharge from the ear, and hearing loss of the conductive type.
Patient presents with enlarged, discrete, mobile, tender, and soft lymph nodes.
inflammation/infection
sensorineural deafness
inner ear infection, loud noise, tumor, trauma, congenital, toxicity (asprin, streptomycin, alcohol), aging (PRESBYCUSIS), and meniere's disease
Plummer-Vinson Syndrome
iron deficiency anemia, dysphagia (difficulty swallowing ) glossitis ( inflammation of tongue
Ninety percent of the blood from the lower extremities
is carried back to the heart by the deep veins
Angina
last 3-10 minutes, brought on by activity, relieved by rest and medication
• Unstable angina or pre-infarct
last over 20 minutes, not relieved by rest, Relived by medication
Myocardial infarct
last over 30 minutes, not relieved by rest or analgesics
Measuring height up to age 2
laying flat on bed
Misalignment of teeth and/or incorrect relation between the teeth and the 2 dental arches
malocclusion
What are the boundaries of the anterior triangle.
mandible midline of the neck anterior border of the sternocleidomastoid
Normal Lymph nodes
may be palpable, particularly large ones such as the femoral lymph nodes. *The size, shape, consistency, mobility and whether the lymph node is tender or not*
Dullness -
medium soft, with a thud-like sound
Droopy sleepy look of
myasthenia gravis
lacrimal apparatus
nasolacrimal duct drains into the inferior meatus
Where does the pain for an MI radiation
neck, left shoulder, back, down either arm or both arms
Acrocyanosis
normal for hours -consider heart disease
S3 (mid-diastolic)
normal in children. Due to rapid ventricular filling. Low pitched
What is the Duration of the apex beat
normal through first 2/3 of systole
Babinkski
normal to 2 years
tympanic membrane
observe: handle of malleus, umbo, and cone of light
Middiastolic
obstruction to flow across semilunar
stye
occur at margin of eyelid, painful, infection
Which skill is used in determining dullness over a pleural effusion?
percussion
symptoms of eye disease
photophobia, decrease or loss of vision (gradual or acute) gradual - advanced glaucoma, catarract, retinopathy acute - medical emergency - acute glaucoma, retrobulbar neuritis (inflammation of optic nerve)
Grade 1 murmurs are often heard in
physiological states of increase/ decrease flows: anemia and hyperthyroidism
List 3 causes of mediastinal shift away from the lesion or disorder.
pneumothorax pleural effusion tumor or growth
Which lymph node will be swollen in otitis media?
post-auricular lymph nodes
Lymphedema praecox
presents in early adulthood (before age 35). It is not clinically evident at birth.
Stokes -Adams
refers to a sudden, transient episode of syncope, occasionally featuring seizures. Prior to an attack, a patient may become pale, their heart rhythm *experiences a temporary pause*, and collapse may follow
What is the normal percussion note of the lungs?
resonance
iris
responsible for controlling the size of the pupil
History of IV drug abuse or a recent infection
septic joint.
Otitic barotrauma
serous effusion, URT infection, diving, airplane, acute pain - will see fluid w/ air bubbles, air is trapped in serous fluid behind tympanic membrane
List 5 characteristics of the face to observe.
symmetry expression involuntary movements swellings and edema paralysis or paresis
Empathy
the capability to share another being's emotions and feelings 2 ASPECTS: • Cognitive - understand another's perspective (situation) • Emotional - feel on behalf of another
Harmless bony growth on the midline of the hard palate that is less than 2 cm in diameter
torus palatinus
Enlarged preauricular nodes (3)
viral illness lymphoma cat scratch fever
cataract
white cornea - opacification
2. CHIEF COMPLAINT
• "Alright, thanks for telling me about yourself. I really appreciate it. So can you now tell me what brought you in today?" • SET THE AGENDA "We are going to talk more about that, but first is there anything else you would like to discuss today?" • If there is more than one chief complaint - determine chronological order and start from there • Beware of premature diving - patient may spontaneously leap into detailed descriptions • Use empathy and do not interrupt
5. FAMILY HISTORY
• "Could you tell me about the health of your family?" • Get PARENTS, CHILDREN, SIBLINGS
8. REVIEW OF SYSTEMS
• "Finally I would like to ask you some questions about your general health. These questions are just going to help me get the bigger picture and figure out what may be going on. • Skin changes? • Headache? • Dizziness? • Vision changes? • Hearing loss? • Sense of smell? • Sense of taste? • Enlarged lymph nodes? • Breathing difficulties? • Chest pain? • Numbness? • Joint pain? • Appetite? • Digestion? • Change in urination? • Mood changes?
1. INTRODUCTION + BIODATA
• "Hello, my name is _________. I am a medical student here at SGU. What is your name? • "Nice to meet you Mr/Ms. ______" *REPEAT NAME • "Since this is our first time meeting, I would like to get to know you a little better, can you tell me about your self?" • Get AGE, WHERE THEY LIVE, WHO THEY LIVE WITH (MARITAL STATUS), WHERE THEY WORK • Use rapport building and active listening
6. SOCIAL HISTORY
• "I would now like to ask you a few questions about your PERSONAL life. I want to assure you that everything you tell me is kept confidential and I ask these questions of all my patients. Can you start by telling me some of your daily activities?" • Get DIET, EXERCISE, SMOKE (how often), DRINK (how often), RECREATIONAL DRUGS
7. OBGYN/SEXUAL HISTORY
• "Now I am going to ask you a few sensitive questions about your sexual history. I want to assure you again that these are routine questions I ask of all my patients and whatever you tell me will be kept confidential, so please feel comfortable." • OBGYN first if female - MENSTRUAL PERIOD? PAP SMEAR? BREAST EXAM? • "At any point in your life have you been sexual active?" - "What about now?" • "At any point in your life have you had more than one sexual partner?" - "What about now?" • "Do you use condoms?" • "Have you ever been tested for sexually transmitted infections?" - "What tests?" "What were the results?" • Important to educate the patient at this step - safe sex = condoms
3. HISTORY PRESENTING ILLNESS
• "OK - could you now tell me more about the ______" • Use open ended questions and continuers • TIMING, FREQUENCY, LOCATION (have them point it out), WHEN IT GETS BETTER OR WORSE, SETTING, CHARACTERISTICS, RELATED MANIFESTATIONS - "Have you noticed any other changes in your body that may have to do with this?"
9. CLOSING THE INTERVIEW
• "Thank you so much for answering all my questions today." • Give SUMMARY • Discuss diagnosis and treatment options • Use partnering • Elicit patient full understanding of the discussion • Agenda check - "Is there any other issue you would like to discuss?" • "Any other questions?"
Tools: Ask-Tell-Ask
• ASK - Establish the patient's baseline knowledge • TELL - Educate the patient - Encourage questions • ASK - Patient to "teach-back"
Prevention
• Accidents - Age-appropriate, anticipatory counseling helps prevent unintentional childhood injuries. • Diabetes - "Regular exercise at least 150 minutes per week and/or a 5-7% weight loss reduces the incidence of type 2 diabetes," in individuals with impaired glucose tolerance. • Heart Disease - "Regular, moderate aerobic-type exercise 30 minutes per day, at least 5 days per week reduces the risk of a heart attack by 50%."
Screening & Health Hazards
• Alcohol Abuse - Alcoholics Anonymous (AA) and other similar 12-step programs are a low or no cost way to treat alcohol abuse. • Tobacco Abuse - "It's time to quit. Please select a quit date and let's set up an appointment when you are ready."
What is the amplitude of the apex beat
• Amplitude - usually small and brisk
Tools: Negotiation
• Be knowledgeable about your position - Read about every patient - Evidence-based medicine • Separate the patient from the problem - The patient is not his or her disease. • Never agree to anything without deliberation - Talk is good. Debate is bad. • Always listen - Active listening is important in any exchange • Allow the patient to make their own conclusions. - Guiding is good. Forcing is bad. • Stick to the truth - Be honest with your patient about what you know. - Be honest with yourself about what you do not know. • Put everything in writing - Document the eventual outcome and specifics concerning the negotiation.
Self Examination & Awareness
• Breast Self Awareness - American College of Obstetricians and Gynecologists (ACOG) - versus - U.S. Preventative Services Task Force (USPSTF) - What do we teach when we are not sure? • Testicular Self Examination - ZERO studies have been done - What do we teach when there is ZERO science to back it up?
CAGE QUESTIONS
• C Cut Down ? • A People Annoyed or Criticize Your Drinking • G Guilty about your drinking ? • E Eye-Opener
Test for deep vein thrombosis
• Circumference of calf • Homan • Pratt
Informed Consent
• Do Not Resuscitate (DNR) • Prior to a Procedure - Consent for Anesthesia - Consent for Surgery - Consent for Invasive Diagnostic Procedures
Peripheral signs of CVD
• Face, eyes and oral cavity • Hands • Pulse • Blood pressure • Funduscopy • Neck - JVP • Chest • Abdomen • Lower limbs
FRICTION RUB
• From peritoneal inflammation • Sounds like leather rubbing together --> Liver / Spleen
Infiltrative Diseases Splenomegaly
• Infiltrative Diseases : • Lymphoma, • Metastatic cancer, • Amyliodosis, • Gaucher's disease , • Myeloproliferative diseases with extramedullary hematopoiesis
What to educate pt on:
• Informed Consent - Do Not Resuscitate (DNR) - Prior to a Procedure • Prevention - Accidents - Diabetes - Heart Disease • Screening & Health Hazards - Alcohol Abuse - Tobacco Abuse • Self Examination & Awareness - Breast - Testicular
Timing your Intervention
• Informed Consent - Must be far enough in advance to allow the patient time to reflect and gather additional information. • Prevention - Accidents/Unintended Injuries - BEFORE they happen - Diabetes - during an annual history & physical exam, and/or anytime for at risk individuals. - Heart Disease - during an annual history & physicalexam, and/or anytime for at risk individuals. • Screening & Health Hazards - At EVERY visit • Self Examination & Awareness - Prior to or during an annual history & physical exam, sports physical (for boys/men), and/or a well woman exam.
Other causes of syncope:
• Orthostatic hypotension • Micturition syncope (situational) • Vertebra-basilar syndrome
KNOW YOUR SYMPTOMS FOR ARTERIAL DISEASE ( will be the only thing given in the stem)
• Pain - initially on activity and relieved by rest (intermittent claudication) due to muscle hypoxia • Rest pain - progression of disease • Paresthesia and numbness • Cool or cold extremity • Skin color changes - pallor (hypoxia),black means gangrene • Ulcers
Giving bad news SPIKES
• S Set - set up the interview (in person, private and comfortable place, in person, with others if desired by patient) • P Patient - assess the patient's understanding of the illness - their hopes, beliefs and expectations • I Invitation - limited or all information required? • K Knowledge - provide knowledge and information to the patient in graduated steps • E patient to elaborate on their emotion. Empathize and legitimize the emotion -"I can imagine how scary this must be for you". • S Strategy and summary - show support (partnering)-"We are here to talk about the results of the tests and to let you know that I will be with you throughout your illness" Schedule follow up visits
jugular venous pulsation
• Two waves • Not palpable • Occluded by mild pressure • Height varies with tilt of patient (uprightness) • Varies with breathing ( BECAUSE ON THE RIGHT SIDE OF THE HEART )
4. PAST MEDICAL HISTORY
• Use empathy and a segue here - "I can understand this must be really hard for you. We are going to work together to figure out what is going on and help you get better. I would like to ask you a few questions about your past medical history, which will help me get the bigger picture." • "Have you had any past illnesses?" What about as a child?" • "Have you ever been hospitalized?" • "How are your immunizations?" • "Do you have any allergies?" • "Are you currently on any medications, supplements?" • "Have you ever been diagnosed with high blood pressure or hypertension? What about high blood sugar or diabetes?"
Peripheral venous disease results from: ( x2)
• Valvular incompetence (venous insufficiency) • Obstruction to flow - venous thrombosis Thrombophlebitis of the communicating veins with destruction of the valves lead to venous insufficiency
VENOUS HUM
• Veins are greatly distended from portal hypertension • Varices in Falciform ligament
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
•Grade 1 - faint and can be easily missed; requires diligence • Grade 2 - soft but easily heard • Grade 3 - moderately loud, easily heard • Grade 4- - loud and associated with a palpable thrill • Grade 5 - very loud and may be heard with stethoscope partly off the chest • Grade 6 - very loud and heard with stethoscope off the chest
