Exam 3 Flashcards

GI, GU

1
Q

Pancreatic ca s/s

A

Painless jaundice, anorexia, weight loss, glucose intolerance, depression

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2
Q

Appendicitis s/s, positive sign names

A
  • 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]
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3
Q

**Parietal pain

A

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
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4
Q

Referred pain

A

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

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5
Q

Renal stone s/s

A

Colicky pain causing doubling over, frequent movement to find comfortable position, cramping pain radiating to the right or LLQ or groin

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6
Q

acute pancreatitis s/s

A

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

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7
Q

GERD s/s

A

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
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8
Q

Alarm GI symptoms

A

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

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9
Q

**Small or large bowel obstruction s/s

A

Diffuse abdominal pain, abdominal distention, hyperactive high-pitched bowel sounds, tenderness on palpation

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10
Q

Colon CA s/s

A

Change in bowel habits with mass lesion

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11
Q

Mesenteric ischemia s/s

A

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

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12
Q

**Ulcerative colitis What and s/s

A

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

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13
Q

**Crohn disease of small bowel What and s/s

A

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

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14
Q

Acute vs. chronic diarrhea

A

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

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15
Q

Constipation criteria and s/s

A

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.
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16
Q

Colorectal CA risk factors and prevention

A
  • 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
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17
Q

**Colorectal CA screening tests

A

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)

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18
Q

**Signs of intestinal obstruction

A

Protuberant abdomen, tympanic throughout, increased peristaltic waves

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19
Q

**Peritonitis s/s

A

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

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20
Q

Normal liver span

A

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.

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21
Q

Spleen percussion

A
  • 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.
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22
Q

Pyelonephritis on exam

A

Pain with pressure or fist percussion, especially when associated with fever and dysuria, although may be musculoskeletal.

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23
Q

**AAA

Risk factors

Likely rupture and relative mortality

A

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.”

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24
Q

Ascites Assessment

A
  • 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

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25
Q

**Appendicitis diagnosis

A
  • 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.

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26
Q

**Murphy sign

A

Assessing for a positive sign in acute cholecystitis (p. 486)

  1. 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.
  2. Ask pt to take a deep breath (INSPIRATION).
  3. Note breathing and degree of tenderness.
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27
Q

**Omphalitis

A

Infection of the umbilical stump

characterized by periumbilical edema and erythema

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28
Q

Palpation of liver in infants

A

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.

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29
Q

**Pyloric stenosis in infants

A
  • 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
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30
Q

Liver span in children

A
  • Increases with age
  • Reaches adult size during puberty
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31
Q

Effect of aging on abdominal disease

A

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.

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32
Q

Articular joint pain

A

decreased active and passive ROM

morning stiffness or gelling

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33
Q

Non-articular joint pain

A

periarticular tenderness, and

only passive ROM remains intact

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34
Q

Severe pain of rapid onset in a red swollen joint suggests…

A

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

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35
Q

**Cardinal features of inflammation

A

swelling, warmth, redness and pain

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36
Q

Helpful LAB TESTS in inflammatory musculoskeletal conditions

A
  • Erythrocyte sedimentation rate
  • C-reactive protein
  • platelet count, and
  • hematocrit
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37
Q

Cauda equina syndrome signs

A
  • 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
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38
Q

Red flags for LBP

A
  • 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
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39
Q

Osteoporosis screening

A

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.

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40
Q

DEXA

A
  • 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
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41
Q

Shoulder - principal bursa is subacromial bursa

Location

Normal palpation

Abnormal palpation

A
  • 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.
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42
Q

Carpal tunnel

A

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

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43
Q

Median nerve

A

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.

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44
Q

**Osteoarthritis common findings

A

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.
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45
Q

Rheumatoid arthritis

A

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

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46
Q

Carpal Tunnel Syndrome Testing

A
  • 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

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47
Q

Instability of the knee

A

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,

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48
Q

During gait, stumbling or “giving way” of the knee during heel strike suggests…

A

quadriceps weakness or abnormal patellar tracking

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49
Q

Patellofemoral pain syndrome

A

Two of three findings are most diagnostic:

  1. Pain with quadriceps contraction
  2. Pain with squatting; and
  3. Pain with palpation of the posteromedial or lateral patellar border.
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50
Q

Palpation Tests for Knee Joint Effusions

A
  1. 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.
  2. 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
  3. 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.)
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51
Q

Achilles tendon rupture s/s

A
  • 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
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52
Q

Lachman Test

A

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.]

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53
Q

Plantar fasciitis

A

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.

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54
Q

Ankle sprains

A

Foot inversion and injury to the weaker lateral ligaments (anterior talofibular and calcaneofibular), with overlying tenderness, swelling and ecchymosis.

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55
Q

Ankle fracture

A

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)

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56
Q

**Normal findings on newborn ABDOMEN

A
  • 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
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57
Q

Technique for assessing abdomen in infants

A

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.

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58
Q

**Bruits in abdomen

A

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.

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59
Q

**Friction rubs over abdomen

A

May be found over liver and spleen

Present in hepatoma, gonococcal infection around the liver, splenic infarction and pancreatic carcinoma.

60
Q

Liver palpation

A

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.

61
Q

Dynamic Stabilizers of the Shoulder

A

S.I.T.S.

Supraspinatus

Infraspinatus

Teres Minor

Subscapularis

62
Q

Genu Valgum “vag = gotta pee!!!!”

A

Knock knees

63
Q

Genu Varum

A

Bow leg knees

64
Q

Infant clavicle abnormal findings

A

Lumps, tenderness, crepitus

May indicate fracture especially during difficult birth

65
Q

Infant meningomyelocele or spina bifida oculta

A

Pigmented spots, hairy patches, deep pits present 1 cm or so from the midline

66
Q

**Ortolani test

A

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

67
Q

**Barlow test

A

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

68
Q

**Developmental dysplasia of hip

A

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.

69
Q

**Normal variants in newborns in which abnormal position can be easily overcorrected past midline

A

Foot inversion, metatarsus adductus, foot adductus, pronation

70
Q

Most common severe congenital foot deformity

A

Talipes equinovarus or clubfoot

71
Q

Acute limp in childhood…

A

usually due to trauma or injury, although infection of the bone, joint, or muscle should be considered.

72
Q

In an obese child with a limp consider…

A

slipped capital femoral epiphysis (SCFE)

73
Q

Trendelenburg sign

A

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.

74
Q

Important risk factors for suddent cardiovascular death during sports include…

A

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.

75
Q

**Metatarsus adductus

A

Forefoot is adducted and not inverted.

AKA pigeon toes

76
Q

**Irritable Bowel Syndrome

A
  • 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
77
Q

**Hip muscle groups

A

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.

78
Q

**Allis sign

A

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.

79
Q

**Gower’s sign

A

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.

80
Q

**Cerebellar disease or foot problems…

A

with a wide base when walking.

Normal is 2 to 4 inches from heel to heel.

81
Q

peptic ulcer and dyspepsia

process, sx’s, timing, location

A

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

82
Q

gastric cancer

process, location, timing, aggrevating factors, relieving factors, sx’s

A

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

83
Q

acute cholecystitis

process, location, timing, sx’s

A

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

84
Q

biliary colic

process, location, timing, agg factors, sx’s

A

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

85
Q

Chronic pancreatitis

process, location, quality, timing, agg/reliv, sx’s

A

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

86
Q

pancreatic cancer sx’s

A

epigastric pain radiating to back

persistent pain, agg by smoking

sx: painless juandice, anorexia, weight loss, glucose interolance, depression

87
Q

acute diverticulosis sx’s

A

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

88
Q

acute bowel obstruction sx’s

A

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

89
Q

mesenteric ischemia sx’s

A

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

90
Q

Organic causes of abdominal pain

A

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

91
Q

Functional causes of abdominal pain

A

no clear etiology for presentation

ex: colicky pain (can’t test for colic), abdominal pain, irritable bowel syndrome (no test for it)

92
Q

hematochezia/melena causes and sx’s

A

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

93
Q

acholic stools

A

when excretion of bile into intestines is completely obstructed, stools become gray or light colored (without bile)

viral hepatitis and obstructive jaundice

94
Q

Oropharyngeal dysphagia

A

delay in intiating swallowing

aspiration into lungs or regurg into nose trying to swallow

motor disorders affecting pharyngeal muscles (stroke, bulbar palsy, neuromuscular)

95
Q

Umbilical hernia

A

Protrusion thru defective umbilical ring

Infants that close 1-2 yrs

96
Q

Incisional hernia

A

Protrusion from op scar

Palpate length & width

Small defect

97
Q

Epigastric hernia

A

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

98
Q

Diastasis recti

A

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

99
Q

abd mass: Lipoma

A

Common, benign, fatty tumors in subcut

Press fingers down edge of lipoma

Slips out from under finger

Well demarcated, nonreducible, nontender

100
Q

rheumatoid nodules

A

subcutaneous nodules from pressure points along extensor surface of ulna in pts with RA or acute rhematic fever

firm, nontender

101
Q

lateral epicondylitis

A

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

102
Q

medial epicondylitis

A

aka pitchers, golfers, little league elbow

repetitive wrist flexion (throwing),

wrist flexion against resistance = pain

causes: tendinosis of pronator teres or flexor carpi radialis

103
Q

testing for lateral epicondylitis

A

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

104
Q

joint pain characteristics

A

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)?

105
Q

4 cardinal features of inflammation

A

swelling, warmth, redness, pain

106
Q

acromioclavicular (AC) joint:

crossover or crossed body adduction test

A

adduct arm across the chest

107
Q

apley scratch test

how and what does it test for?

A

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

108
Q

Painful Arc Test/pain provactive test

tests for? how to do?

A

rotator cuff

fully abduct arm from 0 to 180 degrees

pain: rotator cuff tendonitis

palms have to face down the entire time

109
Q

Neer impingement sign

how to do? tests for?

A

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

110
Q

hawkins impingement sign

how to do test? tests for?

A

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

111
Q

external rotation lag test

tests for? how?

A

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

112
Q

having a negative neer and hawkins means

A

very low likelihood of rotator cuff

113
Q

internal rotation lag test (lift off test)

tests for? how to do?

A

+ 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

114
Q

drop arm test

tests for? how?

A

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

115
Q

External rotation riesistance test

tests for? how?

A

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

116
Q

empty can test

tests for ? how?

A

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

117
Q
  • 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)
A

osteoarthritis

118
Q
  • 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
A

rheumatoid arthritis

119
Q

McMurray Test

how? + means?

A

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

120
Q
A
121
Q

abduction (or Valgus) stress test

+ means? how?

A

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

122
Q

adduction (varus) stress test

+ means? how?

A

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

123
Q

anterior drawer sign

+ means? how?

A

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

124
Q

posterior drawer sign

+ means? how?

A

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

125
Q

Wrist/hand examination

A
  1. inspect position of hands in motion and rest. inspect wrist, hand, finger bones (swelling, deformities, angulation), atrophy, flexor tendons (thickening, contractures)
  2. palpate distal radius and ulna, radial styloid bone, anatomic snuffbox (tenderness), carpal bones, metacarpals, prox/middle/distal phalanges, wrist joint, MCP, PIPs
  3. 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)

126
Q

Finkelstein test is for

A

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

127
Q

thumb abduction

tests for? and how?

A

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

128
Q

Tinel sign

A

repeatedly tapping over the course of median nerve in carpal tunnel

shooting pain, aching, or worsening numbness = + test

129
Q

Phalen Test

A

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

130
Q

Hip joint examination

A
  1. inspect gait (stance, swing, base width, pelvis shift, stride length, knee flexion), lumbar spine (lordosis, spasm), legs (symmetry), anterior/posterior (atrophy/bruising)
  2. 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)
  3. assess ROM, flexion, extension, abd/add, in/external rotation
131
Q
A
132
Q

bowlegged in newborns

A

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

133
Q

scoliosis screening

what test?

A
  • 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

134
Q

Sports screening physical examination

A
  1. stand straight, face forward (assymmetry, swelling of joints)
  2. move neck in all directions (loss of range of motion)
  3. shrug shoulders against resistance (weakness, shoulder neck or trap)
  4. hold arms out to side against resistance and raise arms over head (loss of strength of deltoid muscle)
  5. arms 90deg bent, raise and lower. note loss of external rotation and injury to glenohumeral joint
  6. hold arms out completely bent and straighten elbow then touch shoulders (bicep curl)
  7. hold arms down, bend 90 deg, pronate and supinate forearms (injury to forearm, elbow, wrist)
  8. make a fist, clench and spread fingers
  9. squat and duck walk 4 steps forward (note inability to fully flex knees and diffc standing up from prior knee or ankle injury)
  10. stand straight with arms at sides, facing back. check shoulder, scapula, hips are even (note scolioisis, leg length discrepancy, weakness form injury)
  11. bend forward with knees straight and touch toes. note assymmetry scolioisis or twisting of back from low back pain
  12. stand on heels and rise on toes. note any wasting of calf muscles from prior ankle or achilles tendon injury
135
Q

red

A
136
Q
A

acute gouty arthritis

great toe attacked; very painful tender, hot dusky red swelling

mistaken for cellulitis

involves ankle, tarsal joints, and knee

137
Q
A

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

138
Q
A

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

139
Q
A

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

140
Q
A

hammer toe

2nd toe, hyperextension at metatarsophalangeal joint with flexion at PIP joint

corn develops at pressure point over PIP

141
Q
A

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

142
Q
A

callus

greatly thickened skin develops in region of recurrent pressure

involves THICK skin (sole); painless

if painful, suspect plantar wart

143
Q
A

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)

144
Q
A

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

145
Q

newborn spine defects

A

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)

146
Q

patellafemoral grinding test

A

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

147
Q

cause of acute onset of limp in childhood in a child that’s obese?

A

slipped capital femoral epiphysis if obese.

if not, think bone infection, joint, or muscle or malignancy