Cranberry Pie Dessert
21 year old female with vagina discharge and complains of pain on urination. What the most suitable opening statement?
"I will ask you some questions that I ask of all my patients"
45 year old chronic alcoholic admitted to hospital with 2 day history of vomiting and severe *epigastric pain which radiates to his back.*..the pain is exacerbated by lying down and improved by sitting up and leaning forward. Abdominal exam reveal painless *perilumbical ecchmyosis*
*Acute Pancreatitis* "Epigastric pain that is relieved by sitting up and leaning forwards may indicate acute pancreatitis." "Epigastric pain radiating to the back - is from pancreas" "Cullen's sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. = Pancreatitis"
45 year old woman is referred of stage 2 hypertension .. What describes criteria for stage 2 hypertension
*Diastolic of 105* Normal ( 120, 80) PreHyper (120-139, 80-89) Stage1 (140-159, 90-99) Stage 2 (160+, 100 +)
Fundoscopy with diabetes mellitus
*Dot/Blot Hemorrhages (flame too)* This is a leading cause of blindness in the USA and around the world and is directly related to the duration of the disease (present in most patients with duration over 25 years). Early changes (nonpropliferative) include capillary *microaneurysms (smooth borders and sharp round shape)*, dilatation and tortuosity of vessels and non perfusion of areas. Rupture of microaneurysms, capillaries and venules result in hemorrhages (flame-shaped or blot). *Exudates* (due to leaky capillaries) may appear in clusters, streaks or rings around the fovea. In later stages, *neovascularisation (new vessels)* develops on the disc and/or retina and these can lead to many complications (hemorrhage, retinal tears and detachment)
Bells Palsy
*Facial nerve paralysis*- motor supply to the muscles of the face, forehead and eyelids- a) unable to whistle or puff his cheeks,) close the eye (levator palpebrae superioris action s unopposed, c) sagging of the corner of the mouth, drooling and difficulty in chewing due to paralysis of orbicularis oris and buccinators, d) loss of taste to the anterior 2/3 of tongue via the chorda tympani branch innervates Stapedius and anterior 2/3 of tongue *Hyperacusis*
45 year old alcoholic with 2 month history of bilateral swelling in legs...tingling and numbness in feet, hands and around mouth for past few days. Pulse is 102, 16breaths, BP 120. *While taking his blood pressure by auscultation the cuff was inadvertently inflated to 170 causing a carpal spasm*
*HYPOCALCEMIA* CHVOSTEK'S SIGN - Tap on the face at a point just anterior to the ear and just below the zygomatic bone, over the facial nerve. TROUSSEAU‟S SIGN - Inflate a sphygmomanometer cuff on your patient‟s arm, above 20mmHg systolic blood pressure for several minutes. *Positive response: Carpopedal spasm*
When feeling your patients pulse you notice STRONG pulse with a week pule each time -- this is due to
*Left Ventricle Failure from long standing hypertension*
Snellens Chart can be used to diagnose
*Refractive Error* (cannot focus light) -aging, hyperglycaemia of diabetes (due to reversible osmotic swelling of the lens). -Cataracts (or opacities in media) -retinal macular degen, scarring due to hemorrhage -diabetic retinopaathy, -optic nerve disorders (glucoma)
55 year old man with drooping of his right eyelid for past week -- long time smoker. Pulse is 88bpm, BO is 146/86, and resp 18bm. Mild ptosis of the Right eye and his forehead is dry on same side...what would you find in right pupil
*Small (miosis ,) reacts briskly to light and near reaction* Horners Syndrome Features of this include miosis, ptosis, anhidrosis and apparent enophthalmos. Anisocoria(unequal pupil size) is more marked in dim light: the ptosis is mild: the decreased sweating occurs on the ipsilateral side. There is increased accommodation response due to unopposed action of the parasympathetic. Pupillary response to light and near is normal. The lesion could be preganglionic or postganglionic. 1% hydroxyamphetamine solution instilled in both eyes will cause a pupil with a preganglionic lesion (and the normal pupil) to dilate but not one due to a postganglionic pathology.
What is the name given to palpable vibrations transmitted through the broncho-pulmonary system to the chest wall when the patient repeats 99?
*Tactile Fremetis * (*bronchophony* - sound should become less distinct laterally but in this becomes more loud laterally or in a specific area. *Whispered pectorliquy*- 99 whipser and sounds should NOT be heard, if they are its consolidation *Egophony* - EE repeated and listen for long muffled E - if hear higher pitch 'a' its consolidation)
12 year old boy presents with pain and swelling bilaterally around the angle of the mandible for the past 3 days. He complains of fever and inability to open his mouth fully. On exam diffuse swellings are seen on *either side of his face anterior to the pinna above the angles of the jaw*
*Viral parotitis usually occurs in children* Parotid lymph glands are located superficial and deep to the parotid fascia and within the gland. Other structures located in and around the parotid gland include the facial nerve, the retromandibular vein, the external carotid artery and the great auricular and auriculotemporal nerves (sensory supply to the parotid). Swellings of the parotid gland are palpated at the angle of the mandible and usually lifts the pinna outwards.
Thrills in precordium
*palpable murmurs*, usually of grade 4/6 intensity or greater and resemble the purring of a cat
Buerger Test -lower limb arterial insufficiency
*return of color 10 seconds - venous filling 15 seconds* -both legs 90 degrees
Sensorineural hearing loss
- LOUD NOISE EXPOSURE. -TUMORS. -TRAUMA. *Fracture of Temporal Bone* -CONGENITAL/FAMILIAL DISEASES. - TOXICITYASPIRIN, STREPTOMYCIN ,ALCOHOL. -AGING(PRESBYCUSIS) -MENIERE'S DISEASE.
What tests assess valvular competency in communicating veins of the leg?
1- Retrograde Filling Test (Manual Compression Test) 2- Tredenlenberg Test
Fundoscropy Hypertension
1st stage: Copper wiring, Silver wiring 2nd stage: AV nicking 3rd stage: Hemorrhages [flame shaped], Exudates that are hard or soft [cotton wool] 4th stage: Papilledema & Hemorrhages [flame shaped
More Matching
20/200 = Legally Blind Lens Opacitiy = Cataracts Pupillary Constriction = Near Reaction ExOcular Movements = CN3,4, 6 Conjuntivitis = Red Eye
60 year old female with shortness of breath - you examine her JVP and diagnose her with right sided heart failure - her JVP will most likely be
6cm (2-3cm is normal)
Normal Central Venous Pressure
7-8 cm above sternal angle of louis (patient 30-45 angle at trunk)
Posteriorly the tips of scapula is usually above which rib
7th rib
45 yr old male to the emergency room with acute shortness of breath and restlessness, he had a stab wound on the left side of his chest and tracheldeviation to the right. The shift is due to
A Large pneumothorax on the left
55 year male complains of shortness of breath and cough productive of frothy sputum for last 3 days. He sleeps on 4 pillows at night. On auscultation of his lungs there are creptitations on lung bases biltarally
ALTERNANS PULSE due to left ventricular failure
45 year old male with 2 year history fatigue, enlarging feet, jaw and hands. Weakness of his limbs. Phalen test is positive. X-ray reveals there is frontal bossing and enlarged jaw.
Acromegaly most commonly affects adults in middle age It most commonly it involves a GH-producing tumor called pituitary adenoma *Bitemporal Hemianopsia*
41 year old truck driving presents for routine exam - no history of surgery - no medications. He has been a smoker for many years. He does not use alcohol or illicit drugs. Family History is unremarkable. Right pupil is LARGER than left by .4mm. All else is normal. What is Diagnosis?
Anisocoria 10-20% of individuals have variation in size between the pupils (anisocoria). Size difference of less than 1 mm with normal reaction to light and accommodation is termed physiologic (benign).
Wide Pulse Pressure
Aortice Regurgitation
Hutchinsons teeth associated with
Argyll Robertson Pupils
Prolong expiratory phase of respiration suggests narrowing of the bronchioles in ...
Asthma
80 year old man with failing vision your attempt to examine retina using opthalmascope is unsuccessful this is explained by....
Bi-lateral Mature CATARACTS
Inflammed Lymph Nodes vs Malignant Lymph Nodes
Both Large HARD = Malignant, Soft Firm = Inflammed Only Tender in Inflammed Nonmobile= malignant Discrete = Inflammed, borders not defined in Malginant
What is included in DVT assessment
Bulging veins, tenderness, edema (*Symptoms* of peripheral venous disease *Swelling* of feet and legs *Chronic ulcers* of the lower leg *Pain* in the calf area *Skin hyperpigmentation* and *thickening Prominent veins in the leg*)
65 year old diabetic male presents with worseing vision over past 3 years -- on attempting ophthalmoscopic examination the physician is unable to visualize the red reflex bilaterally
Cataracts Opacification (cataract). Evaluate pupil for any reflected light, showing as grey or silver areas, within each pupil. This may indicate cataract formation or, in children, retinoblastoma Other causes of cataract include Down's syndrome and cretinism, ocular disease such as iritis, systemic diseases such as diabetes and hyperparathyroidism and penetrating eye wounds.
chronic painless 1 cm mass in eye lid
Chalazion (A chalazion is cyst like and has *no acute signs of inflammation*. It is usually due to inspissated secretions of the meibomian glands.) BLOCKAGE OF GLAND NOT INFECTION
Clubbing of Fingers
Cirrhosis Lung Cancer Bacterial endocarditis Congenital Heart Disease Hyperthyroidism Inflammatory diseases (IBD) Fibrosing Alverolitis
Chronic Sniffling Nasal Congestion Nose Bleeds Septal Perforation
Cocaine Abuse
Cheyne Stokes Breathing
Damage to cerebral hemispheres (forebrain), Heart failure, Uremia, Drug induced respiratory depression
Pulse deficit is
Difference between the *heart rate* by auscultation at the apex and the peripheral *pulse rate* by palpation (*rapid irregular rhythm = atrial fibrillation*)
Which of the following is the most important to ensure patient comfort and good assessment during pelvic exam
Draping the patient
What is important to note while examining the lips and surrounding areas when patient is DEHYDRATED
Dryness and Cracking (also depressed frontalles)
Severe heart failure and bed ridden -- what would u find
Elevated JVP Positive Homans (DVT) Edema of Feet Hepatomegaly
When the examiner detects unusual coolness or temperature difference in the hands - should be next step in examination
Feel forearms with back of fingers
Unilateral nonpitting edema
Filarisis
Thyroid gland would be _____ in Hashimotos
Firm
Common cause of airway obstruction
Foreign body Right bronchi is shorter and more straight
45 yr old male presents with severe pain and swelling of his right big toe -- consumed lots of wine -- right metatarso-phalangeal joint is wollen and red and very tender. Nodules are palpable on the extensor surface of the right elbow and also on the helix of right ear
Gouty Arthritis
65 year old is admitted during winter in a comatose state with a body temp of 95F. On exam the patient is obese, with surgical scar in anterior aspect of neck and loss of the lateral 1/3 of her eyebrows.
HYPOTHYROIDISM -can cause *coarsening and dryness of the hair* -hypothermia (35C, 95C) General- Immobile and uninterested, weight gain *Eyes- Periorbital edema* Loss /thinning of lateral 1/3 o the eyebrows Hands- Pulse- bradycardia Temperature- decrease *Onycholysis* Skin- Coarse and dry Myxedematous changes in skin and subcutaneous tissues Yellow discoloration (hypercarotenaemia) Pallor (anemia)
25 yr old African American with prolonged persistant erection - several episodes of abdominal, chest, and joint pain. Hemoglobin is 6gm/dl and his bilirubin level is slightly elevated
Hemochromatosis (look up)
A young man presents to your office with a history of injury to face while playing soccer - during exam of eye you find blood in anterior chamber this is called
Hyphema (Stabismus = tropia, a constant misalignment of the visual axes of both eyes - they cannot point in the same direction).
Order of Approach
IPaPeA Inspection, Palpation, Percussion and Ascultation
Eye Deviation
If they appear misaligned, there will be typically one eye that fixates and the other eye will either deviate outward (exotropia), inward (esotropia) or upward (hypertropia).
Radiofemoral Delay
In disease conditions with obstruction to the flow of blood to the lower extremities, the femoral pulse is delayed in arriving, e.g. Leriche's syndrome (isolated aorto-iliac disease) and post subclavian coarctation of the aorta
Arterial Insufficiency
Intermittant claudication decreased or absent pulses Gangrene Thin, Shint, Atrophic skin (not edema)
If patients eyes are symmetrical but bulging / prominent - you would ask....
Is there any undue sweating and weight loss? (Hyperthyroid) -Restlessness, agitation, weight loss -lid lag, opthalmoplegia, diplopia, chemosis -Palmar erythema, increased temp - Clubbing (Thyroid Acropachy) -Onycholysis (sep from nail bed) -Vitigo, warm moist skin -Pretibial Myxedema (graves dermopathy) -hypertension + muscle weakness
38 year old woman comes to clinic complaining of pain and redness in her eye the past 2 days. She has been having difficulty reading and her left eye has excess tearing. On exam her left high has mucoid discharge and the cornea is hazy w/ some abrasion. The pupil is normal
KERATITIS - impaired eyesight + pain Keratitis is inflammation of the cornea. It is often accompanied by conjunctival hyperemia, tearing and photophobia.
45 year old male presents with severe headache, fever, and neck pain for past 2 days. He has had left ear pain and difficulty hearing on the left side. On exam his temp is 101F. He has tenderness with pressure on the mastoid process -- his neck is stiff.
Kernig's Sign Meningeal Irratation BRUDZINSKI‟S SIGN - Flexing the patient‟s neck causes flexion of the patient‟s hips and knees. - KERNIG‟S SIGN - Flexing the patient‟s hip 90 degrees then extending the patient‟s knee causes pain.
Most important site oral cancer
LIP
Thickened white patches that are hard to remove on tongue and buccal mucosal
Leukoplakia
Ulcers on sole of foot (plantar surface) only occur if
Neuropathic + Arterial disease -look for DIABETIC NEUROPATHY
looking in ear of 16 year old girl which are the follow are normal/abnormal
Normal = see umbo, cone of light, cerumen over membrane and not see incus Abnormal = tympanic membrane convex or bulging
Marathon - guy feels unwell, why?
Orthostatic Hypotension
50 year old male with painless lesion in his eye which has been there for 3 months. On exam there is *yellowish triangular lesion on the nasal side of his left eye over the sclera close to the cornea*
PINGUECULA (a whitish-yellow, triangular, nodular growth on the nasal portion of the bulbar conjunctiva adjacent to the corneal-scleral junction (limbus). It does not grow unto the cornea. )
What symptom accompanies arterial insufficiency besides *postural color changes*?
Pain on Walking (veinous would be pain all the time)
35 year old male with loud mitral murmur If you hear a murmur and need to determine the phase of the cardiac cycle it occurs in this is beset done byy
Palpating the Carotid Pulse while auscultating the heart (not sure on this one) If mitral stenosis: With the bell over the mitral area, ask the patient to roll towards their left side (left lateral decubitus position) and continue to auscultate the mitral area for the mitral stenosis murmur or left ventricular S3 or S4.
All test done to determine
Patency of Radial artery Patency of Ulnar Artery Collateral circulation in hand
Diabetic w/ tingling and numbness in feet for past 2 months. He has difficulty walking. Exam shows decreased pain, touch, vibration along with decreased proprioception in a stocking distrubtion this is due to
Peripheral Neuropathy
Radiofemoral delay due to
Post - subclavian coarctation of the aorta
Auditory acuity is deminished in
Presbyascusis ( hearing loss with aging)
Splitting S2
Pulmonary valve closure tends to be further delayed during inspiration, probably because of increased capacity of the pulmonary capillary bed during inspiration, which prolongs right ventricular ejection. This causes physiologic splitting of S2, accentuated by inspiration, often best heard near the pulmonary area.
Left Ventricular Failure Pulse
Pulsus Alterans
Dorsalis pedis pulse in a 40 year old asymptomatic male without other physical findings
Raynaud's Disease vasospasm(most likely - followed by atherosclerosis or trauma)
Transillumination of the sinuses is a test used to reveal thickened mucosa or secretions in sinus - if late is placed through front sinus what is observed?
Red Glow above the eye
following an illness of 1 week with bloody stools + severe abdominal cramps - your patient develops redness and irration in both eyes and painful inflammatory arthritis of left shoulder - right knee and both ankles - he also notices a discharge from his penis
Reiters Syndrome (Reactive arthritis) (2nd Reiters Question) URETHRITIS ARTHRITIS CONJUNCTIVITIS
Triad of urethritits, conjunctivitis and arthritis
Reiters Syndrome (reactive arthritis)
Bacterial Endocarditis signs
Roth Spots Janeway Lesions Oslers Nodes Splinter Hemorrhages (not heberdens)
Matching
S1 - closure of mitral valve/tricuspid S2 - closure of aortic valve/pulmonary SPLIT - Aortic Valve S3 - occurs after mitral valve opens during *rapid ventricular filling* (normal in kids) S4 - Atrial Contraction (normal in kids) Gallop Rhythym - S3/S4 w/ CHF tachycardia
On *inspection* of posterior thorax what is observed
Shape, Symmetry, Deformities
Criterion visual acuity using Snellens Chart
Smallest line of print that is read correctly
Chronic venous insufficency
Statis Dermatitis Brownish Discoloration of limbs Ulcer on medial ankle Edema of limb (not rubor and decreased pulses - this is arterial)
"Now let me make sure I have the full story...you have a cough for 3 days, that is really bad at night and you started to bring up yellow sputum....and now you have a fever"
Summarization
True fact about second heart sound
When split it may be increased by inspiration Delay closing of pulmonary valve - by inspiration. Fixed - ASD Wide - RV Bundle Paradoxical - LV Bundle Block Given the lower vascular resistance of the pulmonary artery, during inspiration, the pulmonary artery is able to tolerate more volume of blood before the pressure above the valve increases. Additionally, during inspiration, more blood fills the right ventricle leading to a slightly longer ejection time, adding to the delayed pulmonic valve closure.
Pulse pressure wider than normal on all but
Wider: Fever, Anemia, Advanced age, aortic incompetence Narrower: Hypothyroidism
discrete, waxy, yellowish deposit on the medial aspect of the lid.
Xanthelasma -high cholesterol correlating with atherosclerosis
In the refractive error of myopia light focuses ....
anterior to the retina
Tympanosclerosis
calcified plaques may be seen on the surface of the membrane and is usually due to scar formation secondary to incomplete healing of otitis media
Absence of red reflex
cataracts or retinoblastoma (not seen in opacities)
55 year old male presents with tremors in his hands for past 2 months. The tremors are pronounced in his hands. Finger-nose and heel-knee-shin are positive. Also has dysdiadochokinesia
cerebellar disease Patients with cerebellar lesions will have dysmetria (past pointing) and an intention tremor. Inspect the eye for *horizontal nystagmus*
Arterial Insuffiency lower limbs
cold white foot thickening of nails on foot loss of dorsalis pedis pulse loss of hair on dorsum great toe
Name the vaginal end of the cervix
ectocervix
When doing a cover uncover test you note the response is abormal this is due to
extraocular muscle tone
Roth Spots
have a clear white center surrounded by hemorrhage. Seen in infective endocarditis, HIV retinitis and leukemia.
Systolic Murmurs
heard between S1 and S2 (S3, S4 )
Hypothyroidism
immobile, uninterested Periorbital edema and loss of 1/3 eyebrow -bradycardia, decreased temp -oncholysis -coarse dry skin, myxedema -hypercartonemia (yellow skin) -anemia (pallor) -Delayed relax of deep tendon reflexs
Ulcers on tips of toes
just arterial
Right ventricular hypertrophy produces a....
left parasternal heave that can be palpated in these patients.
exacerbation of ear pain upon moving the auricle is suggestive of
otitis externa
palpating pulse you note 2 peaks - only 1 heart beate for 2 waves what best describes this
pulsus Bisferins (biphasic)
Stokes- Adams
syncopy related to CVD (seizures) - remember there are no ABNORMAL finding upon waking
Adies Pupil
three hallmark symptoms, namely at least one abnormally dilated pupil (mydriasis) which does not constrict in response to light, loss of deep tendon reflexes, and abnormalities of sweating -ciliary damage
Hard painless midline lesion in the hard palate
torus palatinus
Correct way to examine patients RIGHT EYE
using right hand, right eye, and RIGHT index finger extended
The internal jugular vein lies deep to SCM and is visible only by its puslations -- what is characteristic of these
variable with inspiration (not palpable, change by position, multicomponent configuration)
