MT Flashcards
visceral abdominal pain vs somatic abdominal pain
stimulation of visceral pain fibers usually on organs, not localized
stimulation of somatic pain fibers usually in peritoneum, is localized
important meds to ask about in abdominal exams
blood thinners, NSAIDs, narcotics, steroids
order of abdominal physical exam
inspection
auscultation
percussion
palpation
RUQ contents
liver, gb, stomach, si/li
RLQ contents
appendix, ovary, si/li
LLQ contents
sigmoid colon, ovary, si/li
LUQ contents
spleen, stomach, si/li
epigastric area contents
pancreas, liver, gb, stomach, si/li
normal bowel sounds
5-34 clicks per minute
high pitched bowel sounds suggest
obstruction
bruits suggest
vascular obstruction
friction rub sounds suggest
inflammation of peritoneal surface of an organ
venous hum sound suggests
increased circulation b/w portal/systemic
where to start w/ abdomen palpation
start farthest from tender area
causes of splenomegaly
portal hypertension, blood malignancies, hematoma, mono
ascites tests
shifting dullness - percuss borders of tympany/dullness and then have Pt lay on side and if it changes (+)
fluid wave - tapping one side of abdomen felt on other side w/ other hand monitoring
mcburney’s point
2 inches medial to R ASIS towards umbilicus
(+) tenderness, appendicitis
rosvings sign
deep palpation in LLQ
(+) tenderness in RLQ, appendicitis
psoas sign
Pt raises R thigh against resistance then lays on left side and extends R leg at hip
+ pain w/ either maneuver, appendicitis
obturator sign
flex Pts R hip w/ knee bent, then internally rotate hip
+ R hypogastric pain, appendicitis
murphy’s sign
palpate under R costal margin then Pt breaths deep
+ sharp pain w/ stop in inspiration, biliary colic
lloyd’s sign
deep percussion down back
+ pain, kidney pathology
signs of peritoneal inflammation
guarding - contraction of abdominal wall w/ palpation
rigidity - reflex contraction of abdominal wall, Pt stiff
rebound tenderness - more pain when letting go after palpation than pushing in
vindicate
vascular infectious/inflammatory drugs/degenerative iatrogenic/idiopathic cogenital AI/allergic/anatomic trauma endocrine/environment
expected sound on percussion of abdomen
tympanic mostly
GERD Sx
heartburn
regurgitation
dysphagia 30% of Pts
lifestyle modifications for GERD
lose weight (if overweight) avoid triggers avoid large meals wait 3 hours to lay down after meal elevate head of bed by 8 inches
rome 3 criteria for constipation
<3 bowel movements/week straining lumpy/hard stools sensation of incomplete defecation manual maneuvering required to defecate
must have 2+ over 3 months
bistol stool chart
1 - lumps 2 - sausage, lumpy 3 - sausage, cracks 4 - sausage, smooth 5 - soft blobs 6 - fluffy pieces, mushy 7 - watery
main cause of gastroenteritis
viral
viral gastroenteritis two “biggies”
norovirus - sudden onset, 12-48 hours after exposure, usually more vomiting; seen w/ ship/casino outbreaks
rotavirus - most immunized for this, kids either have it or immunized by age 5
bacterial gastroenteritis three “biggies”
salmonella - eating something contaminated
C. diff - most common hospital acquired illness, exposure to antibiotics
E. coli - most common w/ travel
parasitic gastroenteritis one “biggie”
giardia - causes greasy diarrhea (tends to float), bloating, cramping; most common from infected water w/ campers etc
parasitic gastroenteritis one “biggie”
giardia - causes greasy diarrhea (tends to float), bloating, cramping; most common from infected water w/ campers etc
cullen sign
ecchymosis around umbilicus secondary to hemorrhage
grey turner sign
flank ecchymosis secondary to hemorrhage
expected liver size
6-12 cm at mid-clavicular line on the right
expected spleen size
from ribs 6-10 at mid-axillary line on left
heel strike indicates
appendicits or peritonitis
chovstek sign
tap facial N when facial Ms relaxed
(+) spasm = hypocalcemia
hypoparathyroidism causes/Sx
causes: removal, DiGeorge, AI disorder
Sx: hypocalcemia (b/c low PTH) -> seizures, dementia, anxiety, paresthesia, stiffness/spasms, prolonged QT
adrenal insufficiency/addison’s disease causes/Sx
causes: primary usually AI, secondary due to lack of ACTH production
Sx: underproduction of cortisol/ACTH -> low blood glucose/Na levels, skin pigment, salty food craving, hypotension, fatigue
adrenal overproduction/cushing’s disease causes/Sx
causes: endogenous w/ tumors, etc; or exogenous due to meds
Sx: cortisol overproduction -> moon face, buffalo hump on shoulders, high blood/glucose, excess body hair growth in women, striae on skin
T4/T3 and relation to thyroid function
t4 = inactive / t3 = active
hypothyroid = TSH high b/c low T4/T3 hyperthyroid = TSH low b/c high T4/T3
T4/T3 and relation to thyroid function
t4 = inactive / t3 = active
hypothyroid = TSH high b/c low T4/T3 hyperthyroid = TSH low b/c high T4/T3
pituitary adenoma Sx
hypersecretion of hormone
deficiency of hormone (LH/FSH)
headaches, visual disturbances, loss of balance, seizures
where does thyroid lie
isthmus over 2-4 tracheal rings
soft thyroid seen in
Grave’s
firm thyroid seen in
Hashiomoto’s and malignancy
tender thyroid seen in
thyroiditis
DM Sx/Labs
Sx: polyurea, thirst, fatigue, cuts/bruises slow to heal, feeling hungry, weight loss
labs: FG > 126 mg/dL
A1C > 6.5%
random glucose > 200 mg/dL
Metabolic Syndrome
Sx: abdominal obesity, insulin resistance, elevated BP, lipid abnormalities
prevalence increases w/ age and body weight but cause unk
geriatric meds assessment
- brown bag check: bring in bag w/ all meds
- ask prescriptions, OTC, vitamins, herbs, supplements
- review meds every visit
- use Beer’s criteria to avoid prescribing meds w/ adverse effects
- start low, go slow (dosage for elderly)
- close followup after starting new medication
assessment tools for functional ability and risk of falls
- ability to perform activities of daily living (ADL)
- -self care, housework, meal prep, taking meds, managing finances, using telephone
- useful scales: Katz, Lawton ADL scales
risks secondary to DM
retinopathy -> blindness
nephropathy -> kidney failure
neuropathy of hands/feet
vascular changes -> MI/strokes
DKA at risk in T1 or T2DM
T1
geriatric vision assessment
- Snellen eye chart
- ophthalmologist referral to monitor DM Pt
- ophthalmologist referral for Pt w/ glaucoma risk (FH)
- assess vision for driving safety
mini-mental status exam
mild = 21-29 moderate = 10-20 severe = 0-9
*not relaible if Pt cant read/write or not fluent
diabetic retinopathy Sx
black spots in visual field
geriatric hearing loss
age-related sensorineural hearing loss most common hearing condition in older Pts, loss of high frequency hearing
Sx: hearing loss w/ tinnitus/vertigo/poor balance (fall risk)
cause: CN8, review meds for ototoxicity
stress incontinence
involuntary leakage w/ sneezing, coughing, laughing, exertion, etc
urge incontinence
detrusor overactivity, leading to uninhibited detrusor contractions
overflow incontinence
continuous leakage due to incomplete emptying, detrusor inactivity or bladder outlet obstruction
risk factors for osteoporosis
white females
older white males
postemenopausal females
vitamin D deficient
osteoporosis screening
dual energy x-ray scan (DEXA) on women 65+
screening women <65 w/ high fracture risk
geriatric vax assessment
tetanus w/ pertussis
flu
pneumococcal pneumonia
herpes zoster
geriatric vax assessment
tetanus w/ pertussis
flu
pneumococcal pneumonia
herpes zoster
RA risk factors and Sx
Tx
often ages 30-50, women, smokers, w/ FH
Sx: joint pain/stiffness (wrists, IP/MP joints), morning stiffness lasting longer than an hour, swelling and synovial thickening of joints on examination
Tx: methotrexate
juvenile RA risk factors and Sx
children w/ painless joint inflammation, limp
Sx must last 6 weeks in at least 1 joint w/ other causes ruled out under age 16
SLE risk factors and Sx
risk factors: black, female
Sx: fatigue, weight loss, fever, arthralgia/myalgia
4 top Sx: coin shaped rash, malar rash, unexplained seizures/psychosis, photosensitivity
psoriasis risk factors and Sx
15-30 y/o, smoker, obese, alcoholic, FH
Sx: scaly skin lesions, erythematous
*consider joint exam when seeing rash/nail pitting
Graves’ risk factors and Sx
Tx
female, FH, AI disorder
Sx: asymptomatic -> thyroid storm; heat intolerance, diaphoresis, tremor, bulged eyes, weight loss
Tx: beta blockers and anti-thyroid meds
Hashimoto’s Sx
Tx
Sx: non-tender goiter, hypothyroidism, high TPO Ab level, weight gain, cold intolerance
Tx: levothyroxine
Ab disorder risk factors and (1ID) Sx
FH strongest predictor
Sx: infections w/ unusual organisms or severe recurrent infections w/ common organisms
agammaglobinemia Sx
absent of B cells
hypogammaglobinemia Sx
low/deficient Ig levels, abnormal Ig response to vaccinations
phagocytic disorder Sx
inability to kill catalase-positive organsism (Ex: staph aureus)
Sx: recurrent fungal infections
complement disorder Sx
infectinos w/ encapsulated organisms (pneumoniae, influenzae)
HIV Sx
Sx: mucocutaneous rash, myalgia/athralgias, anorexia, weight loss, fever, CNS manifestations, fatigue, pharyngitis, GI distress
type 1 hypersensitivity Sx
IgE mediated - allergy activity activating mast cells and increasing vascular permeability; usually targets eyes/nose/respiratory/GI
Sx: allergic conjunctivitis/rhinitis, dermatitis (eczema), diarrhea/cramping
type 2 hypersensitivity Sx
Ab toxicity involving C’ activation; recruitment of inflammatory cells and Abs against receptors
ABO mismatch, rheumatic fever, hemolytic disease of newborns, myasthenia gravis, graves
type 3 hypersensitivity Sx
IgG/IgM and C’ activation -> neuts/Mcs damaging tissue; takes 2 exposures b/c needs Ab deposition
Farmers Lung, Serum Sickness
type 4 hypersensitivity Sx
T cell mediated, no Abs required
allergic contact dermatitis (poison ivy), late phase of Farmer’s lung, PPD skin test for TB
t cell disorder
usual present in early life
diarrhea, failure to thrive, opportunistic infections in a child younger than 3 months should raise suspicion for SCID
assessing sexual dev in physical exam
female puberty = 10-14 w/ menarche 2-3 years after beginning of puberty (secondary sex dev)
male puberty = 11-16
other considerations = hair growth, facial bone changes, thyroid size increase, acne
how to obtain ob/gyn history
menstrual Hx: age and cycle history, LMP
gyn Hx: breast Hx/disease, last mammogram, previous gyn surgery, fertility Hx, last pap smear
ob Hx: # of pregnancies/# of births, TPAL
how/when/why pap smear
mammograms
women 21-65 y/o
- yearly if abnormal
- every 3 years w/ normal
- every 5 years w/ normal and no HPV (reason for PS)
- sample take at ectocervix/endocervix/TZ
50+ years for mammogram
pelvic exam vs pap smear
both require insertion of speculum
pelvic = visual, bimanual exam, swab if needed pap = obtains sample by scraping cervical cells
TPAL acronym
T = term deliveries (>37 wks) P = preterm deliveries (20-37 wks) A = abortion (<20 wks) L = live delivery regardless of age
ectopic pregnancy Sx/Dx
abdominal/pelvic pain w/ vaginal bleeding and may have other pregnancy related Sx
do urine pregnancy test followed by ultrasound
UTI Sx/cause/Tx
Sx: dysuria, may have hematuria, test w/ Lloyd’s punch and uinalysis
Cause: often E. Coli
Tx: antibiotic
when is prostate exam indicated
w/ FH of prostate cancer
when is male wellness exam indicated
not indicated unless having Sx
inguinal hernia Sx/Tx
pain w/ increased abdominal pressure, may have bulge; have Pt cough
Tx: mild = watchful waiting, moderate to severe = surgery
5Ps of sexual history
partners practices prevention protection past history of STI
gonorrhea Sx
Sx: men discharge/dysuria/asymptomatic, women pelvic pain/discharge
chlamydia Sx
Sx: many asymptomatic, can have discharge or dysuria
Syphilis Sx
Sx: chancre, joint pains/fatigue, can be asymptomatic in latent phase
genital herpes Sx/Tx
Sx: clusters of vesicles, burning, tingling
Tx: antiviral
trichomonasis Sx/Tx
Sx: men asymptomatic, women fould smelling discharge, dysuria, pruritis
Tx: antiprotozoal
HPV Sx/Tx
Sx: genital warts
Tx: vax, pap smears, wart removal
cervical myelopathy vs radiculopathy
myelopathy - spinal cord, emergent b/c more systemic Sx
radiculopathy - nerve root, urgen but not emergent
meningitis Dx/Sx
Dx - lumbar puncture
Sx - fever, malaise, headache, pain/stiffness, etc
lumbar puncture level
L4/L5
atraumatic Dx workup
if no red flags, dont require imaging
C4-C5 disc testing
C5 root, biceps
C5-C6 disc testing
C6 root, brachioradialis
C6-C7 disc testing
C7 root, triceps
C4 dermatome
lateral neck
C5 dermatome
lateral upper arm
C6 dermatome
lateral forearm, thumb
C7 dermatome
middle finger
C8 dermatome
medial wrist/forearm
T1 dermatome
medial elbow/upper arm
C1 strength testing
resisted rotation ROM
C2-4 strength testing
scapular elevation
C5 strength testing
deltoid, shoulder abduction
C6 strength testing
biceps, wrist extension
C7 strength testing
triceps, wrist flexion
C8 strength testing
finger flexion
T1 strength testing
finger abduction
T4/T10 dermatomes
T4 - nipple
T10 - umbilicus
spurlings test
compress head down then do the same in extension, SB, and rotation
+ pain -> radiculopathy
*do not perform w/ RA, cervical malformations, or metastatic disease
manual distraction test
distract head
+ relief of pain -> central neuropathy
roos/east tests
Pt abducts shoulder to 90 and ER w/ flexed elbow to 90 (T formation), Pt opens and closes hands for 3 mins
+ reproduciton of Sx -> TOS, compression of SCA
nuchal rigidity
Pt supine, hands behind Pt’s head and flex chin to chest
+ stiffness -> inflammation in subarachnoid space (meningitis or subarachnoid hemorrhage)
brudzinksi’s sign
Pt supine, hands behind Pts head and flex chin to chest
+ flexion in hips and needs -> inflammation in subarachnoid space
kernig’s sign
Pt supine, flex hip and knee to 90 and attempt to passively extend the leg at the knee
+ resistance, pain behind knee -> meningeal/dural irritation
lines in vertebrae
anterior vertebral line - anterior body
posterior vertebral line - posterior body
spinolaminar line - TP line
posterior spinous line - SP line
lines in vertebrae
anterior vertebral line - anterior body
posterior vertebral line - posterior body
spinolaminar line - TP line
posterior spinous line - SP line
scoliosis
usually idiopathic, lateral curve of spine
most common in females
screening recommendations for scoliosis
most cases detected through screening do not advance to significant scoliosis so no Tx needed
significant scoliosis detected w/o screening
red flag pathology w/ scoliosis
- onset before age 8
- severe pain
- rapid curve progression (>1 degree/mo)
- usual left thoracic curve (convex to the left)
- neuro deficits/findings
(ask for these in ROS)
management/Tx of scoliosis
> 45 degree curve needs Tx
Tx w/ bracing, surgery if bad enough
adam’s forward bend test
Pt bends forward, one side of back would be higher if + for scoliosis
acute low back pain characteristics
6-12 weeks of pain b/w costal angles and gluteal folds that may radiate down one or both legs
acute LBP is often nonspecific so it cannot be attributed to a definite cause
red flags of LBP
TUNA FISH trauma unexplained weight loss neuro Sx age (>50) fever IVDU steroid use history of cancer
management/tx of LBP
bed rest NOT helpful
NSAIDs and muscle relaxants, Pt education
back strain (lumbar SD) Sx
usually onset of mild trauma and described as an ache or spasm
exam = discrete tender points, no neuro deficits
psoas syndrome Sx
Sx: dull ache in low back, sometimes referring to groin
exam = tender point at iliacus (medial to ASIS), + Thomas test
herniated nucleus pulposus Sx
pain often originates from lumbar spine and radiates down leg into foot w/ sharp burning pain
exam = weakness in effected myotome, usually +SLR
treat w/ rest
LBP radiating pain patterns
spine (Ms/Ls/discs) -> thigh
SI joint -> thigh, sometimes knee
L1-3 -> high and/or thigh
L4-S1 -> knee
disc herniation at L4/L5 - what nerve root impinged
L5
cauda equina syndrome
large central disc herniation compressing the tail of the lumbar spine causing pain similar to herniated disc; impingment S2-S4 can cause bowel/bladder dysfunction
emergent - w/o surgery can cause paralysis
spinal stenosis
narrowing of space around SC
Sx: LBP radiating down the leg w/ pain, numbness, weakness; pain worsens w/ movement and laying supine
exam = diminished reflexes, weak myotome/dermatome
spondylosis
defect in pars interarticularis w/o anterior displacement, thinning discs and bone spurs - “scotty dog”
usually at L5/S1
spondylolisthesis
vertebral body slips in relation to one below
imaging w/ LBP
only image w/ 6+ weeks or if there are red flags (neuro deficits, or serious conditions)
history questions to ask w/ LBP
age level of trauma IVDU steroid use Hx of cancer
ROS questions w/ LBP
fever
weight loss
neuro Sx
incontinence
GXPXXXX meanings
G4P2112 = 4 pregnancies, 2 full term, 1 preterm, 1 abortion, 2 living kids
tanner stages pubic hair
1 - none
2 - some slightly pigmented hair
3 - darker, coarser hair
4 - adult type hair w/o spread to thighs
5 - adult type w/ horizontal upper border
nexus criteria
- no posterior midline cervical tenderness
- normal alertness
- no intoxication
- no neuro findings
- no painful distracting injuries
*all must be met for no imaging/collar
hoover sign
pt flexes weak leg against resistance, downward pressure should be felt on non-weak leg
+ no pressure = malingering
Gaenslen test
pt flexes one hip and other hip is extended
+ posterior pelvic pain = SI joint pathology
valsava test
bears down
+ sciatica
stork test
pt flexes hip and bends back
+ LBP = par defect/stress fracture, if bilatreal increased spondylolisthesis risk
