Exam 3 Flashcards
GI, GU
Pancreatic ca s/s
Painless jaundice, anorexia, weight loss, glucose intolerance, depression
Appendicitis s/s, positive sign names
- Poorly localized, visceral periumbilical pain due to distention of inflamed appendix which migrates to RLQ as parietal pain due to inflammation of adjacent parietal peritoneum.
- Rovsing sign, + Psoas sign, + Obturator sign, and/or tenderness at McBurney point
- if pain subsides = perforation
- [Note: visceral pain is gnawing, burning, cramping or aching. When severe it causes sweating, pallor, n/v, restlessness]
**Parietal pain
aka somatic pain
- originates from inflammation of parietal peritoneum called peritonitis
- steady, aching, more severe than visceral pain, more precisely localized over involved structure
- usually aggravated by movement or coughing
- patients prefer to lie still
ex: peritonitis s/s pain with absent bowel sounds, rigidity, percussion tenderness and guarding
Referred pain
Pain felt distant to origin due to related innervation of same spinal levels as disordered structures
palpation at site of referred pain does NOT result in tenderness
Ex: duodenal or pancreatic origin pain referred to back. Pain from biliary tree referred to right scapular region or right posterior thorax
Pain from pleurisy or inferior wall myocardial infarction referred to epigastric region
Renal stone s/s
Colicky pain causing doubling over, frequent movement to find comfortable position, cramping pain radiating to the right or LLQ or groin
acute pancreatitis s/s
epigastric tenderness often radiating to the back,
acute onset, persistent pain which may be aggravated by lying supine,
sx: n/v, abdominal distention, fever, recurrent with alcohol abuse or gallstones, some relief with leaning forward with trunk flexed
GERD s/s
Heartburn and regurgitation more than once per week makes accuracy of diagnosis over 90% atypical symptoms:
- chest pain, cough, wheezing and aspiration PNA, hoarseness, chronic sore throat and laryngitis
- risk factors: reduced salivary flow, obesity, delayed gastric emptying; selected medications and hiatal hernia*
timing: after meals, esp after spicy foods
Alarm GI symptoms
Dysphagia, odynophagia, recurrent vomiting, evidence of GI bleeding, early satiety, weight loss, anemia, risk factors for gastric CA, palpable mass, painless jaundice warrant endoscopy to evaluate for esophagitis, peptic strictures, Barrett esophagus or esophageal CA
**Small or large bowel obstruction s/s
Diffuse abdominal pain, abdominal distention, hyperactive high-pitched bowel sounds, tenderness on palpation
Colon CA s/s
Change in bowel habits with mass lesion
Mesenteric ischemia s/s
Food fear, vomiting, bloody stool, signs of shock, abdominal pain, slightly distended/ soft/nontender abdomen, pain disproportionate to physical findings may have underlying cardiac disease, age > 50
**Ulcerative colitis What and s/s
Mucosal inflammation typically extending proximally from rectum to varying lengths of colon s/s: frequent watery stools, often containing blood, abrupt onset, night awakening, cramping pain, fever, fatigue, weakness, linked to Ashkenazi Jewish descendants and to altered CD4 T-cell Th2 response, increased risk of colon CA
**Crohn disease of small bowel What and s/s
Chronic transmural inflammation of bowel wall with skip pattern involving the terminal ileum and proximal wall, may cause strictures
s/s: pain happens insidiously, chronic and recurrent, crampy periumblical, RLQ or diffuse pain with anorexia, fever, and/or weight loss, perianal or perirectal abscesses and fistulas, may cause small or large bowel obstruction.
Often in teens or young adults, more common in Ashkenazi Jewish descendants, linked to altered CD4+ T-cell helper Th1 and 17 response
Acute vs. chronic diarrhea
Painless loose or watery stools during >=75% of defecations in prior 3 months, with symptom onset at least 6 months prior to diagnosis. acute: less than 2 weeks chronic: more than 4 weeks, usually due to Crohn’s or UC
Constipation criteria and s/s
Present in past 3 months with symptom onset at least 6 months prior to diagnosis and meet at least 2 of the following:
- fewer than 3 bms/week
- 25% or more defecations with either straining or sensation of incomplete evacuation;
- lumpy or hard stools;
- or manual facilitation.
Colorectal CA risk factors and prevention
- Increasing age, personal hx of colorectal CA, adenomatous polyps, or long standing IBD, family hx of colorectal neoplasia (1st degree relative, esp when relative age <60), or hereditary colorectal syndrome
- Weaker risk factors: AA, male sex, tobacco use, excessive alcohol use, red meat consumptions and obesity.
- Prevention: screen for and remove precancerous adenomatous polyps
**Colorectal CA screening tests
Adults ages 50-75 (grade A rec)
- High-sensitivity fecal occult blood testing (FOBT) annually, either a guaiac-based or fecal immunochemical test (FIT)
- Sigmoidoscopy every 5 years wtih high-sensitivity FOBT every 3 years
- Screening colonoscopy every 10 years
Adults ages 76-85 years (grade C rec)
- Screening not advised because benefits small compared to risks
- Use individual decision-making if screening adult for first time
Adults > 85 years (grade D rec)
- Screening not advised d/t harm outweighs benefit
Any abnormal finding on a stool test, imaging study or flex sig warrants further evaluation with colonoscopy (gold standard)
**Signs of intestinal obstruction
Protuberant abdomen, tympanic throughout, increased peristaltic waves
**Peritonitis s/s
Positive cough test
Guarding (voluntary contraction of abdominal wall, often accompanied by a grimace)
Rigidity (involuntary reflex due to peritoneal inflammation that persists over several examinations)
Rebound tenderness (pain expressed by patient with sudden removal of hand)
Percussion tenderness
Causes include: appendicitis, cholecystitis, and a perforation of the bowel wall
Normal liver span
6-12 cm in right MCL
4-8 cm in midsternal line
If enlarged, doubles the likelihood of cirrhosis
If decreased, may be indicative of resolution of hepatitis or HF, or less comonly, with progression of fulminant hepatitis
On inspiration, the liver is palpable about 3 cm below the right costal margin in the MCL
Clinical estimates of liver size should be based on both percussion and palpation.
Spleen percussion
- Traube space: percuss the left lower anterior chest wall from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin
Normal - tympanic throughout
Abnormal - dullness
- Splenic percussion sign: Percuss the lowest interspace in the left anterior axillary line (normal: tympanic). Ask patient to take deep breath and percuss again (normal: tympanic). If abnormal (not tympanic), pay attention to palpation of spleen.
Pyelonephritis on exam
Pain with pressure or fist percussion, especially when associated with fever and dysuria, although may be musculoskeletal.
**AAA
Risk factors
Likely rupture and relative mortality
Risk Factors
- Age >= 65 years
- Male gender
- Hx of smoking
- First-degree relative with a history of AAA repair
Periumbilical or upper abdominal mass with expansile pulsations that >= 3 cm in diameter suggests an AAA.
Widths of 3-3.9 cm, 29% AAA
4-4.9 cm, 50%
>=5 cm, 76%
Rupture is 15 times more likely in AAAs > 4 cm than in smaller aneurysms
Which carries 85-90% mortality rate
USPSTF recommends ultrasound screening for men over 65 years who have “ever smoked.”
Ascites Assessment
- Percuss outward to map dullness from ascites
- In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top.
- When percussing the border of tympany and dullness with a patient in supine position, in a person without ascites the border between the two remains constant. It shifts with ascites.
- Test for fluid wave - an easily palpable impulse suggests ascites
- Ballotte the organ or mass - make a brief jabbing movement directly toward the anticipated structure
A positive fluid wave, shifting dullness and peripheral edema makes the presence of ascites 3-6 times more likely
**Appendicitis diagnosis
- Twice as likely in the presence of RLQ tenderness, Rovsing sign and psoas sign
- Three times likely with McBurney point tenderness
- Pain begins in the umbilicus and then moves to RLQ
Note: McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus.
Note: Rovsing sign is pain in the RLQ during left-sided pressure (deep and even)
Note: Psoas sign is pain when placing a hand on the patient’s right knee and s/he attemps to raise that thigh against the hand. Or, if turn to the left side, flexion of the leg at the hip, causes pain. Both are a positive Psoas sign.
Note: A less helpful sign, the obturator sign, is pain with flexion of the right thigh at the hip with knee bent and internal rotation of the leg at the hip.
**Murphy sign
Assessing for a positive sign in acute cholecystitis (p. 486)
- Hook left thumb or fingers of right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin.
- Ask pt to take a deep breath (INSPIRATION).
- Note breathing and degree of tenderness.
**Omphalitis
Infection of the umbilical stump
characterized by periumbilical edema and erythema
Palpation of liver in infants
normal: 1-3 cm below the right costal margin
An enlarged, tender liver may be due to HF or storage diseases.
Hepatomegaly in newborns is d/t hepatitis, storage disease, vascular congestion and biliary obstruction.
**Pyloric stenosis in infants
- Deep palpation: 2 cm firm pyloric mass in RUQ or midline
- While feeding, visible peristaltic waves across abdomen, follwed by projectile vomiting
- Infants present at about 4-6 weeks of age
Liver span in children
- Increases with age
- Reaches adult size during puberty
Effect of aging on abdominal disease
Aging can blunt the manifestations of acute abdominal disease.
Pain is less severe, fever is often less pronounced and signs of peritoneal inflammation, such as guarding and rebound tenderness, may be diminished or even absent.
Articular joint pain
decreased active and passive ROM
morning stiffness or gelling
Non-articular joint pain
periarticular tenderness, and
only passive ROM remains intact
Severe pain of rapid onset in a red swollen joint suggests…
acute septic arthritis or crystalline arthritis (gout, CPPD)
In children, consider osteomyelitis in a bone contiguous to a joint
CPPD = Calcium pyrophosphate dihydrate crystal deposition disease
**Cardinal features of inflammation
swelling, warmth, redness and pain
Helpful LAB TESTS in inflammatory musculoskeletal conditions
- Erythrocyte sedimentation rate
- C-reactive protein
- platelet count, and
- hematocrit
Cauda equina syndrome signs
- S2-S4 midline disc or tumor
- especially with bowel or bladder dysfunction (usu. urinary rentation with overflow incontinence) esp if there is saddle anesthesia or perineal numbness
- ASAP imaging and surgical evaluation due to risk of limb paralysis or bladder/bowel dysfunction
Red flags for LBP
- Age < 20 or > 50 years
- hx of CA
- unexplained weight loss, fever or decline in general health
- pain lasting more than 1 month or not responding to tx
- pain at night or present at rest
- hx of IVDA, addiction or immunosuppression
- presence of active infection of HIV infection
- long-term steroid therapy
- saddle anesthesia, bladder or bowel incontinence
- Neurologic symptoms or progressive neurologic deficit
Osteoporosis screening
Per USPSTF, all women age >=65 years,
younger women with 10-year fracture risk equallying or exceeding that of an average 65 yr old white woman
No guideline from USPSTF for men
Per American College of Physicians, periodic assessment of older men with osteoporosis risks
Use FRAX calculator (courtesy of WHO)
USPSTF recommends a threshold of 9.3% when considering bone density screening in women ages 50-64.
DEXA
- Dual Energy X-ray Absorptiometry
- Bone of femoral neck, best predictor of hip fracture
- Osteoporosis: T score < -2.5 (>2.5 SDs below the young adult mean)
- Osteopenia: T score btwn -1.0 and -2.5 (1.0 to 2.5 SDs below the young adult mean)
- Z scores represent comparisions with age-matched controls
- They help determine whether bone loss is cuased by an underlying disease or condition
Shoulder - principal bursa is subacromial bursa
Location
Normal palpation
Abnormal palpation
- Normally, not palpable
- Positioned between the acromion and the head of the humerus
- If inflamed (subacromial bursitis), may be tender just below the tip of the acromion, pain with abduction and rotation, and loss of smooth movement.
Carpal tunnel
A channel beneath the palmar surface of the wrist and proximal hand.
Contains the sheath and flexor tendons of the forearm muscles and the median nerve.
In carpal tunnel syndrome (CTS), you may find the unar atrophy in median nerve compression.
(In ulner nerve compression, there is hypothenar atrophy.)
Signs: hand or arm numbness (paresthesias), dropping objects, inability to twist lids off jars, aching at the wrist or even the forearm, and numbness of the first three digits, warrants a test for carpal tunnel syndrome
Risk factors: forceful repetitive handwork with wrist flexion such as keyboarding or mail sorting, vibration, cold environments, wrist anatomy, pregnancy, RA, DM, and hypothyroidism are RFs for CTS
Median nerve
provides sensation to the palm and the palmar surface of most of the thumb, the second and third digits and half of the fourth digit.
It innervates the thumb muscles of flexion, abduction and opposition.
**Osteoarthritis common findings
Hands: Heberden nodes (DIP joints) and Bouchard nodes (PIP joints)
Spinal:Decreased spinal mobility (flexion, extension, rotation and lateral bending)
Hip: Restricted abduction and internal and external rotation
Knee OA: Bony enlargement at the joint margins, genu varum deformity (bow-legs), and stiffness lasting <= 30 minutes are typical. Crepitus common. Thickening, bogginess, or warmth occurs with synovitis and nontender effusions from knee OA.
- Patellofemoral OA: Crepitus with flexion and extension of the knee joint, a probable precursor of knee OA.
Rheumatoid arthritis
Persisting bilateral swelling and/or tenderness
Symmetric deformity in the PIP, MCP and wrist joints
Later if chronic, there is MCP subluxation and ulnar devation
“swan neck deformities” from inflammatory destruction of joints and supporting ligaments
MCPs are often boggy and tender
Tenderness on compression of the forefoot is an early sign of RA
boutonniere deformity (less common) - persistent flexion of PIP joint with hyper extension of DIP joint
Carpal Tunnel Syndrome Testing
- Thumb abduction - weakness against resistance is a positive sign
- Tinel Sign - Aching and numbness in the median nerve is a positive sign
- Phalen sign - numbness and tingling in the median nerve distribution within 60 seconds is a positive sign
Note: Tinel and Phalen signs do not reliably predict positive electrodiagnosis of CTS
Instability of the knee
It is the largest joint in the body that is dependent on four ligaments (collaterals and cruciates) to hold its articulating femur and tibia in place.
knee highly vulnerable to injury bc lever action of the femur on the tibia and the lack of padding from overlying fat or muscle,
During gait, stumbling or “giving way” of the knee during heel strike suggests…
quadriceps weakness or abnormal patellar tracking
Patellofemoral pain syndrome
Two of three findings are most diagnostic:
- Pain with quadriceps contraction
- Pain with squatting; and
- Pain with palpation of the posteromedial or lateral patellar border.
Palpation Tests for Knee Joint Effusions
- The bulge sign (for minor effusions) - A fluid wave or bulge on the medial side between the patella and the femure is a positive test for effusion.
- The balloon sign (for major effusions) - A palpable fluid wave is a positive test or “balloon sign.” A palpable returning fluid wave into the suprapatellar pouch further confirms a major effusion, present in knee fractures
- Balloting the patella (for major effusions) - A palpable fluid wave returning into the pouch is also a positive test for a major effusion. (A palpable patellar click with compression may also occur, but is more false positives.)
Achilles tendon rupture s/s
- Absent plantar flexion
- Sudden severe pain, “like a gunshot”
- An ecchymosis from the calf into the heel, and
- a flat-footed gait with absent “toe-off” may also be present
Lachman Test
Significant forward excursion is a positive test for an ACL tear.
[Place the knee in a 15 degree of flexion and externally rotate. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. Simultaneously pull the tibia forward and the femur back.]
Plantar fasciitis
Focal heel tenderness at the attachment site of the plantar fascia
Risk factors: anatomic (overpronation, flat feet), improper footwear, excessive use, and overtraining with prolonged heel-strike exercise.
Presence or absence of a heel spur does not change the diagnosis.
Ankle sprains
Foot inversion and injury to the weaker lateral ligaments (anterior talofibular and calcaneofibular), with overlying tenderness, swelling and ecchymosis.
Ankle fracture
Pain in the malleolar zone plus either bone tenderness over the posterior aspects of either malleolus (or over the navicular or base of the fifth metatarsal) or an inability to bear weight for four steps is suspicious and warrants radiography (Ottowa ankle and foot rules)
**Normal findings on newborn ABDOMEN
- Protuberant abdomen
- Noticeable peristalsis
- Umbilical cord with 2 arteries and 1 vein at 12 o’clock position
- Cord with cutaneous and amniotic portion
- Amniotic portion dries up and falls off within 2 weeks
- Cutaneous portion retracts and becomes flush with abdominal wall
- Umbilical hernias are detectable by few weeks of age
- Most disappear by 1 year
- Nearly all by 5 years
- Diastasis recti - midline ridge, benign condition, resolves in early childhood
Technique for assessing abdomen in infants
Inspect: Umbilical (red/swelling)
Normal: foul smelling
Skin around umbilicus same as body color
Infected: omphalitis (edema and erythema)
Auscultaiton: musical tinkling; increased pitch/freq= gastroenteritis
Simultaneous percussion and auscultation: can feel liver and spleen
- silent, tympanic ,tender abd = peritonitis
hepatomegaly = hepatitis, storage disease, vascular congestion
can feel pulsation in epigsatric by aorta (deep palpation)
Relax the infant by holding legs flexed at knees and hips with one hand and palpate the abdomen with the other.
A pacifier may quiet the infant in this position.
**Bruits in abdomen
Aorta, renal artery, iliac artery, femoral artery
Bruits suggest vascular occlusive disease.
Vascular sounds resembling heart murmurs over the arteries.
A bruit with both systolic and diastolic components strongly suggest RENAL ARTERY STENOSIS as the cause of hypertension.
**Friction rubs over abdomen
May be found over liver and spleen
Present in hepatoma, gonococcal infection around the liver, splenic infarction and pancreatic carcinoma.
Liver palpation
Starting palpation too close to the right costal margin risks missing the lower edge of an enlarged liver that extends into the RLQ.
Place right hand on the right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness.
With all techniques, have the patient take a deep breath in & try to feel for the liver as it slides down to meet your fingertips. Firmness, bluntness or rounding of liver edge & surface irregularities are suspicious for liver disease. Enlarged liver is measured in finger breadths.
Dynamic Stabilizers of the Shoulder
S.I.T.S.
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Genu Valgum “vag = gotta pee!!!!”
Knock knees
Genu Varum
Bow leg knees
Infant clavicle abnormal findings
Lumps, tenderness, crepitus
May indicate fracture especially during difficult birth
Infant meningomyelocele or spina bifida oculta
Pigmented spots, hairy patches, deep pits present 1 cm or so from the midline
**Ortolani test
Detect presence of posteriorly dislocated hip. “Start with knees on stomach and draw outward circles”
flex legs to form right angles ABDUCT both hips simultaneous until lateral aspect of knee touches table
feel a “clunk” as femoral head back into place constitutes a positive test
**Barlow test
Tests for the ability to sublux or dislocate an intact but unstable hip.
ADDUCT with posterior force
Feeling that the head of the femur slips into the posterior lip of acetabulum is a positive test
**Developmental dysplasia of hip
Limited abduction in infants beyond 3 months of age, even with a negative Ortolani or Barlow sign, may still have a dislocated hip due to tightening of the hip muscles and ligaments.
**Normal variants in newborns in which abnormal position can be easily overcorrected past midline
Foot inversion, metatarsus adductus, foot adductus, pronation
Most common severe congenital foot deformity
Talipes equinovarus or clubfoot
Acute limp in childhood…
usually due to trauma or injury, although infection of the bone, joint, or muscle should be considered.
In an obese child with a limp consider…
slipped capital femoral epiphysis (SCFE)
Trendelenburg sign
Test for severe hip disease and the associated weakness of the gluteus medius muscle
A pelvis that remains level when weight is shifted from one foot to the other is a negative Trendelenburg sign.
With a positive test (severe hip disease), the pelvis tilts toward the UNaffected hip during weightbearing on the affected side.
Important risk factors for suddent cardiovascular death during sports include…
episodes of dizziness or palpitations, prior syncope (particularly if associated with exercise), or family history of sudden death or cardiomyopathy in young or middle-aged relatives.
Assess carefully for cardiac murmurs and wheezing in the lungs. For past head injuries or concussion, perform a a focused neurologic exam.
**Metatarsus adductus
Forefoot is adducted and not inverted.
AKA pigeon toes
**Irritable Bowel Syndrome
- Intermittent pain for 12 weeks of the preceding 12 months
- Relief with defecation
- change in frequency of BMs, or
- change in form of stool (loose, watery, pellet-like)
- linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity
- Produces functional abdominal pain
**Hip muscle groups
Flexor - flexes the thigh - ilipsoas
Extensor - extends the thigh - gluteus maximus
Adductor - swings thigh toward the body - arise from the rami of the pubis and ischium and insert on the posteromedial aspect of femur.
Abductor - lateral, extending from iliac crest to the greatert trochanter and moves thigh away from the body - gluteus medius and minimus.
**Allis sign
Test for femoral shortening
Also called Galeassi
Place feet with knee flexed and scrum flat on table together and note nay difference in knee heights.
**Gower’s sign
Tests for weakness of proximal muscles spec. LE muscles.
The sign describes a patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength.
**Cerebellar disease or foot problems…
with a wide base when walking.
Normal is 2 to 4 inches from heel to heel.
peptic ulcer and dyspepsia
process, sx’s, timing, location
mucosal ulcer in stomach or duodenum > 5 mm, covered in fibrin, H pylori
epigastric, radiating straight to back
wakes pt up at night, occurs few weeks then disappears for months then recurs
sx’s: n/v, belching, bloating, heart burn, weigh tloss, dyspepsia
gastric cancer
process, location, timing, aggrevating factors, relieving factors, sx’s
adenocarincoma in 90% either intestinal or diffuse
location: “cardia” and GE junction, distal stomach
timing: pain slow, persistent progression
agg: food, H. pylori
relieve: not food or antacids
sx: anorexia, nausea, early satiety, weight loss, bleeding, common 50-70 yrs old
acute cholecystitis
process, location, timing, sx’s
inflammation of gallbaldder from persistent obstruction of the cystic duct by gallstone in 90%
RUQ or epigastrium, radiates to R shoulder or interscapular area
steady, persistent aching
sx’s: anorexia, n/v, fever, NO juandice
biliary colic
process, location, timing, agg factors, sx’s
intermittent obstruction of the cystic duct by a gallstone
epigastric or RUQ, radiate to R scapula/shoulder
rapid onset over few mins, lasts hrs, recurrent
agg: large fatty meals
sx: anorexia, n/v
Chronic pancreatitis
process, location, quality, timing, agg/reliv, sx’s
irreversible destruction of the pancreatic parenchyma from recurrent inflammation
loc: epigastric, radiating to back
agg: alochol, medication,
sx: pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and diabetes mellitus,
longstanding perisistent pain
pancreatic cancer sx’s
epigastric pain radiating to back
persistent pain, agg by smoking
sx: painless juandice, anorexia, weight loss, glucose interolance, depression
acute diverticulosis sx’s
acute inflammation of colonic diverticula, outpouchings usually in sigmoid or descending colon
steady LLQ pain with diarrhea with hx of constipation
abd mass with rebound tenderness in LLQ
sx: fever, diarrhea, urinary sx’s, anorexia
acute bowel obstruction sx’s
bowel obstruction from adhesions, hernias (small bowel) or cancer or strictures (colon)
nonspecific diffuse abd pain with abd distension, nausea, emesis, lack of flatus
cramping, colicky
no passage of flatus, bowel movement, n/v progressive abd distension
mesenteric ischemia sx’s
occlusion of blood flow to small bowel, arterial or venous thrombosis, cardiac embolus or hypoperfusion
vague, nonspecific
abrupt, persistent
relieve: volume resuscitation
sx: vomiting, bloody stool, soft distended abd, systemic shock
Organic causes of abdominal pain
Identifiable medical/pick up on imaging
Picked up on screening test, diagnostic testing
ex: inflammatory bowel syndrome (IBS) on testing, there’s increased CRP and positive findings on colonscopy
Functional causes of abdominal pain
no clear etiology for presentation
ex: colicky pain (can’t test for colic), abdominal pain, irritable bowel syndrome (no test for it)
hematochezia/melena causes and sx’s
Hematochezia: bright red stool
- From colon, rectum or anus, less freq jejunum or ileum
- Lower GI with > 1 L
Rapid transit leaves insufficient time for blood to turn black from oxidation of iron in hemoglobin
causes: colon ca, polyps, diverticula, UC, crohns, infectious diarrea, proctitis from anal sex, hemorrhoids, anal fissure
Melena: black tarry stool
-upper GI bleeding 100mL; esophagus, stomach, 7-14 hrs
Causes: gastritis, GERD, peptic ulcer, gastritis, stress ulcers, reflux esophagus, mallory weiss tear
Sx’s:
Epigastric discomfort from heartburn
Dysmotility
Recent ingestion of alcohol, aspirin, antiinflammatory drugs
acholic stools
when excretion of bile into intestines is completely obstructed, stools become gray or light colored (without bile)
viral hepatitis and obstructive jaundice
Oropharyngeal dysphagia
delay in intiating swallowing
aspiration into lungs or regurg into nose trying to swallow
motor disorders affecting pharyngeal muscles (stroke, bulbar palsy, neuromuscular)
Umbilical hernia
Protrusion thru defective umbilical ring
Infants that close 1-2 yrs
Incisional hernia
Protrusion from op scar
Palpate length & width
Small defect
Epigastric hernia
Small midline protrusion thru defect in linea alba b/t xiphoid process and umbilicus
Have pt cough or valsalva maneuver, palpate fingertips down linea alba
Diastasis recti
Separation of 2 rectus abd muscles
Midline ridge extending form xiphoid to umbilicus
Seen only when pt raises head and shoulders
Repeated pregnancy, obesity, chronic lung disease
Benign
abd mass: Lipoma
Common, benign, fatty tumors in subcut
Press fingers down edge of lipoma
Slips out from under finger
Well demarcated, nonreducible, nontender
rheumatoid nodules
subcutaneous nodules from pressure points along extensor surface of ulna in pts with RA or acute rhematic fever
firm, nontender
lateral epicondylitis
aka tennis elbow
repetitive extension of wrists or pronation - supination of forearm
caused by: chronic teninosis of extensor carpi radialis brevis
pain when pt extend wrist against resistance
medial epicondylitis
aka pitchers, golfers, little league elbow
repetitive wrist flexion (throwing),
wrist flexion against resistance = pain
causes: tendinosis of pronator teres or flexor carpi radialis
testing for lateral epicondylitis
cozen test
stabilize pt’s elbow and palpate lateral epicondyle. ask pt to pronate and extend wrist against resistance. pain should be reproduced along lateral aspect of elbow
joint pain characteristics
Is this articular or extra-articular?
Is this an acute symptom (usually < 6 weeks) or chronic (> 12 weeks)?
Is this inflammatory or non-inflammatory?
Is this localized (monoarticular) or diffuse (polyarticular)?
4 cardinal features of inflammation
swelling, warmth, redness, pain
acromioclavicular (AC) joint:
crossover or crossed body adduction test
adduct arm across the chest
apley scratch test
how and what does it test for?
ask pt touch the opposite scapula using 2 motions: tests abduction and external rotation and tests adduction and internal rotation
tests overall shoulder rotation
pain = rotator cuff d/o or adhesive capsulitis
Painful Arc Test/pain provactive test
tests for? how to do?
rotator cuff
fully abduct arm from 0 to 180 degrees
pain: rotator cuff tendonitis
palms have to face down the entire time
Neer impingement sign
how to do? tests for?
press on scapula to prevent scapular motion in one hand and raise the pt’s arm with the other
this compresses the greater tuberosity of humerous against acromion
tests for: subacromial impingement/rotator cuff tendinitis
hawkins impingement sign
how to do test? tests for?
flex pt’s shoulder and elbow 90 degrees with palm facing down, then with 1 hand on forearm and 1 on the arm, rotate the arm internally
this compresses greater tuberosity against supraspinatus tendon and coracoacromial ligament
pain is + for supraspinatus or rotator cuff tendonitis
external rotation lag test
tests for? how?
tests for: supraspinatus and infraspinatus tear of rotator cuff tear
arm 90 deg flexed, palms up, rotate arm into full external rotation and ask to hold arm in this position
having a negative neer and hawkins means
very low likelihood of rotator cuff
internal rotation lag test (lift off test)
tests for? how to do?
+ test: can’t keep wrist in position; subscapularis of rotator cuff
stand behind pt’s rear, bring dorsum of hand behind the low back of elbow flexed at 90 degrees. grip the wrist an dlift the hand off the back, which further internally rotates the shoulder. ask pt to keep hand in this position as u release the wrist
drop arm test
tests for? how?
pt fully abduct arm to shoulder level up to 90 degrees, slowly lower it.
+ test is a/s with supraspinatus rotator cuff tear or bicipital tendinitis
External rotation riesistance test
tests for? how?
ask pt to adduct and flex arm to 90 degrees, with thumbs turned up. Stabilize elbow with 1 hand and apply pressure proximal to pt’s wrist as pt presses the wrist outward in external rotation
+ test: infraspinatus; limited external rotation points of glenohumeral disease or adhesive capsulitis
empty can test
tests for ? how?
elevate arms to 90 degrees and internally rotate the arms with thumbs pointing down, as if emptying a can. ask pt to resist as you place downward pressure on the arms
+ test: supraspinatus rotator cuff tear
- non-inflamm, loss of joint cartilage from mechanical stress, damage to underlying bone
- monoarticular, nonsymmetrical
- MCP not involved
- radial deviation of distal phalanx
- knees, hips, spine, wrist, hands
- brief (10 min) stiffness in AM or after activity
- Herberden nodes (DIP)
- Houchard nodes (PIP)
osteoarthritis
- chronic inflammation of synovial membranes with erosion of cartilage and bone
- damage to ligaments and tendons
- systemic, polyarticular, symmetrical
- starts in hands (PIP, MCP, MTP)
- ulnar deviation of fingers
- bilateral swelling and tenderness
- MCP boggy and tender
- stiffness for at least an hour in AM and after inactivity
- generalized sx’s: low grade fever, fatigue
rheumatoid arthritis
McMurray Test
how? + means?
Pt supine, grasp heel and flex the knee, cup other hand over knee joint with fingers and thumb along medial joint line.
Medial meniscus: from the heel, externally rotate the lower leg and slowly extend the lower leg in external rotation
Lateral meniscus: same but internal rotation of foot
CLICK felt or heard during flexion and extension of knee or if tenderness noted = meniscus tear
abduction (or Valgus) stress test
+ means? how?
pt supine, knees slightly flexed, move thigh 30deg latrally to side of table. place 1 hand against lateral knee to stabilize the femur and other hand around medial ankle. push medially against the knee and pull laterally at the ankle to open knee joint on medial side (valgus stress)
feel for excess widening of joint and lack of endpoint that may mean ligament is no longer intact
+ = pain or gap in medial joint for medial collateral ligament injury
adduction (varus) stress test
+ means? how?
thigh and knee insame position, change my position so i can place 1 hand against the medial surface of the knee and the other around the lateral ankle. push laterally against the knee and pull medially at the ankle to open the knee joint on the lateal side (Varus stress)
feel for widening of joint and lack of endpoint = ligament not intact
anterior drawer sign
+ means? how?
supine, hips & knees flexed at 90 degrees, feet flat on floor, cupt ahnds around knee with thumbs on medial and lateral joint. sit on pt’s foot. draw the tibia forward (towards me) and observe it slide forward (like a drawer) from under the femur. compare with opposite knee.
the knee should haev a firm endpoint with minimal movement.
excess movement = ACL no longer intact
test for ACL tear
posterior drawer sign
+ means? how?
supine, knees flexed 90 degrees, feet flat on table, cut hands around knee with thumb of medla and lateral joint and fingers on medial and lateral insertions of hamstrings. sit on pt’s foot. push tibia posteriorly and observe degree of backward movement of femur.
should be minimal posterior movement and excursion of tibia
excess movement = + for torn PCL / posterior cruciate ligament
Wrist/hand examination
- inspect position of hands in motion and rest. inspect wrist, hand, finger bones (swelling, deformities, angulation), atrophy, flexor tendons (thickening, contractures)
- palpate distal radius and ulna, radial styloid bone, anatomic snuffbox (tenderness), carpal bones, metacarpals, prox/middle/distal phalanges, wrist joint, MCP, PIPs
- assess ROM. Wrist: flexion & extension, abduction (radial deviation) and adduction (ulner deviation). fingers (MCP, PIP, DIP): flexion and extension and abduction and adduction. thumb: flexion and extension, abd/add, and opposition
hand grip strength, thumb tenosynovitis (finkelstein test), nerve entrapment neuropathy (sensation, thumb abduction and opposition, Tinel sign, phalen sign)
Finkelstein test is for
testing for tenosynovitis
ask pt to grasp thumb against palm and move the wrist toward midline in ulnar deviation
pain identifies as quervain tenosynovitis (gamers thumb) from inflamed abductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths
thumb abduction
tests for? and how?
carpal tunnel syndrome
ask pt to raise thumb straight up from the palm at 90 deg angle from hand as i apply downward resistance
can also do thumb opposition by asking pt to touch thumb to 5th fingertip as i put pressure against base of the thumb
Tinel sign
repeatedly tapping over the course of median nerve in carpal tunnel
shooting pain, aching, or worsening numbness = + test
Phalen Test
pt hold’s wrist in full flexion and juxtaposing the dorsum of each hand against each other for 60 seconds with elbows fully extended
or ask pt to press backs of both hands together to form right angles
= compresses median nerve
+ = numbness and tingling in median nerve within 60 seconds
Hip joint examination
- inspect gait (stance, swing, base width, pelvis shift, stride length, knee flexion), lumbar spine (lordosis, spasm), legs (symmetry), anterior/posterior (atrophy/bruising)
- palpate anterior landlarks: iliac crest, iliac tubercle, anterior-superior iliac spine, greater trochanter of femur, palpate posterior (iliac spine, greater trochanter, ischial tuberosity and sacroiliac joint, palpate inguinal ligament (bulges, nodes, tenderness), psoas bursa, trochanteric bursa, and ischiogluteal bursa (tenderness)
- assess ROM, flexion, extension, abd/add, in/external rotation
bowlegged in newborns
twisiting or torsion of tibia inward or outward (normal)
tibial torsion corrects itself during 2nd or 3rd year of life
pathologic tibial torsion is a/s with deformities of feet or hips
scoliosis screening
what test?
- assess symmetry of shoulder, scapula, hips
child bend foward with knees straight and head hanging straight down b/t extended arms (Adamsforward bend test); eval for any assym
use scoliometer for degree of scoliosis
angle > 7 degrees = concern
Sports screening physical examination
- stand straight, face forward (assymmetry, swelling of joints)
- move neck in all directions (loss of range of motion)
- shrug shoulders against resistance (weakness, shoulder neck or trap)
- hold arms out to side against resistance and raise arms over head (loss of strength of deltoid muscle)
- arms 90deg bent, raise and lower. note loss of external rotation and injury to glenohumeral joint
- hold arms out completely bent and straighten elbow then touch shoulders (bicep curl)
- hold arms down, bend 90 deg, pronate and supinate forearms (injury to forearm, elbow, wrist)
- make a fist, clench and spread fingers
- squat and duck walk 4 steps forward (note inability to fully flex knees and diffc standing up from prior knee or ankle injury)
- stand straight with arms at sides, facing back. check shoulder, scapula, hips are even (note scolioisis, leg length discrepancy, weakness form injury)
- bend forward with knees straight and touch toes. note assymmetry scolioisis or twisting of back from low back pain
- stand on heels and rise on toes. note any wasting of calf muscles from prior ankle or achilles tendon injury
red
acute gouty arthritis
great toe attacked; very painful tender, hot dusky red swelling
mistaken for cellulitis
involves ankle, tarsal joints, and knee
flat feet
longitudinal arch flattens so sole touches floor
normal concavity of medial side of foot becomes convex
swelling along medial malleoulus to plantar
obesity, diabetes, foot injury
hallux valgus
lateral deviation of great toe, enlargement of head of 1st metatarsal on medial side, forming a bursa or bunion (can become inflamed)
women 10x more likely
morton neuroma
-tenderness over plantar surface b/t 3rd and 4th metatarsal heads
from perineural fibrosis; repetitive nerve irritation (not true neuroma)
check for pain radiating to toes when press on plantar surface
sx: hyperesthesia, numbness, aching, burning from metatarsal heads into 3rd and 4th toes
hammer toe
2nd toe, hyperextension at metatarsophalangeal joint with flexion at PIP joint
corn develops at pressure point over PIP
painful conical thickening of skin from recurrent pressure on thin skin
apex. points inward = painful
over bony prominces like 5th toe
when in moist areas like pressure points b/t 4th and 5th = soft corns
callus
greatly thickened skin develops in region of recurrent pressure
involves THICK skin (sole); painless
if painful, suspect plantar wart
plantar wart
-hyperkeratotic lesion by HPV (sole of foot)
looks like callus
small dark spots that give stippled appearance to a wart
tender if pinched side to side (callus tender with direct pressure)
neuropathic ulcer
- pain sensation dim or absent (diabetic neuropathy)
dev at pressure points on feet
deep, infected, indolent, but painless bc sensory disruption
underlying osteomyelitis and amputation ensue
newborn spine defects
pigmented spots, hairy patches, or deep pits
meningomyeloceles present 1cm from midline, overlie external openings of sinus tracts that extend spinal canal
spina bifida occulta (defect of vertebral bodies)
patellafemoral grinding test
pt tightens quads as patella moves in trochlear groove, check for smooth sliding motion
pain and creptius from underneath patella’s rough surface as it touches femur
knee pain using stairs and getting up from chair
cause of acute onset of limp in childhood in a child that’s obese?
slipped capital femoral epiphysis if obese.
if not, think bone infection, joint, or muscle or malignancy
