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PCM III > PCM III Midterm Exam Material > Flashcards

PCM III Midterm Exam Material Flashcards

1
Q

What is the proper sequence of Abdominal examination?

A

Inspection, Auscultation, Percussion, Palpation

IAPP

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2
Q

What is Cullen Sign and Grey Turner Sign?

A

CS: ecchymosis around umbilicus due to intraabdominal or retroperitoneal hemorrhage

GTS: flank ecchymosis from blood tracking subcutaneously from retroperitoneal/intraperitoneal source

pancreatitis

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3
Q

What are Striae and Caput Medusa?

A

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

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4
Q

What is the difference between Normal, Abnormal, and Decreased/Absent bowel sounds?

A

N: 5-34 clicks per minute

A: high-pitched; due to OBSTRUCTION

D: absent; due to ILEUS

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5
Q

What is the difference between Tympany and Dullness on percussion of the abdomen?

A

T: found in majority of abdomen; AIR-FILLED VISCERA

D: flat sound w/o echoes over ORGANS; liver/spleen/feces/FLUID

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6
Q

Visceral Pain vs Parietal Pain

A

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
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7
Q

What are :

McBurney's Point
Rovsing's Sign
Iliopsoas Muscle Test
Obturator Muscle Test
Heel Strike (Markle's Sign)
A

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

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8
Q

What are:

Murphy’s Sign
Courvoiser’s Sign
Lloyd’s Punch (CVA)

A

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

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9
Q

Ascites

Shifting Dullness vs Fluid Wave

A

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

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10
Q

What is Colicky Pain?

A
  • pain that waxes and wanes in intensity

- pt. shifts frequently because they cannot find comfortable position

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11
Q

What is Acne Vulgaris?

What is the difference between Open and Closed Comedones?

A
  • 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

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12
Q

What is Atopic Dermatitis (eczema)?

What is important in making the diagnosis?

A
  • 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
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13
Q

What is Seborrheic Dermatitis?

A
  • dandruff to fulminant rash w/dryness, pruritus, fine and greasy scaling lesions
  • on scalp eyebrows, nasolabial folds, ears, eyelids
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14
Q

What is Seborrheic Keratosis?

A
  • “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
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15
Q

What is a Dermatofibroma?

What is the Fitzpatrick Sign?

A
  • firm, smooth papule/nodule usually on legs; round-ovoid with well-defined borders
  • squeezing margins = ‘dimple’ or ‘Fitzpatrick Sign’ = lesion will dimple
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16
Q

What is Rosacea?

What is a classic physical exam finding of this condition?

A
  • 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)
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17
Q

What is a Sebaceous Cyst (Epidermoid Cyst)?

A
  • 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)
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18
Q

What is a Nevus (mole)?

A
  • 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)
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19
Q

What is Eruptive Xanthoma?

A
  • 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
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20
Q

Dermatomyositis

What are 4 physical exam findings associated with this condition? (HR/ADP/NT/SS)

A

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

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21
Q

What is Dermatomyositis?

A
  • 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
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22
Q

What is Actinic Keratosis (Solar Keratosis)?

A
  • 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
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23
Q

What is Solar Lentigo?

A
  • “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
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24
Q

What is Basal Cell Carcinoma?

A
  • 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
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25
Q

What is the difference between Infiltrating and Superficial Basal Cell Carcinoma?

A

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

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26
Q

What is a Melanoma?

What are the ABCDE’s of melanoma and what does ‘ugly-duckling lesion” mean?

A
  • 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
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27
Q

What is Cutaneous Squamous Cell Carcinoma?

What condition puts a patient at higher risk of developing this condition?

A
  • 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
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28
Q

What testing should be done for Chronic Gastritis?

A
  • 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

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29
Q

What combination therapy would be used to treat H. pylori-induced Chronic Gastritis?

A

PPI + Clarithromycin + amoxicillin

  • clarithromycin resistance –> add bismuth for quadruple therapy
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30
Q

How is GERD pain described?

What test should be performed for this condition?

A
  • 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

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31
Q

What is the difference between Duodenal and Gastric Ulcers?

A
  • 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)

32
Q

What are 3 common lithogenic medications? (E/C/T)

A

estrogen, clofibrate, thiazides

33
Q

Who is most likely to develop gallstones and what are 3 risk factors for development?

A
  • more common in middle-aged, obese women

Risk factors: obesity, caloric excess, and rapid weight-loss due to starvation, fasting, or gastric bypass

34
Q

How do Transabdominal Ultrasound, Sonographic Murphy’s Sign, and HIDA Scans help diagnose Biliary Disease?

A

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

35
Q

How are Ulcerative Colitis and Crohn Disease affected by appendectomy and smoking?

A

UC: appendectomy is protective, smoking may prevent disease

CD: appendectomy is NOT protective, smoking may CAUSE disease

36
Q

What are the ANTERIOR Chapman’s Points for:

  1. Esophagus/bronchus/thyroid/myocardium
  2. Upper Lung
  3. Lower Lung
  4. Stomach (acidity) and Liver
  5. Stomach (peristalsis), Liver, and Gallbladder
  6. Spleen and Pancreas
A
  1. 2nd intercostal space
  2. 3rd intercostal space
  3. 4th intercostal space
  4. 5th intercostal space (S - left, L - right)
  5. 6th intercostal space (S- left, L/G - right)
  6. 7th intercostal space (S - liver, P - right)
37
Q

What are the POSTERIOR Chapman’s Points for:

  1. Esophagus/bronchus/thyroid
  2. Upper Lung/myocardium
  3. Upper Limb
  4. Lower Lung
  5. Stomach (acidity) and Liver
  6. Stomach (peristalsis), Liver, and Gallbladder
  7. Spleen and Pancreas
  8. Large Intestine
A
  1. T2
  2. upper T3
  3. between T3-T4
  4. T4
  5. T5 (S - left, L - right)
  6. T6 (S - left, L/G - right)
  7. T7 (S - left, P - right)
  8. L2-4
38
Q

What is Molluscum Contagiosum?

A
  • 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
39
Q

What is Erythema Multiforme?

What are 3 common associations it is seen with? (H/A/E)

A
  • 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)
40
Q

What is the difference between Erythema Multiforme Minor and Major?

A

Minor: acral distribution, usually symmetrical, minimal mucosal involvement

Major: progressing involvement, more centripetal and multiple mucus membranes involved

41
Q

What is Subungal Acral Lentiginous Melanoma?

A

NAIL CANCER –> most deadly form of melanoma

  • higher incidence in people of color, found under the nails of fingers/toes
42
Q

How does Diascopy differentiate erythema from telangectasia?

A
  • 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)
43
Q

What is Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis?

A
  • 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

44
Q

What are the two types of Clinical Reasoning?

A

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
45
Q

What is Problem Representation and Diagnostic Justification?

A

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
46
Q

What is Diagnostic Justification used for?

A
  • 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
47
Q

Probability of Disease

What is the difference between Sensitivity and Specificity?

A

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)
48
Q

Probability of Disease

How do you calculate N1 and N2?

A

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

49
Q

Probability of Disease

How do you calculate Sensitivity and Specificity using N1/N2?

A

Sensitivity = A/N1
* N1 = A + C

Specificity = D/N2
* N2 = B + D

50
Q

Probability of Disease

How is Likelihood Ratio calculated?

A

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

51
Q

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

A

Decreasing LR:

  • 0.5 = -15%
  • 0.2 = -30%
  • 0.1 = -45%

Increasing LR:

  • 2 = +15%
  • 5 = +30%
  • 10 = +45%
52
Q

What is an Illness Script?

A

an organized mental summary of a provider’s knowledge of a disease

  • mental cue cards to represent individual diseases
53
Q

Tension Headache vs Migraine Headache

Age, presentation, associated symptoms

A

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
54
Q

What is the prodrome of Migraine Headaches?

A

irritability, food cravings, yawning up to 48 hrs before onset

55
Q

Streptococcus Pharyngitis Illness Script

A
  • 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
56
Q

Viral Pharyngitis Illness Script

A
  • 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
57
Q

What is the VINDICATE mneumonic?

A 
V - vascular
I - iatrogenic
N - neoplasm
D - drugs
I - inflammatory/infections/autoimmune
C - congenital
A - anatomical
T - trauma
E - environmental/endocrine
58
Q

What are the your top 5 differentials for cervical lymphadenopathy? (URTI/BI/M/L/TL)

A
  • upper respiratory tract infection
  • bacterial infection (upper extremity)
  • metastasis
  • lymphoma
  • tuberculosis lymphadenitis (scrofula)
59
Q

What are your top 5 differentials for neck masses in the cervical region? (RL/SA/P/CBT/M)

A
  • reactive lymphadenopathy
  • skin abscess
  • parotitis
  • carotid body tumor
  • metastatic thyroid carcinoma
60
Q

Basic treatment for reactive lymphadenitis

A

10 days of antibiotics then check-up

  • do biopsy of LN if swelling, pain, or enlargement persists or worsens
61
Q

What is a HIDA scan used for?

A
  • 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
62
Q

What does Dyspepsia mean?

A

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
63
Q

What is the best way to visualize acute pancreatitis?

How is acute pancreatitis treated?

A

CT is normally obtained but MRI w/contrast is MORE sensitive

Tx: NPO, pain meds, FLUID RESUSCITATION, correct underlying disease (alcohol, hyperlipidemia, medications

64
Q

What are the locations of Anterior Chapmans Points for:

  1. Esophagus
  2. Stomach
  3. Liver
  4. Pancreas
  5. Small Intestines
A
  1. between ribs 2-3 parasternally
  2. LEFT SIDE between ribs 5-6 and 6-7 at costochondral junction
  3. RIGHT SIDE between ribs 5-6 and 6-7 at costochondral junction
  4. RIGHT SIDE between ribs 6-7 at costochondral junction
  5. between ribs 9-11 bilateral at costochondral junction
65
Q

What are the locations of the Posterior Chapmans Points for:

  1. Esophagus
  2. Stomach
  3. Liver
  4. Pancreas
  5. Small Intestines
  6. Gallbladder
A
  1. between Spinous and Transverse process of T2
  2. between Spinous and Transverse process of T5 and T6 on LEFT
  3. between Spinous and Transverse process of T5 and T6 on RIGHT
  4. between Spinous and Transverse process of T7 on RIGHT
  5. Transverse processes of T8-T10
  6. between Spinous and Transverse process of T6 on RIGHT
66
Q

What are Diverticulosis and Diverticulitis?

A

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
67
Q

What is the Popliteal Fascia Release?

A
  • 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
68
Q

What are the 5 models of Osteopathic Medicine?

A

Biomechanical, Respiratory-Circulatory, Metabolic, Neurologic, Behavioral

69
Q

What does the severity of palpated tissue texture abnormality relate to?

A
  • relates to severity of visceral problem
70
Q

What is Phrenic Pain and where does it refer to?

A
  • due to stimulation of hemidiaphragm or liver capsule
  • refers to ipsilateral shoulder
  • consider with Neurologic Model of Osteopathic Medicine
71
Q

What is Viscerosomatic Pain?

A
  • 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
72
Q

What are the two Sympathetic and Parasympathetic components of the GI Autonomic Nervous System?

A

Sympathetic:

  • Thoracic Splanchnic N: Celiac/Superior Mesenteric
  • Lumbar Splanchnic N: Inferior Mesenteric Ganglion

Parasympathetic:

  • Vagus N. (CN X)
  • Pelvic Splanchnic N. (S2-S4)
73
Q

What are the vertebral levels of:

  1. Celiac Ganglion
  2. Superior Mesenteric Ganglion
  3. Inferior Mesenteric Ganglion

What do they supply?

A
  1. T5-T9
    • supplies distal esophagus, stomach, prox. duodenum
    • liver, gallbladder, spleen, part of pancreas
  2. T10-T11
    • supplies distal duodenum, part of pancreas
    • jejunum, ascending colon, proximal 2/3 of transverse colon
  3. T12-L2
    • supplies distal 1/3 of transverse colon, descending colon, sigmoid colon, and rectum
74
Q

What do the Vagus N. and Pelvic Splanchnic N. innervate along the GI tract?

A

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

75
Q

What do the Celiac (4), Superior Mesenteric (4), and Inferior Mesenteric (3) LNs drain?

A

C: stomach, duodenum, spleen, liver

S: jejunum, ileum, ascending and transverse colon

I: descending and sigmoid colon, rectum

76
Q

Where do the GI LNs drain into?

A
  • drain into Cisterna Chyli (L1-L2) just right of the abdominal aorta
  • then drain to thoracic duct –> left subclavian vein
77
Q

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?

A 
Hyperthyroidism = DIARRHEA
Hypothyroidism = CONSTIPATION
Hypercalcemia/hypokalemia = CONSTIPATION
Hyperkalemia = DIARRHEA

Diarrhea –> metabolic acidosis (loss of Na bicarbonate)
Vomiting –> metabolic alkalosis w/hypokalemia
- loss of HCl

PCM III (2 decks)

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