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.