PCM III Midterm Exam Material Flashcards
What is the proper sequence of Abdominal examination?
Inspection, Auscultation, Percussion, Palpation
IAPP
What is Cullen Sign and Grey Turner Sign?
CS: ecchymosis around umbilicus due to intraabdominal or retroperitoneal hemorrhage
GTS: flank ecchymosis from blood tracking subcutaneously from retroperitoneal/intraperitoneal source
pancreatitis
What are Striae and Caput Medusa?
S: stretch marks; associated with weight or muscle mass change and skin tension
CM: dilated veins from inc. pressure of PORTAL VEIN transmitted to collateral venous channels
- radiate from umbilicus to the ribs
What is the difference between Normal, Abnormal, and Decreased/Absent bowel sounds?
N: 5-34 clicks per minute
A: high-pitched; due to OBSTRUCTION
D: absent; due to ILEUS
What is the difference between Tympany and Dullness on percussion of the abdomen?
T: found in majority of abdomen; AIR-FILLED VISCERA
D: flat sound w/o echoes over ORGANS; liver/spleen/feces/FLUID
Visceral Pain vs Parietal Pain
V: due to distension, stretching, contracting of organs
- felt at midline at level of involved organ
- NOT localized
P: due to inflammation of parietal peritoneum
- constant and more severe than visceral
- LOCALIZED, aggro by movement/coughing
What are :
McBurney's Point Rovsing's Sign Iliopsoas Muscle Test Obturator Muscle Test Heel Strike (Markle's Sign)
MP: 2/3 distance from umbilicus to ASIS (Appendicitis)
RS: pain in RLQ w/palp in LLQ (Appendicitis)
IMT: pt. flex hip against resistance (Appendicitis)
- irritation of psoas muscle/inflammation of appendix
OBT: flex pt. right thigh and internally rotate hip (Appen)
- irritation of obturator muscle/appendix inflammation
HS: pt. supine, strike heel; abdominal pain = (+)
- appendicits or peritonitis
What are:
Murphy’s Sign
Courvoiser’s Sign
Lloyd’s Punch (CVA)
MS: pain/sudden stop to inspiration on deep palpation of right costal margin
(+) = acute cholecystitis or cholelithiasis
CS: enlarged non-tender gallbladder
(+) = pancreatic disease/cancer
LP: gently tap area of the back over the kidney
(+) = perinephric abscess, pyelonephritis, renal stone
Ascites
Shifting Dullness vs Fluid Wave
SD: fluid (dullness) moves to the lowest (gravity) point
- tympanic where air is, dull where fluid is
FW: have assistant place hands on pts. midline while doctor taps on one flank monitoring for impulse of wave on opposite side
What is Colicky Pain?
- pain that waxes and wanes in intensity
- pt. shifts frequently because they cannot find comfortable position
What is Acne Vulgaris?
What is the difference between Open and Closed Comedones?
- chronic inflammation of pilosebaceous follicles usually beginning around puberty (adolescent - 25 yo)
Open: black-heads; flat/elevated papule with black keratin plug
Closed: white-heads; 1-mm yellow papules
face, back, chest, shoulders
What is Atopic Dermatitis (eczema)?
What is important in making the diagnosis?
- chronic pruritic condition with allergic rhinitis and/or asthma (susceptible to staph infections - impetigo)
- usually in flexural surfaces, antecubital/popliteal fossas
- PMH of allergies and family history (since it typically runs in the family) are important for making diagnosis
What is Seborrheic Dermatitis?
- dandruff to fulminant rash w/dryness, pruritus, fine and greasy scaling lesions
- on scalp eyebrows, nasolabial folds, ears, eyelids
What is Seborrheic Keratosis?
- “stuck-on” appearance w/waxy scale; well-circumscribed tan to dark brown/black usually in older patients
- warty scaly lesion; with trauma: may fall off and regrow in same site
What is a Dermatofibroma?
What is the Fitzpatrick Sign?
- firm, smooth papule/nodule usually on legs; round-ovoid with well-defined borders
- squeezing margins = ‘dimple’ or ‘Fitzpatrick Sign’ = lesion will dimple
What is Rosacea?
What is a classic physical exam finding of this condition?
- chronic inflammatory condition with relapsing course; facial flushing, telangiectasias, and papules/pustules on nose/cheeks/brows/chin in 30-50 yos
- SPARES nasolabial folds
- rhinophyma (enlarged, cobblestoned appearance of nose due to edema and sebaceous hyperplasia)
What is a Sebaceous Cyst (Epidermoid Cyst)?
- squamous epi cyst containing macerated keratin and lipid-rich debris on that is asymptomatic unless infected; ALL AGES
- dome-shaped, firm, flesh-colored nodule that has pore-like opening (“central punctum”)
- contents have FOUL ODOR (distinct)
What is a Nevus (mole)?
- typically arise during childhood and may darken during pregnancy (new lesions less common after age 50)
- darkened skin lesion that can be macular (junctional) or papular (compound)
What is Eruptive Xanthoma?
- domed yellow-orange firm papules that appear abruptly with rapid onset and all lesions at same stage of development
- pruritus/pain may be present, redness
Dermatomyositis
What are 4 physical exam findings associated with this condition? (HR/ADP/NT/SS)
Heliotrope Rash: edematous periorbital edema
Atrophic Dermal Papules: red, scaly, flat-topped papules on dorsal MCP joints
Nail Telangiectasia: erythema/telangiectasias at base of nails
Shawl Sign: poikilodermatous erythema of upper back, posterior neck, and shoulders
What is Dermatomyositis?
- multiple skin changes with systemic manifestations and proximal muscle weakness
- dysphagia, pulmonary involvement, cardiac problems
- up to 40% of pts have occult malignancy or will develop it within 2-3 years
What is Actinic Keratosis (Solar Keratosis)?
- pre-cancerous lesion on sun-exposed surfaces that can progress to SQUAMOUS CELL CARCINOMA
- feels gritty, has white-yellow surface scale
- inc. in frequency of appearance with age and if on sun-exposed areas
What is Solar Lentigo?
- “senile lentigo”; age spot or liver spot
- benign pigmented macule related to UV radiation (sun-exposure) associated with multiple sun burns in fair-skinned individuals
- smooth/flat macules with hyperpigmented tan-brown color
What is Basal Cell Carcinoma?
- most common skin cancer, usually more likely in men
- inc. incidence with age and sun-exposed areas (MC on NOSE)
- smooth pearly papule/nodule with rolled borders and telangiectasias
What is the difference between Infiltrating and Superficial Basal Cell Carcinoma?
I: slightly raised/depressed thin pink-white scar plaque with scale, crust, erosion, and telangiectasia
S: well-defined red patch or thin plaque scale that expands horizontally over time
What is a Melanoma?
What are the ABCDE’s of melanoma and what does ‘ugly-duckling lesion” mean?
- median age of 60 and skin that are PIGMENTED; can be on palms, soles, nails
A - asymmetry, B - irregular borders, C - change in color, D - diameter > 6mm, E - evolution
- “ugly duckling”: look for lesions that stand out from others on pts. with multiple pigmented lesions
What is Cutaneous Squamous Cell Carcinoma?
What condition puts a patient at higher risk of developing this condition?
- inc. with age and sun-exposure, usually 80x more likely in lighter skin individuals
- variable presentation with hyperkeratotic papules/nodules
- presence of ACTINIC KERATOSIS indicates individual is at HIGHER RISK of developing cSCC
What testing should be done for Chronic Gastritis?
- test for H. pylori using Urea Breath Test or stool Ag test (proton pump inhibitors can cause false negative)
- serum Ab testing, if positive, only confirms past infection and does NOT prove current infection
inc. risk of developing cancer in pts. with H. pylori induced gastritis
What combination therapy would be used to treat H. pylori-induced Chronic Gastritis?
PPI + Clarithromycin + amoxicillin
- clarithromycin resistance –> add bismuth for quadruple therapy
How is GERD pain described?
What test should be performed for this condition?
- post-prandial (30-60 min) epigastric/retrosternal pain that migrates upwards that feels like burning/heartburn
- exacerbated by large meals, bending over, lying supine; foods and antacids can alleviate
Test: occult blood stool test
What is the difference between Duodenal and Gastric Ulcers?
- both described as dull, gnawing, or “hunger-like”; smoking retards ulcer healing and inc. recurrence
D: peaks between 30-55 yo, H. pylori caused with pain that wakes pt. up (2/3 of pts), and typically occurs 90-180 min after a meal
G: peaks between 55-70 yo, usually caused by NSAIDS with pain that wakes patient up (1/3 pts)
What are 3 common lithogenic medications? (E/C/T)
estrogen, clofibrate, thiazides
Who is most likely to develop gallstones and what are 3 risk factors for development?
- more common in middle-aged, obese women
Risk factors: obesity, caloric excess, and rapid weight-loss due to starvation, fasting, or gastric bypass
How do Transabdominal Ultrasound, Sonographic Murphy’s Sign, and HIDA Scans help diagnose Biliary Disease?
TAUS: do in RUQ after 6 hours of fasting; most appropriate test to facilitate diagnosis
SMS: pain over gallbladder by ultrasound probe
HIDA: lack of stone w/biliary colic –> radioactive technetium is taken up by liver and excreted into biliary tree which enables visualization
- no gallbladder after 60 min is diagnostic
CT is NOT sensitive for gallstone detection
How are Ulcerative Colitis and Crohn Disease affected by appendectomy and smoking?
UC: appendectomy is protective, smoking may prevent disease
CD: appendectomy is NOT protective, smoking may CAUSE disease
What are the ANTERIOR Chapman’s Points for:
- Esophagus/bronchus/thyroid/myocardium
- Upper Lung
- Lower Lung
- Stomach (acidity) and Liver
- Stomach (peristalsis), Liver, and Gallbladder
- Spleen and Pancreas
- 2nd intercostal space
- 3rd intercostal space
- 4th intercostal space
- 5th intercostal space (S - left, L - right)
- 6th intercostal space (S- left, L/G - right)
- 7th intercostal space (S - liver, P - right)
What are the POSTERIOR Chapman’s Points for:
- Esophagus/bronchus/thyroid
- Upper Lung/myocardium
- Upper Limb
- Lower Lung
- Stomach (acidity) and Liver
- Stomach (peristalsis), Liver, and Gallbladder
- Spleen and Pancreas
- Large Intestine
- T2
- upper T3
- between T3-T4
- T4
- T5 (S - left, L - right)
- T6 (S - left, L/G - right)
- T7 (S - left, P - right)
- L2-4
What is Molluscum Contagiosum?
- benign, self-limited eruption caused by localized DNA poxvirus spread via direct contact (children) or sexual transmission (adults)
- is umbilicated, papular skin lesion that is usually few/scattered; commonly seen around groin area
- also transmitted via swimming in pool facilities contaminated by fomites
What is Erythema Multiforme?
What are 3 common associations it is seen with? (H/A/E)
- well-circumscribed, erythematous macules or papules < 3 cm; classic “target lesions”
- appears on palms/soles; usually symmetrically on acral sites and progresses in centripetal fashion
- associated with multiple disease processes –> Herpes Simplex Virus, Group A Strep, EBV (can be triggered by penicillin)
What is the difference between Erythema Multiforme Minor and Major?
Minor: acral distribution, usually symmetrical, minimal mucosal involvement
Major: progressing involvement, more centripetal and multiple mucus membranes involved
What is Subungal Acral Lentiginous Melanoma?
NAIL CANCER –> most deadly form of melanoma
- higher incidence in people of color, found under the nails of fingers/toes
How does Diascopy differentiate erythema from telangectasia?
- press slide firmly on skin lesion
- if blanches: it is due to vasodilation (blood in vessel)
- if no blanch: it is purpura (blood outside vessel)
What is Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis?
- conditions that present with TARGET Lesions (looks like erythema multiforme Major)
SJS: due to drugs and can be immediate, progresses to Toxic Epidermal Necrolysis
TEN: widespread involvement with skin sloughing (looks like extensive burns); tracheobronchial involvement that is necrotizing (Acute Tubular Necrosis)
- risk of dehydration, hypernatremia, sepsis
What are the two types of Clinical Reasoning?
Non-Analytical (System I)
- utilizes basic knowledge and past experiences
- pattern recognition w/minimal analytical effort
Analytical (System II)
- process of hypothesis testing
- evidence-based guidelines and biostatistics
What is Problem Representation and Diagnostic Justification?
PR: a summary sentence, or list, that highlights the findings of the case
DJ: hypothesis generated based on appropriate facts and assumptions
- supportive evidence and problem representation
- use above as process justifying decisions
What is Diagnostic Justification used for?
- logically think through a case presentation and clearly describe your train of though, identify flaws in reasoning and make adjustments (basically a mental algorithm)
- it is NOT about your ability to immediately identify the correct diagnosis
Probability of Disease
What is the difference between Sensitivity and Specificity?
Sensitivity: proportion of pts. WITH the disease or finding = POSITIVE RESULT
- sensitivity when negative RULES OUT disease
- (SNout)
Specificity: proportion of pts. WITHOUT the disease or finding = NEGATIVE RESULTS
- specificity when positive RULES IN disease
- (SPin)
Probability of Disease
How do you calculate N1 and N2?
N1 = A + C
A = disease present and finding present
C = disease present and finding NOT present
N2 = B + D
B = disease NOT present and finding present
D = disease NOT present and finding NOT present
Probability of Disease
How do you calculate Sensitivity and Specificity using N1/N2?
Sensitivity = A/N1
* N1 = A + C
Specificity = D/N2
* N2 = B + D
Probability of Disease
How is Likelihood Ratio calculated?
probability of finding in patient WITH disease / probability of the same finding in patient WITHOUT disease
Positive LR = Sensitivity / (1-Specificity)
Negative LR = (1-Sensitivity) / Specificity
Probability of Disease
What is the % decrease or increase associated with:
Dec: LR of 0.5/0.2/0.1
Inc: LR of 2/5/10
Decreasing LR:
- 0.5 = -15%
- 0.2 = -30%
- 0.1 = -45%
Increasing LR:
- 2 = +15%
- 5 = +30%
- 10 = +45%
What is an Illness Script?
an organized mental summary of a provider’s knowledge of a disease
- mental cue cards to represent individual diseases
Tension Headache vs Migraine Headache
Age, presentation, associated symptoms
TH:
- A: 20-50 yo, female predominance
- P: bilateral/symmetric, mild-moderate, 30 min-7 days
- pressure, tightness, band-like
- AS: none
MH:
- A: 10-40 yo, female predominance, strong genetics
- P: starts unilateral, minority bilateral; 4 hrs-3 days
- throbbing and pounding
- AS: prodrome, 25% have visual disturbance
What is the prodrome of Migraine Headaches?
irritability, food cravings, yawning up to 48 hrs before onset
Streptococcus Pharyngitis Illness Script
- relatively severe with sudden onset with fever over 100.4 degrees; pharyngeal and tonsilar erythema, hypertrophy (w or w/o exudate), palatal petechiae
- burning/raw quality typically with no upper resp. symptoms; ages 5-15
- use Rapid Antigen Test and Centor Criteria
Viral Pharyngitis Illness Script
- mild to moderate sore throat often proceeding other viral symptoms by 1-2 days lasting 5-7 days
- aching, sore quality with low grade fever, if any; affects all ages but mostly those under 5 yo
- about 50-80% of sore throats are viral in nature
What is the VINDICATE mneumonic?
V - vascular I - iatrogenic N - neoplasm D - drugs I - inflammatory/infections/autoimmune C - congenital A - anatomical T - trauma E - environmental/endocrine
What are the your top 5 differentials for cervical lymphadenopathy? (URTI/BI/M/L/TL)
- upper respiratory tract infection
- bacterial infection (upper extremity)
- metastasis
- lymphoma
- tuberculosis lymphadenitis (scrofula)
What are your top 5 differentials for neck masses in the cervical region? (RL/SA/P/CBT/M)
- reactive lymphadenopathy
- skin abscess
- parotitis
- carotid body tumor
- metastatic thyroid carcinoma
Basic treatment for reactive lymphadenitis
10 days of antibiotics then check-up
- do biopsy of LN if swelling, pain, or enlargement persists or worsens
What is a HIDA scan used for?
- assesses gallbladder function
- radionucleotide injected that collects in the liver within 5 minutes and moves into gallbladder, given with CCK activate gallbladder to eject bile (reproduce symptoms of GB attack)
- failure to see gallbladder is (+) for obstruction of cystic duct and or biliary dyskinesia
What does Dyspepsia mean?
Indigestion
- RUQ that can be colicky as stone/sludge moves through common duct (or becomes lodged)
- radiates to right lower ribs/back and can have (+) Murphy Sign
- use transabdominal US to visualize
What is the best way to visualize acute pancreatitis?
How is acute pancreatitis treated?
CT is normally obtained but MRI w/contrast is MORE sensitive
Tx: NPO, pain meds, FLUID RESUSCITATION, correct underlying disease (alcohol, hyperlipidemia, medications
What are the locations of Anterior Chapmans Points for:
- Esophagus
- Stomach
- Liver
- Pancreas
- Small Intestines
- between ribs 2-3 parasternally
- LEFT SIDE between ribs 5-6 and 6-7 at costochondral junction
- RIGHT SIDE between ribs 5-6 and 6-7 at costochondral junction
- RIGHT SIDE between ribs 6-7 at costochondral junction
- between ribs 9-11 bilateral at costochondral junction
What are the locations of the Posterior Chapmans Points for:
- Esophagus
- Stomach
- Liver
- Pancreas
- Small Intestines
- Gallbladder
- between Spinous and Transverse process of T2
- between Spinous and Transverse process of T5 and T6 on LEFT
- between Spinous and Transverse process of T5 and T6 on RIGHT
- between Spinous and Transverse process of T7 on RIGHT
- Transverse processes of T8-T10
- between Spinous and Transverse process of T6 on RIGHT
What are Diverticulosis and Diverticulitis?
Diverticulosis:
- low fiber/high fat diet slows transit
- inc. pressure causes pseudodiverticuli
- typically seen in SIGMOID COLON
Diverticulitis:
- inflammation of diverticuli = microperforation
- can rupture and develop in abscess
What is the Popliteal Fascia Release?
- pt. supine with leg relaxed
- fingertips just superior to popliteal fossa, grasping tissue with fingers, providing anterior/inferolateral force
- maintain balanced tension at areas of resistance until release
What are the 5 models of Osteopathic Medicine?
Biomechanical, Respiratory-Circulatory, Metabolic, Neurologic, Behavioral
What does the severity of palpated tissue texture abnormality relate to?
- relates to severity of visceral problem
What is Phrenic Pain and where does it refer to?
- due to stimulation of hemidiaphragm or liver capsule
- refers to ipsilateral shoulder
- consider with Neurologic Model of Osteopathic Medicine
What is Viscerosomatic Pain?
- referred pain from visceral disturbances that can cause activation of somatic muscle activity
- results in somatic changes paraspinally that reflexes to the side of the spine that the organ is on
What are the two Sympathetic and Parasympathetic components of the GI Autonomic Nervous System?
Sympathetic:
- Thoracic Splanchnic N: Celiac/Superior Mesenteric
- Lumbar Splanchnic N: Inferior Mesenteric Ganglion
Parasympathetic:
- Vagus N. (CN X)
- Pelvic Splanchnic N. (S2-S4)
What are the vertebral levels of:
- Celiac Ganglion
- Superior Mesenteric Ganglion
- Inferior Mesenteric Ganglion
What do they supply?
- T5-T9
- supplies distal esophagus, stomach, prox. duodenum
- liver, gallbladder, spleen, part of pancreas
- T10-T11
- supplies distal duodenum, part of pancreas
- jejunum, ascending colon, proximal 2/3 of transverse colon
- T12-L2
- supplies distal 1/3 of transverse colon, descending colon, sigmoid colon, and rectum
What do the Vagus N. and Pelvic Splanchnic N. innervate along the GI tract?
Vagus N:
- RIGHT: lesser curvature, liver/GB, SB, right colon
- goes to mid-transverse colon
- LEFT: greater curvature, ends at duodenum
Pelvic Splanchnic N:
- descending colon, sigmoid colon, rectum
What do the Celiac (4), Superior Mesenteric (4), and Inferior Mesenteric (3) LNs drain?
C: stomach, duodenum, spleen, liver
S: jejunum, ileum, ascending and transverse colon
I: descending and sigmoid colon, rectum
Where do the GI LNs drain into?
- drain into Cisterna Chyli (L1-L2) just right of the abdominal aorta
- then drain to thoracic duct –> left subclavian vein
Metabolic Energetic Model
What GI issues do Hyper/Hypothyroidism lead to?
What GI issues does electrolyte imbalance cause?
What Acid-Bases imbalances due GI issues cause?
Hyperthyroidism = DIARRHEA Hypothyroidism = CONSTIPATION
Hypercalcemia/hypokalemia = CONSTIPATION Hyperkalemia = DIARRHEA
Diarrhea –> metabolic acidosis (loss of Na bicarbonate)
Vomiting –> metabolic alkalosis w/hypokalemia
- loss of HCl
