CPD 3 Midterm Flashcards
Anatomy of the penis:
- Shaft: 2 lateral dorsal columns (corpora cavernosa) and 1 ventral column (corpora spongiosum/ cavernosum urethrae) which contains urethra
- head = glans penis, forms a shoulder (corona) at jxn w shaft.
- Prepuce= foreskin, covers glans (unless circumcised)
Before you begin the male exam:
- Always wear gloves.
* Have pt stand while you sit to his side
Order of Male exam palpation:
• inguinal nodes, penis, scrotum, testis, epididymis, spermatic cords, inguinal canals
Inguinal LN chains (M), and what they drain:
- horizontal: just below inguinal ligament. drains skin of lo abd wall, external genitalia (except testis), anal canal, lower vagina, and gluteal area.
- vertical: beside upper segment of great saphenous v, drains that area of leg. often palpable.
M Inguinal LN palpation, LA:
- note size (in cm), consistency, symmetry, and tenderness.
- no validated scales for lymphadenopathy
- UL: infx scrotum, epididymis, urethritis, chancroid, lymphogranuloma. Testes drain deep into pelvic nodes, so LA dt testicular issue won’t be palpable
- BL: mb syphilis or gonorrhea
Inspection and Palpation of Penis:
- View in dorsal position, then have pt retract prepuce (if present)
- Begin at root, palpate entire length of shaft
- Note nodules, ulcers, scars, tenderness, bruising, retraction of foreskin, edema, fracture of shaft
- nits or lice at base of hair shaft.
- location of urethral meatus.
- Check terminal urethra by compressing glans bw thumb and forefinger. Look for redness, d/c
Anatomy of scrotum:
- L testicle and scrotum usu lower than right
- Thin skin overlies dartos tunic muscle, internally separates scrotum into 2 halves; each half contains testis, epididymis, spermatic cord
- Drains to inguinal nodes
Potential finding in scrotum:
- Sebaceous cysts: Common, usu multiple. Firm, nontender. Yellowish contents of cyst may show through skin.
- Edema: Assoc w generalized edema (CHF). Thickened walls pit on pressure. Lymphedema (elephantiasis) dt blocked ducts from filariasis
- Hernia: may auscultate for bowel sounds
- Carcinoma: painless nodule
Anatomy of testis & epididymis:
- Solid ovoid in shape, suspended in scrotum, vertical long axis
- upper pole capped by head of epididymis
- body of epididymis attached vertically to posterior surface of testis
- tail of epididymis continuous with vas deferens and other vessels, forms spermatic cord
Palpation and inspection of Testis, Epididymis, Spermatic cord:
- T: Use thumb and forefinger; assess size, shape, consistency, sensitivity to pressure. Transilluminate each if any significant findings (eg swelling)
- E: vertical ridge of soft nodule at upper testicular pole, usu behind testis (~7% are anterior, a normal variant). Compare head, body, tail segments BL
- S: distinct hard cord, width of a lead pencil, contains vas deferens. trace cord down to testis and compare BL
Potential finding of testicle:
- Maldescended testis = cryptorchism: In children, one side mb raised. May result in sterility.
- Hydrocele: NT accum serous fluid from infx or trauma. Testis and epididymis usu behind the mass. Transilluminates
- Hematocele: NT accum blood. Swells like hydrocele, but opaque on transillumination
- Chyocele: NT lymph accum. Mass is translucent.
- Tuberculosis: Large hard nodular mass (neoplasm and tertiary syphilis also produce indurated NT masses).
- Acute orchitis: Painful, tender, swollen. Assoc w mumps, infx dz. Mb simultaneous epididymitis. Must r/o testicular torsion (mb after rigorous workout)
- CA: painless nodule
Potential findigs with spermatic cord:
• Deferentitis: Inflam vas deferens. Tender, swollen.
Hydrocele: dt failure of succus vaginalis to obliterate around spermatic cord →fills w fluid → mass, smooth, resilient, sausage-shaped, above testis
• Varicocele: Varicosities of pampiniform plexus of veins of spermatic cord. soft, irregular mass. Feels like bag of worms. L mc dt pressure of L venous outflow. Collapses slowly when scrotum is elevated in supine pt
• Testicular torsion: Twisted spermatic cord occludes blood to and from testis. Acutely painful, tender, swollen; retracted upward in scrotum. Pt may flex same leg for pain relief
Know the technique for palpating the inguinal ring for hernias.
- Place tip of index finger at most dependent part of scrotum, slowly direct it up into external inguinal ring.
- Have pt strain (valsalva) and cough (away from you). Note any palpable herniating mass against your fingertip
Know the difference between direct and indirect inguinal and femoral hernias.
- Indirect: MC, tissue herniates thru internal ring often into scrotum
- Direct: LC, us M >40, tissue herniates behind external ring rarely into scrotum, dt weak floor of inguinal canal
- Femoral: least common, F>M (PG and birth), never into scrotum; go into femoral canal, more likely to stangulate
What is the normal size and shape of the testicle?
- 5-7cm x 2.5cm
* ovoid
Know the difference between acute orchitis and acute epididymitis.
- Orchitis: entire testicle inflamed, usu seconday to mumps
* Epididymitis: bacterial infection (usu Chlamydia)
Size, position, anatomy of a normal prostate:
- 2.5 cm, about size of a chestnut
- 2 cm posterior to symphisis pubis, posterior surface next to rectal wall
- median sulcus: shallow, divides into R & L lateral lobe
- median lobe delineated by slight depression near superior edge
- Seminal vesicles near superior margin only palpable if inflamed
Prostate Exam:
- Pt lies in left lateral simms position, or bends over table
- Insert lubed gloved finger past anal canal into rectal ampulla. Keep pad of forefinger facing anterior wall
- Note: Smooth or nodular; Round or flat; Atrophied, normal size, or enlarged; Elastic, hard, boggy, soft; Mobile or fixated; Tender or nontender
- Normal feels like tip of nose, boggy like cheek, hard like forehead
Work-up for Prostate CA:
o Prostate Cancer Risk Calculator combines DRE, PSA, FHx; correlates well w bx
o Bx: indicated w abn DRE: induration, asymmetry, palpable nodularity
o DRE can detect tumors in posterior and lateral lobes. Up to 35% in other parts, not palpable
o PSA: for dx and px. Only do before bx (rises a lot). Ok to do after DRE (will rise a little)
Prostatic massage:
• Contraindicated in acute prostatitis
Know the difference between BPH, prostatic cancer, and acute prostatitis on digital rectal exam (DRE).
- BPH: smooth, enlarged symmetric lobes, elastic—rubbery, nontender
- Prostate cancer: hard, nontender nodules, median sulcus may be obscured
- Acute prostatitis: enlarged, tender prostate with asymmetrical edematous tissue, boggy
What is Peyronie’s disease? What are the findings on PE?
• Scarring of the tunica albuginea in the corpora cavernosa formation of plaques that can cause painful erection and dorsal curvature
• Sections of the neuro exam:
o Mental status o Cranial nerves o Motor system o Coordination o Sensory system o Reflexes, including deep tendon reflexes
• Motor system screening:
o Observe: o Walking: Normal gait; Tandem Heel-to-toe; On toes (plantarflexion); On heels (dorsiflexion) o Hopping in place o shallow knee bend on each leg o Drift of upper extremities (20-30 sec) o Assess grip strength
How do we rate muscle strength? How do we test muscle tone? What is spasticity? What is cogwheel rigidity? What conditions cause them?
- Strength: 0-5 scale, hold active resistance for 3-5 seconds
- Tone: resistance even when patient passive
- Spasticity: UMN/corticospinal tract system lesion, rate dependent hypertonia. “clasp-knife resistance”. ↑Tone w rapid passive movement
- Cogwheel rigidity: ratchet like jerkiness, parkinsonism
Muscle strength scale:
- 0: No mm contraction, no joint movement
- 1: Visible contraction w/o strength to move joint
- 2: can move joint, but not overcome gravity
- 3: moves against gravity, but not active resistance
- 4: moves against gravity and some resistance by examiner
- 5: Normal strength, active movement against full resistance w/o fatigue
Things to note w mm strength and tone:
- Plegia (partial or incomplete paralysis)
- Paresis (weakness)
- Involuntary movements (tremor, chorea, myoclonus, dystonia)
- Muscle bulk or atrophy
- Muscle tone (flaccidity, spasticity or rigidity)
Muscle Movements and the Corresponding Nerves:
- Elbow Flexion; C5, 6
- Elbow Extension; C6, 7, 8
- Wrist Extension; C6, 7, 8
- Grip Strength; C7, 8; T1
- Finger Abduction; C8, T1, ulnar nerve
- Thumb Adduction, opposition; C8, T1, median nerve
- Hip Flexion; L2, 3, 4
- Hip Adduction; L2, 3, 4
- Hip Abduction; L4, 5; S1
- Knee Extension; L2, 3, 4
- Knee Flexion; L4, 5; S1, 2
- Ankle Dorsiflexion; L4, 5; S1
- Ankle Plantarflexion; S1, 2
What tests check coordination?
- Rapid alternating movements of arms on lap; dysdiadochokinesis (inability, sign of cerebellar dysfunction)
- Finger tapping test: rapidly tap DIP of thumb w tip of index finger (normal 2 taps/sec)
- finger-to-nose test: dysmetria (ataxia, can’t control distance, power, speed), cerebellar disorders. Extend arm fully. Note any intention tremor
- forearm rolling
- heel to shin test: supine. Also test proprioception.
Pain, temp, light touch sensation and their sensory tracts:
- Note: anesthesia, hypesthesia, paresthesia. Compare arms, legs, trunk
- Pain (LSTT): sharp vs. dull. Don’t reuse sharps (risk transmit infx)
- Temp (LSTT): hot vs. cold
- Light touch (ASTT): brush, cotton, or Semmes-Weinstein monofilament. Diabetic foot: insensate to 5.07 monofilament, ↑risk subsequent foot ulceration and amputation
Posterior Column:
• vibration and proprioception.
Digit Position sense for proprioception:
• hold digit in a “neutral”, up, down, position. Usu big toe, or other
Vibration:
- Tests proprioception
- 128-Hz tuing fork. Strike on your palm ~20 cm
- heathy 40yo should perceive vibrations for at least 11 secs at med malleolus, 15 at lat, 15 at ulnar styloid. ↓ 2 secs w every decade > 40
• Discriminative sensations:
o Depends on normal cortical function
o Stereognosis: recognize common objects 90% of time in 5 secs
o Graphesthesia: identify numbers or letters (1 cm height on fingertips, 6 cm elsewhere)
o 2-point discrimination: distinguish 2 sharp points simultaneously on skin. Normal: 3 cm on hand or foot, 6 mm on fingertips
• Grade Deep Tendon Reflexes (DTRs) on a 0-4 Scale
o 0: Areflexia, absence of any reflex
o 1: Reduced, weak, or only w Jendrassik reinforcement (may bring out reflexes)
o 2: Average, normal
o 3: Brisk, upper normal
o 4: Extremely brisk hyperreflexia, with clonus (rapid involuntary alt contraction and relaxation)
• Deep Tendon and Cutaneous Reflexes w Corresponding Nerves:
o Biceps; C5, 6 o Triceps; C6, 7 o Brachioradialis; C5, 6 o Abdominal; T8-12; Frequently not seen in obese individuals o Cremasteric; L1,2 o Knee; L2, 3, 4 o Ankle; S1, 2; Ankle clonus suggests UMN disease o Plantar; L4, 5; S1, 2; Check Babinski
Describe a Babinski reflex. What does a positive Babinski sign indicate in a 21-year old patient versus an 18-month old child?
- Stroke lateral aspect of sole, curving medially across the ball
- Negative: toes flex
- Positive: toes abduct and extend (big toe dorsiflex) (physiologic response in infants)
- (+) > 2 suggests UMN dz
What do deviation from normal DTRs indicate?
- Alone, do not signify neuro dz. sign only if assoc w other clinical findings
- absent reflex: LMN dz (weakness, atrophy, facsiculations)
- exaggerated reflex: UMN dz (weakness, spasticity, clonus, Babinski sign)
- asymmetric: mb LMN or UMN dz
- brisk compared to reflexes from higher spinal level: spinal cord dz at some level bw
- ↓DTRs: must localize lesions in cervical or lumbosacral nerve roots (radiculopathy)
Know tests for meningeal irritation.
- Both tests are insensitive for meningitis!
- Brudzinski: flex supine pt’s neck → flex both hips and knees
- Kernig: hip and knees flexed, (+) when resists extension of knee
- Neck stiffness: involuntary resistance to neck flexion
Order of most →least sens/spec tests for UL cerebral hemisphere dz:
- Arm rolling
- Pronator drift
- Finger tapping
- Babinski
- Hyperreflexia
- Hemianopsia
- Hemisensory disturbance
What does “glove and stocking distribution” mean in terms of sensory testing?
• Affects distal extremities
How are discriminative sensations tested? What part of the nervous system is responsible for sensory discrimination?
- Depends on normal cortical function
- Stereognosis: ability to recognize common objects 90% of time in 5 s
- Graphesthesia: ability to identify numbers or letters
- 2 point discrimination: sharp objects. Normal distance is 3cm for hand, 6mm for fingertips
What is a dermatome?
• area of skin that is mainly supplied by a single spinal nerve
Never OMIT for mental status:
- Orientation: Time: day, day of the week, month, season, year; Place: Where they live, where they are; Person: Knows own name, family names, of medical personnel
- Memory: Recent: pick a fact you can verify; Remote: Check a fact they should know
- Intelligence: Calculating ability, knowledge (names of last 4 presidents), Abstract reasoning (interpreting a proverb, comparing similars apple/pear, piano/violin)
- Talk: Speech, rate, quantity, fluency, articulation
MSE: Appearance
• Level of consciousness, posture, hygiene, facial expression, manner/affect, speech, mood
MSE: Thought processes
• Asses logic, relevance
a. circumstantiality: indirect delayed speech
b. flight of ideas: continuous rapid flow of speech
c. neologisms: invented words
d. incoherence
e. blocking: loss of though
f. confabulation: Wernick-Korsakoff
g. preservation: repeating words/ideas
h. echolalia: echoing
i. clanging: choosing word based on sound
MSE: Thought content
a. Obsessions: recurrent thoughts thatunhappy
b. Compulsions: acting on obsession
c. Phobias
d. Anxieties
e. Feelings of unreality
f. Depersonalization
g. Delusions
h. Rigid/repetitive
MSE:
- Perceptions, Insight:
- Cognitive functions
- Language and motor skills
- Higher intellectual functions
P: Illusions/hallucinations
I: are they aware may be abnormal
• CF: Orientation, attentions, memory, new learning ability
• L: Comprehend words, name objects, copy figures
• H: Assess vocab, judgment
Assessing suicide risk:
Sex: male Age: teens/elder Depressed Previous attempt Ethanol Rational thinking loss Social support loss Organized plan No spouse Sickness
Cranial Nerves:
I-Olfactory II-Optic III-Occulomotor IV-Trochlear V- Trigenimal VI- Abducens VII- Facial VIII- Vestibulocochlear IX- Glossopharyngeal X- Vagus XI- Accessoty XII- Hypoglossal
Olfactory N test:
- smell, use a familiar non-irritating substance.
- Painful or irritating stimulates CN V
- Check for patency: ↓smell often dt rhinitis, smoking, aging.
- UL loss w optic deficit and personality change → lesion in frontal lobe
Optic N test:
- visual acuity: Snellen for far, Rosenbaum for near
- visual fields by confrontation
- Ophthalmoscopic exam: clarity of optic disc, cup/disc ratio, optic atrophy, papilledema, Spontaneous venous impulses (absence suggests ↑intracranial P)
Oculomotor N test:
- Motor to pupil, eyelid, EO muscles
- PERRLA
- Note: ptosis (Drooping of the eyelid)
- Slow pupilary response: CN II sensory lesion (optic atrophy)
- EO extraocular movements with H in space
- Horner’s syndrome = ptosis with miosis enophthalmos. Lesion of T1 sympathetic nerves
Trochlear N test:
- EO movements (down and in, assists with down and out)
* X in space
Abducens N test:
- Responsible lateral movement of the eye.
- H in space
- Nystagmus: Note quick and slow components. plane of movement (horizontal, vertical). A few beats of horizontal nystagmus is normal in extreme lateral gaze. Vertical nystagmus suggests brainstem lesion.
- Diplopia: True = weakness or imbalance in EO mm. “how many fingers am I holding up?” True= disappears when one eye is closed. Problems w the lens or cornea may cause blurring that mimics diplopia.
Trigeminal N test:
- Motor to the masseter and temporal muscles. Sensory to the face
- “clench your teeth”
- 3 divisions: ophthalmic, maxillary and mandibular. cotton ball for light touch
- Corneal reflex: only if deficit on light touch. Touch cornea (not conjunctiva) w cotton (no contact lens). CN V is sensory, CN VII is motor.
Facial N test:
- Motor to face, Taste on anterior 2/3 of tongue
- “raise eyebrows, frown, close eyes tightly, smile (volitionally), puff out cheeks”
- attempt to elicit a spontaneous smile.
- weakness or asymmetry? only lower half or entire side?
- Lesions in cerebral cortex → contralateral weakness of mouth, but not the forehead.
- Peripheral lesions (ieBell’s Palsy) → total facial paralysis on ipsilateral side.
Acoustic N test:
- Auditory acuity, Balance
- Gross hearing, if deficit → Weber and Rinne (conductive or sensorineural)
- Romberg: vestibular system and proprioception when eyes are closed. Loss of balance with eyes open suggests cerebellar ataxia (incoordination)
Glossopharyngeal N test:
- Sensory to pharynx, Taste on posterior 1/3 of tongue.
- cotton swab to stimulate gag reflex (minimum dose).
- Is reflex symmetrical?
Vagus N test:
- Motor to pharynx
- “swallow.” Note symmetry.
- “say ‘ahh’.” soft palate should elevate symmetrically, uvula should stay midline.
- asymmet gag w normal swallow and phonation prob dt CN9 lesion.
- asymmet gag w UL loss elevation on phonation and asymmet swallow prob dt CN10 lesion
Spinal accessory nerve test:
- Motor to trapezius and SCM
- Usu injured from trauma to neck.
- “shrug against manual resistance.”
- Test SCM if trap tests abn.
- Use caution in cases of neck trauma
Hypoglossal N test:
- Motor to tongue
- “stick out your tongue”
- Deficit: tongue deviates toward side of lesion.
- If question, have pt press tongue into their cheeks
What is the normal ROM of the TMJ? What other findings will you encounter?
- 3cm bw upper and lower incisors
* Palpate: swelling, crepitus, deviation, ROM
Cervical Spine tests:
- Compression & Distraction (traction)- pt looks straight ahead, and head rotated 20º to each side.
- Adson’s: + in TOS (peripheral neuropathy) paresthesias/↓ radial pulse (compression of Subclavian a) when abduct, extend, ER arm, look to same side and valsalva
Inspect and Palpate hands and wrists:
- for swelling (note Heberden’s and Bouchard’s nodes), redness, deformity, nodules or atrophy.
- Hand ROM: Extension: Spread fingers of both hands. Flexion: Make a fist with both hands. MCP joints: Flexion 90º, Extension 35º. PIP jts: 100º. DIPs: 90º
- Wrist ROM: Flexion: 80º; Extension: 70º; Ulnar deviation: 30º; Radial deviation: 20º
What is Finkelstein’s test?
• Make fist with thumb inside, eviate fist ulnarly. severe pain + Finkelstein: indicates tenosynovitis
What are the best exams for ruling in/out Carpal Tunnel syndrome? Others?
- RULE IN Best clinical: Katz hand diagram [gold standard: electrodiagnostic] and weak thumb abduction
- RULE OUT Hypalgesia: ↓ perception painful stimuli along palmar aspect of index finger compared to little finger
- (also good predictor of electro-dx) Weak Thumb Abduction. elevate thumb against resistance. (+) = weakness.
- Tinel’s sign: Percuss lightly over flexor retinaculum. (+) = tingling sensation
- Phalen’s sign. maintain position for 60 seconds. (+)=sensation of tingling in median n distribution over hand
Inspect and Palpate elbows:
- redness and swelling. lateral and medial epicondyles for point tenderness
- ROM: Flexion: 135-150º; Extension: 0-5º; Supination and pronation: 180º
Shoulder assess:
- swelling, crepitus, deformity.
- Palpate SC jt, ACjt, bicipital groove for tenderness
- Screening Method: Apley’s Scratch Test: ER and abd, IR and add
- ROM: Abduction: 180º; Adduction: 45º; Flexion: 90º; Extension: 45º; Internal rotation: 55º; External Rotation: 40º
What are the findings in tennis elbow? Golf?
- Tennis= Lateral= painful, tender lateral epicondyle
* Golf= medial Epicondylitis
Where is the subacromial bursa?
• On top of humerus
Assess Feet and ankles:
- All done w pt supine
- Inspect: swelling, redness, nodules (podagra on great toe common in gout), deformity
- Palpate: toes for tenderness. metatarsals.
- ROM: Dorsiflexion: 20°; Plantar flexion: 50°; Inversion: 5°; Eversion: 5°; Adduction: 20°; Abduction: 10°
- Ankle Drawer Sign: Hold calcaneus, pull anterior, push posterior.
Assess knee:
- Inspect: alignment, deformity, swelling, atrophy. Note any atrophy of quadriceps
- Palpate: swelling, bogginess, tenderness. tibial plateau for meniscal injuries. tibial tuberosity in adolescents for Osgood-Schlatter dz. Note any suprapatellar pouches.
- Tests for Fluid: Bulge sign, Ballottement
Tests for lig stability in knee:
- Valgus and Varus Stress: w knee extended and slightly flexed
- Apley’s Compression/Distraction: meniscus and collateral ligs
- McMurray’s Test: meniscus tears. Apply valgus stress to flexed knee while ER leg (toes point out) and slowly extend knee while still in valgus. popping, clicking, guarding = tears of medial meniscus. Repeat w varus stress and IR for lateral meniscus.
- Anterior Drawer Sign: ACL
- Lachman’s Test: ACL. knee flexed 20 to 30º, tibia displaced anteriorly to femur. soft endpoint or > 4 mm displacement is (+)
- Posterior Drawer Sign: PCL
- Patellar Entrapment: Chondromalacia patella
- Thessaly: meniscus. Test normal knee first. (+)= med or lat jt line discomfort, mb locking or catching
What test most sensitive for ACL tear?
• Lachman’s test: + when knee flex 20-30 degrees, >4mm displacement of tibia anterior to femur
How does one test the knee for effusion? Where would you expect to find tenderness to palpation in a meniscal tear?
- Bulge sign: look and milk
- Ballotement: downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.
Assess Hip:
- Inspect: alignment, deformity, swelling, atrophy. Inspect greater trochanter.
- ROM: Flexion (knee to chest) 135°; Abduction: 45°; Adduction: 20°; Rotation with hip at 90°
Hip ortho tests:
- Patrick-Fabere: flexion, abduction, ER. (+) in hip or SI dz
- Gaenslen’s: extension, psoas tenderness, SI dz
Assess spine:
- Inspect: scoliosis, lordosis, kyphosis. levels of ears, shoulders, scapulae, iliac crests
- Note any genu varus/valgus, pronation, eversion of feet. hypertrophy or atrophy of paraspinal muscles.
- ROM :
- Flexion: 90°. Measure how close to ground can reach w fingertips
- Extension: 30°
- Lateral bending: 20°. Should be equal on both sides.
- Rotation: 30°. Compare both sides.
Lumbar spine ortho test:
- SLR: active and passive. Most sensitive.
- Bragard’s SLR until painful, lower until pain stops then dorsiflex foot
- Valsalva: (+) in lumbar disc syndrome
- Kemp’s: R, E, LF. (+)=pain w f acet dz and lumbar disc herniation
- X-SLR: SLR of CL limb reproduces more specific but less intense pain on affected side
- Sit to Stand: Most reliable to detect quadriceps weakness. attempt to rise from chair using only one leg at a time
Tests for lumbar disc herniation:
- SLR
- X-SLR
- Sit-to-stand
What are the tests for non-organic back pain (i.e. malingering)?
- Flip test: + when SLR restricted/painful but pt can sit up and extend wihout pain
- Hoover’s test: + when contralateral foot does not press into table w SLR
What are the findings of DJD and RA in the hand?
- Degenerative joint disease: swollen knuckles, phalanges deviated
- Rheumatoid arthritis: boutonnière deformity of thumb, ulnar deviation of metacarpal phalangeal joints
What is hallux valgus?
• Looks like a bunion. Medial deviation of the MT1 and lateral deviation/rotation of hallux
