PCM 2 Exam 1 Flashcards
What are the risk factors for type 2 diabetes?
age >45, BMI >25, 1st degree relative with disease, sedentary lifestyle, history of gestational diabetes, hypertension (140/90), dyslipidemia, A1c >5.7 or fasting >100, PCOS, vascular disease
What are the top 3 the clinical presentations for type 2 diabetes?
poylyuria, polydypsia, and polyphagia
What are some other clinical presentations of type 2 diabetes?
rapid weightloss, increased hunger and weight gain, dehydration, fatigue, blurry vision, acanthosis nigricans, <b>impaired healing</b><b>, </b><b>recurrent UTI</b><b>, </b><b>candidal vulvovaginitis</b>, tingling, pain, numbness in extremities</b>
What is the ADA criteria for diagnosis of DM
A1c > 6.5%, fasting glucose > 126, 2 hour glucose > 200 with classic symptoms of hyperglycemia
What should the initial workup after diagnosis of type 2 diabetes include?
fasting lipid, liver enzymes, renal function, microalbuminuria, dilated eye exam, and a foot exam
What should a diabetic foot exam include?
Look for callus/corn formation, breaks in skin, erythema or dryness. Check pulses and sensation including vibratory sensation and monofilament testing
What should be included in therapeutic intervention for type II diabetes?
lifestyle changes, oral metformin or other oral agents, insulin if needed
How often should you check HbA1c for type 2 diabetes management?
every 3 months while adjusting treatment, then every 6 months when stable
What other interventions are recommended for type 2 diabetes management?
smoking cessation, blood pressure, and hyperlipidemia control
What is the ominous octet of hyperglycemia in type 2 diabetes?
increased glucose reabsorption, decreased gluose uptake, decreased incretin effect, increased hepatic glucose production, increased glucagon, impaired insulin secretion, NT dysfunction, increased lipolysis and reduced glucose uptake
What organs or cells are involved in the ominous octet?
kidney, muscle, GI, liver, pancreas X2, brain, fat cells
What are the microvascular diseases associated with type 2 diabetes?
retinopathy (blurred vision), nephropathy (CKD), neuropathy (numbness, tingling)
What are the macrovascular diseases associated with type 2 diabetes?
MI, stroke, peripheral vascular disease
What abnormal infections are increased with type 2 diabetes?
necrotizing fasciitis, malignant otitis externa, etc as well as an increase in other common infections
What are the signs of DKA?
mental changes, nausea, vomiting, abdominal pain, signs of dehydration, Kussmaul respirations, fruity smelling breath
What are the signs of dehydration?
decreased skin turgor, dry oral mucosa, tachycardia, hypotension
What are Kussmaul respirations?
deep, rapid respirations characteristic of acidosis
What is the glucose level requirement for DKA vs HHS (hyperosmolar hyperglycemic state)?
DKA is >200, HHS is >600
Which pathological hyperglycemic state has metabolic acidosis?
DKA. Venous pH <7.3 or plasma bicarb <15
What is the venous pH and serum bicarb in HHS?
venous pH >7.25, serum bicarb >15
Which pathological hyperglycemic state is in ketosis?
DKA. HHS usually has absent or mild ketosis with marked elevation in serum osmolality (>320)
What is the management for DKA/HHS?
admit to hospital. IV fluids, IV insulin, and potassium replacement. DO NOT MANAGE OUTPATIENT
What are the risk factors for Type 1 DM?
genetic susceptibility, possibly environmental trigger
What is the clinical presentation for Type 1 DM?
polydipsia, polyuria, weight loss with hyperglycemia and ketonemia or ketonuria, DKA
What are the associated conditions with type 1 DM?
autoimmune thyroiditis, celiac disease, and addison’s disease
What is the management of type 1 DM?
education and insulin
What are the risk factors for metabolic syndrome?
overweight/obesity, sedentary lifestyle, genetics, aging, DM type 2, CVD, lipodystrophy
What is the diagnosis of metabolic syndrome? (3 of the following)
abdominal obesity (waist circumference >40 inches for men, 35 for women), triglycerides >150, HDL <40 in men and 50 in women, BP > 130/85, fasting glucose >100.
What are the associated conditions with metabolic syndrome?
PCOS, obstructive sleep apnea, nonalcoholic fatty liver disease, hyperuricemia
What is the management for metabolic syndrome?
<b>lifestyle changes</b>, weight loss medication or surgery, statin medication, fibrate medication, BP medication, metformin</b>
What are the three broad causes of endocrine dysfunction?
hormone excess, hormone deficiency, or hormone resistance
What falls under the category of hormone excess?
hormone secreting neoplasm, autoimmune disorders, or excess exogenous hormones
What falls under the category of hormone deficiency?
autoimmune destruction, destructive tumor, surgical removal, infection, inflammation, and hemorrhage
What falls under the category of hormone resistance?
inherited defects for receptors, altered pathways for feedback, etc, genetic, and immunologic
What type of tests can be used to conduct endocrine testing?
suppression (assesses hyperfunction) and stimulation tests (assesses hypofunction)
What are the broad treatment options for endocrine disorders?
replacing deficient hormone and suppressing excessive hormone production
What are examples of benign neoplastic endocrine disorders causing hyperfunction?
pituitary adenomas, hyperparathyroidism, autonomous thyroid or adrenal nodules, pheochromocytoma
What are examples of malignant neoplastic endocrine disorders causing hyperfunction?
adrenal cancer, medullary thyroid cancer, carcinoid
What are examples of ectopic neoplastic endocrine disorders causing hyperfunction?
ectopic ACTH, SIADH secretion
What are examples of multiple endocrine neoplasia causing hyperfunction?
MEN1, MEN2
What are examples of autoimmune endocrine disorders causing hyperfunction?
graves’ disease
What are examples of iatrogenic endocrine disorders causing hyperfunction?
Cushing’s syndrome, hypoglycemia
What are examples of infections/inflammatory endocrine disorders causing hyperfunction?
subacute thyroiditis
What are examples of activating receptor mutations causing hyperfunction?
LH, TSH, Ca2+, PTH receptors, and Gsa
What are examples of autoimmune endocrine disorders causing hypofunction?
hashimoto’s thyroiditis, type 1 DM, addison’s disease, polyglandular failure
What are examples of iatrogenic endocrine disorders causing hypofunction?
radiation-induced hypopituitarism, surgical hypothyroidism
What examples of infectious/inflammatory endocrine disorders causing hypofunction?
adrenal insufficiency, hypothalamic sarcoidosis
What are examples of hormone mutation endocrine disorders causing hypofunction?
GH, LH-beta, FSH-beta, vasopressin
What is an example of an enzyme defect causing endocrine hypofunction?
21-hydroxylase deficiency
What are examples of developmental defects resulting in endocrine hypofunction?
Kallmann’s syndrome, Turner’s syndrome, trascription factors
What are examples of nutritional/vitamin deficiencies resulting in endocrine hypofunction?
vitamin D deficiency, iodine deficiency
What are examples of hemorrhage/infarctions resulting in endocrine hypofunction?
Sheehan’s syndrome, adrenal insufficiency
What are receptor mutations leading to hormone resistance?
membrane receptor mutations failing to respond to hormones released by anterior pituitary as well as leptin and calcium, or nuclear receptor mutations
What is an example of a signaling pathway mutation resulting in hormone resistance?
Albright’s hereditary osteodystrophy
What are examples of postreceptor endocrine disorders resulting in hormone resistance?
Type 2 DM, leptin resistance
What are the clinical signs of hyperthyroidism?
weight loss, anxiety, diaphoresis, heat intolerance, palpitations, amenorrhea, tremor, polyphagia, frequent bowel movements, proximal muscle weakness
What are the potential causes for hyperthyroidism?
Graves’ disease, toxic multinodular goiter, toxic adenoma, subacute thyroiditis (De Quervain’s), hashimoto’s thryoiditis (initial phase)
Which drug main cause hyperthyroidism?
amiodarone via thyroiditis
Which disorders should be on the differential for hyperthyroidism clinical signs?
anxiety, acute psychiatric, mania, cancer, exophthalmos, atrial fibrillation, high estrogen states
What is the clinical presentation for hypothyroidism?
fatigue, weight gain, anorexia, dry skin, cold intolerance, weakness, cramps, arthralgia, impaired memory, depressed, hearing changes, hoarse voice, brittle hair, diminished sweating
Which drugs may cause hypothyroidism?
lithium, amiodarone, PTU, methimazole, sulfonamides
What are the potential causes of hypothyroidism?
Hashimoto’s thyroiditis, Subacute thyroiditis (after hyper phase), severe illness, deficient pituitary, Riedel’s thyroiditis
What should be on the differential with hypothyroidism?
depression, chronic fatigue, heart failure, irregular vaginal bleeding, anemia, amyloidosis
What is the mnemonic for hyperparathyroidism?
Bones, stones, abdominal moans, and psychic groans
What is Trousseau’s sign?
carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes. Associated with hypocalcemia
What is Chvostek’s sign?
contraction of ipsilateral facial muscles elicited by tapping facial nerve anterior to ear. Associated with hypocalcemia
What are the signs of excess of PTH?
signs of hypercalcemia, bone disease, nephrolithiasis, hypophasphatemia, increased calcitriol, proximal renal tubular acidosis, hypomagnesemia, hyperuricemia, gout, anemia
What are the signs of hypercalcemia?
polyuria, nephrolithiasis, constipation, anorexia, nausea and vomiting, peptic ulcer, lethargy, muscle weakness, confusion, decrease QT interval, bradycardia, hypertension
Which clinical manifestations are more common primary hyperparathyroidism?
nephrolithiasis and bone disease
Which clinical manifestations are more common with rapid hypercalcemia?
anorexia, nausea, vomiting, constipation, polydipsia, and polyuria
What are the potential causes of hyperparathyroidism?
adenoma, hyperplasia, carcinoma, MEN syndromes, chronic renal failure
What should be considered in the differential for hyperparathyroidism?
hypercalcemia of malignancy, multiple myeloma, familial hypocalciuric hypercalcemia, vitamin D intoxication, sarcoidosis, hyperthyroidism
What is the most common cause of hypocalcemia?
Hypoparathyroidism
What are the potential causes of hypoparathyroidism?
surgical removal, DiGeorge’s syndrome, and hereditary autoimmunity syndrome
What are the signs of hypoparathyroidism?
Chvostek’s sign, Trousseau’s sign, seizures, dementia, parkinsonian syndrome, paresthesia around mouth and fingers/toes, muscle stiffness, myalgia and spasms, CHF, hypotension, prolonged QT interval, diaphoresis, cataracts, hyperpigmentation, steatorrhea
What is the clinical presentation of Cushing’s syndrome?
HTN, central obesity, weakness, ecchymosis, hirsutism, depression, abdominal striae, moon face, buffalo hump
What should be the differential considerations in Cushing’s syndrome?
chronic alcoholism, DM, depression, osteoporosis, obesity, primary hyperaldosteronism, anorexia nervosa with high free urinary cortisol
What are the potential causes of primary adrenal insufficiency?
autoimmune (addison’s), surgical removal, infection (TB, histoplasmosis), adrenal hemorrhage, cancer, congenital adrenal hyperplasia, hemochromatosis or amyloidosis
What are the potential causes of secondary adrenal insufficiency?
pituitary failure, exogenous steroids
What are the clinical manifestations of adrenal insufficiency?
hyperpigmentation, weakness, fatigue, anorexia, nausea and vomiting, hypotension, salt craving, syncope
What other differentials should be considered with adrenal insufficiency?
hypotension, hyperkalemia, rhabdomyolysis, occult cancer, SIADH, cirrhosis, abdominal pain
Which hormones are secreted by the anterior pituitary?
ACTH, GH, FSH, LH, TSH, Prolactin, and MSH
What hormones are released from the posterior pituitary?
ADH and oxytocin
What non-endocrine related symptoms usually occur with pituitary tumors?
headache, visual loss, or diplopia
Which hypothalamic diseases cause hypopituitarism?
tumors, radiation, sarcoidosis, langerhans cell histiocytosis, TB meningitis, traumatic brain injury, stroke
Which pituitary diseases cause hypopituitarism?
tumors, surgery or radiation, hypophysitis, hemochomatosis, infection, Sheehan syndrome, apoplexy, genetic mutations, empty sella
Where does the isthmus of the thyroid lie?
2nd-4th tracheal rings
If the thyroid is enlarged on palpation, what other step should be performed during the physical exam?
listen over lateral lobes for bruit, which may be heard in hyperthyroidism or toxic multinodular goiter
What would the thyroid feel like in a patient with Graves disease?
soft
What would the thyroid feel like in a patient with Hashimoto’s thyroiditis or malignancy?
firm
What could a tender thyroid indicate?
thyroiditis
What is exopthalmos associated with?
hyperthyroidism (Graves disease)
What is the Chvostek sign and what is it indicative of?
twitching of facial muscles in response to tapping over the facial nerve. Found in hypocalcemia
What is Trousseau’s sign?
BP cuff inflated and causes a carpal spasm. Found in hypocalcemia
What other physical exam finds are present in hypocalcemia?
cataracts, dry coarse skin, hyperpigmentation, eczema, steatorrhea
What should be completed during a diabetic foot exam?
- inspection of feet, b/w toes, and nails. Check for warmth or other signs of infection<br></br>- DTRs<br></br>- Pulses<br></br>- 10-g monofilament pressure sensation PLUS vibration sensation, pinprick sensation, or ankle reflexes
Where on the foot should you use the 10-g monofilament?
- Big toe<br></br>- Little toe<br></br>- Ball of the foot under the big toe, middle toe, and little toe<br></br>- Heel
What is the normal fasting glucose?
70-100 mg/dL
What is the normal 2 hour post-prandial glucose?
<140 mg/dL
What is the normal random glucose?
<200 mg/dL
When palpating the sinuses, what are you asking the patient to identify?
An area that is more tender than another. Palpation of sinuses will usually be tender, so increased tenderness should alert you
At what age do frontal sinuses develop?
8-10 years old
What do normal turbinates look like?
non-erythematous, not swollen, moist.
What could brown spots on the inner oral mucosa be indicative of?
addison’s disease
What could a beefy red tongue be indicative of?
Vitamin B12 deficiency due to megaloblastic anemia
What is cobblestoning of the pharynx indicative of?
post-nasal drip due to viral rhinitis or anything that is irritating that lymph tissue. It may also be due to uncontrolled GERD
What is Torus palatinus?
A bony overgrowth at the midline of the hard palate. also called oral exostosis. Most likely hereditary
What do normal tympanic membranes look like on physical exam?
Clear, not-bulging, non-erythematous, cone of light<b>*</b><b>*</b>
What do the tympanic membranes look like in otitis media?
Bulging TM, varying degrees of erythema, loss of cone of light<b></b></b>
What are signs of strep throat?
- Beefy red soft palate<br></br>- Uvulitis<br></br>- prepalatine petechiae<br></br>- small red hemorrhages on the soft palate
What are the common symptoms associated with viral pharyngitis?
- Coryza<br></br>- conjunctivitis<br></br>- malaise or fatigue<br></br>- hoarseness<br></br>- low-grade fever
Why do people sometimes feel nauseated when they have pharyngitis?
due to the proximity of the pharynx on the homunculus to the intra-abdominal organs
What factors contribute to the likelihood of a diagnosis being Group A beta hemolytic streptococcus (GABHS)?
- Children 5-15<br></br>- Winter and early spring<br></br>- Absence of cough<br></br>- Tender anterior cervical lymphadenopathy<br></br>- Tonsillar exudate<br></br>- Fever
What is the centor score?
indicates whether or not you need to pharyngitis with antibiotics. Greater than or equal to 4 points you would empirically treat for strep
What would give you a point towards the centor score?
- Fever<br></br>- Tonsillar exudate<br></br>- Absence of cough<br></br>- Anterior cervical lymphadenopathy<br></br>- Age 3-14
What would give you 0 points toward the centor score?
15-44 years old
What would give you -1 points towards the centor score?
Age >44
What is the treatment for strep throat?
Amoxicillin
How would acute suppurative otitis media appear on PE?
inflammation of the middle ear with purulent material in the middle ear. Usually caused by bacteria or virus
How would serous otitis media appear on PE?
inflammation and effusion in middle ear w/out bacterial or viral infection. Usually due to dysfunction of Eustachian tubes
What is considered chronic otitis media?
otitis media lasting longer than 6 weeks
How would otitis externa present?
Pain with touching the external ear. May report drainage from the ear. May be caused by bacteria entering a small break in the skin of the canal. Treated with ear drops
What is otosclerosis?
Abnormal growth of bone in middle ear (specifically the stapes) resulting in progressive conductive hearing loss. Sensory loss is due to otic capsule sclerosis
If the weber test lateralizes to the right ear, then air conduction lasts longer than bone conduction in the right ear, what is the diagnosis?
sensorineural hearing loss in the left ear
If the weber test lateralizes to the right ear, then bone conduction lasts longer than air conduction in the right ear, what is the diagnosis?
conductive hearing loss in the right ear
What are some causes of conductive hearing loss?
- cerumen impaction<br></br>- foreign body obstruction<br></br>- middle ear fluid<br></br>- lack of movement of ossicles<br></br>- other obstruction
What are some causes of sensorineural hearing loss?
- Hereditary<br></br>- Meniere disease<br></br>- MS<br></br>- Trauma<br></br>- Ototoxic drugs<br></br>- Barotrauma
How does bacterial sinusitis commonly present?
- Double sickening (gets slightly better, then gets much worse)<br></br>- Pain over maxillary sinuses<br></br>- Fever<br></br>- Pressure when bending over
How does croup present?
- barking cough<br></br>- steeple sign on xray (subglottic edema)<br></br>- caused by parainfluenza, influenza, RSV<br></br>- Inspiratory stridor
What is the cause of epiglottitis? How does it present?
- Haemophilus type b influenza<br></br>- GABHS<br></br>Rapid onset of symptoms, sore throat, muffled voice, drooling, high grade fever, toxic appearance, stridor
What is the proper way to hold the ear in adults while using the otoscope?
pull up, out, and posterior
What is the proper way to hold the ear in children while using the otoscope?
pull down, out, and posterior
How is a normal whisper test performed?
stand behind patient and have patient occlude 1 ear. Whisper a combination of letters and numbers. The patient repeats the sequence. repeat with other ear
What should be performed if a patient fails to correctly identify the first sequence in the whisper test?
repeat with a different sequence. If the patient can identify 3 out of the 6 letters/numbers it is normal. If they cannot, it is abnormal
What external structures should be visualized on the nose exam?
- Ala nasi<br></br>- Columella<br></br>- Vestibule<br></br>- Bridge
What internal structures should be visualized on the nose exam?
- Septum<br></br>- Vestibule<br></br>- Turbinates
What are abnormal lymph node findings?
- Large<br></br>- Irregular shape<br></br>- Hard<br></br>- Tender<br></br>- Fixed<br></br>- Red, warm, edematous
What are aphthous ulcers?
canker sores
What is cheilitis and what is it a sign of?
red cracks at the corner of the mouth, usually a sign of a vitamin B12 deficiency
What is hypopnea?
decrease depth and rate of respiration
What is bradypnea?
regular rhythm, but slower than 14/min
What is hyperpnea?
increased depth and rate of respiration (usually in exercise)
What is tachypnea?
rapid breathing >20-25/min
What is Dyspnea?
feeling short of breath
What is the difference between hypoxia and hypoxemia?
Hypoxic is deficiency in amount of O2 reaching tissues, hypoxemia is an oxygen deficiency in arterial blood
What is atelectasis?
collapse of the alveoli in the lung
What is the pleximeter and plexor finger?
Pleximeter is the finger of the non-dominant hand for percussion. The plexor finger is the tapping finger of the dominant hand
Where is the needle decompression (thoracentesis) performed for a tension pneumothorax?
2nd intercostal space, midclavicular line
Where is a chest tube inserted?
4th intercostal space at mid or anterior axillary line just superior to the margin of the 5th rib
Where do the neurovascular bundles run in the ribs?
on the inferior border, this is why we insert chest tubes and needles at the superior margin
How do pulse oximeters work?
Oxygenated hemoglobin absorbs infrared light and allows red light to pass through. Deoxygenated does the opposite. The photodetector on the other side calculates the ratio of red to infrared and calculates the SpO2
What are causes of a bad wave form on pulse oximetry?
improper placement, hypo perfusion, hypothermia, motion artifact
What is the EtCO2?
end tidal CO2. Concentration of CO2 in exhaled air at the end of respiration. Normal PETCO2 is 35-40 mmHg
What is clubbing of the nails a sign of?
hypoxia. >180 degrees
What are the causes of clubbing of the nails?
- Heart disease<br></br>- Interstital lung disease<br></br>- Bronchiectasis<br></br>- Pulmonary fibrosis<br></br>- Cystic fibrosis<br></br>- Lung abscess<br></br>- Malignancy<br></br>- Inflammatory bowel disease
What could tracheal deviation suggest?
Mediastinal mass, atelectasis, pleural effusion, or a large pneumothorax
What is barrel chest seen in?
COPD
What is accessory muscle use a sign of?
respiratory distress seen in asthma, COPD, airway obstruction, RSV
How do you check for symmetry of thoracic expansion?
place thumbs at level of 10th ribs, fingers loosely grasping and parallel to lateral rib cage. Ask patient to inhale deeply, watch distance b/w thumbs during inspiration
What would a decreased or absent tactile fremitus be a sign of?
COPD, pleural effusions, fibrosis, pneumothorax, infiltrating tumor
What would increased tactile fremitus be a sign of?
pneumonia (consolidation)
What could dullness on percussion of the lungs be a sign of?
lobar pneumonia, pleural accumulations (effusion, hemothorax, empyema), fibrous tissue or tumor
What could generalized hyperresonance be a sign of?
chronic bronchitis, COPD, asthma. Heard in hyper inflated lungs
What does unilateral hyperresonance suggest?
large pneumothorax or possibly a large air-filled bulla in the lung (COPD/Emphysema)
Where should you auscultate the lungs?
2 spots anterior, 4 posterior, and right middle. Have patient breathe through OPEN MOUTH
What are causes of stridor?
croup, epiglottitis, upper airway foreign body, anaphylaxis
What are causes of wheezing?
- Reactive airway disease<br></br>- Asthma<br></br>- COPD
What are causes of crackles?
- Pneumonia<br></br>- CHF<br></br>- Atelectasis<br></br>- Pulmonary fibrosis<br></br>- bronchiectasis<br></br>- COPD<br></br>- Asthma
What would an abnormal bronchophony, whispered pectoriloquy, or ego phony suggest?
tumor, pneumonia, effusions, etc. Distinctness will increase with lung consolidations
What could intercostal retractions be a sign of?
severe asthma, COPD, or upper airway obstruction
What are the sites of retraction?
- Supraclavicular (above, over, or below)<br></br>- Substernal <br></br>- Intercostal
What is the presentation of a patient with COPD?
- Sit leaning forward with shoulders elevated (tripoding)<br></br>- Barrel chest<br></br>- Retractions<br></br>- pursed lips
What is the relative intensity, pitch, duration, and an example location of a flat percussion note?
Soft, high, short, and on the thigh, respectively
What is the relative intensity, pitch, duration, and an example location of a dull percussion note?
Medium X 3, on the liver, respectively
What is the relative intensity, pitch, duration, and an example location of a resonant percussion note?
Loud, low, long, and a healthy lung, respectively
What is the relative intensity, pitch, duration, and an example location of a hyperresonant percussion note?
Very loud, lower, longer, and should not be found anywhere normally, respectively
What is the relative intensity, pitch, duration, and an example location of a tympanitic percussion note?
Loud, high, longer, and over a gastric bubble, respectively
What are the normal breath sounds?
- Vesicular (soft and low pitched, best over parenchyma)<br></br>- Bronchovesicular (intermediate in intensity and pitch, best heard in 1st and 2nd interspaces ant. and b/w scapula post.)<br></br>- Bronchial (loud and high pitched, best heard over manubrium)<br></br>- Tracheal
What are the abnormal breath sounds?
- Crackles<br></br>- Wheezes<br></br>- Rhonchi<br></br>- Stridor<br></br>- Pleural friction rub
What is bronchophony?
“when you hear the patient say ““99”” more clearly or louder than normal”
What is egophony?
“when you hear the patient say ““ee”” it sounds like ““A”””
What is whispered pectoriloquy?
a patient whispers 123 or 99 and it is heard louder and clearer during auscultation
What type of technique is diaphragmatic excursion?
percussion technique
What is the treatment for atelectasis?
incentive spirometry
What is diaphragmatic excursion?
Is the movement of the thoracic diaphragm with inspiration and expiration. Normal excursion distance is usually 3 to 5 cm. The diaphragm is usually higher on the right than the left because it lies over the liver. This may be increased in conditions like atelectasis and phrenic nerve paralysis
How would a patient present with a tension pneumothorax?
sudden-onset dyspnea, ipsilateral chest pain, diminished breath sounds, hyperresonant percussion on the affected side, distended neck veins, tracheal deviation, and hemodynamic instability.
What aspects of the inspection portion of the physical exam should be noted during a cardiac exam?
- Different facies associated with cardiac diseases<br></br>- jaundice<br></br>- cyanosis<br></br>- pallor<br></br>- nail clubbing<br></br>- body habitus<br></br>- hydration<br></br>- temperature
What facies/diseases should be noted for the cardiac exam?
- acromegaly<br></br>- Cushing’s <br></br>- down’s syndrome<br></br>- hyperthyroid<br></br>- myxedema
For each 1 degree increase in body temperature, how many BPM should a patient’s heart rate increase under normal circumstances?
~10 bpm
Where do you auscultate the aortic valve?
2nd intercostal space directly to the right of the sternum
Where do you auscultate the pulmonic valve?
2nd intercostal space on the left
Where do you auscultate the tricuspid valve?
4th ICS, LSB
Where do you auscultate the mitral valve?
5th intercostal space on the midclavicular line to the left of the sternum
What would thrills be a sign of during palpation?
turbulent blood flow causing murmurs
Where is the normal point of maximal impulse?
4th-5th intercostal space at the mid clavicular line
What is the most common cause of an elevated JVP?
elevated right ventricle diastolic pressure
What is heart sound S1?
Mitral and tricuspid valve closure, beginning of ventricular systole
What is heart sound S2?
aortic and pulmonic closure, marks the end of systole, beginning of diastole
What is the normal JVP and what is it an estimate of?
0-9, estimate of the central venous pressure
What does the A wave of the JVP represent?
right atrial contraction, coincides with S1, and precedes carotid pulsation. Tricuspid valve is open
What would a giant A wave be seen in?
- tricuspid stenosis<br></br>- increased pressure in RV<br></br>- pulmonary hypertension<br></br>- pulmonary embolism <br></br>- AV dissociation (complete heart block. VT)
What is the C wave in the JVP?
RV contraction causing pushback of tricuspid valve during isovolumetric contraction
What is the represented by the X wave in JVP?
passive atrial filling and atrial relaxation
What would cause a steep X descent in the JVP?
cardiac tamponade and constrictive pericarditis
What is the V wave in JVP?
increased right atrial pressure due to filling against closed tricuspid valve
What is a prominent V wave found in?
tricuspid regurgitation** and pulmonary hypertension
What is the Y slope in JVP?
open tricuspid valve and rapid RV filling in RV diastole
What would a deep Y descent represent?
severe tricuspid regurgitation
What would a slow Y descent suggest?
obstruction to RV filling, like tricuspid stenosis or right atrial myxoma
What would an increased JVP be seen in?
- SVC obstruction<br></br>- severe heart failure<br></br>- constrictive pericarditis, cardiac tamponade, or RV infarction<br></br>- Restrictive cardiomyopathy
What would cause a positive hepatojugular reflex (HJR)?
- poorly compliant RV, RV failure<br></br>- constrictive pericarditis<br></br>- obstructive RV filling by tricuspid stenosis or Right atrial tumor
What is the cause of heart sound S3?
high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase. May be heard in heart failure
What is the cause of heart sound S4?
atrial gallop from force of contraction of atria against a stiffened ventricle. May be normal in trained athletes
How are murmurs graded?
- 1 barely audible<br></br>- 2 soft, but easily heard<br></br>- 3 loud, without a thrill (last grade without thrill)<br></br>- 4 loud with a thrill<br></br>- 5 loud with minimal contact between stethoscope and chest - thrill<br></br>- 6 loud, can be heart without a stethoscope - thrill
What should be assessed while palpating and auscultating the carotid arteries?
rate, rhythm, amplitude. You should only assess one carotid at a time feeling for any thrills and listening for any bruits
What is the normal capillary refill time?
less than 2 seconds
How is edema graded?
0 - absent<br></br>+1 barely detectable, nonpitting (2mm)<br></br>+2 slight indentation (4mm); 10-15 seconds<br></br>+3 indentation (6mm); greater than 1 min<br></br>+4 very marked indentation (8mm); 2-5 min
What is the normal right atrial pressure?
0-8 mmHg
What is the normal right ventricular pressure?
25/6 mmHg
What is the normal pulmonary artery pressure?
mean 10-20 mmHg
What is the pulmonary capillary wedge pressure?
8-15 mmHg
What is the diaphragm of the stethoscope used to listen to?
high pitched sounds like S1, S2, aortic regurgitation, mitral regurgitation, and friction rubs
What is the bell of the stethoscope used to listen to?
low pitched sounds like S3, S4, mitral stenosis, and carotid bruits
What are the steps to the cardiovascular exam?
- inspection<br></br>- palpation<br></br>- percussion<br></br>- auscultation
What should you ask the patient to do while listening for carotid bruits?
inhale and hold breath
Where does a systolic murmur fall and what could cause it?
between S1 and S2. <br></br>- aortic or pulmonic stenosis<br></br>- mitral or tricuspid regurgitation
Where does a diastolic murmur fall and what could cause it?
between S2 and S1<br></br>- aortic or pulmonic regurgitation<br></br>- mitral or tricuspid stenosis
How do you perform the Allen test?
Pressure to ulnar and radial arteries at the same time, ask to open and close hand, hand should blanch, release pressure from ulnar artery while continuing to compress the radial artery. Observe for color return to hand w/in 5-10 seconds. Repeat w/radial artery
What would a lack of dual blood supply to the hand on the Allen test be a negative indication for?
negative indication for radial catheterization
WhatWhat would a PMI greater than 2.5 centimeters be indicative of?
left ventricular hypertrophy from hypertension or aortic stenosis
What may cause the patient to have a PMI elsewhere besides the left ventricle?
In diseases like COPD, the PMI may be in the xiphoid or epigastric area due to right ventricular hypertrophy
What could a laterally displaced PMI be indicative of?
left ventricular hypertrophy and also in ventricular dilation from MI or heart failure
What is an S3 heart sound?
abrupt deceleration of inflow across the mitral valve.
What is an S4 heart sound?
due to increased LV end diastolic stiffness, which decreases compliance
What is systolic heart failure?
Reduced cardiac contractility
What is diastolic heart failure?
inability to relax and fill results in decreased cardiac output
What is an opening snap heart after S2?
mitral valve snapping open
What is a wide physiologic splitting of S2?
refers to an increase in the splitting of S2 caused by delayed closure of the pulmonic valve (pulmonic stenosis or right bundle branch block) or early closure of the aortic valve (mitral regurgitation)
What is fixed splitting of S2?
wide splitting that does not vary with respiration. Due to prolonged right ventricular systole, ASD, and right ventricular failure
What is paradoxical or reversed splitting of S2?
splitting that occurs on expiration and disappears on inspiration. Most common cause is left bundle branch block
What is the most common cause of P2 being louder than A2 in the left parasternal intercostal space?
pulmonary hypertension
What are the causes of a systolic murmur?
- Aortic stenosis<br></br>- Aortic sclerosis<br></br>- benign murmur<br></br>- Hypertrophic cardiomyopathy<br></br>- VSD<br></br>- tricuspid regurgitation<br></br>- mitral valve prolapse<br></br>- mitral insufficiency
Where would aortic sclerosis and stenosis be heard best?
right upper sternal border
Where would a benign or hypertrophic cardiomyopathy best be heard?
left upper sternal border
Where would a VSD or tricuspid regurgitation best be heard?
left lower sternal border
What would a mitral valve prolapse or mitral insufficiency best be heard?
left midclavicular line at cardiac apex
What are the causes of diastolic murmurs?
- aortic insufficiency<br></br>- pulmonic regurgitation<br></br>- mitral stenosis <br></br>- Tricuspid stenosis
Where would you hear aortic insufficiency the best?
right upper or left mid sternal border, best heard with the bell
Where would pulmonic regurgitation be best heard?
left upper sternal border
Where would mitral stenosis be best heard?
right lower sternal border in left lateral decubitus position
Where would tricuspid stenosis be best heard?
left lower sternal boder
Where is physiologic splitting best heard?
2nd left intercostal space, closer to the sternal border during inspiration
What is the most common cause of mitral valve stenosis?
rheumatic mitral valve disease
What are common continuous murmurs?
- PDA<br></br>- Coarctation of the aortia<br></br>- Arteriovenous fistulas
What are the proper steps to the abdominal exam?
- Inspection<br></br>- Auscultation<br></br>- Percussion<br></br>- Palpation
What is the Cullen sign?
ecchymosis around the umbilicus secondary to intraperitoneal hemorrhage
What is the Grey Turner sign?
flank ecchymosis secondary to retroperitoneal hemorrhage
What other things are you looking for on inspection?
- Jaundice<br></br>- scars/striae<br></br>- dilated veins<br></br>- rashes and lesions<br></br>- Abdominal distension<br></br>- hernias/masses<br></br>- surface motion<br></br>- pulsations
What are the normal amount of clicks for bowel sounds?
5-34 per minute
What would be abnormal bowel sounds?
high pitched or decreased/absent
Where would you auscultate for the abdominal aorta?
midline above the umbilicus
Where would you auscultate for the renal arteries?
RUQ and LUQ, just lateral to midline
Where would you auscultate the iliac arteries?
RLQ and LLQ, just inferolateral to the umbilicus
What are the normal percussion sounds of the abdomen?
tympany
Where do you normally hear dullness in the abdomen?
liver, spleen, fluid in the peritoneum, and feces
What is the expected liver span?
6-12cm at the midclavicular line; 4-8cm at the midsternal line
What is the expected span of the spleen?
ribs 6-10 at the mid-axillary line on the left
What is considered light, moderate, and deep palpation?
- 1 cm<br></br>- 2-3 cm<br></br>- >3 cm
How do you palpate the liver?
Place hand under right lower rib cage with other hand supporting their 11th and 12th ribs posteriorly and pressing anteriorly. Have patient inhale
How is the spleen palpated?
Place hand under left right cage, other hand supporting rib cage posteriorly, pressing anteriorly. Normally should not be palpated
How do you palpate the kidney?
place one hand in either RUQ or LUQ while the other hand is on the ipsilateral back just below and parallel to the 12th rib. Press down firmly and deeply at the peak of patient’s inspiration
What is the expected width/palpation of the abdominal aorta?
2-3 cm in width, pulsation in anterior-inferior direction. >3 cm would be abnormal
What is the cause of visceral pain?
secondary to distention, stretching, or contracting of the hollow organs, stretching the capsule of solid organs or organ ischemia.
How is visceral pain described?
Diffuse, Crampy pain, not localized, usually felt at the midline of at the level of the structure involved
What is parietal pain/
secondary to inflammation in the parietal peritoneum, usually constant and more severe than visceral, localized, aggravated by movement or coughing
What is abdominal guarding?
voluntary tightening of abdominal muscles secondary to pain
What is abdominal rigidity?
abdomen is hard, involuntary reflex contraction of abdominal wall
What is McBurney’s point?
rebound tenderness or pain 1/3 of the distance from the ASIS to umbilicus. Indicates possible appendicitis/peritoneal irritation
What is rebound tenderness?
pain upon releasing the palpating hand that is pushing on the abdomen
What is Rovsing’s sign?
RLQ pain upon palpation of LLQ, indicates possible appendicitis
What is the iliopsoas muscle test?
have patient raise thigh against resistance then turn the patient on their left side and extend the right leg at the hip. Increased abdominal pain indicates irritation of the psoas muscle from inflammation of the appendix
What is the obturator muscle test?
Flex the patient’s right thigh at the hip, with the knee bend and rotate the leg internally at the hip. Right hypogastric pain is a positive test. Irritation of obturator from appendicitis
What is the heel strike test?
strike patient’s heel. Abdominal pain indicates possible appendicitis or peritonitis
What is the fluid wave test for ascites?
with assistant placing ulnar aspects of hand on midline, tap on side of the patient and see if you feel it on the other side. If you do, it may indicate fluid in the peritoneal cavity (ascites)
What is Murphy’s sign?
palpate deeply under the right costal margin during inspiration. Positive test of pain or sudden stop in inspiratory effort indicates acute cholecystitis or cholelithiasis
What is Courvoisier’s sign?
enlarged non-tender gall-bladder. Indicates pancreatic disease/cancer
What is the Lloyd punch?
Punch over kidneys, pain indicates an infection around kidney, pyelonephritis, or renal stone
What could cause RUQ pain?
- cholecystitis<br></br>- Pyelonephritis<br></br>- ureteric colic<br></br>- hepatitis <br></br>- pneumonia
What could cause LUQ pain?
- gastric ulcer<br></br>- pyelonephritis<br></br>- ureteric colic<br></br>- pneumonia
What could cause RLQ pain?
- appendicitis<br></br>- ureteric colic<br></br>- inguinal hernia<br></br>- IBD<br></br>- UTI<br></br>- gynecological <br></br>- testicular torsion
What could cause LLQ pain?
- Diverticulitis<br></br>- Ureteric colic<br></br>- Inguinal hernia<br></br>- IBD<br></br>- UTI<br></br>- Gynecological<br></br>- Testicular torsion
What type of pain would periumbilical pain with early appendicitis be?
visceral pain
What commonly aggravates and alleviates parietal pain?
aggravated by movement or coughing, alleviated by remaining still
Where would pain be palpated in acute diverticulitis?
LLQ
Where is duodenal and pancreatic pain commonly referred to? Biliary tree?
Duodenal and pancreas to the back. Biliary tree to the right shoulder
What type of ROS questions should be asked for GI?
nausea, vomiting, diarrhea, black stool or blood in stool, blood in vomit
What type of ROS questions should be asked for GU?
dysuria, polyuria, hematuria, flank or CVA pain
What type of GYN ROS questions should be asked?
vaginal bleeding or discharge, LMP, possibility of pregnancy
What are the complaint specific PMH for an abdominal complaint?
- Hepatitis<br></br>- GERD/PUD<br></br>- Gall bladder<br></br>- IBD<br></br>- Cancer<br></br>- Chronic abd pain<br></br>- Constipation
What abdominal specific PSH should be asked about?
- Cholecystectomy<br></br>- Appendectomy<br></br>- Hysterectomy<br></br>- C-section<br></br>- Ovarian cyst
How should the patient be draped for an abdominal exam?
Gown should be pulled up to right underneath the breasts, pants pulled down to the level of the ASIS. Drape may be tucked into the patient’s pants
What is the order of the abdominal exam?
inspection, auscultation, percussion, palpation
What is in the RUQ?
- liver<br></br>- gallbladder
What is in the RLQ?
appendix<br></br>ovary
What is in the LLQ?
Colon<br></br>Ovary
What is in the LUQ?
stomach<br></br>Spleen
What is in the epigastric area?
Pancreas
What are absent bowel sounds a sign of?
no bowel sounds for >2 minutes<br></br>- long-lasting intestinal obstruction<br></br>- intestinal perforation<br></br>- mesenteric ischemia
What are decreased bowel sounds found in?
no bowel sounds for 1 minute<br></br>- post-surgical ileus <br></br>- peritonitis
What are increased bowel sounds found in?
- Diarrhea<br></br>- Early bowel obstruction
What are high pitched bowel sounds indicative of?
sounds like raindrops on metal, suggests early intestinal obstruction
What are friction rub sounds?
grating sounds with respiratory variation. Due to inflammation of the peritoneal surface of an organ. Listen over liver and spleen
What is a venous hum sound?
soft humming noise. due to increased collateral circulation between portal and systemic venous systems. Listen over epigastric and umbilical regions
What are causes of an enlarged liver?
- cirrhosis<br></br>- lymphoma<br></br>- hepatitis<br></br>- right-sided heart failure<br></br>- amyloidosis<br></br>- hematochromatosis
What is the cause of a shrunken liver (decreased vertical span)?
cirrhosis
What would cause an irregular edge/nodules on the liver?
heptaocellular carcinoma
What would cause increased firmness of the liver?
- Cirrhosis<br></br>- Hematochromatosis<br></br>- Amyloidosis<br></br>- Lymphoma
What are some causes of splenomegaly?
- Portal HTN<br></br>- Blood malignancies <br></br>- HIV<br></br>- Splenic infarct<br></br>- Hematoma<br></br>- Mononucleosis
How are normal abdominal findings documented?
Abd- soft, NT/ND, BS+ X4, no HSM
What is the most common digestive complaint in the US?
constipation
What is used to categorize constipation?
Rome III Criteria, Bristol stool scale
What is the Rome III criteria for constipation?
Must have at least 2 of these symptoms over the preceding 3 months:<br></br>- Fewer than 3 bowel movements/week<br></br>- Straining<br></br>- Lumpy or hard stools<br></br>- Sensation of incomplete defecation<br></br>- Manual maneuvering required to defecate
What is the Bristol stool scale?
1 - separate hard lumps, like nuts<br></br>2 - sausage shaped, but lumpy<br></br>3 - sausage shaped, but cracks on surface (normal)<br></br>4 - sausage or snake-like, smooth and soft (normal)<br></br>5 - soft blobs with clear-cut edges (easy to pass)<br></br>6 - fluffy pieces with ragged edges, mushy<br></br>7 - watery, no solid pieces
What are non-concerning/non-urgent associated symptoms with constipation?
- Abdominal bloating<br></br>- Low back pain<br></br>- Tenesmus<br></br>- Pain on defecation
What are concerning associated symptoms with constipation that may warrant urgent evaluation?
- Rectal bleeding<br></br>- Abdominal pain<br></br>- Inability to pass flatus<br></br>- Vomiting
What type of physical exam should be performed for a constipation complaint?
- Abdomen exam<br></br>- Pelvic exam for females<br></br>- Anorectal exam
How can large abdominal wall hernias interfere with defecation?
interferes with the generation of intra-abdominal pressure required for initiation of defecation
What may distention or masses indicate?
colonic stools or tumors
What should be palpated on a pelvic exam for constipation?
Posterior vaginal wall at rest and straining to check for internal prolapse or rectocele
What lifestyle modifications should be made for constipation?
- Increase fiber and water in diet<br></br>- use bathroom right away, don’t try to hold it<br></br>- Increase exercise<br></br>- Schedule interrupted time every day for a bowel movement
What are the causes of gastroenteritis?
- Viral (50-70%)<br></br>- Bacterial (15-20%)<br></br>- Parasitic (10-15%)<br></br>- Food-borne toxigenic<br></br>- Drug-associated
How does norovirus present?
Sudden onset with uncontrolled vomiting 12-48 hours after exposure, usually more vomiting than diarrhea. Resolves about 36 hours after onset of symptoms.
Besides norovirus, what other virus is a major cause of gastroenteritis?
Rotavirus. However, immunization is available now. Prior to immunization. 55-70K hospitalized per year
What are the three major bacterial causes of Gastroenteritis?
- Salmonella<br></br>- C. Diff<br></br>- E. Coli
How does salmonella present?
Onset 12-36 hours after eating contaminated food
What is the most common cause of C. Diff?
hospital-acquired, exposure to antibiotics
How is E. coli transmitted?
Food, water, person-to-person. Most common cause of traveler’s diarrhea. Starts within 5 days and lasts 2 weeks
What is the most common cause of parasitic gastroenteritis? Symptoms?
Giardia. Causes diarrhea (greasy stools that tend to float), bloating, abdominal cramping, nausea, vomiting. Most commonly transmitted form infected water (campers, hikers, travelers)
What are causes of drug-associated gastroenteritis?
- Antibiotics<br></br>- Laxatives<br></br>- Colchicine <br></br>- Quinidine <br></br>- Sorbitol<br></br>- PPIs
What is common in irritable bowel syndrome?
- Postprandial urgency<br></br>- Alternating b/w constipation and diarrhea, with one dominating over the other<br></br>- Intractability to laxatives <br></br>- Defecation improves abdominal pain, but does not relieve it
What is the hallmark of Cholera?
copious rice water diarrhea
What may a white/bulky stool indicate?
small bowel pathology, malabsorption
What are some historical cues for a GI complaint?
Recent travel, change in meds, hiking, camping
What OS treatment could be considered for constipation?
Mesenteric release
What OS treatment could be considered for diarrhea?
Ganglion inhibition
What is gonadarche?
activation of the gonads by FSH and LH secreted from the anterior pituitary
What is adrenarche?
increase in androgen hormone production by the adrenal cortex
What is the thelarche?
breast development due to estrogen from the ovaries
What is menarche?
the first menstrual period
What is spermarch?
first sperm production
What is pubarche?
development of pubic hair
What age does puberty occur in females?
10-14 years old, menarche onsets 2-3 years after beginning of puberty. Secondary sex characteristics are breast/areolar development
What age does puberty occur in males?
11-16 years old. Secondary sex characteristics are penile growth and pubic hair development
What are the signs of puberty besides secondary sex characteristics?
- Increase in height and weight<br></br>- growth spurt and bone growth<br></br>- Development of facial hair, axillary hair<br></br>- Increase length of vocal cords<br></br>- Facial morphologic changes in the mandible, nose, maxilla, brow, etc<br></br>- Increase thyroid size<br></br>- Skin changes
What are the tanner stages development of external genitalia for boys?
1 - prepubertal <br></br>2 - Enlargement of testes and scrotum<br></br>3 - enlargement of penis, growth of testes<br></br>4 - increase size of penis, development of glans, growth<br></br>5 - adult genitalia
What are the tanner stages of breast development?
1 - prepubertal<br></br>2 - Breast bud stage with elevation of breast and papilla. Enlargement of areola<br></br>3 - further enlargement of breast and areola<br></br>4 - Areola and papilla form a second mound above level of breast<br></br>5 - Mature stage: projection of papilla only
What are the tanner stages of pubic hair development?
1 - Prepubertal<br></br>2 - sparse growth of long, slightly pigmented hair<br></br>3 - Darker, coarser, more curled <br></br>4 - hair adult in type, but covering smaller area than adult; no spread to medial surface of thighs<br></br>5 - adult in type and quantity, with horizontal upper border
What tanner stage of development does menarche usually onset?
breast stage 3 or 4
What age does breast development and pubic hair development occur?
8-13 years
What age does pubic hair and penile development occur?
9-13.5 years of age
What does the acronym TPAL stand for?
“GyPxxxx, where the ““Xs”” are replaced with TPAL<br></br>- Term deliveries >37 weeks<br></br>- Preterm delivery 20-37 weeks<br></br>- Abortion <20 weeks<br></br>- Live delivery regardless of age”
What is appropriate contraceptive/sexual history?
- Contraception method<br></br>- Current sexually active<br></br>- Number of partners last year or lifetime<br></br>- New partner in last 3 months<br></br>- Condom use<br></br>- History of sexual abuse
What ages should a Pap smear be performed for?
21-65. <br></br>- Yearly for abnormal pap smear<br></br>- Every 3 years with consecutive normal pap smear<br></br>- Every 5 years with consecutive normal Pap smear and negative HPV test
What age should mammograms begin?
50 years or earlier for women who are at high risk
Which 4 regions should be tested in a Pap smear?
- Ectocervix<br></br>- Endocervix<br></br>- Transitional zone<br></br>- Squamocolumnar junction
What GU DDX should be considered for pelvic pain?
UTI, STI, Pelvic inflammatory disease, hernia
What GYN DDX should be considered for pelvic pain?
Ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, spontaneous abortion, tubo-ovarian abscess, uterine fibroid
What is the classic presentation of an ectopic pregnancy?
- Abdominal or pelvic pain with vaginal bleeding<br></br>- May have other pregnancy related symptoms like breast tenderness, nausea, etc
If symptoms of an ectopic pregnancy are present, what should be performed?
- Pregnancy test<b>*</b><br></br>- Speculum exam<br></br>- If pregnant, transvaginal ultrasonography is recommended
What is the classic presentation of a UTI?
- Dysuria (pain, burining, or discomfort with urinating)<br></br>- Urinary frequency or urgency<br></br>- Suprapubic pain<br></br>- May have hematuria
What are the components to a male genital exam?
- Inspection of scrotum, penile shaft, glans, inguinal region<br></br>- Palpate penile shaft and scrotum with thumb and first two fingers<br></br>- Palpate inguinal region and examine for hernias<br></br>- Examine prostate by palpation on DRE<br></br>- Males should perform self testicular exam
Which GU issues should be considered in groin pain?
- Groin lesion<br></br>- Scrotal mass<br></br>- Epididymitis<br></br>- Hydrocele<br></br>- Testicular cancer or torsion<br></br>- UTI<br></br>- Varicocele<br></br>- Inguinal hernia<br></br>- Kidney stones
What is the classical presentation of an inguinal hernia?
- Pain with increased intra-abdominal pressure<br></br>- May have palpable bulge on affected side<br></br>- On PE, invaginate scrotum into inguinal canal and have patient cough or perform Vasalva maneuver to help feel hernia
What is the most common type of inguinal hernia?
Indirect, occurs above the inguinal ligament near its midpoint, often extends to scrotum
What are the 5 P’s of sexual history?
- Partners<br></br>- Practices<br></br>- Prevention of pregnancy<br></br>- Protection from STIs and HIV<br></br>- Past history of STI
What are the risk factors for STI or STD?
- New partner in the last 60 days<br></br>- Multiple partners or partner with multiple partners<br></br>- Partners with recently treated STI<br></br>- Inconsistent condom use<br></br>- Trading sex for money or drugs<br></br>- Sexual contact with sex workers<br></br>- Meeting anonymous partners on the internet
What are some complications of untreated STIs?
- Pelvic inflammatory disease (gonorrhea or chlamydia)<br></br>- Upper genital tract infections<br></br>- Infertility<br></br>- Chronic pelvic pain<br></br>- Cervical cancer<br></br>- Chronic infection with HSV, hepatitis, and HIV
What is the classic presentation of Gonorrhea?
- Gram-negative intracellular diplococci<br></br>- Males penile discharge and dysuria, may be asymptomatic<br></br>- Females pelvic pain or mucopurulent vaginal discharge
What do we usually treat in a patient that also has Gonorrhea?
Chlamydia
What is the classic presentation of Chlamydia?
Gram negative bacteria Chlamydia trachomatis<br></br>- Most cases are asymptomatic<br></br>- Males penile discharge, pruritus, dysuria<br></br>- Females vaginal discharge, bleeding, pain during intercourse, or dysuria
What is the classic presentation of syphilis?
- Primary is a chancre (painless genital ulcer)<br></br>- Secondary: joint pains, fatigue, lymphadenopathy, mucopapular rash<br></br>- Latent phase may be asymptomatic <br></br>- Tertiary: neurosyphilis (confusion, HA, stiff neck, vision loss)
What is the classic presentation of genital herpes?
- Single or clusters of vesicles on the genitalia<br></br>- Burning, tingling, and pain prior to vesicle appearance
What is the classic presentation of Trichomonasis?
Caused by protozoa with flagella<br></br>- May be asymptomatic<br></br>- Most males are asymptomatic, may have penile discharge<br></br>- Females present with foul smelling thin or purulent vaginal discharge, vaginal pruritus, dysuria
What is the classic presentation of HPV?
genital warts. High risk strains can lead to cancer of the oropharyngeal region or lower genital tract
