Stuff we should know from past PCM sessions

Question 1

Diaphragmatic excursion

Answer 1

• determine the distance betwen the level of dullness on full expiration and the level of dullness on full inspiration by progressive percussion down from resonance to dullness
• normal is 3-5.5 cm

Question 2

Bonchophony

Answer 2

99, spoken words become louder and clearer

Question 3

Egophony

Answer 3

patient says “ee” but it sounds like “A”

-in pts with fever and cough, triples likelihood of pneumonia

Question 4

Whispered pectoriloquy

Answer 4

whispers are heard louder and clearer during auscultation

Question 5

Grey turner sign

Answer 5

flank ecchymosis secondary to hemorrhage

Question 6

Cullen sign

Answer 6

ecchymosis around the umbilicus secondary to hemorrhage

Question 7

Rebound tenderness

Answer 7

pain upon removal of pressure, rather than the application of pressure to the abdomen…. tests for peritoneal inflammation

Question 8

Rosving’s sign

Answer 8

pain in the RLQ during left-sided pressure… referred to as rebound tenderness seen in appendicitis

Question 9

McBurney’s point

Answer 9

rebound tenderness or pain 1/3 of the distance from the ASIS to the umbilicus- may suggest appendicitis/peritoneal irritation

Question 10

Murphy Sign

Answer 10

palpate deeply under right costal margin during inspiration, and observe for pain and or sudden stop in inspiratory effort
-tests for acute cholecystitis or cholelithiasis

Question 11

Courvoisier’s sign

Answer 11

enlarged non-tender gallbladder secondary to pancreatic disease or cancer

Question 12

symp for esophagus

Answer 12

T2-8

Question 13

Symp for stomach

Answer 13

T5-9

Question 14

gallbladder and liver

Answer 14

T6-9

Question 15

small intestine

Answer 15

T9-11

Question 16

Colon

Answer 16

T10-L2

Question 17

Pancreas

Answer 17

T5-11

Question 18

Appendix

Answer 18

T12

Question 19

Parasympathetic for esoph to transverse colon

Answer 19

OA, AA (vagus n.)

Question 20

Parasympathetic to descending colon, sigmoid, rectum

Answer 20

S2-4 (pelvic Splanchnic n.)

Question 21

Iliopsoas muscle test

Answer 21

have patient flex their hip against your rresisitance, incrased abdominal pain is a positive test
-this suggests irritation of the psoas muscle from inflammation of the appendix

Question 22

Obturator muscle test

Answer 22

flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip
-right hypogastric pain is a positive test…. this suggests irritation of the obturator muscle from an inflamed appendix

Question 23

When do you suspect choledocholithiasis on ultrasound?

Answer 23

when the common bile duct is >6mm

• normal in non-elderly, with an intact gallbladder is 3-6 mm
• elderly or post cholecystectomy can get up to 10mm

Question 24

What do you have to consider when giving a biliary patient opioids?

Answer 24

NSAIDs are preferred first

• ALL OPIOIDS INCREASE SPHINCTER OF ODDI PRESSURE, WHICH THE CLINICAL CONCERN IS IT WOULD WORSEN THEUNDERLYING PROBLEM AND MORE PAIN
• There are insufficient data to suggest that morphine should be avoided
• opioids slow the digestive tract as well (possible ileus, constipation?)