Written Final Flashcards
(208 cards)
1
Q
What does elevated respiratory rate mean?
A
may indicate respiratory distress secondary to states causing hypoxia such as pneumonia or decompensated heart failure. It may also be seen in cases of metabolic acidosis (e.g. sepsis or ketoacidosis) with at attempt at respiratory compensation (blowing off CO2). You may also sometimes see elevated respiratory rates in patients in pain or patients who are having anxiety, stress, or a panic attack.
2
Q
What does decreased respiratory rate mean?
A
Depressed respiratory rates can be a secondary to overdose (e.g. narcotics or benzodiazepines). In patients that present with a primary respiratory condition (COPD or asthma exacerbation or pneumonia) who initially have a high respiratory rate that then slows down, it is possible that the condition is improving. However, it is also possible that the condition is worsening, with the patient physically tiring and unable to keep up with the needed work of breathing or with the patient retaining CO2 (becoming hypercapnic) and edging towards respiratory failure and a need for mechanical ventilation.
3
Q
How is orthostatic hypotension diagnosed?
A
Drop of more than 20 systolic and/or drop of more than 10 diastolic
4
Q
What are common causes of orthostatic hypotension?
A
Orthostatic hypotension can occur in settings of volume depletion (blood loss, dehydration from decreased fluid intake or excessive losses), autonomic failure (neuropathies or neurodegenerative disorder), medication side effect, or changes to vascular tone seen in aging (decrease in baroreceptor sensitivity).
5
Q
How well does oral temperature measure?
A
Temperatures may be underestimated if checked orally in patients who are breathing rapidly
6
Q
How well does taking the temperature in the ear measure?
A
Temperatures may be underestimated if patient has earwax (cerumen)
7
Q
How well does taking the temperature rectally measure?
A
Best measurement of core temperature
8
Q
What is the normal range for pulse ox?
A
95-100%
9
Q
What is giant cell arteritis? How does it present?
A
Giant cell arteritis is an inflammatory condition of medium and large vessels. It can present in many ways including unilateral (or sometimes bilateral) temporal headaches, jaw claudication, vision loss, or arm claudication and can also be associated with weight loss and malaise. If it affects the temporal arteries it is often referred to as temporal arteritis and the patient is found to have prominent arteries on inspection with tenderness of the artery on palpation. This condition occurs more commonly in the elderly.
10
Q
What does diminished light reaction mean?
A
If reaction to light is diminished: it may be an afferent defect from optic nerve disease (ex: multiple sclerosis affecting CN II) or efferent defect (tumor affecting CN III)
11
Q
What does anisocoria mean?
A
Pupils of different size: may be normal in some cases, may secondarycto conditions such as Horner syndrome (disruption of the sympathetic trunk) or CN III lesion.
12
Q
What is bitemporal hemianopsia? What causes it?
A
Loss of peripheral vision, caused by a pituitary adenoma encroaching on the optic chiasm
13
Q
What does not being able to smile, raise eyebrows, puff out cheeks mean?
A
Because of dual-sided innervation, a central CN VII lesion (ex: stroke) will result in sparing of the frontalis muscle (will retain innervation from the other side). However a peripheral CN VII lesion (ex: Bell’s palsy) will also cause frontalis weakness.
14
Q
What does symmetric elevation upon “ah” mean?
A
Symmetric elevation of soft palate suggests intact IX/X function. Deviated uvula can indicate a paratonsillar abscess, or a cranial nerve lesion.
15
Q
What does the gag reflex demonstrate?
A
sensory IX and motor X
16
Q
What are the different cranial nerves?
A
I: Olfactory II: Optic III: Occulomotor IV: Trochlear V: Trigeminal VI: Abducens VII: Facial VIII: Vestibulocochlear IX: Glossopharyngeal X: Vagus XI: Spinal Accessory XIII: Hypoglossal
17
Q
What does tongue deviation away from the midline mean?
A
Tongue deviation away from midline may indicate stroke or peripheral CN XII damage. Central lesions will cause
deviations away from side of the lesion and peripheral lesions will cause deviation to side of the lesion.
18
Q
What does papilladema indicate?
A
Elevated intercranial pressure (may be caused by a variety
of conditions that includes intracranial mass, severely elevated blood pressure (hypertensive emergency), or other causes of cerebral edema)
19
Q
What is otitis externa?
A
Otitis externa (also known as swimmer’s ear) is an infection of the external auditory canal (EAC). Patients will complain of ear pain and often clear or purulent (containing puss) drainage from the ear. Exam will reveal pain with tug of the pinna (the external ear) and pain upon insertion of the otoscopic tip into the EAC. In addition, the EAC may be quite edematous (swollen and inflamed) limiting full visualization of the tympanic membrane or full insertion of the otoscopic tip. Risk factors include swimming, trauma to the ear (scratching/placement of objects in ear) or dermatologic conditions that might compromise the skin barrier (atopic dermatitis or psoriasis). Organisms include pseudomonas aeruginosa and staph epidermidis.
20
Q
What are common causes of conductive hearing loss?
A
cerumen impaction, otitis media, or otosclerosis
21
Q
What are common causes of sensorineural hearing loss?
A
age-related hearing loss (presbycusis), side effects of medications such as aminoglycoside antibiotics
(gentamicin), noise trauma, and Meniere’s disease
22
Q
What are the findings of conductive hearing loss?
A
Rinne: Air equal to or worse than bone conduction
Weber: Lateralizes to the “bad” ear
23
Q
What are the findings of sensorineural hearing loss?
A
Rinne: Air better than bone conduction
Weber: Lateralizes to the “good” ear
24
Q
What is acute otitis media?
A
Acute otitis media is an infection of the middle ear. This condition is more common in pediatric populations but can also occur in adults. The patient will complain of ear pain
and may complain of decreased hearing on the affected side (conductive hearing loss). On exam, the ear tug may not be painful. The tympanic membrane exam will reveal a
bulging eardrum and the structures of the middle ear will be obscured because of an effusion behind the tympanic membrane
25
When are nasal septal ulcerations or perforation seen?
Cocaine use
26
When are nasal polyps seen?
patients with allergic rhinitis and may cause obstructed
| breathing and may predispose chronic sinusitis
27
When is tenderness over sinuses seen?
Tenderness over sinuses may be seen with sinus congestion in both viral rhinosinusitis and bacterial sinusitis
28
What are the Centor Criteria?
Clinical prediction rules called the Centor criteria can help to stratify risk for step infection in adults. Four criteria were associated with a strep infection in adults:
• Tonsillar exudate
• History of or presence of fever
• Lack of cough
• Anterior cervical lymphadenopathy
The positive predictive value (likelihood of having the condition given positive test results) with the Centor criteria is not great (the presence of the features does not reliably rule in the disease). However, the absence of the factors can help you rule it out, especially if you have another likely diagnosis in mind
29
What are reactive lymph nodes?
Those that are draining from a regional infection. For
| instance, pharyngitis can present with reactive cervical lymph nodes. Such nodes are small, soft, mobile and tender
30
What are signs of malignant lymph nodes?
Lymph nodes that are concerning for malignancy are those that are large, hard, fixed to underlying tissues, and non-tender.
31
When is parotid gland enlargement seen?
mumps, sarcoidosis (a granulomatous disease that can affect many organs of unknown etiology), tumors, or in salivary gland stones (sialadenitis) and bacterial infection called suppurative parotitis.
32
When is an enlarged thyroid seen?
An enlarged thyroid can be seen with hypo and hyperthyroidism and with multinodular goiter. Subacute thyroiditis, an inflammatory thyroid condition, may be associated with thyroid pain and tenderness.
33
What does a thyroid bruit indicate?
With a grossly enlarged thyroid, you may also want to listen for thyroid bruits, which may be heard in some cases of hyperthyroidism secondary to Graves’ disease because of the hypervascularity seen in this condition. This bruit, which is a continuous sound that can be heard in systole and diastole, is thought to be quite specific for Graves’.
34
When would you see trachea deviation?
You may see the trachea deviate toward the side of the condition in pneumothorax, atelectasis or lobar collapse and away from the condition if a tumor or pleural effusion
is present
35
When is increased AP diameter seen?
patients with hyperinflated lungs, such as those
| with COPD
36
When is tripoding seen?
Advanced COPD
37
What is lung excursion? What does it mean?
Done when lung pathology is suspected. You are examining whether both sides of the thorax expand symmetrically with inspiration. If the patient has a pneumothorax, atelectasis, lobar pneumonia, lobar collapse, or lung cancer there may be asymmetric chest wall movement, with the affected side moving less than the unaffected side because of reduced air entry or reduced chest wall movement on the affected side.
38
What does hyperresonant lung percussion mean?
The area of the chest affected by a pneumothorax or the lung fields that are diseased with COPD may be hyper-resonant on percussion
39
What does dull lung percussion mean?
Percussion over a pleural effusion (fluid between
the lung and the chest wall) will sound dull. Percussion over a lung tumor or over an area of lung consolidation (pneumonia) may also sound dull.
40
What is a wheeze and what does it mean?
These are continuous high-pitched sounds that are prolonged and musical in nature. In asthma, they are typically end-expiratory in mild distress but in more severe
exacerbations, patients may be found to have both inspiratory and expiratory wheezes. They are classically found in patients with asthma, but can be found in other conditions where there is airway obstruction.
41
What are ronchi and what do they mean?
These are continuous relatively lower pitched rattling sounds that are representative of processes in the larger sized airways in the lungs. In chronic bronchitis, they can sometimes clear with coughing.
42
What are crackles and what do they mean?
These are discontinuous sounds that are associated with alveolar processes. They can be heard in heart failure exacerbations (typically found bilaterally at the “bases”
– or the lower posterior lung fields), in pneumonia over the area affected, and in fibrotic lung diseases (can be diffuse or focal depending on the etiology and region of affected
lung).
43
What is stridor and what does it mean?
This is a sound that represents upper airway obstruction that is heard on inspiration, louder over the neck than over the lungs. It may indicate a partial obstruction of the larynx or trachea. In pediatric patient that is having difficulty breathing,stridor may be concerning for croup (caused by parainfluenza) or other infectious or noninfectious processes. This is an ominous sign and these patients should be evaluated immediately and monitored very closely.
44
What do reduced or absent breath sounds mean?
You may encounter diffusely reduced breath sounds in patients who are very obese, in patients with advanced COPD even when they are not having an exacerbation. In patients with an exacerbation of COPD or asthma, reduced breath sounds (especially if different from baseline) may be an ominous sign that can be described as “poor air movement”. Focal reduction in breath sounds may be heard in patients with large pneumothorax, lobar collapse, atelectasis or pleural effusion over the affected side.
45
What does increased tactile fremitus mean?
In a pulmonary consolidation (pneumonia), there may be increased tactile fremitus.
46
What does reduced tactile fremitus mean?
In pneumothorax and pleural effusion, there will be a decrease transmission of lung sounds in tactile fremitus while percussion will yield a hyperresonance in pneumothorax and dullness in pleural effusion.
47
Where should PMI usually be felt?
The 5th intercostal space in the midclavicular line is the normal position of the point of maximal impact (PMI).
48
What does a carotid bruit mean?
A carotid bruit can be an indication of turbulent blood flow in the carotid artery, or a sign of a increased risk for cerebrovascular disease
49
What is a thrill?
A thrill is a murmur that is strong enough for its vibrations to be felt – this corresponds to murmur grades IV-VI.
50
What is parasternal heave?
Assess for a parasternal heave (“RV heave”) at the left parasternum. Feel with the heel of your hand for a strong impulse with systole. Recall that the anterior surface of
the heart is mainly the RV. Thus, a parasternal or RV heave may be felt in patients with RV hypertrophy (pulmonary disease or pulmonary hypertension).
51
What are the 6 dimensions of a heart murmur?
a. Location (ex: Heard loudest at 2nd right intercostal space)
b. Radiation (ex: Radiates to the carotids)
c. Timing: systole or diastole and when during those phases
d. Shape (ex: Crescendo-decrescendo systolic murmur peaking in mid-systole)
e. Intensity: 1: Very faint, 2: Quiet, 3: Moderately loud, 4: Loud, and associated with a
thrill 5: Very loud and can still hear even when stethoscope is partially off chest wall,
6: Can be heard even when stethoscope is off chest
f. Quality (ex: “harsh”, or “blowing”)
52
What are concerns for small bowel obstruction?
if a patient comes in with severe abdominal pain, distension, absence of bowel sounds, and also has a healed surgical scar, the concern for small bowel obstruction (SBO) is very high. The leading cause for SBO is adhesions, or fibrous intra-abdominal bands that develop post-surgically and which can mechanically restrict bowel function. If there is suspicion for early small bowel obstruction, you might hear an area of highpitched
hyperactive bowel sounds. There might be a paucity or absence of bowel sounds in bowel obstruction or in inflammatory states (ileus = cessation of normal gut motility as a response to a local stress such as infection, trauma or surgery).
53
What are borborygmi?
Extended bowel sounds
54
What is a renal bruit?
Renal artery stenosis, if present, is a possible secondary cause of hypertension. Turbulent flow of blood can be appreciated as a bruit best heard a few cm above the umbilicus and at the lateral edges of the rectus abdominis muscles.
55
What are common causes of peritonitis?
a perforated stomach (ex: ulcer), perforated small or large intestine (ex: ruptured appendix or perforated bowel
from diverticulitis or obstructing cancer), ruptured gall bladder (rupture in setting of cholecystitis) or other causes of peritoneal infection
56
What are the differences between voluntary and involuntary guarding?
Involuntary guarding is a more ominous sign and describes a situation where the patient has a tonically stiff or ‘rigid’ abdomen. Voluntary guarding, though still important, may be less ominous and is found when the patient voluntarily tenses the abdomen as the examiner attempts to palpate a tender region. Thus, if the clinician describes “guarding” it is important that she specifically describes whether the guarding is involuntary or voluntary.
57
When might you find a small liver span?
advanced cirrhosis
58
When might you find a large liver span?
hepatitis, hepatic congestion from right sided heart failure, liver cancer or metastatic disease to the liver
59
When might you find an enlarged spleen?
cirrhosis (and other causes of portal hypertention), infectious mononucleosis, myeloproliferative
disorders, and certain types of lymphoma and leukemia
60
When might you find CVA tenderness?
classic finding in pyelonephritis (ascending infection of the urinary tract) or nephrolithiasis (kidney stones)
61
What does shifting dullness indicate?
ascites - Ascites can be caused by many conditions, including congestive heart failure, hepatic cirrhosis, and gastrointestinal or gynecological malignancy.
62
What is Murphy's Sign? What does it indicate?
A. Place hands in the right upper quadrant and ask the patient to take a deep breath. Palpate deeply in this area during the deep inspiration.
B. A positive sign is found when the patient halts inspiration because of tenderness in the right upper quadrant
Perform this specialized maneuver when you are concerned about cholecystitis (inflammation of the gall bladder, often from a gall stone that is blocking the cystic
duct).
63
What is antalgic gait?
A painful gait is referred to as an antalgic gait, where the phase of the gait is shortened on the injured side to alleviate the pain experienced when bearing weight on that side.
64
What does TMJ pain indicate?
Temporomandibular Joint Dysfunction Syndrome (TMJ), is a pain syndrome localized to this joint, and can be secondary to several causes, including osteoarthriris, stress, jaw malocclusion, jaw clenching, or bruxism (grinding of teeth, often at night).
65
What does pain and crepitus at the acromioclavicular joint indicate?
AC arthritis
66
What does tenderness in the bicipital groove indicate?
tendonitis of the long head of the biceps
67
What are common causes of elbow pain and where do they present?
Two common causes of elbow pain include inflammation occurring at tendonous insertions at the medical and lateral epicondyles. These are both repetitive motion
injuries that can be related to work duties or recreational activities. Lateral epicondylitis (see first two images below), also known as tennis elbow, will present
with tenderness with palpation at that location. Medial epicondylitis, also known as golfer’s elbow, presents with tenderness with palpation of medial epicondyle
68
What does swelling and pain at the olecranon bursa indicate?
Olecranon bursitisis inflammation at the olecranon bursa, which is located posteriorly over the olecranon process of the ulna. The condition presents as a swelling and pain
at the bursa, which may be due to trauma, or more commonly, from repeated minor injury such as chronically resting the elbow on a hard surface. Inflammatory arthritis
or a septic process may also cause such swelling.
69
What is a distal radius fracture?
Colles’ fracture, or distal radius fracture is a commonly encountered injury that occurs when a patient falls on an outstretched hand. It is more likely to be seen in the elderly or those with poor bone health.
70
What does palpation at the anatomical snuff box indicate?
If a patient falls onto an outstretched hand or suffers a blow to the wrist you may also be concerned about a scaphoid fracture. It is the most common carpal bone fracture. A fracture of the scaphoid can result in an
interruption of vascular supply and subsequent avascular necrosis. Tenderness warrants an x-ray
71
What is carpal tunnel syndrome?
Carpal tunnel syndrome – a condition that occurs when the median nerve is compressed in the carpal tunnel – can present with pain at the wrist or pain or parasthesias or numbness along the distribution of the median nerve in the hand. Look for atrophy of the thenar prominence in suspected cases of long-standing and advanced carpal tunnel syndrome.
72
What is a Phalens test?
In a positive Phalens maneuver, parasthesias are experienced after maximally flexing at the wrist and holding for 30-60 seconds
73
What is a Tinel test?
For the Tinel test, percuss over the carpal tunnel at the wrist. A positive test occurs when the patient has pain or paresthesias over the median nerve distribution
74
What is Finkelstein's maneuver?
If a patient with presents with pain at the radial side of the wrist when pinching or movement of the thumb or wrist one condition to consider is de Quervian’ tenosynovitis. This is a condition of inflammation of extensor pollicis brevis or abductor pollicis longus – both muscles which abduct the thumb. It is usually seen in women from 30-50 years of age and presents with pain at the radial side of the wrist when pinching or movement of the thumb or wrist. To perform the maneuver, ask the patient to wrap his/her fingers around the thumb, and passively move thumb in an ulnar direction.
75
What is the Adams forward bend test?
In pediatric populations or in persons with chronic back pain, you may consider the presence of scoliosis. Scoliosis is defined as the excessive lateral curvature along with rotation of the spine. The Adams forward bend
test demonstrates the rotational component of scoliosis. It is performed by observing the patient from the back while he or she bends forward at the waist until the spine becomes parallel to the horizontal plane. The patient's feet should be together, knees straight ahead, and arms hanging free. Asymmetry of the upper thoracic, midthoracic, thoracolumbar, or lumbar region is noted.
76
How does hip OA present?
often presents with inguinal or groin pain that in some cases may radiate to the knee. The patient may also have pain with internal rotation at hip and limited internal rotation to less than 15 deg
77
How does trochanteric bursitis present?
This condition is due to an inflammation of the trochanteric bursa, located between the tendon of the gluteus medius muscle and the greater trochanter where it inserts. In patients with tense gluteus medius muscles and with repeated flexion at the hip, the bursa may become inflamed and result in lateral hip pain and tenderness over the bursa.
78
What is patellofemoral syndrome and how does it present?
PFS represents a host of conditions that may present with anterior knee pain, particularly with the movement of the patella over the femur. This condition, more common in women than men, and typically occurs in young athletes,
results from poor tracking of the patella over the trochlear groove of the femur, resulting in inflammation of the cartilaginous articulation of the patella and the femur.
To perform the patellofemoral compression test, keep the leg in full extension and press down on the patella against the femur. Pain on this maneuver suggests PFS.
79
What is a Thompson test?
This is a test to detect rupture of the Achilles tendon. Place the patient prone with the ankle and feet hanging over the edge of the table. Squeezing the gastrocnemius should result in movement at the foot (plantar-flexion) in a patient with an intact Achilles tendon. Lack of foot movement on the Thompson test suggests a ruptured Achilles tendon. Patients may have a history of sudden plantar or dorsiflexion at the ankle and report a sensation of being hit in the back of the leg. Some may report a snapping sound at time of injury.
80
What is plantar fasciitis and how does it present?
This painful foot condition produces stiffness and pain on plantar surface of the foot and results from inflammation of the plantar fascia. The patient often complains of heel or foot pain often when initiating walking in the morning.
Suspicion for this diagnosis is strengthened when tenderness is elicited when dorsiflexing the toes with one hand and palpating the plantar fascia from heel to
forefoot with the other hand/thumb
81
What does the straight leg raise show?
This is used to test for sciatic nerve root irritation/compression (‘sciatica’ can be caused by disc herniation, osteoarthritis, or spinal stenosis). The patient often complains of pain radiating from the back down the lateral or posterior leg, often to below the knee. The pain can be worse with coughing or valsalva maneuver. With the patient supine, leg straight, and ankle dorsiflexed, lift leg. A positive test occurs when pain radiates down the leg past the knee when leg is lifted 10 to 60 deg
82
What are the Ottawa ankle rules?
When a patient has acute ankle injury and pain. Check for tenderness in 4 areas to determine whether you will need to obtain an ankle film to rule out an ankle fracture: The
posterior aspect of the medical and lateral malleolus, the base of the 5th metatarsal, and over the navicular bone.
83
What are the part of the mental status exam?
```
Appearance
• Level of consciousness
• Speech
• Behavior
• Orientation
• Mood
• Affect
• Thought Process
• Thought Content
• Memory
• Calculations
•Judgment
• Higher cortical functioning and reasoning
```
84
What is a macule?
flat lesion smaller than 1 cm
85
What is a patch?
flat lesion larger than 1 cm
86
What is a papule?
raised and smooth lesion smaller than 1 cm
87
What is a plaque?
raised and smooth lesion larger than 1 cm
88
What is a cyst?
Raise lesion with liquid and/or semisolid material within
89
What is a nodule?
hard lesion that contains solid material within; usually less than 1 cm
90
What is scale?
From the stratum corneum, usually white or grey
91
What is a vesicle?
Fluid filled lesion of less than 1 cm
92
What is a bulla?
Fluid filled lesion of greater than 1 cm
93
What is a pustule?
lesion filled with purulent material
94
What is erythema?
blanchable, or redness disappears with palpation – can be tested with a glass slide as well
95
What is erythroderma?
larger areas of erythema and can be associated with desquamated skin
96
What is telangectasia?
dilation of small superficial blood vessels
97
What is palpable purpura?
non-blanching papules associated with vascular inflammation
98
What is skin atrophy?
thinning of skin – seen in topical steroid use
99
What is a skin ulcer?
circumscribed loss of epidermis and at least part of upper dermis
100
What is an erosion?
loss of epidermal or mucosal epithelium
101
What is an eschar?
Scab or dry crust
102
What does acral mean?
distributed on head, hands, and feet
103
What does intertriginous mean?
in axilla, in perineum, under breasts, under skin folds
104
What is the ABCDE of melanoma?
Presence of these traits raise suspicion of melanoma and prompt referral to dermatology for biopsy:
A: Asymmetry
B: Border irregularity
C: Color variegation (different colors in same area)
D: Diameter 6+mm (tip of pencil eraser)
E: Evolution – size, color, shape are evolving
105
What is clubbing?
Enlargement of the terminal phalanges of the fingers. Can be associated with many diseases including: Interstitial lung disease, lung cancer (especially large cell),
mesothelioma, subacute bacterial endocarditis, Crohn’s disease, and primary biliary cirrhosis
106
What is oncholysis?
separation of the nail plate from the nail bed that appears white on inspection. This finding can be due to many conditions including psoriasis, sarcoidosis, hyperthyroidism, amyloidosis, and trauma.
107
What is nail pitting?
can be due to many conditions including psoriasis, alopecia areata, and sarcoidosis
108
What should be the max difference between blood pressure between arms?
10-15 mmHg
109
What is BOLDCARTS of HPI?
```
B: Before (baseline)
O: onset
L: location
D: duration
C: character
A: aggravating and alleviating
R: radiation
T: timing
S: severity
```
110
What is the formulation?
A couple of sentences summarizing the major findings (history/PE/data): “This is a 74 yo M with a history of known CAD presenting with intermittent chest pain. Physical exam revealed clear lung fields and was otherwise unremarkable. EKG showed new T wave inversions in lateral leads.”
111
What is diascopy?
Differentiate between a blanching erythema and non-blanching purpura by pressing with a glass slide, a procedure called diascopy
112
What is the normal size of adult testicle?
20-30cc in volume
4-5cm long, 3cm wide
Smooth, slightly firm, oval
113
How do you check for cremasteric reflex? What is the nerve that innervates this reflex?
Tickle inner thigh; Genitofemoral nerve (L1-L2)
114
What is balanitis?
Inflammation of the glans and/or foreskin. Can cause redness, irritation, and soreness (caused by irritation, allergy, infection)
115
What is lichen sclerosus?
Patchy, white skin on foreskin of penis
116
What is phimosis?
foreskin cannot be retracted over the glans penis; can affect urination or sexual function
117
What is paraphimosis?
urologic emergency - retracted foreskin of uncircumcised male can't be returned to anatomic position (can result in gangrene or amputation)
118
What is hypospadius?
Birth defect in which the urethra in boys develops somewhere other than the head of the penis (can be anywhere on shaft or where penis and scrotum meet)
119
What is Peyronie's disease?
curved erection caused by connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis
120
What does a penile fracture look like?
Penis can become crooked and purple - like an eggplant
121
What is cryptochidism?
absence of 1 or both testes from the scrotum; Most of the time, a boy’s testicles descend by the time he is 9 months old. Undescended testicles are fairly common in infants who are born early. The problem occurs less often in full-term infants.
122
If a patient is missing 1 or more testes from the scrotum, where might you find it?
found anywhere along the "path of descent" from high in the posterior (retroperitoneal) abdomen, just below the kidney, to the inguinal ring; found in the inguinal canal; ectopic (found to have "wandered" from that path, usually outside the inguinal canal and sometimes even under the skin of the thigh, the perineum, the opposite scrotum, or the femoral canal); found to be undeveloped (hypoplastic) or severely abnormal (dysgenetic); found to have vanished (also see anorchia). About two thirds of cases without other abnormalities are unilateral; one third involve both testes. In 90% of cases an undescended testis can be felt in the inguinal canal; in a minority the testis or testes are in the abdomen or nonexistent (truly "hidden").
123
What is a hydrocele?
fluid-filled sac around the testicle that causes swelling in the scrotum
124
What is a spermatocele?
a benign cystic accumulation of sperm that arises from the head of the epididymis. Although often disconcerting to the patient when noticed, these lesions are benign. Spermatoceles can develop in varying locations, ranging from the testicle itself to locations along the course of the vas deferens
125
What is urine extravasation?
the condition where an interruption of the urethra leads to a collection of urine in other cavities, such as the scrotum or the penis
126
What is Fournier's gangrene?
a polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas; Impaired immunity (eg, from diabetes) is important for increasing susceptibility to Fournier gangrene. Trauma to the genitalia is a frequently recognized vector for the introduction of bacteria that initiate the infectious process
127
What is a varicocele?
an abnormal enlargement of the pampiniform venous plexus in the scrotum. This plexus of veins drains the testicles
128
What are the varicocele grades?
Grade I – only visible during Valsalva
Grade II – palpable without Valsalva
Grade III – visible, bag of worms
129
What should be checked for on digital rectal exam?
```
Perianal abnormalities: hemorrhoids, skin lesions, fistula
Anal sphincter tone
Pelvic floor musculature
Rectal contents: masses, stool
Prostate characteristics
Size
Pain
Boggy
Presence of nodules, masses
```
130
What are the characteristics of a normal adult prostate?
```
20cc in volume
3cm long x 4cm wide
Heart shaped
Midline sulcus (right and left lobes)
Smooth, slightly rubbery.
```
131
How big can the prostate get in benign prostate enlargement? At what ages does it typically occur?
Age 20 to 55 years: 20-30 ml volume (normal)
| Age over 55 years: Increased growth (>40 ml volume is considered large)
132
What are the pap testing guidelines?
First pelvic exam and pap test at age 21
Yearly well woman pelvic exams between 21 and 65
Pap tests every 3 years if no history of abnormal paps, or every 5 years if combined with HPV
HPV testing every 5 years for women 30 and over
Pap testing can be discontinued after age 65 if history of normal paps
133
What are characteristics of the clitoris?
Glans—what you see
Shaft—contains 2 corpora cavernosa, measures 1-2 inches in length
Crura (legs)—each measures 2 to 4 inches in length
134
Review the path from GU and GYN!
Go do it now!
135
What are the 4 steps of the pelvic exam?
1. inspection and palpation
2. speculum exam
3. bimanual exam
4. rectovaginal exam
136
When might you see a bounding pulse with wide pulse pressure?
hyperthyroidism
137
How does recent cigarette or alcohol use affect blood pressure?
It can increase it
138
How does pregnancy affect BP readings?
in pregnancy, the sounds of turbulent flow may continue to be heard below the actual diastolic pressure, making the diastolic blood pressure more difficult to assess.
139
What is "normal" BP?
NOTE BP GUIDELINES AND LEVELS HAVE NOW BEEN UPDATED ON JNC-8. “NORMAL” BP IS LESS THAN 140/90
140
Where are tongue cancers most commonly present?
lateral aspects of the tongue
141
How might acute cardiac ischemia present in an elderly patient?
Particularly in the elderly hospitalized patient, acute cardiac ischemia or infarction may present as delirium, a general reduction in cognition, with waxing and waning levels of consciousness.
142
What do S1 and S2 mean?
S1 marks the beginning of systole or ventricular contraction, and corresponds to the closure of the mitral and tricuspid valves. S2 signifies the onset of diastole, or ventricular relaxation, and corresponds to aortic and pulmonic valve closure
143
How do the S1 and S2 sounds differ?
S1 is usually louder than S2. S2 is followed by a longer pause than the one heard after S1. Furthermore, S1 is louder than S2, particularly at the apex, and S2 is typically louder than S1 at the base. The base is an area that includes the second left and right intercostal spaces.
144
What is an aortic regurgitation murmur like?
The seated cardiac auscultation is also used to listen to aortic regurgitation murmurs. Ask the patient to exhale, lean forward, and then hold his or her breath. Then, listen at the left sternal border and apex for an aortic regurgitation murmur. This murmur occurs in diastole.
145
What does a carotid bruit signify?
Presence of a bruit can indicate atherosclerotic disease of the carotid artery, a risk factor for anterior circulation stroke.
146
What are some common causes of murmurs?
- Turbulent flow that can be due to a stenotic or regurgitant valve
- Endocarditis or bacterial growth on a heart valve.
- A hyper-dynamic state such as anemia or infection
147
Where is diverticulosis typically found?
The left lower quadrant is the location of the descending, and sigmoid colon, a common site for diverticulosis. Thus, when presented with an elderly patient with pain in the left lower quadrant, the examiner must consider an infection or an irritation of the diverticuli, a condition called diverticulitis.
148
What are the levels of the evidence pyramid?
Systems (top): computerized decision support systems
Summaries: evidence-based textbooks
Synopses of synthesis: evidence-based abstraction journals, DARE, etc
Syntheses: systematic reviews (Cochrane, etc)
Synopses of studies: evidence-based abstraction journals
Studies: original articles published in journals
149
Where can you search for a topic using a "semantic" search engine (aka searches concepts and not words)?
Access Medicine
150
Where is the best place to go for info in a clerkship case?
textbooks
use UptoDate with caution
primary literature only if necessary
151
Which muscles are innervated by C5?
elbow flexors
152
Which muscles are innervated by C6?
wrist extensors
153
Which muscles are innervated by C7?
elbow extensors
154
Which muscles are innervated by C8?
finger flexors
155
What are the grading stages of muscle strength?
0: no muscle movement
1: muscle movement with joint movement
2: moves with gravity eliminated
3: moves against gravity but not resistance
4: moves against gravity and light resistance
5: normal strength
156
Which muscles are innervated by L2?
hip flexors
157
Which muscles are innervated by L3?
knee extensors
158
Which muscles are innervated by L4?
ankle dorsiflexors
159
Which muscles are innervated by L5?
great toe extensors
160
Which muscles are innervated by S1?
plantar flexors
161
What is the best mnemonic for handoffs?
```
SBAR
Situation
Background
Assessment
Recommendation
```
162
What are common causes of shoulder pain?
Rotator cuff tendinopathy
Acromioclavicular joint OA
biceps tendinopathy
cervical radiculopathy
163
How can you test for rotator cuff tendinopathy?
Painful arc
| Hawkins-Kennedy
164
How can you test for acromioclavicular joint OA?
cross arm maneuver
165
How can you test for bicepstendinopathy?
palpation at biceps tendon
| Speed's test
166
How can you test for cervical radiculopathy?
Spurling's
167
Where does true hip pain present?
iliac crest
168
What presents as pain in the outer hip area?
Trochanteric bursitis
169
How do you position yourself for a fundoscopic exam?
45 degrees from the patient
lights down
use the eye to look at the eye, close other eye (r/r/r/r)
170
What happens if you damage CN I?
loss of smell
171
What happens if you damage CN II?
visual loss, loss of pupillary constriction
172
What happens if you damage CN III?
dilated pupil, ptosis, eyes down and out
173
What happens if you damage CN IV?
diplopia
174
What happens if you damage CN V?
sensory loss along CNV, masseter weakness
175
What happens if you damage CN VI?
eye can't move laterally
176
What happens if you damage CN VII?
weakness of facial muscles
177
What happens if you damage CN VIII?
hearing loss
178
What happens if you damage CN IX?
loss of taste
179
What happens if you damage CN X?
sagging of soft palate (uvula points away from side of lesion), hoarse voice
180
What happens if you damage CN XI?
weak shoulder shrug, weak SCM (weak contralateral head turn)
181
What happens if you damage CN XII?
tongue protrudes in direction of lesion
182
What do you see with upper motor neuron damage?
```
increased tone
Babinski
clonus
Hoffman test
hyperreflexia
```
183
What do you see with lower motor neuron damage?
atrophy
hypotonia
hyporeflexia
fasciulations
184
What is a normal respiratory rate in a newborn?
40-60
185
What is a normal HR in a newborn?
120-160
186
Why do you check femoral pulses in a newborn?
Way to detect ductal-dependent coarctation of the aorta
187
What percentage of newborns have major malformations?
6%
188
What percentage of newborns have minor malformations?
14%
189
What does S3 mean?
Heard in early diastole
| Representative of large volume passive ventricular filling in a dilated ventricle
190
What does S4 mean?
Heard in late diastole
| Active atrial contraction against a stiff ventricle
191
What are the 6 grades of a murmur?
I: very faint
II: quiet
III: moderately loud
IV: loud and associated w/ a thrill
V: very loud and can be heard with stethoscope partially off of the chest wall
VI: can be heard even with stethoscope fully off of the chest wall
192
When is aortic stenosis heard?
systole
193
When is mitral regurgitation heard?
systole
194
When is aortic insufficiency heard?
diastole
195
When is mitral stenosis heard?
diastole
196
What is heard best in left lateral decubitus?
mitral stenosis
S3
S4
197
How far above the right atrium is the sternal angle?
5 cm
198
What is the normal JVP level above the sternal angle?
3-4 cm
199
What is the sequence in counting boxes for rate on EKG?
```
300
150
100
75
60
50
```
200
What is atopic dermatitis?
rash that itches
flexural surfaces
often in youth
seen along w/ allergies and asthma
201
What is seborrheic dermatitis?
underlying erythema with light overlying scale
mild pruritus
scalp (dandruff), nasolabial folds, perioral
202
What is psoriasis?
extensor surfaces
salmon-colored base
scale
joint symptoms
203
What is seen on derm in chronic steroid use?
thinning of skin
striae
telangectasia
204
What are symptoms of chronic liver disease?
```
portal hypertension
ascites
spider angiomata
palmar erythema
hyperbilirubinemia
hepatoportal encephalopathy
asterixis
```
205
What is associated with epigastric pain?
PUD
pancreatitis
gastritis
206
What is associated with hypogastric/suprapubic pain?
```
cystitis
prostatitis
uterine fibroids
endometriosis
ectopic pregnancy
PID
ovarian cyst
ovarian torsion
UTI
```
207
What lung findings are seen in CHF?
crackles at base
208
What is the fremitus sign in pleural effusion?
decreased
