test 2 Flashcards
cough less than 3 weeks
acute
cough 3-8 weeks
subacute
cough greater than 8 weeks
chronic
if a toddler has a cough - what’s on your differential
FB aspiration
pneumonia
vaccinated? pertussis?
URI
geriatric with cough
Pulmonary embolism
COPD
from medication? ACE
aspiration
cough with seasonal allergies
allergic disease with increased pollen count
cough with asthma
from bronchospasm
wheezing or lack of air movement, hypoxia, hypercapnia, acidosis
Asthma
flushing, pruritis, anxiety, faintness, sneezing, vomiting
anaphylaxis
difficulty breathing after a trauma
think pneumo
tall, lanky adolescence with acute SOB
spontaneous pneumo
risk factors for pulmonary embolism
age older than 60yr Pulmonary HTN CHF chronic lung disease ischemic heart disease stroke cancer surgery fracture family history of clotting disorders
SOB that worsens with increasing activity and improves by rest
pulmonary or cardiac
risk factors for pulmonary embolism
age older than 60yr Pulmonary HTN CHF chronic lung disease ischemic heart disease stroke cancer surgery fracture family history of clotting disorders Exogenous estrogen malignancy within 6 mos history of DVT/PE
not ever vaccinated with shortness off breath - what needs to be ruled out
poliomyelitis
tetanus
what do you think in a child younger than 1 who has new onset resp distress with vomiting and diarrhea. started eating honey this morning
Clostridium botulinum source of contamination by honey cause resp distress
incubation is only a few hours. symptoms include cranial nerve involvement, diplopia, weak suck, facial weakness and absent gag. hypotonia and weakness => resp failure
not ever vaccinated with shortness off breath - what needs to be ruled out
poliomyelitis tetanus pertussis influenza covid
what do you think in a child younger than 1 who has new onset resp distress with vomiting and diarrhea. started eating and trying new foods
Honey - botulism
Clostridium botulinum source of contamination by honey cause resp distress
incubation is only a few hours. symptoms include cranial nerve involvement, diplopia, weak suck, facial weakness and absent gag. hypotonia and weakness => resp failure
Asymmetrical chest movement
lobar pneumonia
pleural effusions
involvement of the supraglottic area, proximal to vocal cords, muffled voice
tonsillitis
epiglottitis
normal voice with stridor
subglottic
tracheal lesion
common anomalies that predispose infants to upper airway obstruction
infants younger than 6 mos
anomalous vascular rings
laryngeal webs
laryngomalacia
tracheomalacia
tracheal shift
pneumothorax
JVD
heart failure
pallor of sclera or nail beds
severe anemia
clubbing
chronic hypoxia
rapid new onset clubbing
infective endocarditis
edema of lower extremeties
think increased r heart filling -> primary lung disease or Left ventricular failure
in young infants edema appears as
hepatomegaly and periorbital or flank edema
crepitus
chest injury
pneumothorax
cutaneous emphysema
tactile fremitus is diminished in
pneumothorax
asthma
emphysema
other conditions that trap air in the lung
can cause a spontaneous pneumo from rupture of subpleural blebs located at the apex of the upper lobe or in the superior seg of the lower lobe
cystic fibrosis
most common cause of persistent stridor in infancy
bronchomalacia
brassy cough and difficulty swallowing in infants with inspiratory stridor and expiratory wheeze
vascular ring
cough that is paroxysmal and young child or infant not vaccinated
pertussis “whooping cough”
Persistent nocturnal paroxysmal coughing
asthma
coughing at night usually between midnight and 2 am
Asthma hallmark
caused by the low level of cortisol (glucocorticoid) in the body at that time
a severe cough in the early morning indicates
postnasal drip, CF or bronchiectasis
Cough that is worse at night
croup
postnasal drip
lower resp tract infection
allergic reaction
a cough that disappears with sleep
habit cough
dry brassy cough indicates
pharyngeal or tracheal irritation, allergy or habit
paroxysmal cough
asthma
pertussis
CF
foreign body aspiration
sudden short burst of cough in infants (Staccato cough)
C. trachomatis
a harsh dry cough caused by airway compression from enlarged nodes in the perihilar or paratracheal regions seem to occur with
TB
fungal infection
sudden short burst of cough in infants (Staccato cough)
C. trachomatis (chlamydial pneumonia)
causes cough through direct sim of cough receptors by gastric acid
GERD
cobblestone appearance of the posterior pharynx
caused by lymphoid hyperplasia secondary to chronic stimulation of postnasal drip
Barrel chest
AP diameter is 1/3 -1/2 of Lateral diameter
COPD
also children with chronic cough secondary to CF or severe asthma
diagnostic for CF
sweat test
eosinophilia
bronchial asthma
allergic rhinitis
atopic dermatitis
greenish or rusty colored sputum
Bacterial pnemonia
most common cause of infection in the lower resp tract in children and young adults
mycoplasma pneumoniae
infant (3-11 wks)with fine rales, no wheezing. chest x ray shows hyperinflated lungs with diffuse interstitial or alveolar infiltrates
chlamydial pneumonia (C. Trachomatis)
child younger than 2 fever rhinorrhea cough wheezing tachypnea tachycardia resp distress nasal flaring
x ray shows hyperinflation with mild interstitial infiltrates
bronchiolitis (RSV)
steeple sign
croup
high risk for gerd
cigarette smokers
overweight
overuse alcohol
when does it become chronic bronchitis
at least 3 consecutive months
for more than 2 years
rasping, hacking cough resonant to dull chest possible barrel chest prolonged expiration possible wheezes
chronic bronchitis
weight loss
hemoptysis
SOB
bronchogenic carcinoma
FTT
productive cough
poor weight gain
initially dry and hacking then goes to loose and produces purulent material
scattered or localized coarse rales and rhonchi audible
CF
allergic shiners
allergic salute
eczema
rhinorrhea with clear watery drainage
allergic rhinitis
chronic cough worse at night
persistent coldlike symptoms
noisy breathing or snoring at night
chronic sinusitis
Brassy cough is the most common symptom
TB
chronic cough worse at night
persistent cold like symptoms
noisy breathing or snoring at night
chronic sinusitis
child or adult with dry cough, headache malaise, sore throat, fever, rales and rhonchi
Mycoplasma pneumoniae
dry cough
sore throat
frequent throat clearing
mucoid secretions posterior pharynx with cobblestone appearance, sinuses tender
UACS (upper airway cough syndrome)
mimics croup, high fever, copious amounts of purulent sputum
follows infection of S. Aureus or H Influenzae
bacterial tracheitis
Risk factors ACS
older than 65 >=3 risk factors CAD -hypercholesterolemia -htn -DM -smoker -family history -obesity
CAD
Family history of sudden death
Cocaine/tox use
Symptoms of ACS
Chest pain pain that radiates to shoulder, arm, neck, jaw and to epigastrium N/V Diaphoresis ischemic pain
Clinical signs ACS
Hypotension
pain >60 min
Acute decompensated HF signs
ischemic changes on ECG
Tearing or ripping pain
sudden onset
pain radiates to back
HTN
thoracic aortic dissection
what is stable angina
anginal symptoms present for at least 3 months
does not occur at rest
where are the locations for typical anginal pain
substernal chest
jaw
shoulder
arms
exacerbating factors for angina
exertion
emotional stress
heavy meal
cold
quality of pain for angina
pressure
tight
heavy
similar to prior angina
timing for angina
lasting 15 seconds to 15 min
relief for angina
rest
sublingual nitro
chest pain after GI procedure or retching
evaluate for esophageal rupture
Chest pain with history of Sickle cell disease
evaluate for acute chest
chest pain with skin tenderness or rash
evaluate for herpes zoster
chest pain with prominent cough and fever
eval for pneumonia
Due to its high sensitivity, a negative d dimer assay is sufficient to r/o a PE in most patients with chest pain
true or false
false
Pleuritic pain relieved by sitting forward
friction rub viral prodrome abrupt onset sinus tachycardia low grade fever
Pericarditis
what does EKG look like for Acute pericarditis vs MI
Diffuse ST elevation
PR depression
MI localized ST elevation T wave inversion Q waves hyper-acute T waves No PR depression
Chest pain mild dyspnea anywhere from fatigue to cardiogenic shock Orthopnea edema JVD Viral prodrome is common ischemic pattern on ECG
Myocarditis
burning epigastric or substernal pain
usually in relation to sleep, eating or when laying supine
acid taste
chronic cough
GERD
Gastritis
PUD
risk factors for acute aortic syndrome
aortic disease bicuspid aortic valve inherited connective tissue dz -Marfan syndrome - Ehlers Danlos Vasculitis Family hx of aortic disease or sudden death
Pulse deficit
SBP differential >20mmHg
HTN DBP >100mgHg
focal neurologic deficit
Acute aortic syndrome
what do you use diaphragm
higher frequency sounds
S1, S2
when do you use bell
lower frequency
S3, S4
Murmurs grade I-III
Atrioventricular valves include
Tricuspid and Mitral
acute hoarseness
less than 2 weeks
Hoarseness > 2 weeks
refer out to an ENT for possible to r/o neoplasm
what cranial nerve is involved in hoarseness and voice change
CN X - vagus nerve
damage to CN X can be
hormone imbalance
bacterial infection
tumor
transgender voice surgery
what upper resp infections can cause vocal cord inflammation
Acute laryngitis
epiglottitis
Acute laryngotracheobronchitis (Croup)
what kind of breathing can lead to morning hoarseness
nasal congestion can lead to mouth breathing
Carnett sign
lifting head up and lifting legs up - if the pain worsens, it is a positive Carnett sign meaning that it is an intra abdominal cause (visceral) of pain
LLQ
colon
ureter
bladder
uterus
diverticulitis
CT with contrast
Bloody diarrhea means one of the diverticula may have ruptured. Go to the ER otherwise it can be managed outpatient
ABX
f/u in a week
Kehrs sign
occurence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity
Kehr sign
pressure on the LUQ eliciting left shoulder pain - due to diaphragmatic irritation by the ruptured spleen and strongly suggests splenic injury. CT would be used to identify and grade the splenic injury
Murphy sign
pain on inspiration when hand placed over gallbladder (cholecystitis)
Rovsings sign
Pain in the RLQ with palpation pressure in the LLQ - positive is a sign of acute appendicitis
(Hepato-Jugular Reflex)
Pt supine with upper body elevated to 30-45 degrees. Have pt turn head to L and to R
Looking at the IJ - Push on RUQ (Hepato-Jugular Reflex) - Elevated CVP - measure from angle of Louis - normal 7-9 cm
where is the apical pulse found in infants and young children younger than 7
fourth intercostal space, left mid clavicular line
where is the apical pulse found in adults and children older than 7
5th intercostal space, left midclavicular line
if the apical pulse is felt lower, what could it mean
could indicate cardiac enlargement
colonoscopy recommendations (no risk factors)
starting at 45, then every 10 years until 75 then physician/health dependent till 85. No colonoscopies after 85
murmur
very soft, heard in quiet room with cooperative pt
Grade I
murmur loud with thrill, audible with stethoscope off of chest 1 cm
Grade VI
Easily heard murmur, not loud
Grade II
Loud murmur with thrill, audible with stethoscope at 45 degree angle
Grade V
Murmur loud with palpable thrill
Grade IV
Murmur loud but n thrill
Grade III
waking up with headaches in mornings for the past 2-3 weeks
neoplasm
headache with bilat tight squeezing
tension headache
recent surgery, anxious and sob
think pulmonary embolism
a thrill felt in the suprasternal notch
Aortic stenosis
pulmonary stenosis
PDA
COA
Thrill ULSB
originates from pulmonary valve or artery
pulmonary stenosis
PA stenosis
PDA (rare)
Thrill URSB
aortic origin
Aortic stenosis
Thrill LLSB
VSD
why would you listen to heart in the axillaries on the back
listening for pulmonary stenosis
new onset fever and diarrhea x 4 days
shigella
fever and diarrhea
Campylobacter
Issues with dizziness and vertigo what CN
VIII (8)
what is S1 and where is it best heard
closure of mitral and tricuspid
Apex or Lower left sternal border
wide splitting can be due to
Ebstein’s anomaly (displaced tricuspid valves down towards the apex)
GERD symptoms
Vomiting Food refusal Feeding aversion Unexplained crying Sleep disturbances Abd pain Choking Coughing Gagging Older children and adolescents Epigastric pain Heartburn Pain in relation to sleep, eating or when lying supine Acid taste Chronic cough
S2 what is it
closure of aortic and pulmonic valves
A2
closure of Aortic
P2
closure of pulmonic
Unstable angina vs. stable angina
Unstable- does not improve with rest/ medication
Last greater than 15 minutes
Chest pain occurs with very little activity
Male vs. female cardiovascular disease
Men generally develop CVD at a younger age and have a higher risk of coronary heart disease than women. Women in contrast, are at a higher risk of stroke, which often occurs at an older age.
cranial nerves 2, 4, 6
2- optic nerve
IV- Trochlear nerve
VI- Abducens nerve
all control eyes
what can cause a wide S2 split
ASD
Pulmonary stenosis
Right Bundle branch block
Mitral regurgitation
What can cause a narrow S2 split
pulmonary HTN
Aortic Stenosis
Patient can’t taste or smell
what cranial nerves
Facial nerve (CN VII)
glossopharyngeal (CN IX)
Vagus nerve (CN X)
Olefactory (CNI)
holosystolic is most commonly heard in
VSD
Midsystolic murmurs
Aortic Stenosis or Pulmonary stenosis
Lat systolic murmurs
mitral valve prolapse
Most common innocent murmur
Stills
worsens with fever, infection, anxiety
ages 3-7
LLSB
What neuro disease causes demyelination in the 3rd and 4th decade of life?
Multiple sclerosis
recent surgery than gets anxious and short of breath
PE
Newborn with systolic murmur
Don’t worry, normal finding
dizzy when stands up
hypovolemic
morning headaches
neoplasm
headache with bilat tight squeezing
Tension headache
CN
1- olefactory II - Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Vestibulocochlear IX Glossopharyngeal X Vagus XI Accessory XII Hypoglossal
self limited means
it goes away on its own
CN can you smell your coffee
I olefactory
what CN controls muscle function and pupil response
Oculomotor III
early diastolic murmur caused by a
incompetent aortic or pulmonary valve
Mid diastolic begins with ____ and is caused by ___- usually from ___
Begins with S3
Caused by turbulence from the mitral or tricuspid valves usually from stenosis
Late diastolic caused by active
atrial contraction into the ventricle
CN responsible for downward, outward and inward eye movements
Trochlear (IV)
When do you refer murmurs
greater than III/VI Loudest at the LUSB Harsh quality Pansystolic (holosystolic) Systolic click Abnormal second heart sound
largest of your cranial nerves
opthalmic - sends sensory info from your upper part of face
maxillary - sensory form middle part of face
mandibular - sensory infor from ears, lower lip, and chin
controls muscles of jaw and ear
CN V
Trigeminal
CN thats associated with eye movement (lateral rectus muscle)
CN VI Abducens
CN for making facial expressions
taste for most of your tongue
salivary glands
tear producing glands
communicating sensations from outer parts of ear
VII facial
CN
think ear
cochlear - detect vibrations from sound based off of the sounds loudness and pitch This generates nerve impulses that are transmitted to cochlear nerve
Vestibular - adjust balance and equilibrium
CN VIII - Vestibulocochlear
CN
sensory from sinuses, back of throat, inner ear and back of your tongue
providing a sense of taste for back part of your tongue
stimulating voluntary movement of a muscle in back of throat called the stylopharyngeus
CN IX glossopharyngeal
CN
sensation from ear canal and parts of throat
sensory from organs in chest and trunk such as heart and intestines
motor control of muscles in throat
stim muscles of organs in chest and trunk (to include food through digestive tract - peristalsis)
sense of taste near root of tongue
CN X Vagus nerve
father died from colon cancer. what do you need to know to find out when to screen pt
what age did his father get diagnosed? Back it up 10 years from that point
CN controls the muscles in your neck
CN XI Accessory
CN responsible for movement of tongue
XII hypoglossal
LLQ
colon
ureter
bladder
uterus
Pain worse after meals and when laying down, better when stand
GERD
what sign
push on the left side of the abdomen and the Right side sings
RoVsings
appendicitis
Psoas sign
lift one leg, you apply resistance
appendicitis
flex right thigh
rotate knee inward
you do it for them (passive)
obturator
Appendicitis
Markels sign
stand up on the tippy toes and drop down
pain and it hurts
or hit heel of foot
appendicitis
pain = positive
murphys sign
acute cholecystitis - asking pt to take a deep breath while palpating the r subcostal area - pain with inspiration - positive
tests for H pylori
Breath in a bag
cant be on PPI for 2 weeks. send to the lab
serum
stool antigen
direct biopsy (if already in)
Mallory weiss tear caused from
from retching too hard
main symptom for pancreatitis
severe pain mid epigastric
what are you doing for pancreatitis
NPO complete bowel rest
watch for a pseudocyst
what kind of meds (for what problem) causes pancreatitis
diabetic meds
what signs are specific for pancreatitis and where is it
Grey turners on the flank (bruising)
Cullens - bruising on the (C around umbilicus)
what sign?
extend arms, flex hands at wrists, close eyes. push lightly back and watch them flap their hands
Asterixis sign
“liver flap”
liver disease
McBurney’s point
appendicitis
skin issue on liver disease
Spider nevi
Fluid in abdomen
aceites
Murphys sign
instruct pt to let out all breath, you will push in under your R rib area then pt inflate lungs with full breath
if pt sucks back in with pain its a positive murphys sign
gallbladder
what 2 big chronic issues have bloody diarrhea
Ulcerative colitis (only cure is to take out colon) Crohns - colon resections - no cure
only definitive is biopsy to determine which it is
gluten intolerance
celiac disease
biopsy confirms
mesenteric vessels problems
DVT of mesenteric veins
Arterial stenosis
drugs that can call bowel ischemia
vasopressin
double vision associated with what CN
VI -
headache thunderclap or with exertion or sex
Subarachnoid hemorrhage
headache that wakes them from sleep
think increased intracranial pressure
which cranial nerve is sweet vs salty
CN VII
headache unilateral throbbing nausea photophobia exacerbation with activity
migraine without aura
what criteria is for migraine
POUND criteria pulsatile last between 4-72 hours without meds unilateral nausea debilitating 4/5 migraine diagnosis
what headache is not disabling
tension
photophobic paresthesia numbness weakness nausea vomiting
migraine with aura
headache not emergency
migraine
tension
cluster
headache
throbbing constant pain during waking hours with symptoms of tightness, pressure and muscle contraction
mixed headache
occurs with movement of head/rolling/turning
vertigo
falling over, lack of balance
Disequilibrium:
