For Final Flashcards
The retina contains the major landmarks of the eye (4)
- Optic disc
- Retinal arteries and veins
- Macula
- Fovea centralis
Which of the major landmarks of the eye can you see on the fundoscopic exam?
- Optic disc
- Retinal arteries and veins
- Macula
generally need to have eye dilated to see the fovea centralis
Infants are born with ____ vision.
myopia - 20/200
Middle age adults become presbyopic due to the ___ becoming rigid and the ____ becoming weak.
lens becomes rigid
ciliary muscle becomes weak
Oldest adults develop changes in the macula causing ___ or ____
low vision or decrease in central vision (macular degeneration)
Adult visual acuity of 20/20 develops by ___
years of age.
4 to 6
Can hormonal changes with the onset of puberty cause vision changes?
yes, can cause a change in refraction.
Pregnancy vision changes - hormonal adaptations where?
Pregnancy causes hormonal adaptations in the cornea and can cause a change in refraction.
By age 70, functionality of the extraocular muscles ___
decreases
By age 70, functionality of the extraocular muscles decreases and often upward gaze is limited to ____
15 degrees from horizontal plane.
For oldest adults, fibers in the central region of the lens may cause ___ in the lens.
cloudiness
For oldest adults, pupil size ___ and pupillary reflex becomes ____
decreases
sluggish, reacting slowly to changes in light
RUQ of abdomen - 2 main organs
liver, gallbladder
LUQ of abdomen - 2 main organs
stomach, body and tail of pancreas
Linea alba
white line that runs midline in the superficial layer of abdominal muscles/tendons
Pain from stomach is usually felt where?
epigastric area
Duodenum is around the head of the ___, which also extends across quadrants
pancreas
Biliary tree refers to
all of the ducts from the gallbladder, pancreas, liver that drain into the duodenum
Aorta is slightly ___ of center
left
Which is lower: right or left kidney?
right
The ___ and ___ muscles are important to assess for appendicitis
iliacus and psoas
When dividing the abdomen up into 9 regions, the three that are most referred to are
epigastric, umbilical, and hypogastric or suprapubic
LLQ of abdomen main organ: sigmoid colon
sigmoid colon
Right Lower Quadrant of abdomen main organ
appendix
If stomach pain is in LLQ, think
diverticulitis
Diverticulitis is most commonly found in
sigmoid colon (LLQ)
Environments that foster low levels of physical activity coupled with dependence on calorie-rich diets have been linked to development of DM and obesity, both of which are risk factors for ____
nonalcoholic fatty liver disease.
Hepatitis C infection, a major cause of ____ in the U.S., is associated with low SES, drug use, and incarceration.
cirrhosis
Once cirrhosis is established, lower surveillance rates for hepatocellular carcinoma (HCC) are seen in patients with ___ and ___
low SES and poor insurance.
What other systems should you be thinking about with abdominal symptoms aside from GI/GU? (5)
- Respiratory
- Cardiovascular
- Musculoskeletal
- Hematologic
- Psych
Visceral abdominal pain - what is it caused by? what are the chief characteristics?
When hollow organs forcefully contract or become distended, or solid organs swell against their capsules
Gnawing, cramping or aching
Often poorly localized—points with hand
May writhe on table
Visceral abdominal pain examples (2)
gastroenteritis, biliary colic of gall stones (cholelithiasis) in cystic duct
cholelithiasis
biliary colic of gall stones
Parietal abdominal pain - what is it caused by? what are the chief characteristics?
When there is inflammation of the parietal peritoneum AKA peritonitis
Steady/constant
Often localized—points with finger
Likely lies still with knees up
peritonitis
inflammation of the parietal peritoneum
2 main examples of Parietal abdominal pain
appendicitis, inflammation of gall bladder (cholecystitis)
cholecystitis
inflammation of gall bladder
RUQ or epigastric visceral pain may be coming from ___ or ___
biliary tree or liver
epigastric visceral pain may be coming from ___ or ___ or ____
stomach, duodenum, pancreas
periumbilical visceral pain may be coming from what 3 organs?
small intestine, appendix, proximal colon
suprapubic or sacral visceral pain may be coming from the
rectum
Hypogastric visceral pain may be from what 3 organs?
colon, bladder, uterus
Referred pain from gallbladder may be felt in the ___ or ___
right shoulder and back
Referred pain from pancreas may be felt in the ___
mid-lower back
Hx of abdominal surgery is a risk factor for
obstructions
Order of abdominal exam
Inspection, auscultation, percussion, palpation
When should you examine painful areas in abdominal exam?
last
Signs that hernia might be strangulated (blood supply cut off)
changes in color, n/v, fever, pain, no bowel movements
Sign of hernia incarceration
can’t push in
Diastasis Recti - is this benign or not? when is it common?
When linea alba separates and some abdominal contents protrude
Benign
Common in pregnancy
Normal contour of infant abdomen:
round/protuberant
Normal contour of preschool abdomen:
lumbar lordosis
8 Fs of Abdominal Distention
Fat Fetus Flatus Feces Full bladder Fibroids Fluid Fatal tumor
6 conditions where you may hear more bowel sounds
diarrhea, colic, malrotation, intussusception, early obstruction, diverticulitis
5 conditions where you may hear less bowel sounds
total obstruction, paralytic ileus, peritonitis, severe ascites, post-surgery
Spleen percussion: 2 techniques
- Percuss for splenic dullness from border of cardiac dullness at 6th rib to anterior axillary line and down to costal margin (Traube’s space)
- Splenic percussion sign - percuss, then have patient take deep breathe, and it’ll move - if enlarged, it’ll move into intercostal space that you’re percussing
Easiest to palpate organs in what patient population?
younger children
Why does the spleen float and liver doesn’t?
Because liver is next to diaphragm and can’t move as easily
What is a hernia?
Protrusion of peritoneum or intestine through weakened spot in musculature of abdominal wall
Hernia characteristics
Usually painless, intermittent, reducible, bulges with crying/ straining
Umbilical hernias in infants ___ need intervention
rarely
What 3 kinds of hernias are surgically corrected?
Inguinal, femoral, and most ventral hernias
Scaphoid contour means
markedly concave or hollowed
Peristalsis is often seen in what type of patient? Often indicates what?
thin
obstruction
Pulsations from the abdominal aorta are often seen in what type of patient? May indicate what 2 things?
thin
aneurysm or widened pulse pressure
Abdominal breathing normal in ___ and ___
infants and toddlers
Subcostal retractions may indicate ____
respiratory distress
___ or ____ may present with complaint of abdominal pain and altered respirations
Pneumonia or pleural effusion
If a patient is guarding or having pain with walking or coughing, and abdominal distention may be present, and they prefer supine position with knees flexed, what might this be?
Appendicitis/peritonitis
What 2 things are we auscultating the abdomen for?
- Bowel sounds
- Vascular sounds – listen for bruits over aorta, renal, iliac and femoral arteries
____ on abdominal auscultation may be heard with pleural inflammation or peritoneal inflammation
Friction rub
In appendicitis, bowel sounds may be ___ or ____
decreased OR hyperactive
Why do you need to auscultate right lower lobe (RLL) of lungs carefully with appendicitis pain?
to rule out lobar pneumonia with referred pain
Normal bowel sounds are clicks and gurgles, ___/min
5-35
Absence of bowel sounds established after ___ minutes
5
5 key points/steps of abdominal percussion
1) Start w/overview of 4 quadrants for gas, fluid or masses
2) Liver span and tenderness
3) Spleen size
4) Costovertebral angle tenderness (+ or - CVAT)
5) Pain over other areas of
inflammation - Watch facial expressions, may be too uncomfortable to perform in appendicitis
Tympany
High pitched sound, musical quality
Heard over air-filled structures (stomach, gas in
GI tract)
Dullness
Short high-pitched sound
Little resonance
Heard over solid or fluid filled organs adjacent to air containing organs (liver, spleen, distended bladder)
Resonance
Sustained note, moderate pitch
Heard over lung tissue primarily
Liver span in adult usually ___ cm and usually does not extend below right costal margin more than ___ cm
6-12 cm
2 cm
Liver percussion for span - how?
Start at right mid-clavicular line, below umbilicus, percuss upward until dullness, then percuss downward until dullness
Bimanual percussion for tenderness of liver and kidneys
Place palm of one hand over organ
Strike hand with ulnar surface of other hand
If organs are inflamed, there will be pain
What does light abdominal palpation assess for?
skin turgor, muscle tone, superficial lesions or masses, areas of resistance, muscular or peritoneal tenderness
What does moderate abdominal palpation assess for?
slow approach to deep palpation, further assessment of tender areas
What does deep abdominal palpation assess for?
Identify liver edges, kidneys, and masses by location, size, shape, consistency, tenderness, pulsation, mobility
RUQ: liver palpation
PALPATE WITH RIGHT HAND
STARTING BELOW UMBILICUS
AND MOVING UPWARD UNTIL LIVER IS PALPABLE
alternative: hooking
If kidney is enlarged, may be felt at ____ between opposing examining hands
inferior lateral border of ribs
Which kidney is more likely palpable?
right
how to palpate spleen
- With one hand below the left costal margin, palpate under costal margin at the anterior axillary line
- Attempt to lift spleen anteriorly by lifting with one hand and palpating with the other
- Roll client onto right side to bring spleen towards midclavicular line and examining hand
palpation of abdominal aorta is particularly important for what patients?
Important in adults > 50 and anyone with known or suspected cardiovascular disease
Note that you will __ rupture an aneurysm when palpating abdominal aorta
not
Concerned about abdominal aortic aneurysm (AAA) if lateral pulsations ___ cm diameter
> 3
If newborn has if scaphoid, abdomen, think
diaphragmatic hernia
femoral pulses will be weak or absent in infant with
coarctation of the aorta
in newborns/infants, you might be able to palpate liver edge ___ cm and spleen edge ___ cm below costal margin
1-3
1-2
normal abdomen contour in toddlers/children is
protuberant
If toddler very upset, palpate abdomen when?
during inspiration between cries
Why should you percuss suprapubic area in older adults?
for urinary retention
While there is abdominal fat accumulation in older adults, there is less ___ and ___, so palpation may be
easier
less muscle mass and connective tissue
Positive Murphy’s sign for cholecystitis
Palpate deeply at costal margin at mid-clavicular line
Patient takes deep breath, which forces liver and gall bladder down toward examining fingers
Sharp increase in tenderness is +
Most common cause of acute surgical abdomen in childhood
appendicitis
When is appendicitis most common? When is it rare?
Rare in early childhood or elderly, most common 11-20 y.o.
How is appendicitis diagnosed?
Diagnosed by CT or during surgery
Main symptoms of appendicitis
Anorexia and dull, aching, steady peri-umbilical pain that localizes to right lower quadrant after 4-6 hours. May have -
▪ nausea and vomiting starting AFTER abdominal pain
▪ diarrhea or constipation
▪ low grade fever
▪ urinary or respiratory symptoms
Inflammation of appendix secondary to obstruction, may suppurate and wall off or rupture, leading to
peritonitis
McBurney’s point
just below the middle of a line joining the umbilicus and the anterior superior iliac spine
Rovsing’s sign
If palpation of LLQ increases the pain felt in the RLQ, the patient is said to have a positive Rovsing’s sign and may have appendicitis
“referred tenderness”
Iliopsoas sign
passive extension and flexion of hip - positive if abdominal pain during these exercises
Obturator sign
Patient lies supine with right thigh flexed 90 degrees
Examiner immobilizes right ankle with right hand
Left hand rotates right hip by:
Pull right knee laterally (hip external rotation)
Pull right knee medially (hip internal rotation)
Left obturator/Pelvis examined in similar fashion
What 3 CN are you testing with extraocular movements?
III, VI, IV
Choroid
vascular layer between the retina and scleral area
Visual cortex does processing in the ___ area of the skull
occipital
When an athlete presents with concussion, what is sometimes the first symptom they have on the field?
blurred vision
because it impacts the occipital area which is the processing area for vision
With latino infants, you’ll see thickened ___ which makes it a little more challenging to evaluate muscle balance
thickened epicanthal folds
Myopia more common in what 2 ethnicities?
Asian and Filipino-Americans
Latino and Asian - retina appears
pale
African American - retina appears
dark
European - retina appears
reddish or orange
what impacts eye during neonatal?
If they need resuscitation or are on oxygen
visual changes can be induced in last trimester by
HTN/diabetes
medications in older adults that can cause eye issues?
anticholinergics which dry out the eyes, long-term steroids
What does 20/20 mean?
You can see at 20 feet what the average person can see at 20 feet
If 20/40, you can see at 20 feet what the average person can see at 40 feet
Start doing visual acuity checks at what age? What result would you refer?
age 3
If they’re 20/40 or above
Corneal Light Reflex
tests the balance of the extra-ocular muscles.
Light should be symmetrically reflected off the cornea.
Cover uncover test
confirms balance of the extraocular muscles and detects unequal refraction in eyes
Pupillary reflex
response to light both direct and consensual
Often done in ER if you present with trauma post MVA
If glaucoma, they will have a significant change in the _____ of the cornea
curvature
Cornea examination
testing the curvature of the cornea by shining the light source obliquely (45 degree angle) - also to evaluate the clarity of the chamber and the lens
Red or Retinal Light Reflex (RLR)
Light illuminating from the retina and indicates the clarity of cornea, lens and chamber
Normal cup:disc ratio in retina is
<1:2
Comparing the arteries vs. veins in retina
arteries are brighter red and narrower than the veins
avascular area on the retina with irregular borders
macula
area of central vision on macula
fovea centralis
chronic exposure to dust/wind/sun can cause ___ which is common in migrant farm workers
pterygium
pooling blood in iris caused by trauma to the head
hyphema
Always evaluate ___ in UE complaints, and ____ in LE complaints.
neck in UE
lower back in LE
Always include neurovascular exam ___ and ____ to the complaint.
distal and proximal
What peripheral nerve is compressed/ entrapped/”pinched” in carpal tunnel syndrome?
A. Ulnar
B. Radial
C. Median
C. Median
No numbness, tingling, or pain into thumb, 2nd and 3rd digits bilaterally after 60 seconds. What does this mean?
negative Phalen’s bilaterally.
Numbness into 2nd digit at 20 seconds on right hand. What does this mean?
positive Phalen’s on right (R=20 seconds at D2)
Pain up into left` forearm at 30 seconds. What does this mean?
negative Phalen’s on left
Numbness and pain into all digits on right
positive Phalens-all digits on right (but think higher up compression)
Guyon’s canal is what nerve?
ulnar
Cubital tunnel is what nerve?
ulnar nerve
Tarsal tunnel is what nerve?
tibial nerve
Numbness, pain or tingling into thumb, 2nd and/or 3rd digits of left` hand (palmar).
– Positive Tinel’s at left carpal tunnel (into thumb)
– Negative Tinel’s at right carpal tunnel.
What is the name of bony osteophytes on the DIP joint? A. Bouchard’s nodes B. Rheumatoid nodules C. Heberden’s nodes D. Tophaceous gout
C. Heberden’s nodes
Lateral epicondylitis (AKA tennis elbow): the epicondyles are part of what bone?
A. Proximal Ulnar
B. Proximal Radius
C. Distal Humerus
C. Distal Humerus
the olecranon is the proximal _____
proximal ULNA
High yield questions in MSK presentations (5)
- Antecedent events leading up to the symptom
(Any acute trauma? Cumulative exposures?) - Focus on the functional impact of the symptoms: ADL? Work? Sports? Exercise?
- Hand dominance?
- Trying to identify exact location of pathology: is it bone, joint space, tendon/ligament, muscle, bursa?
- Do not forget about referred pain
Key PMH in MSK presentations (6)
- Osteoarthritis?
- Rheumatoid arthritis?
- Fibromyalgia?
- Osteoporosis?
- Cancer?
- Obesity/anorexia?
Note that Fluoroquinolone antibiotics (e.g., Ciprofloxacin) have a Black box warning for what?
tendon rupture
risk increases with age
Occupational History - Work (“WHACS”) (in/out of home)
W- What do they do for work? (Percent time sitting, standing, lifting, pulling, pushing? How much weight lifted, pushed, pulled?)
H - How do they do it?
A - Anyone concerned about exposures on/off the job?
C - Coworkers with similar symptoms?
S - Satisfaction with work?
If you were worried about acute hot red joint….search for what?
Search for port of entry for infection: • Any STD exposure? • IVDA? • Dental procedures? • Abscess/Cellulitis? • Cystometrics (bladder testing)?
Example of neck problem that causes acute or chronic referred shoulder pain?
Cervical radiculopathy
Example of pulmonary problem that causes chronic referred shoulder pain?
Pancoast tumor of the lung (located in the superior pulmonary sulcus)
Example of cardiac problem that causes acute referred shoulder pain?
Angina
Example of dermatology problem that causes acute referred shoulder pain?
Herpes Zoster (Shingles)
Example of GI problem that causes acute referred shoulder pain?
Ruptured colon after colonoscopy
Apley Scratch Test (3 components)
External rotation and abduction (Lift and pat self on back)
Internal rotation and adduction (Touch scapula from behind with opposite arm)
Internal rotation and abduction (Scratch shoulders)
4 muscles of the rotator cuff
- Supraspinatus tendon (posterior)
- Infraspinatus tendon (posterior)
- Teres minor tendon (posterior)
- subscapularis (anterior)
Intrinsic risk factors for tendon injury (2)
- Narrowed space under the acromium
* Excessive physical training with inadequate muscle rest
Example of hip issue that could cause chronic referred pain to lumbar spine?
Avascular necrosis of the hip
Example of hip issue that could cause acute or chronic referred pain to lumbar spine?
Abdominal aorGc aneurysm
Example of hip issue that could cause acute or chronic referred pain to lumbar spine?
Ruptured ovarian cyst or malignancy
Example of hip issue that could cause acute or chronic referred pain to lumbar spine?
Acute prostatitis or prostate malignancy
Example of hip issue that could cause acute or chronic referred pain to lumbar spine?
Herpes Zoster (Shingles)
Example of hip issue that could cause acute or chronic referred pain to lumbar spine?
Pyelonephritis or polycystic kidney disease
Straight leg test for lumbar spine (passive)
– 30-60 degrees
– Lower 2 inches to remove hamstring factor
– Dorsiflex ankle
– If painful in lumbar area or down leg, POSITIVE
FABER Hip Exam
F: Flexion
AB: Abduction
ER: External Rotation
If patient presents with hand pain, always examine the ____
neck
4 point approach to the MSK PE
Inspection → Palpation → ROM → Provocative tests
Drawer test
pulling the tibia towards you to see if anterior cruciate is intact
if you can open the drawer, it’s positive for a sprain of the ligament which would be grade 1, 2 or 3
complete rupture would be a grade 3 spain
Lachman test is very similar to what other test?
Drawer test
Focus of the pre-sports participation exam is what?
Injury prevention
Carpal tunnel/median nerve compression could be caused by…?
Pregnancy/fluid retention
thyroid disorders
amyloidosis
multiple myelomas → anything that lays down deposits in confined space
Work-related: Repetitive motion, venous congestion, scar tissue
Median nerve primarily innervates sensory portions of which fingers?
first, second, third, and palmar ½ of third finger
2 provocative tests for carpal tunnel are what?
Tinel’s test
Phalen’s test
Tinel’s test
Percuss reflex hammer over the pillar of the palm - trying to stimulate the numbness/tingling (if they feel it, it would be positive) - positive is reproduction of their paresthesias in D1, D2, D3, or D4
Phalen’s test
Forced flexion of wrists (hold wrists against one another) for 60 seconds
If patients say they feel buzzing in a particular hand/digit - you time it - the EARLIER they’re feeling the symptoms, the higher the predictive value that they have carpal tunnel syndrome
If all digits, you might not think CT - maybe think diabetes or compression in brachial plexus
Classic symptoms of carpal tunnel:
numbness, tingling, pain, wake up in middle of night with numbness (because we curl up and flex our wrists)
thenar wasting/atrophy on the hand is an associated advanced finding of what?
carpal tunnel
osteoarthritis
usually symmetrical
common finding with aging
Swann neck deformities
(NOT normal but sadly common in rheumatoid arthritis) - subluxation of the joint
How do you treat Ganglion cyst?
Hit them with a bible - they’ll rupture and reabsorb
Sometimes they’ll spontaneously reabsorb within 9-12 months
Tendons vs. ligaments
Tendons are muscles to bone
Ligaments are bone-to-bone
Grade 3 sprain would indicate what
total rupture off the bone - worried about can that person weight-bear off that joint?
Remember that you’re supposed to approach a task with your arms ____
supinated
not pronated (protects the elbows)
Tennis elbow (Lateral epicondylitis) test
Take the wrist straight in neutral position, make them flex wrist, and have them extend and lift - examiner will apply resisted wrist flexion - if they say “ouch” at the elbow, that’s positive
This is diagnostic for Lateral epicondylitis
Same test for medial epicondylitis
septic joint? Think
STI
___ is probably most important access point of infection
IV drug use
Medial and Lateral Collateral Ligaments…
• A. Prevent the anterior-posterior movement of the tibia
• B. Stabilize the meniscus placement between the femur and the tibia.
• C. Stabilize the lateral motion of the tibia relative to the femur
• D. Prevent the patella from grinding between the femoral condyles.
• C. Stabilize the lateral motion of the tibia relative to the femur
Sperm is produced in ___, mature in ___, travel up the ____
testes
Epididymis
Vas Deferens
Spermatic Cord is what we examine anatomically, and it contains what 4 things?
arteries, veins, nerves, lymphatics
Where Glans meets penile shaft
Corona
Opening at tip of glans
Meatus
Covers the glans
foreskin
Connects foreskin to glans
Frenulum
When performing Femoral Vein venipuncture, aim ___ to pulse
medially
If there’s a Femoral Vein DVT, you would see pain and tenderness in the ____
medial upper thigh
If there is an increase in testicular or penile size before age 9, would you refer?
yes, urgent referral
If there is an increase in pubic hair before age 9, would you refer?
non-urgent but would refer
Delayed puberty in boys is defined as
no increase in penile or testicular size by age 14
Ages 40-60 in men sees decrease in testosterone, which leads to what 6 things?
- Takes longer to achieve erection
- Erection maintained longer
- Orgasm may be less intense
- Longer refractory period
- Penile size decreases
- Scrotum more pendulous
If there’s Dysuria in the Meatus, think
local lesion
If there’s Dysuria in the Length of penis, think
urethritis
If there’s Dysuria in the Suprapubic area, think
cystitis
What type of incontinence: Leakage w/ exertion, sneezing, coughing
Stress incontinence
What type of incontinence: Can’t make it to void; can’t defer urge
Urge incontinence
What type of incontinence: Leaks from full bladder or Nocturnal enuresis (bedwetting)
Overflow incontinence
Lice vs nits
Nits: stuck on hair base
Lice: move
Maculae Ceruleae
bluish spots where lice have fed
Foreskin too tight is known as
Phimosis
What is it called if the Foreskin is stuck in retraction? Is this an emergency?
Paraphimosis
yes, surgical emergency
Fordyce Spots: where are they found? Are they normal?
- From sebaceous glands. Normal. Harmless.
* Commonly on penis, scrotum, labia, lips
Peyronie’s Disease
painful erections
Herpes progression
Vesicles / Pustules –> Ulcers –> Crusts
If there is a solitary, painless, non-tender ulcer w/ raised borders, think
Primary Syphilis – Chancre
Balanitis
Usually Yeast
Red; not just Smegma
***Itchy
Warts with “Cauliflower” appearance are called
Condylomata Acuminata (warts)
Pearly Penile Papules (PPP’s) are a ___ variant
normal
Penile Enlargement Surgery is or is not approved by Amer. Urological Assoc.
not
Average Flaccid Penile Length and girth
length: 9cm
girth: 10cm
When would you perform Transillumination of testes?
If unexplained swelling
Are Testes usually the same size? Average size? What testis normally hangs lower?
Yes
3.5-5.0 cm. long x 3 cm. x 3 cm.
Left
___ in particular is sensitive to touch on PE
Epididymis
Testicular Cancer has a : ____ incidence, ___ cure rate. Occurs in men: ___ y.o. 4 main risk factors:
low incidence, high cure rate
15-35 years old
Risk factors: Cryptorchidism, Down’s, Fam. Hx, HIV
Do any professional organizations recommend routine screening for testicular cancer?
no
Undescended testes/ Cryptorchidism
– High risk of cancer
– Common in infancy; 1% of 1 y.o. boys
How do you treat Epididymitis-Orchitis? More common in what age?
Cultures and Antibiotics
(maybe IV)
Adults
How do you treat Testicular Torsion? More common in what age?
emergency surgery
Kids
Varicocele most commonly feels like what? Which side?
Bag of worms
Left side (right side very rare)
it’s Varicose veins
usually asymptomatic, can affect fertility
Spermatocele
- Fluid-Filled Cyst
- Always superior to testis, posterior aspect
- Palpated as distinct from testis
- Ultrasound if necessary
- No treatment unless big and uncomfortable
Hydrocele
- Fluid within scrotal membranes
- Transilluminates (solid masses don’t)
- Usually develop over long period of time
- New acute onset may warrant ultrasound
- No treatment unless uncomfortable
If you detect Suprapubic Dullness, think
bladder distention
Prostate exam is part of the ___ exam
rectal
Perform an inguinal exam only ___
if indicated by history
What is the most common type of herniation
Indirect Inguinal Hernia
Indirect Inguinal Hernia
- Most common type
- Herniation through internal inguinal ring
- Often not visible
- Can remain in canal or pass into scrotum
- May only be felt during Valsalva
Findings of Incarceration or strangulation
very tender
often nausea / vomiting
Rectum is __ cm long and ___ to anus
12 cm long, superior to anus
Anus: how long? Lower vs. upper half
• 2.5-4.0 cm long (adult)
- Lower half innervated by somatic sensory nerves
- Upper half under autonomic control – Insensitive
internal vs external sphincter
• Internal is involuntary
– Urge to defecate when feces fill rectum
– Reflexive stimulation to relax sphincter
• External is voluntary
By 12 months, infants should have ___ stools per day. Control external sphincter by ___ months
1-2
18-24
Afferent neurons in rectal wall ___ with aging – interferes with relaxation of internal sphincter
degenerate
Aging leads to rectal ___ with stool
distention
– Requires increased pressure to sense stool – Leads to stool retention and constipation
Internal sphincter ___ tone with aging
loses
Minor vs major fecal incontinence
– Minor: staining w/ flatus or liquid stool
– Major: involuntary excretion of feces
Technique for rectal exam on kids
On back, legs lifted up and held flexed on abdomen
“Smooth, firm, symmetrical, sulcus palpable. No tenderness, no nodules.” -
normal prostate
“Sulcus palpable” =
Not Enlarged
Normal prostate not palpable in __ and ___
Children, Young Adolescents
Normal prostate size:
walnut
If there is tenderness from local lesion, you might think
Fissure; Perirectal abscess
Diffuse Rectal Tenderness – think
Proctitis
Main cause of bladder cancer?
Cigarettes
The one orifice you can’t get Chlamydia from?
the mouth
Highly unlikely to get HIV from __ sex
oral
What single question can distinguish Organic etiology (physical causes) from Psychological etiology of erectile dysfunction?
Early morning erections?
Retrograde ejaluation (goes back into the bladder) can be a side effect of __ meds
BPH
Urethral discharge indicates
STI of some sort
Masses of testicular cancer
Hard and fixed
non tender
Best patient position to examine inguinal lymphadenopathy or femoral pulse?
supine
Best patient position to examine hernia?
patient standing, examiner sitting
Which hernia is more common in women?
femoral
5 parts of the neuro exam
1) Mental Status
2) Cranial Nerves
3) Motor and Reflexes
4) Sensory
5) Cerebellar and Gait
What is consciousness?
State of awareness of self and environment
Wakefulness - what is it, what part of brain is it associated with?
● eye opening (spontaneous or to external stimulus)
● in cerebral hemispheres, particularly in cortex –> brainstem and thalamic reticular activating system (RAS)
Awareness- what is it, what part of brain is it associated with?
● cognition, affect, memory, and other mental functions
● cerebral hemispheres (with RAS)
coma definition - how would you test
eyes-closed state of unarousable unresponsiveness
sternal rub, nailbeds
To assess wakefulness, choose what tool?
Glasgow Coma Scale
What are the 3 parts of the GCS?
eye opening
verbal response
motor
Cognitive Impairment and Dementia - 5 components
- Orientation, attention, and memory
- Language impairment
- Visuospatial dysfunction
- Executive dysfunction
- Personality and behavioral changes
Vast majority of language impairment is in the ___ hemisphere
left - dominant
Visuospatial dysfunction and some forms of attention live in the ____ hemisphere
right/non-dominant
Executive dysfunction (ability to solve problems, not perseverate) live ____ lobes
bilaterally in frontal lobes
Personality/behavior is ___ distributed in the brain
diffusely distributed in the brain
_____ is where motor function lives (picking something up)
prefrontal gyrus in the frontal lobe
____ lobes have analog of sensory function (pain, temp, proprioception, light touch, etc.) - sensory association cortex
parietal lobes
____ lobe contains auditory processing and comprehension of language, both together important in memory
temporal lobes
____ lobe processes visual information that comes in from eyes (eye exam is high-yield part of neuro exam b/c the pathways)
occipital
Orientation becomes more fluid going from ____ to ____
eft to right (patients are rarely disoriented to person/often know at base level who they are)
Person, place, date, situation
4 components of orientation
Person, place, date, situation
How do you assess attention in the general part of the mental status exam?
Digits - 6 forward or 4 backward, serial 7s or 3s
spelling WORLD backwards and forwards
How do you assess memory in the general part of the mental status exam?
— 3 objects: ask patient to remember them, then ask for them at 5 minutes
- “2/3 @ 5 min without cues, 3/3 with cues”
___ hemisphere is dominant in nearly all right-handed, most left-handed people
Left
Test language carefully if ___ hemiparesis
right
Dysarthric
abnormality in motor articulation of speech
Testing the left hemisphere/dominant hemisphere for language: 3 components
naming, repetition, comprehension
Indicates lesions in various areas/lobes
“No ifs, ands, or buts about it”
___ hemisphere controls Neglect and Visuospatial Function
Nondominant Hemisphere – right
___ hemisphere is the non-dominant hemisphere in nearly all righties, most lefties
Right
Test for neglect syndromes carefully if ___ sided hemiparesis
left
striking, memorable syndromes (3) of there being an issue in the Nondominant (right) Hemisphere relating to Neglect and Visuospatial Function
anosognosia
asomatognosia
hemispatial neglect
anosognosia
can’t articulate what’s wrong with them (can’t articulate that they have paralysis in one arm)
asomatognosia
don’t recognize their own hand
loss of recognition or awareness of part of the body
Hemispatial neglect
not moving left side of body, head turned to right
characterised by reduced awareness of stimuli on one side of space, even though there may be no sensory loss
4 points of exam of Nondominant (right) Hemisphere relating to Neglect and Visuospatial Function
- constructional apraxia (inability of patients to copy accurately drawings or three-dimensional constructions)
- agraphesthesia (can’t tell what shape being drawn in hand)
- extinction
- neglect clock
symptoms of Frontal lobe dysfunction (4)
disinhibited, slow, concrete, perseverative
Mini-Mental Status Exam – how many points are there? Whats the cutoff score? What are the limitations?
- 30 point scale that’s a screening battery
- Typical cutoff is 24 (below that is considered cognitively impaired)
- Limitations: education level, language, NOT diagnostic
- Should not be used for anyone under 8th grade school level
Causes of anosmia:
- head trauma
- early Parkinson’s
- normal aging
- URI, meds, and many others
Is CN I (olfactory) tested in clinical?
Not really/rarely
How do you test CN I (olfactory)? What is the primary symptom of CN I (olfactory) dysfunction?
Test with aromatic, not noxious, compounds.
sx: anosmia
common and underrecognized consequence of traumatic brain injury
Note that anosmia can diminish ___ and is associated with ___
taste
weight loss in the elderly
CN I (olfactory) is not a peripheral nerve but a ___
CNS tract
CN I
olfactory
CN II
optic
CN III
oculomotor
CN IV
trochlear
CN V
trigeminal
CN VI
abducens
CN VII
facial
CN VIII
vestibulocochlear - auditory
CN IX
glossopharyngeal
CN X
vagus
CN XI
spinal accessory
CN XII
hypoglossal
CN II (optic) is not a peripheral nerve but a ____
CNS tract
What is the only part of the nervous system that you can directly look at
CN II optic
CN II is the ___ limb of the pupillary reflex
afferent
4 components of CN II assessment
- Check acuity: “+C” (if possible) - eye card
- Fundi
- Pupillary reflex
- Visual fields (also tests optic chiasm & optic radiations to occipital lobe)
Large lesions in the optic chiasm will take out the ____ fields of both eyes (bitemporal hemianopsia)
outer
If there’s a lesion behind the optic chiasm, there will be a loss of the ___ optic fields
homonymous
If there’s a lesion behind the ____ lobe, the patient will have difficulty with less visual field in each eye
right occipital
Is Binasal hemianopsia rare?
yes
CN 3 (oculomotor), 4 (trochlear), 6 (abducens) are the ___ to extraocular muscles
motor
CN ___ is levator palpebrae, pupillary sphincter
3
Eye muscles: Lateral rectus muscle corresponds to CN ___ = 6
Superior oblique = 4
Everything else is 3
6
Eye muscles: Superior oblique muscle corresponds to CN ___
4
CN ___ is the efferent limb of the pupillary reflex
3
Assessment of CN 3, 4, 6
- PERRL (pupils equal, round, reactive to light)
- ptosis
- Ask patient to track your finger in “H” shape: eyes should move smoothly & conjugately
Ptosis would be present if there’s a ___ palsy
3rd nerve
3 divisions of the trigeminal nerve
VI Ophthalmic
VII Maxillary
VIII Mandibular
Sx of CN 3, 4, 6
diplopia, that goes away if they close one eye
CN V trigeminal is ____ to the face and ___ to the temporalis muscle and other muscles of mastication
Sensory to face
motor to the muscles
Positive and negative CN V (trigeminal) symptoms
numbness (negative), pain or paresthesias (positive)
CN V (trigeminal) is the ___ part of the corneal reflex
afferent
How to assess CN V (trigeminal)
Touch on both sides in all 3 divisions (not easy to do in patient who isn’t cooperative)
To check motor: bite down while palpating
CN VII (facial) is ___ to the muscles of facial expression. It’s also the ___ part of the corneal reflex.
motor
efferent
Symptoms of CN VII (facial) dysfunction
- weak face
- labial dysarthria (manifests as P and B sounds - they’ll get gutturals or linguals but can’t say Pa Pa Pa)
- hyperacusis
- loss of taste in anterior 2/3 of tongue
How to test the corneal reflex
touch cornea with cotton swab - eyes closing consensually
How to assess CN VII (facial)
Raise eyebrows
Close eyes tightly
Smile
Say pa-pa-pa, ba-ba-ba
note that nasolabial fold asymmetry on one side would be problematic
Upper vs Lower Motor Neuron Facial Weakness: Weak right face could indicate what 2 things?
Either problem with the right CN7 (aka a LMN facial weakness
OR
Problem on left mid-pons/brainstem or above the medulla (UMN facial weakness)
If a patient is very weak on the right side, the forehead will be
smooth
LMN lesions involve the upper and lower face ____, while UMN lesions tend to relatively spare the ___ part of the face
symmetrically
upper
so if a patient really can’t close their eye, that’s probably a lower motor neuron lesion -
give them eye drops and eye patch so they don’t dry out the cornea
Sx of CN 8 (Vestibulocochlear - Acoustic) (4)
hearing loss, tinnitus, vertigo, imbalance
Assessment of CN 8 (Vestibulocochlear - Acoustic)
Compare whisper or rubbed fingers side to side.
May see nystagmus when checking extraocular movements.
CN 9 (glossopharyngeal) and 10 (vagus) are the ____ and ____ of pharynx, with autonomic functions. Also the ___ reflex
sensory and motor
also gag reflex
(important in patients that are comatose, may help to decide if they need to be intubated)
Sx of CN 9 (glossopharyngeal) and 10 (vagus)
dysphagia, palatal dysarthria (K and G sounds are sloppy)
How to assess CN 9 (glossopharyngeal) and 10 (vagus)
“Say ah:” uvula deviates AWAY from affected side
Say ka-ka-ka, ga-ga-ga (gag reflex)
CN 11: Spinal Accessory is ___ to trapezius and sternocleidomastoid
motor
Sx of CN 11 dysfunction:
shoulder weakness, pain
How to assess CN 11
Ask patient to:
Shrug
Turn head side to side against resistance
If there is an issue with right CN 11, the patient will ____
Raise R shoulder Turns head to L
CN XII Hypoglossal is ___ to the tongue muscles
motor
sx: lingual dysarthria Ask patient to:
Protrude tongue: deviates toward affected side (with atrophy if chronic)
Say la-la-la
Sx of CN XII Hypoglossal dysfunction
lingual dysarthria - motor speech disorder
sometimes trouble swallowing
How to assess CN XII Hypoglossal
Protrude tongue: deviates TOWARDS affected side (with atrophy if chronic)
Say la-la-la
Pupillary reflex: afferent is CN ___, efferent is CN ___
a: 2
e: 3
Corneal reflex: afferent is CN ___, efferent is CN ___
a: 5 (VI)
e: 7
Gag reflex: afferent is CN ___, efferent is CN ___
a: 9
e: 10
single cranial neuropathies
Bell’s
DM CN 6 palsy
(many others)
multiple cranial neuropathies could signal issue in the
subarachnoid space?
If you see multiple neuropathies, are they all in the same side, which might indicate ____ or ____?
a mass in subarachnoid space or compression in skull where nerves run together
If you see multiple neuropathies, are they in multiple levels on different sides, which could indicate ____?
Chronic meningitis
Multiple neuropathies on long tract sides, think ____
Problem in brainstem bc nuclei live here and long tracts
Weak in limbs and only motor impairment in cranial nerves, think ___ problem
motor
3 long tracts
corticospinal (motor)
spinothalamic (sensory) - carries pain and temp
dorsal column (sensory) - carries proprioception
If it’s UMN weakness - ___ and ___ are common early signs
stiffness and spasticity
When performing the motor exam and reflexes, you’re assess motor system function of
corticospinal tract + motor unit (also extrapyramidal system)
When performing the motor exam and reflexes, can often assess ____ of weakness by history
pattern
distal vs proximal, generalized, focal
Proximal weakness complaints example
they might tell you they do ok walking on flat surface but have trouble getting upstairs, because they’re having weakness in hip girdle muscles
Distal weakness complaints example
buttoning buttons, zippers
Lower extremities weakness example
catching toe on stairs bc you can’t dorsiflex foot to clear the step
For EPS (extra pyramidal symptoms) ___ is key
DISTRIBUTION knowledge is key i.e. is it right side, left side, both sides? Legs, arms, both? Proximal, distal, both?
EPS
Slow to move (Parkinson’s)
tremor
myoclonus (jerk/twitching)
chorea (jerky movements of shoulder/hip/face)
Parts of the motor exam:
- Inspect: atrophy (and fasciculations)
abnormal movements: tremor, chorea,
myoclonus vs paucity of movement
- Palpate: tenderness
- Examine:
- tone
- pronator drift and dexterity (finger/toe taps):
- sensitive corticospinal tract tests
- reflexes
- strength testing
tendon reflexes may diminish with ___, especially Achilles
age
age 65 or so - not pathological
pathological Babinski (toe goes up) is a ___ sign
UMN
tends to be confirmatory rather than hanging diagnosis on in isolation
Increased tone (hypertonia) is ____ sign
UMN
Decreased tone (hypotonia) is ___ sign
LMN
____ is a very sensitive sign of corticospinal tract dysfunction
Pronator drift (hold arms up and close eyes)
are there are nerve roots that don’t have reflexes that are associated with it?
yes
Achilles reflex may also be abnormal in patients with peripheral neuropathies, even if it’s subclinical – examples (4)
long-standing diabetes, alcoholism, advanced HIV, neurotoxic chemotherapy
Documenting DTRS is a ___ grading. What grade is “normal”?
0 absent 1+ diminished 2+ normal 3+ increased 4+ transient clonus 5+ sustained clonus
“Breakway” weakness suggests
poor effort
UMN weakness
“pyramidal” (anti- gravity muscles
relatively spared)
UMN atrophy
miminal or absent
UMN fasiculations
absent
UMN tone
increased
UMN reflexes
increased
UMN Babinski
present
LMN weakness
myopathy: proximal polyneuropathy: distal focal: root, plexus, nerve
LMN atrophy
prominent, especially if peripheral nerve
LMN fasciculations
present in motor neuron disease (rarely neuropathy)
LMN tone
diminished or normal
LMN reflexes
diminished or normal
LMN Babinski
absent
MRC scale (strength):
0 no contraction 1 contraction, no movement 2 movement without gravity 3 movement against gravity 4 with resistance (4- to 4+) 5 normal
Spinothalamic tract - carries what?
pain, temperature
Dorsal column - carries what?
vibration, proprioception, Romberg
Cortical modalities (2)
- Graphesthesia (recognize writing on hand)
- Stereognosis (can say what the object is with eyes closed)
C2 and 3 are above the ___
neck
C3 and 4 are ___
shoulder
Sensory exam is best interpreted in context of ___, ___, or both
in context of sensory symptoms, motor signs, or both
Brown-Séquard syndrome
incomplete spinal cord lesion
patient who was, say, stabbed in the back at the thoracic level
they will have:
- Pain/temp down on contralateral side
- Diminished proprioception and weakness on ipsilateral side
B12 deficiency or balance issues - check ____
proprioception
What 3 symptoms may indicate cerebellar dysfunction?
Dysarthria, nystagmus or hypotonia
How to assess Cerebellar hemispheres:
finger-nose-finger, heel-knee-shin, rapid alternating movements
How to assess Midline cerebellum:
truncal, gait ataxia
signs of early gait ataxia
gait appears normal, with impaired tandem (can occur with advanced age)
signs of late gait ataxia
broad-based gait (think EtOH intoxication)
hemiparetic gait
problem with unilateral corticospinal tract
scissoring gait
problem with bilateral corticospinal tract
waddling gait
problem with proximal weakness (myopathy)
steppage gait
problem with distal weakness (neuropathy)
Considerations in assessing gait: (4)
age, pain, injury (acute or old), medications
___ and ___ are sensitive long tract signs
Drift and dexterity
High yield parts of the neuro exam: (3)
eyes, reflexes, gait
Good idea to check CN with ____ exam
HEENT
Check strength ___ tone and TRs
after
Arm + leg Face + arm (+/-leg): think
cord or brain
Face + arm (+/-leg) Hemiparesis: think
aphasia if right, neglect if left
Which of the following is NOT a normal finding upon ophthalmoscopic examination?
A. A cup to disk ratio of <1:2
B. Dark red veins larger than bright red arteries
C. An avascular macula with an irregular border
D. An optic disc with diffuse margins
D. An optic disc with diffuse margins
Pain of duodenal or pancreatic origin may be referred to the: A. right shoulder B. epigastric region C. back D. right flank
C. back
Your client presents with a complaint of worsening abdominal pain over the past few hours, beginning as mild and now severe. The pain is described as being in “my whole belly.” Physical examination reveals rebound tenderness upon palpation of the right lower quadrant. You suspect: A. Acute cholecystitis B. Acute diverticulitis C. Appendicitis D. Small bowel obstruction
C. Appendicitis
Risk factors for abdominal aortic aneurysm (AAA) include:
A. Age 65 or older
B. Smoking history
C. First-degree relative with a history of AAA repair
D. All of the above
D. All of the above
Which of the following is NOT a normal finding upon digital rectal examination?
A. Smooth prostate gland with palpable sulcus
B. Tarry stool on the examiner’s gloved finger
C. Walnut-sized prostate gland
D. Palpation of two sphincters within the anal complex
B. Tarry stool on the examiner’s gloved finger
Which of the following is a urological emergency? A. epididymitis B. varicocele C. testicular torsion D. hydrocele
C. testicular torsion
Impulse control is located in which lobe? A. temporal B. frontal C. occipital D. parietal
B. frontal
Which cranial nerve is affected in Bell’s Palsy? A. V B. VI C. VII D. VIII
C. VII
Upper motor neuron lesions presents with: A. hypertonia B. hypotonia C. muscle atrophy D. fasciculations
A. hypertonia
Significant anterior excursion of the knee (positive Lachman’s test) indicates an injury to which ligament? A. Anterior cruciate B. Posterior cruciate C. Medial collateral D. Lateral collateral
A. Anterior cruciate
Which type of skin cancer consists of more mature cells that usually resemble the spinous layer of the epidermis? A. basal cell carcinoma B. squamous cell carcinoma C. melanoma D. kaposi’s sarcoma
B. squamous cell carcinoma
Hypopigmented macules that appear on the face, hands, feet, extensor surfaces, and other regions and may coalesce into extensive areas that lack melanin suggest: A. café-au-lait spot B. seborrheic dermatitis C. vitilgo D. cyanosis
C. vitilgo
Where is McBurney’s point? important for appendicitis
halfway between the umbilicus and the right iliac crest
Description of skin condition should always include what 5 points?
- Primary lesion (i.e. papule)
- Secondary change (i.e. scaly) or absence of Color
- Size, shape, demarcation
- Configuration, Distribution (rash) or location (growth/lesion)
Primary morphology: Smaller than 1cm + completely flat (non- palpable)
Macule
Primary morphology: Greater than 1cm + completely flat (non- palpable)
Patch
Vitiglio is an example of a
patch
petechiae is an example of
Macules
Primary morphology: Smaller than 1 cm, Raised (palpable), may be thin (“flat topped”) or thick (“dome-shaped”)
Papule
molluscum is an example of
Papules
Primary morphology: Greater than 1 cm, Raised (palpable)
plaque
psoriasis is an example of a
plaque
____ = smaller than 1 cm, serous or bloody fluid
Vesicle
____ = greater than 1cm, serous or bloody fluid
Bulla
____: always under 1cm, purulent fluid
Pustule
Zoster is an example of
vesicles
bullous pemphigoid is an example of
Bulla
pustular psoriasis is an example of
Pustules
When the epidermis is partially removed, this is an ___; fully removed would be an ____
erosion
ulcer
pyoderma gangrenosum is an example of an
ulcer
Primary morphology: Dome-shaped growth > 1cm, May be above or below skin surface
nodule
keratoacanthoma is an example of a
Nodule
Secondary changes are adjectives to describe the ___ of primary morphology
surface
Ring-shaped but clear in the center would be what?
Annular
Coin-shaped solid circle would be what?
Nummular
erythema multiform is an example of a ____ shape lesion
Targetoid
cutaneous larva migrans is an example of a ____ shape lesion
Serpiginous
lichen planus is an example of a ____ shape lesion
Polygonal
subacute cutaneous lupus is an example of a ____ shape lesion
Arcutate
Atopic dermatitis is often on the ___ parts of the body
flexural (like backs of knees)
Psoriasis is often on the ___ parts of the body
extensoral (backs of elbows)
Primary lesions of Dermatitis a.k.a Eczema are _____
Ill-defined erythematous papules/plaques of highly variable size and spacing
If Dermatitis a.k.a Eczema appears wet/weeping with microvesicles/round crusts or combination scale/crust, you know it’s what stage?
Acute
If Dermatitis a.k.a Eczema appears dry, scaly and lichenified, you know it’s what stage?
chronic
History for Dermatitis a.k.a Eczema is almost always ___
itchy
Tx for Dermatitis a.k.a Eczema
steroids/gentle skin care
Nummular eczema vs Tinea
Solid circle is more consistent with eczema
Ring (clearing in the center): Tinea - almost concentric circles (ripple-like effect)
a flake, a build up of stratum corneum or dead skin on the surface of the lesion
scale
dried fluid (serum, blood, pus)
crust
shiny, cigarette paper type wrinkling
atrophy
accentuation of the skin markings due to chronic rubbing and scratching - kind of like a callous - this is itchy
Lichenification
True red erythema
think neutrophils, cellulitis is an example
Purple erythema
lymphocytic inflammation
Red-brown erythema
granulomas
superficial (melasma) is what kind of brown
Muddy-tan brown
Tindle effect
more transmission of the blue tones so that’s why we see grey when we have a deeper lesion
Most tinia will be what shape?
annular
Ezcema is what shape
nummular
Koebner phenomenon
Papules in linear fashion - lesions pop up along the line where it was scratched
Koebner phenomenon
Papules in linear fashion - lesions pop up along the line where it was scratched
Seborrheic
hair-bearing areas of the skin: scalp, eyebrows and globella, nasal creases, beard region for men, then hair areas in chest, genitals, etc.
Photodistributed
accentuated where the sun hits exposed skin
Flexures
crooks of arms
Extensors
elbows and knees
Inverse
affect the body folds like trunk, under breast, armpits, groin
Is there any utility in biopsy for dermatitis?
no
small eczematous papules - very specific areas - finger webs, wrists, umbilicus/waist, genitals, ankles
scabies
honey-colored crusting or pustules superimposed on dermatitis/eczema would indicate
staph infection
Tinea
= dermatophyte
- Scale, erythema, omen papules at the leading edge of the plaque
- Not always annular– omen “waves” of papules expanding concentrically like ripples in a pond
Example of Class I topical steroid to tx dermatitis
Clobetasol
Example of Class II topical steroid to tx dermatitis
Fluocinonide
Example of Class III topical steroid to tx dermatitis
Triamcinolone 0.1%
Example of Class V topical steroid to tx dermatitis
Desonide
Example of Class VI topical steroid to tx dermatitis
Hydrocortisone 2.5%
Example of Class VII topical steroid to tx dermatitis
Hydrocortisone 1%
Topical steroids come in Class IX- VII, with Class I is ____, VII is ____
I is strongest
VII is weakest
Face, axillae, groin– use topical steroid class ___ or weaker
V
Hands, feet, elbows, knees– use topical steroid class ___ or stronger
III
Primary morphology of Psoriasis
well-marginated scaly papules/plaques (“papulosquamous” reaction pattern)
With Psoriasis, there is often no scale on ____ skin
moist intertriginous
Psoriasis treatment depends on what 4 things
- body sites involved
- type of psoriasis
- body surface area
- presence of arthritis
Treatment for dermatitis/eczema
Bathe daily with lukewarm water - no soap or very gentle soap like Dove only to armpits and groin
Follow bath with grease up in something thick - oily emollient to trap the water - Aquaphor, Vaseline, coconut oil (eucerin, cerave) - scoop out from jar rather than pump
topical steroids if necessary
for infant less than a year, use class ___ or lower of topical steroids
V
Benign: Brown/pink/white/yellow lesion, very common, warty sticker-like
Seborrheic keratosis
Benign: Bright red/pink/purple dilations in the skin - occur with aging
cherry angioma
Benign: Face/hands - “age or sun spots” - from sun damage
solar lentigines
As moles age, they go from flat and brown to dome-shaped, flesh toned, and lose pigment– becoming
Benign intradermal nevis
4 main types of Malignant neoplasms
Melanoma
Squamous cell carcinoma
Basal cell carcinoma
Actinic keratosis - precursor to squamous cell carcinoma
If they’ve already had a skin cancer, are they much more likely to have another?
yes
classic “drug eruption” presentation
Pink macules/papules that look like measles
