Written Final Flashcards
What does elevated respiratory rate mean?
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.
What does decreased respiratory rate mean?
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.
How is orthostatic hypotension diagnosed?
Drop of more than 20 systolic and/or drop of more than 10 diastolic
What are common causes of orthostatic hypotension?
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).
How well does oral temperature measure?
Temperatures may be underestimated if checked orally in patients who are breathing rapidly
How well does taking the temperature in the ear measure?
Temperatures may be underestimated if patient has earwax (cerumen)
How well does taking the temperature rectally measure?
Best measurement of core temperature
What is the normal range for pulse ox?
95-100%
What is giant cell arteritis? How does it present?
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.
What does diminished light reaction mean?
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)
What does anisocoria mean?
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.
What is bitemporal hemianopsia? What causes it?
Loss of peripheral vision, caused by a pituitary adenoma encroaching on the optic chiasm
What does not being able to smile, raise eyebrows, puff out cheeks mean?
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.
What does symmetric elevation upon “ah” mean?
Symmetric elevation of soft palate suggests intact IX/X function. Deviated uvula can indicate a paratonsillar abscess, or a cranial nerve lesion.
What does the gag reflex demonstrate?
sensory IX and motor X
What are the different cranial nerves?
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
What does tongue deviation away from the midline mean?
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.
What does papilladema indicate?
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)
What is otitis externa?
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.
What are common causes of conductive hearing loss?
cerumen impaction, otitis media, or otosclerosis
What are common causes of sensorineural hearing loss?
age-related hearing loss (presbycusis), side effects of medications such as aminoglycoside antibiotics
(gentamicin), noise trauma, and Meniere’s disease
What are the findings of conductive hearing loss?
Rinne: Air equal to or worse than bone conduction
Weber: Lateralizes to the “bad” ear
What are the findings of sensorineural hearing loss?
Rinne: Air better than bone conduction
Weber: Lateralizes to the “good” ear
What is acute otitis media?
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
When are nasal septal ulcerations or perforation seen?
Cocaine use
When are nasal polyps seen?
patients with allergic rhinitis and may cause obstructed
breathing and may predispose chronic sinusitis
When is tenderness over sinuses seen?
Tenderness over sinuses may be seen with sinus congestion in both viral rhinosinusitis and bacterial sinusitis
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
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
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.
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.
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.
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’.
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
When is increased AP diameter seen?
patients with hyperinflated lungs, such as those
with COPD
When is tripoding seen?
Advanced COPD
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.
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
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.
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.
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.
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).
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.
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.
What does increased tactile fremitus mean?
In a pulmonary consolidation (pneumonia), there may be increased tactile fremitus.
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.
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).
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
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.
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).
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”)
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).
What are borborygmi?
Extended bowel sounds
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.
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
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.
When might you find a small liver span?
advanced cirrhosis
When might you find a large liver span?
hepatitis, hepatic congestion from right sided heart failure, liver cancer or metastatic disease to the liver
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
When might you find CVA tenderness?
classic finding in pyelonephritis (ascending infection of the urinary tract) or nephrolithiasis (kidney stones)
What does shifting dullness indicate?
ascites - Ascites can be caused by many conditions, including congestive heart failure, hepatic cirrhosis, and gastrointestinal or gynecological malignancy.
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).
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.
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).
What does pain and crepitus at the acromioclavicular joint indicate?
AC arthritis
What does tenderness in the bicipital groove indicate?
tendonitis of the long head of the biceps
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
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.
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.
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
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.
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
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
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.
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.
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
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.
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.
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.
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
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
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.
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
