Exam 3 Flashcards
GI, GU
Gastric ulcer s/s
Weight loss, not as painful as duodenal ulcer, pain not relieved by food or antacids, n/v, belching, bloating, common in people over age 50.
Duodenal ulcer s/s
Pain that wakes up at night, occurs intermittently over few weeks than disappears for months, then recurs, n/v, belching, bloating, heartburn, more common age 30-60 years
Pancreatic ca s/s
Painless jaundice, anorexia, weight loss, glucose intolerance, depression
Appendicitis s/s, positive sign names
- Visceral periumbilical pain due to distention of inflamed appendix which gradually changes to parietal pain the RLQ due to inflammation of adjacent parietal peritoneum.
- Rovsing sign, + Psoas sign, + Obturator sign, and/or tenderness at McBurney point
- [Note: visceral pain is gnawing, burning, cramping or aching. When severe it causes sweating, pallor, n/v, restlessness]
**Parietal pain
Steady, aching, more severe than visceral pain, 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
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
Pancreatitis s/s
Sudden knife-like epigastric pain often radiating to the back, acute onset, persistent pain which may be aggravated by lying supine, 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*
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.
Mechanisms of jaundice
- Increased production of bilirubin
- Decreased uptake of bilirubin by hepatocytes
- Decreased ability of liver to conjugate bilirubin
- Decreased excretion of bilirubin into bile, resulting in absorption of conjugated bilirubin back into the blood
Painless vs. painful jaundice
Painless: malignant obstruction of the bile ducts seen in duodenal or pancreatic carcinoma
Painful: infectious in origin, e.g. hepatitis A and cholangitis. Itching occurs in cholestatic or obstructive jaundice
Risk factors for liver disease
Travel, exchange of bodily fluids through sexual contact or use of shared needles, alcohol use, use of toxic agents, gallbladder disease or surgery, hereditary disorders
Classic findings of alcohol abuse
Hepatosplenomegaly, ascites, caput medusae (dilated abdominal veins), jaundice, spider angiomas, palmar erythema, Dupuytren contractures (finger muscle contractures), asterixis (flappy hand tremor) and gynecomastia
Screening for ETOH abuse
CAGE, Alcohol Use Disorders Identification Test (AUDIT) or the shorter AUDIT-C questionnaire
Moderate drinking
- Women <=1 drink/d
- Men <=2 drinks/d
Unsafe drinking
- Women > 3 drinks/d and > 7 drinks/wk
- Men > 4 drinks/d and > 14 drinks/wk
Binge drinking
- Women >=4 drinks on one occasion
- Men >=5 drinks on one occasion
1 drink = 12 oz of beer or wine cooler, 8 oz malt liquor, 5 oz wine, 1.5 oz 80-proof spirits
Hepatitis B vaccine prioritized for the following groups
- Sexual contacts
- People with percutaneous or mucosal exposure to blood
- Travelers to endemic areas
- People with chronic liver disease and HIV
- All adults in high risk settings, i.e. STD clinics, HIV test and tx programs, drug rehab programs, correctional facilities, hemodialysis facilities, facilities for people with developmental disabilities
High risk groups prioritized for Hepatitis A vaccine
- all children at age 1 year
- Individuals with chronic liver disease
- High risk groups: travelers to areas with high endemic rates, MSM, injection and illicit drug users, people who work with nonhuman primates and persons with clotting factor disorders
Hepatitis A: post-exposure ppx
Hepatitis A vaccine or a single dose of immune globulin within 2 weeks of exposure
Also apply to close personal contacts
Hepatitis B screening
More serious threat than Hep A infection
Screening for:
- People born in countries with high endemic prevalence
- Persons with HIV Injection drug users
- MSM
- Household contacts and sexual partners of HBV-infected persons
- All pregnant women in first trimester
Hepatitis C
Most prevalent chronic bloodborne pathogen in U.S.
Main risk factor: IVDA
Additional RF: blood transf or organ txp before 1992, transfusion with clotting factors before 1987, HD, HCW with needlestick injury or mucosal exposure to HCV-positive blood, HIV, birth from HCV-positive mother
Hepatitis C becomes a chronic illness in over 75% of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver txp for ESLD
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 annually, either a guaiac-based or fecal immunochemical test
- 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)
Complications of colonscopy
Perforation and bleeding, patients are usually sedated during procedure but many are averse to the extensive bowel preparation required.
**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
Sciatica: physical signs
Pain that increases with cough or Valsalva
May be associated with a disc disorder, usually at L4-L5 or L5-S1
Disk hernation most likely if:
- Calf wasting
- weak ankle dorsiflexion
- absent ankle jerk
- positive crossed straight-leg raise (pain in affected leg when healthy leg tested)
- negative straight-leg raise makes diagnosis highly unlikely
- Ipsilateral straight-leg raise sensitive
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
- Must pursue immediate 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
Yellow flags in LBP
- Anxiety
- depression
- work stress
- mal-adaptive coping
- inappropriate fears or beliefs
- tendency to somatization
Risk factors of Osteoporosis
- Post-menopausal status
- Age >= 50 years
- prior fragility fracture
- low BMI
- Low dietary calcium
- vitamin D deficiency
- Tobacco and excessive alcohol use
- immobilization
- inadequate physical activity
- osteoporosis in first-degree relative
- Clinical conditions such as thyrotoxicosis, celiac sprue, IBD, cirrhosis, CRD, DM, HIV, MM, Anorexia, rheumatologic and autoimmune disorders
- medications such as oral and high-dose inhaled corticosteroids, anticoagulants, aromatase inhibitors for breast CA, MTX, select anti-sz meds, immunosuppressive agents, PPI, antigonadal therapy for prostate CA
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.
Rotator cuff tear
Physical symptoms
Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine within 2-3 weeks
Infraspinatus atrophy has a positive LR of 2 for rotator cuff disease
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 thenar 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
Heberden nodes (DIP joints) and Bouchard nodes (PIP joints)
Decreased spinal mobility (flexion, extension, rotation and lateral bending) is common in spinal OA
Restricted abduction and internal and external rotation are common in hip OA
Knee OA - Bony enlargement at the joint margins, genu varum deformity (bow-legs), and stiffness lasting <= 30 minutes are typical. Crepitus is also common.
Thickening, bogginess, or warmth occurs with synovitis and nontender effusions from knee OA.
Crepitus with flexion and extension of the knee joint signals patellofemoral OA, a probable precursor of knee OA.
Rheumatoid arthritis
Persisting bilateral swelling and/or tenderness at the wrist
Symmetric deformity in the PIP, MCP and wrist joints
Later, there is MCP subluxation and ulnar devation
May show swan neck deformities
MCPs are often boggy and tender
Tenderness on compression of the forefoot is an early sign of RA
Carpul 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
Location of sciatic nerve
Lies midway between the greater trochanter and the ischial tuberosity as it runs through the sciatic notch.
Sciatic nerve tenderness is seen with a herniated disc or nerve root impingement from a mass lesion.
Waddell signs - non-organic physical signs
superficial or nonanatomic tenderness, pain on axial loading or simulated rotation, nonreproducibility of pain when the patient is distracted, regional weakness or sensory change, and overreaction to stimuli that should not cause back pain.
Flexion deformity of the hip
As opposite hip is flexed (with the thigh against the chest), the affected hip does not allow full hip extension and the affected thigh appears flexed.
May be masked by an increase, rather than flattening in lumbar lordosis and an anterior pelvic tilt.
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.
This feature, in addtition to the lever action of the femur on the tibia and the lack of padding from overlying fat or muscle, makes the knee highly vulnerable to injury.
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 (LR 2.5).
- Balloting the patella (for major effusions) - A palpable fluid wave returning into the pouch is also a positive test for a major effusion. (Note: A palpable patellar click with compression may also occur, but yields 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
McMurray Test
A palpable click or pop along the medial or lateral joint line is a positive test for a TEAR OF THE POSTERIOR PORTION OF THE MEDIAL OR LATERAL MENISCUS (LR of 4.5).
The tear may displace meniscal tissue, causing “locking” on full knee extension.
[Medial menisucus tear: With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee. From the heel, externally rotate the lower leg then push on the lateral side to apply valgus stress on the medial side of the joint.]
[For lateral meniscus: same maneuver with internal rotation of the foot stresses the lateral meniscus.]
Lachman Test
Significant forward excursion is a positive test for an ACL tear (positive LR of 17.0).
[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.]
Posterior Drawer Sign
If the proximal tibia falls back, this is a positive test for PCL injury (positive LR of 97.8).
Isolated PCL tears are less common, usually resulting from a direct blow to the proximal tibia.
[With the patient supine, hips and knees flexed to 90 degrees and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and fingers on the medial and lateral insertions of the hamstrings. Draw the tibia posteriorly and observe the degree of backward movement in the femur.]
**Anterior Drawer sign
A few degrees of forward movement are normal if equally present on the opposite side.
A forward jerk showing the contours of the upper tibia is a positive test, or anterior drawer sign, with a positive LR of 11.5 for an ACL tear.
ACL injuries result from knee hyperextension, direct blows to the knee, and twisting or landing on an extended hip or knee.
Note: ACL tears are notably more frequent in women, attributed to ligamentous laxity r/t estrogen cycling and to differences in anatomy and neuromuscular control.
[With the patient supine, hips and knees flexed to 90 degrees and feet flat on the table, cup your hands around the knee with thumbs on the medial and lateral joint line and fingers on the medial and lateral insertions of the hamstrings. Draw the tibia forward and observe if it slides forward from under the femur.]
**Abduction (or Valgus) stress test
Pain or a gap in the medial joint line is a positive test for an MCL injury
[With the patient supine, move the thigh about 30 degrees laterally to the side of the table. Place one hand against the lateral knee and the other around the medial ankle. Pursh medially against the knee and pull laterally at the ankle.]
Adduction (or Varus) Stress test
Pain or a gap in the lateral joint line points is a positive test for LCL injury (less common than MCL injuries).
[With the patient supine, move the thigh about 30 degrees laterally to the side of the table. Place one hand against the medial knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle.]
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)
Signs of wearing high heeled shoes with narrow toe boxes
Hallux valgus, metatarsalgia, and Morton neuroma
**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
Simultaneous percussion and auscultation
Scratch test
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.
Osgood-Schlatter syndrome
S/s knee pain due to inflammation of the patella
Painful symptoms brought on by running, jumping, and other sports-related activities.
The inflamed tibial tubercle is always tender when pressure applied.
Dynamic Stabilizers of the Shoulder
S.I.T.S.
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Genu Valgum
Knock-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” A palpable movement of the femoral head back into place constitutes a positive test
**Barlow test
Tests for the ability to sublux or dislocate an intact but unstable hip. 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 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.
