17466593 Physical Diagnosis Information Overview[1]

7/26/2019 17466593 Physical Diagnosis Information Overview[1]

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TABLE of PHYSICAL FINDINGSDownload a copy of this study guide

Finding Description, Comments Associated Diseases!

Adie"s P#pi$ Similar to Argyll Robertson Pupil, except thataccommodation is also impaired. May also see

impaired deep tendon reflexes.

Adie"s S%ndrome

Angioid Strea&s FUDUS!"P#!$ Pigmented lines radiating out%ardfrom the optic disc

Pse#do'ant(oma E$astic#m

Angio&eratomas Purplish, red papules, on lo%er abdomen, groin, orscrotum.

Fa)r%"s Disease$ &ereditary '(ipidosis.

Arc#s Seni$is 'ray band of opacity around the cornea., a normalfinding %ith aging.

Arg%$$ *o)ertsonP#pi$s

o pupillary light reflex, but accommodation is intact. Ne#ros%p(i$is

Arg%$$ *o)ertsonP#pi$

)*+ ea- or absent direct pupillary reflex, )+Retained ability to accommodate for near /ision, )0+Failed pupillary dilation after atropine administration.

Ta)es Dorsa$is Ne#ros%p(i$is

Arterio+eno#s A!Nic&ing

FUDUS!"P#!$ Arteriolar narro%ing and

compression of /eins, %here the arteries cross the

/eins. Due tosclerotic changesin both arteries and/eins.

H%pertensi+e *etinopat(%$ St
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Ba)ins&i"s Sign Fanning of big toe %hen you stro-e the plantar aspectof the foot

P%ramida$ Tract Lesion

B$#e-co$ored Sc$erae 1hin collagen in sclera ma-es /enous blood /isible. .steogenesis Imperfecta

Bor)or%gmi (oud, high2pitched bo%el sounds, often associated%ith rushes. Sma$$ Bo/e$ .)str#ction

Bo#tonniereDeformit%

Flexion contracture of P#P 3oints, plus hyperextension

of D#P 3oint, as if one %ere pushing a button through abutton hole.

*(e#matoid Art(ritis

Bra'ton Hic&sContractions

Painless uterine contractions occurring after the 4th

%ee-.

Pregnanc%

Bro/n-co$ored Sc$era May also be seen in normal blac- men. A$&apton#ria

Br#s(fie$d Spots 'ray2%hite spots on iris. Do/n"s S%ndromeB#ffa$o H#mp Fatty deposit o/er !5 C#s(ing"s S%ndrome

B#$$o#s 0%ringitis 6ullous inflammation of the tympanic membrane,/isible through the otoscope.

MycoplasmaPne#monia

Caf1 A# Lait Spots eurofibromas on *ec&$ing(a#sen Disease2Ne#rofi)romatosis T%pe I

C(addoc&"s *ef$e' hen the external malleolar s-in area is irritated,extension of the great toe occurs.

P%ramida$ Tract Lesion

C(ad/ic&"s Sign 6luish or purple discolor of the /agina Pregnanc%

C(err%-*ed Spot of0ac#$a

FUDUS!"P#!$ Abnormally dim retinalbac-ground, %ith redness on macula.

Ta%-Sac("s Disease, *etina$ A.cc$#sion

C(e%ne-Sto&es*espiration

!yclic alternations bet%een apnea and hyperpnea, in%hich P!" fluctuates and is unstable. #t occurs

%hen the respiratory centers of the brain become

insensiti/e to changes in !".

Congesti+e Heart Fai$#re CH

Also 3remia, 0eningitis, Pne


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C(+oste&"s Sign 1ap o/er facial ner/e anterior to ear, and loo- forcontraction of the facial muscles, especially shutting

of eyes.

Tetan%

Circinate Ba$an#s !ircular rash around penis *eiter"s S%ndrome

C$#))ing !haracteristic do%n2turning of fingernails Centra$ C%anosisfrom any cauEndocarditis

Copper /iring FUDUS!"P#!$ 6lood may appear orange ratherthan red, due to arteriolar narro%ing.

H%pertensi+e *etinopat(%

Cornea$ Arc#s Arc#sSeni$is!

"pa7ue grayish ring around cornea resulting from

fatty deposits

At(erosc$erosisin young peopnormal finding in old people.

Corrigan"s P#$se !ollapsing Pulse, or a bris- pule %ith large /olume Aortic Ins#fficienc%

Cotton 4oo$E'#dates FUDUS!"P#!$ Softexudates caused by ischemia toner/e2fiber layers. H%pertensi+e *etinopat(%$ St

Dot Hemorr(ages FUDUS!"P#!$ &emorrhage appearancecharacteristic of diabetes.

Dia)etic *etinopat(%

Do/ager"s H#mp 9yphosis of thoracic spine, from /ertebral micro2fractures.

.steoporosis

D#ro5ie5 0#rm#r 6ruit heard o/er the femoral artery, during bothsystole and diastole. Should be heard coincident %ith

!orrigan:s Pulse.

Aortic Ins#fficienc%

Er%t(ema0arginat#m

(arge erythematous patches %ith 3agged edges and

central clearing. "ne of the Ma3or ;ones !riteria.

*(e#matic Fe+er

E'op(t(a$mos 6ulging eyes. Gra+e"s Disease. Also 22 AcromCa+erno#s Sin#s T(rom)osis

Fascic#$ations Muscle t%itching due to spontaneous repetiti/e firingof motor ner/es. #t can occur normally in the cold.

Am%otrop(ic Latera$ Sc$erosiother upper motor demyelinatin

F$ai$ C(est "ne side of the chest mo/es paradoxically relati/e to #n3ury$ Rib fractures


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the other side. !aused by multiple rib fractures.

F$ame-s(aped(emorr(ages

FUDUS!"P#!$ &emorrhage appearance

characteristic of hypertension.

H%pertensi+e *etinopat(%

Gi))#s Deformit% Sharp change of angle of spine, instead of gradualchange of angle Pott"s Disease21uberculous Sp

Goode$$"s Sign 6luish discoloration plus softening of the cer/ix Pregnanc%

Grasp *ef$e' Stro-e the patient:s palm, causing him to grasp yourfingers. A positi/e test occurs %hen the patient doesnot let go of your fingers.

Fronta$ Lo)e Lesion$ A primit

Gre% T#rner"s Sign orsecond fingers.

P%ramida$ Tract Disease$ Onl

finding is unilateral. #f the findthen the meaning is uncertain.

H#tc(inson"s Triad !lassical triad ofInterstitial Keratitis, Deafness,Notched Teeth

Congenita$ S%p(i$isin the ne%

ImpairedCon+ergence

#nability to normally focus and loo- in%ard for

extreme near /ision.

Gra+e"s Disease

7ane/a% Lesions on2tender, raised erythematous nodules on thepalms.

asc#$itis


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8eratodermaB$ennorr(agia

Rash on the palms and soles *eiter"s S%ndrome

8op$i&"s Spots hite spots on the buccal mucosa 0eas$es

8#ssma#$*espirations


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.s$er"s Nodes 1ender erythematous nodules on the distal finger2pads.

Infecti+e Endocarditis

Pa$momenta$ *ef$e' Rub the thenar eminence 222222= elicit reflexi/econtraction of the muscles of the chin.

Fronta$ Lo)e Lesion$ A primit

Pect#s E'ca+at#m

F#nne$-C(est!

Sternum cur/ed in%ard. *ic&ets, 0arfan S%ndrome

Pect#s Carinat#m

Pigeon C(est!

#ncreased anteroposterior length of chest. Ribs bo%edout%ard.

*ic&ets, 0arfan S%ndrome

Petec(iae !apillary hemorrhages Endocarditis$ !on3uncti/al peseen.

Ping#ec#$ae Small, yello%ish ele/ations of the con3uncti/ae. #t iscaused by hyaline degeneration of con3uncti/al tissue.

Ga#c(er"s Disease$ ill see bdiscoloration of Pingueculae

Pse#domem)rane hitish, dirty2bro%n membrane o/er the tonsils. Dip(t(eria

Ptosis Droopy eyelids. Failure of levator palpebraemuscleto hold up eyelids )inner/ated by ! ###+

Horner"s S%ndrome, Myasthe


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*om)erg Test Patient can:t maintain balance %ith legs tight together,%ith eyes closed.

Cere)e$$ar Disease

*ot("s Spots FUDUS!"P#!$ Retinal hemorrhages %ith pale or%hite centers.

Infecti+e Endocarditis, !ollagDysproteinemias, (eu-emia. Pe

Anemia

Sa#sage-s(apedfingers

S%elling of the tendon sheath Psoriatic Art(ritis, *eiter"s S%

Simian Crease Single large horiBontal crease on palms. Do/n"s S%ndrome

Stra/)err% Tong#e


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maintain for *2 minutes. (oo- for induction of carpal

spasm.

3$nar De+iation De/iation of fingers or enter %rist to%ard ulnar)medial+ side.

*(e#matoid Art(ritis

4a'% E'#dates FUDUS!"P#!$Hardlipid2exudates on retina Dia)etic *etinopat(%$ 6ac-grRetinopathy

4(ee5e "n expiration, s7uea-ing high pitched sound, oftenaudible to unaided ear

Ast(ma, Emp(%sema, C.PD

:ant(e$asma ello%, flat lipid2containing lesions around the eyes. H%per$ipidemias


CHAPTE* ;2 HEAD and NEC8

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1he


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S3DDEN L.SS of ISI.N$ Potential !auseso A0A3*.SIS F3GA:21emporary, monocular, ischemic blindness.

Painless

!aused bu ipsilateral !arotid stenosis or emboliBation of the retinal artery.

o *ETINAL DETACH0ENT2Flashing lights, floating halos, and blurry /ision beforethe

blindness is indicati/e of retinal detachment.o 3EITIS$ #nflammation of u/eal tract 22 iris, ciliary body, and choroid.

Al%ays painful

Associated %ith multiple diseases$ connecti/e tissue diseases, histoplasmosis,

sarcoidosis, tuberculosis.

G*AD3AL L.SS of ISI.N$ Potential !auseso CATA*ACTS2"pacities of the lens, occurring %ith age.o GLA3C.0A2#ncreased intraocular pressure.

#t is the ost coon reason for loss of vision over age !".

o 0AC3LA* DEGENE*ATI.N2Secondary to Diabetes, and expected to cause /isualblindness.

Dia)etic *etinopat(%.o .PTIC NE*E C.0P*ESSI.N$ !aused by an intracranial neoplasm, or pituitary adenoma.o .PTIC NE3*.PATHY .ptic Ne#ritis!20#$tip$e Sc$erosis, and drugs such as


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EYELIDS$

PT.SIS2 Droopy eyelids8 failure of lids to open fully.o !aused by failure of levator palpebrae, inner/ated by ! ###, or failure of Tarsal $uscle,

inner/ated by sympathetics.

o Some causes$ &orner:s Syndrome, Myasthenia 'ra/is,


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o !ircular bands of bro%nish pigment on lateral and medial margins of cornea.

o Found in 4i$son"s Disease PING3EC3LAE2Small, yello%ish ele/ations of the con3uncti/ae, %hich appear bro%n in 'aucher:s

disease. #t is caused by hyaline degeneration of con3uncti/al tissue.

ANIS.C.*IA23ne?#a$ p#pi$s, caused by miosis or mydriasis of one pupil.

P3PILS$

0A*C3S G3NN P3PIL2A pupil that dilates )rather than constricts+ as light s%ings to%ard it.o #t indicates either se/ere macular disease or optic ner/e disease in the affected eye.

P3PILLA*Y *EFLE:ES$o A)sent Direct *ef$e'2#ndicates a problem %ith the afferent branch )1rigeminal ?*+ of the

reflex.o A)sent Consens#a$ *ef$e'2#ndicates a problem %ith the efferent branch )! ###,


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Interna$ Stra)ism#s2A ratio can befound, indicating /enous distension.

Stage I$ Arteriolar narro%ing but no A?2nic-ing. Stage II$ Focal spasm, A-nic&ing. Stage III$ &emorrhages and exudates


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Stage I$ Papi$$edema, .ptic disc edema)due to ischemia+ and hemorrhage, %hich canlead to retinal detachment.

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THE EAR

TINNIT3S2Ringing in ear.

E*TIG.2

.)6ecti+e ertigo$ 1he earth is mo/ing around you.

S#)6ecti+e ertigo$ ou are mo/ing in space.

*INNE TEST21est for conductive hearing lossby comparing air conduction to bone conduction.

First hold tuning for- right near auricle, then place it o/er the Mastoid Process.

"RMA($ #t should sound louder near the auricle, because air conduction should be better than straight

bone conduction.

A6"RMA($ #f it sounds louder o/er the mastoid process instead, that indicates a conductive hearing

lossin the middle ear.

4EBE* TEST2Place tuning for- o/er head. #t should be heard e7ually in both ears.

"<


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NOSE and THROAT

N.SE$

EPISTA:IS26loody nose.o Transient Epista'is$ May occur %ith forceful nose2blo%ing, sneeBing, nose2pic-ing, facial

trauma.o *ec#rrent Epista'is2Differential diagnosis G hypertension, coagulopathies, renal failure,

cirrhosis, (ereditar% (emorr(agic te$angiectasia. *HIN.PHY0A2Se/ere acne rosacea found in association %ith s-in hypertrophy and congestion of

subcutaneous tissue, around the nose.

TH*.AT$

S.*E TH*.AT$ #nfection mononucleosis, strep2throat )streptococcal pharyngitis+. H.A*SENESS$ (arynigitis, (aryngeal cancer, hypothyroidism, smo-ing 222222= broncho2genic

carcinoma.

ABN.*0AL TASTE$

H%pog#esia$ #mpaired ability to taste. Seen in UR#:s, glossitis, stomatitis.

D%sg#esia$ Unpleasant taste. Differential diagnosis$o Medications$ metronida5o$eo ?itamin and mineral deficiencies$ Binc depletion

o !hyronic hypercalcemia, hyperparathyroidism.

o ?iral hepatitis

T.NG3E$

0AC*.GL.SSIA2(arge tongue can occur %ith amyloidosis and acromegaly. GL.SSITIS2#nflammation on sides, base, and underside of tongue.
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o ?itamin and mineral deficincies

o Medications$ metronidaBole, phenytoin

o #nfections$ candidiasis

o Pernicious Anemia

o !ytotoxic drugs, radiotherapy.

0.3TH E:A0INATI.N$

.*AL 3LCE*S2Recurrent oral ulcers differential diagnosis$o *ec#rrent ap(t(o#s #$cers)can-er sores+$ !ommon, fre7uently associated %ith #nflammatory

6o%el Disease.

o #nfections$ HS-


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Pulmonary > Mechanical causes$ Ast(ma, #rritants, aspiration #nfectious$ T#)erc#$osis, Histop$asmosis, Pne#monia 1emperature$ #nhaling cold air

P#$monar% Em)o$ism, p#$monar% edema on2Pulmonary$ external ear canal irritation.

o Details$ Smo&er"s Co#g(usually occurs in morning and is producti/e. Ast(matic Co#g(usually is non2producti/e.

SP3T302#t is al%ays abnormal.o PR"DU!1#?< !"U'&S are seen in$

!hronic 6ronchitis, Smo-er:s cough

Bronc(iectasis$ chronically dilated bronchioles. (arge /olume of sputum, %hich separates into t%o or three layers upon standing.

1umors$ 6ronchoal/eolar !arcinoma

#nfections$ Pneumonia, tuberculosis, (ung Abscess

ill usually see %e$$o/ or greensputum. Pulmonary


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DYSPNEA2Difficult, labored breathing.o Differential Diagnosis$ A laundry list of possible causes

Pulmonary Disease$ !"PD, cancer, asthma, chronic or acute bronchitis, emphysema,

pneumonia, pulmonary emboli, pneumothorax

!ystic Fibrosis$ S%eat test

!ardiac causes$ !&F, Pulmonary edema, PD &ematologic$ Anemia, !"2Poisoning

Metabolic$ 9etoacidosis

Salicylate poisoning

o Symptoms$ Dyspnea may be mas-ed by tac(%pnea)shallo%, rapid breathing+. H%perpneais not tachypnea 22 it is hyper/entilation )not labored breathing+ usually

caused by metabolic acidosis and is unrelated to dyspnea. Distinguish the t%o %ith

pulmonary function studies.

.*TH.PNEA2Dyspnea %ith onset occurring %hile lying do%n, and %hich is iediately correctedupon restoring upright position.

o Differential Diagnosis$ Congesti+e Heart Fai$#re or C.PD Also bilateral paralysis of diaphragms.

PA*.:YS0AL N.CT3*NAL DYSPNEA PND!2Dyspnea at night, created by lying do%n, but%hich does not iediately iprove upon standing up. Patient feels acutely air2hungry and fre7uently

%a-es up at night. ight s%eats common.

o Differential Diagnosis$ Ac#te P#$monar% Edema secondary to congesti+e (eart fai$#re. 4HEE=ING2 &igh2pitched musical breath sound usually heard on expiration, but can be heard on

inspiration.

o !AUS


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!ardiac causes$ Shunt )1etralogy of Fallot+, pulmonary edema )cor pulmonale+

*HIN.**HEA2asal discharge C.*Y=A2asal discharge caused by a /iral upper respiratory tract infection.

FAM#( > S"!#A( S1"R$

Pre/ious 1uberculosis infection, PPD test.

Poor dental hygiene is a ris- for a lung abscess.


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CHEYNE-ST.8ES *ESPI*ATI.N2!yclic alternations bet%een apnea and hyperpnea, in %hichP!"fluctuates and is unstable. #t occurs %hen the respiratory centers of the brain become insensitive to

changes in *O-o ASS"!#A1

!ause$ normal or from aging, osteoporosis.o Sco$iosis2(ateral cur/ature of spine.

May be detected by patient bending for%ard and noting une/en para/ertebral bac-

muscles.

o Lordosis$


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Tacti$e Fremit#s2?ibration on lungs %hen you ha/e patient say Jninety2nineJo #ncreased fremitus is found %ith pulmonary consolidation in pneumonia.

o Fremitus cannot be heard belo% the le/el of fluid in emphysema or pleural effusion, because the

fluid stops the sound from being transmitted further.

PNE30.TH.*A:2Trachea will shift toward opposite side as the pneuothora#. 1he side of thepneumothorax ac7uires positi/e pressure, thus trachea de/iates to the other side.

Trac(ea$ De+iation$ 1racheal de/iation can be caused by other things than pneumothorax.o P$e#ra$ Eff#sion, Emp(%semamay also cause trachea to de/iate to the opposite side.o Ate$ectasisof lung may cause trachea to de/iate to%ardsaeside as diseased lung.

Tension Pne#mot(ora'2Medical emergency in %hich air enters the pleural ca/ity and is trapped duringexpiration

o Intrathoracic pressure builds to values higher than atospheric pressure, compresses the lung,

and may displace the mediastinum and its structures to%ard the opposite side, %ith conse7uentdisad/antageous effects on blood flo%.

PE*C3SSI.N$

*esonance2ormal breath sound H%perresonance2#ncreased resonance o/er thorax.

o May be found in


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o Bronc(o+esic#$ar So#nds2&eard near branching of main bronchi, combination of bronchialand /esicular sounds.

o esic#$ar So#nds2Soft, lo%2pitched, airy, s%ishing, heard belo% the le/el of the bronchi. C*AC8LES *ALES, C*EPITATI.NS!2Soft, short, high2pitched fine sounds.

o !AUS


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Cor P#$mona$e Cro#p29ids under 0 years old. Rapid, staccato coughs.

o Differential Diagnosis is bet%een inflammatory !roup or Spasmodic !roup.

C%stic Fi)rosis P$e#ra$ Eff#sion$Dullnesson percussion.Decreased freitus. Reduced breath sounds.

Emp(%sema Epig$ottitis$ #n -iddies, don:t inspect the pharynx %ithout a chest tube nearby. Pne#monia


CHAPTE* 2 CA*DIAC


!ARD#A! SMP1"MS, S1"R$

CHEST PAINo ANGINA ISCHE0IC CA*DIAC PAIN!$ S7ueeBing, crushing, strangling, constricting pain

in center of chest. Pain may radiate to left shoulder, left arm, right shoulder, 3a%.

Sta)$e T%pica$! Angina$ Angina upon effort, or angina induced by increased bloodpressure or increased heart2rate. Angina is relie/ed by nitroglycerin, although

nitroglycerin is not specific to this type of angina. Le+ine"s Sign$ Patient ma-es fist and holds it up to his chest, to describe the pain. Second-/ind P(enomenon2#f patient repeats same acti/ity after the attac-, he

may not feel the attac- again the second time.

4a$&-t(ro#g( Angina$ 1he pain subsides as patient continues the acti/ity. At%pica$ Angina$ Atypical presentation of typical angina.

&typical Syptos/Sharp or stabbing pain, rather than crushing pain.

&typical *auses/Angina %ith change in position, for example, rather than angina

strictly upon effort.

&ngina 0uivalents/"ther symptoms that are caused by myocardial ischemia.


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ausea, indigestion.

DiBBiness, s%eating.

3nsta)$e Angina$ Angina e/en at rest, or angina that has recently gotten %orse. #t isassociated %ith sharply increased ris- for myocardial infarct %ithin C months.

Angina Dec#)it#s is a specific term for angina occurring at rest.

ariant Angina Prin5meta$ Angina!2)arado#ic anginaoccurring during rest butusually not during exercise. #t is caused by coronar% arter% spasm. #t can be hard to spotbecause it can coexist %ith typical angina.

!haracteristic

bronchitis, or pleural effusion.

P#$monar% H%pertension$ Dyspnea is a more common symptoms than pleuritic pain. Pne#mot(ora'$ Pain may be confused %ith pain of an M#. 0ediastina$ Emp(%sema$ Free air in the mediastinum produces chest tightness and

dyspnea.

Hamman"s Sign2!runching, rasping sound heard synchronous %ith theheartbeat, indicati/e of mediastinal emphysema.

o 'AS1R"#1


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Ga$$stone Co$ic$ !olic-y RU@ pain radiating to bac- and to right shoulder. "ccasionallyit may be confused %ith angina.

o !&


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S#'S$ Pin-, frothy sputum, and bubbly breath sounds.

o AL3LA* HEA*T DISEASE$ 0itra$ Stenosisis associated %ith dyspnea.o !"'


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0%'omas, benign myocardial tumors, may cause outflo% obstruction and lead tosyncope.

Tetra$og% of Fa$$otis associated %ith fainting attac-s. 0%ocardia$ Isc(emia Carotid Sin#s S%ncope$Hypersensitivity of the *arotid Sinus in elderly enis common

cause of syncope. Impaired asomotor *ef$e'es$ #mpairment of 6aroreceptors. Syncope is associated

%ith orthostatic hypotension.

Decreased B$ood o$#meo FL3ID *E0.AL$

0ict#rition S%ncope2Syncope occurring %ith micturition but at no other time.Associated %ith remo/al of fluid from the body.

o P.ST-T3SSIE SYNC.PE$ Syncope after a bout of coughing, or after the ?alsal/a maneu/er,may occur in patients %ith !"PD.

HE0.PTYSIS$ 0itra$ a$+e Stenosisis a cardiac disease that may cause hemoptysis. Mitral Stenosis222222= pulmonary /enous congestion 222222= may lead to hemoptysis.

EDE0A$o Pitting Edemais a common sign of !ongesti/e &eart Failure.o Presacra$ Edemamay be found in bed2ridden patients, and may lead to decubitus ulcers.o Anasarca2Se/ere generaliBed edema and ascites, as seen in se/ere !&F, li/er cirrhosis, or

nephrotic syndrome.

o L%mp(edemamay be caused Filariasis or a tumor obstructing a lymphatic /essel. CYAN.SIS$ Presence of excessi/e deoxygenated hemoglobin in the blood. #t becomes /isible %hen the

concentration of deoxygenated hemoglobin exceeds K g > d( 22 a higher rate of desaturation than is foundin the venous bloodof normal people.

o Centra$ C%anosis$ ?isible in the lips, face, con3uncti/ae, tongue. #t is caused bypriarysysteic hypo#iadue to impaired oxygenation of blood.


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1&< M"U1&$

1&< S9#$

o *(e#matic Fe+er2!haracteristically you %ill see Er%t(ema 0arginat#mand S#)c#taneo#sNod#$es.

1&< 1&"RA$

1&< A6D"M


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ith patient sitting up, cla/icles are * cm abo/e right atrium, thus !?P G 3ugular

/enous distension abo/e cla/icles L * cm. ith patient ele/ated 0, sternal Angle of (ouis is normally about K cm abo/e right

atrium, and #nternal ;ugular should be /isible about 0 cm directly /ertical )use a ruler+,abo/e the sternal Angle of (ouis.

o R


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systole to be transmitted to the periphery. 1he lapse bet%een apical and radial pulse is the pulse

deficit.

o Bigemina$ P#$se21%o consecuti/e heartbeats closely coupled, %ith subse7uent pause before thenext beat.

?olume Abnormalities$

o H%per&inetic P#$se2@uic- up stro-e and full /olume, seen %ith hypertension, anxiety.o Corrigan"s P#$se2A bris- pulse %ith large /olume, or J!ollapsingJ pulse, seen in Aortic

Regurgitation.

D#ro5ie5 0#rm#rshould be heard across the femoral artery simultaneous %ith thecollapsing pulse.

o 9#inc&e"s P#$se2?isible capillary pulsations in the nail2bed. Another sign of Aortic#nsufficiency.

o P#$s#s Bisferiens26ifid pulse. 1%o distinct impulses %ith each heartbeat. Seen in$ Aortic Regurgitation

&ypertrophic !ardiomyopathy.

o P#$s#s A$terans2"ne pulse feels large, the next one small. Due to decreased cardiac

contractility and carries a poor prognosis.o P#$s#s Parado'#s2ea-ening of the pulse %ith inspiration more than normal.

Systolic pressure normally decreases by less than * mm &g. Paradoxical pulse occurs

%hen decrease is greater than * mm &g. #ndicati/e of constricti/e cardiac disease$ Pericardial effusion, constricti/e pericarditis.

'rading Pulses$ Scale of to C

o Scale$

G no pulse @G normal pulse G bounding pulse

o Intermittent C$a#dication$ 1emporary %ea-ening of lo%er extremities due to arterial

insufficiency.o Leric(e"s S%ndrome2Atherosclerosis of abdominal Aorta, reducing flo% to lo%er extremities

and leading to impotence.

o Ta&a%as#"s Disease2Pulseless disease 22 no pulse in arms, due to progressi/e obliterati/earteritis.

1&< PR


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P#$monic ?al/e$ Second left interspace )upper left 22 on opposite side because the Pulmonary arteriesbifurcate behind the Aorta.+

Tric#spid a$+e2(o%er parasternum )centrally located+ 0itra$ a$+e2Apex Er)"s Point2Place to listen to right2sided pathologies, at the third left interspace.

PALPATI.N PE*C3SSI.N$

Point of 0a'ima$ Imp#$se P0I!2Should be at the apex.o #f it is located more centrally and do%n, that is indicati/e of C.PDdue to barrel chest and

constantly inflated lungs, displacing the heart centrally )right2sided shift+.

o Right ?entricular &ypertrophy can shift the PM# posteriorly, as the right2/entricular mass mas-s

the left2/entricular PM#, ma-ing it difficult to palpate.

S(oc&2An impulse of a heart sound transmitted to the examining hand. Hea+e Lift2Forceful, systolic thrust that mo/es the palpating hand up a little. T(ri$$2A palpable murmur. A palpable /ibration that by definitionis accompanied by an audible

murmur.

STETH.SC.PE$ 'et a good one. 1he shorter the tube, the better. Double2barreled tubes are better thansingle2barrel.

DIAPH*AG0$ &igh2pitched )primarily systolic+ sounds, and press firmly. BELL$ (o%2pitched )primarily diastolic+ sounds, and press lightly.

HEA*T S.3NDS$

N.*0AL HEA*T S.3NDS$ ormal order of e/ents G 0


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#1


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1iming

(ocation

!onfiguration$ !rescendo > Decrescendo

#ntensity$

o Grade I26arely audible by an expert.

o Grade III2Moderately loud %ith palpable thrill.o Grade I2So loud it can be heard %ithout the stethoscope ma-ing complete contact %ith the

s-in.

Fre7uency

@uality

1RASM#SS#"$ here does the sound transmit to 1his is characteristic for certain pathologies and

can be diagnostic.

SYST.LIC 03*03*S$ !ardiac disorders and their associated findings.

A.*TIC STEN.SIS$Diaond3shaped systolic e4ection urur.o (ocation$ "/er the Aortic /al/e, at the second right intercostal space.o 1ransmission$ to the carotids bilaterally.

P3L0.NIC STEN.SIS$Diaond3shaped systolic e4ection urur.o (ocation$ Second or third left parasternal interspace.

HYPE*T*.PHIC .BST*3CTIE CA*DI.0Y.PATHY$Diaond3shaped idsystolic urur.o PA1&"("' of D#Sreduced.1his is paradoxic beha/ior as compared to most murmurs Handgrip222222= increase in left /entricular /olume 222222= decreased urur. 1his

occurs because the septal obstruction is relati/ely less significant.

a$sa$+a 0ane#+er$ Murmur becomes louderin the late2stage of the ?alsal/a Maneu/errather than softer as in most murmurs.

Murmur becomes 7uieter %hen the patient s7uats 22 also paradoxical beha/ior.

0IT*AL ALE P*.LAPSE$ #f it occurs %ith mitral regurgitation, a late systolic murmur %ill beheard after the midsystolic clic-.

o


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H.L.SYST.LIC 03*03*S$ 1hey indicate that blood is flo%ing do%n a pressure gradient %hen itshouldn:t be, as in insufficiencies.

o !AUS


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Parado'ica$ Sp$ittingalso occurs. 0IT*AL STEN.SIS$$iddiastolic urur

o !AUS


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First *2*K seconds$ #nitially, cardiac output increases, and the intensity of left2sided

murmurs increase accordingly. After *2*K seconds$ !ardiac then begins to decrease, as /enous return from the lungs

decreases. Most left2sided murmurs then gro% softer again.

o

0O of cases+.o #!R


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o #!R


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o Po$%p(agia2Seen in hyperthyroidism, malabsorption syndromes, especially pancreaticinsufficiency.

NA3SEA AND .0ITING$o De$a%ed Gastric Empt%ing$ #t is a common cause of nausea. Possible causes of delayed gastric

emptying$

Pyloric "utlet "bstruction$ Ulcers, pyloric stenosis, !rohn:s Disease, neoplasms. euromuscular$ Scleroderma, /agotomy, demyelinating diseases )MS+, Polio

Metabolic$ Dia)etic gastroparesis, (%pot(%roidism Drugs$ Anti2cholinergics, ganglionic bloc-ers, opiates

Psychiatric$ Anorexia er/osa

o Pro6ecti$e omiting$ Special /omiting that can signify increased intracranial pressure )#!P+.o *eg#rgitation2?omiting %ithout nasea. !auses$

"/ereating.

Achalasia.

Delayed gastric emptying


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Pre/ious rectal or perirectal surgery.


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o 0aroon-Co$ored Stoo$sare indicati/e of massi/e blood loss ) to 0 units of blood+. Usually %illsee unstable /ital signs. (oo- for complications of PUD, such as perforated ulcer.

INSPECTI.N$

P*.T3BE*ANT .* DISTENDED ABD.0ENo Partia$ Bo/e$ .)str#ction2Distended abdomen plus peristaltic mo/ements heard o/er the

distension is practically diagnostic.

o Ps#edoc%esis, Ps#deopregnanc%2oman %ho %ants to be pregnancy de/elops a distendedabdomen psychogenically.

o #ncreased air in bo%el causing abdominal distension$

Mechanical factors, carcinoma or adhesions

Adynamic paralytic ileus.

o Ascites$ Most common cause is alcoholic cirrhosis leading to portal hypertension. F$#id 4a+e2Press do%n abdomen and create a fluid %a/e. #t is indicati/e of ascites. P#dd$e Sign$ &a/e patient lie prone and then get on hands and -nees, to get all ascites to

go to a dependent position. 1hen flic- and auscultate the abdomen, listening for changesin intensity of sounds. Positi/e test indicates ascites.

C(%$o#s Ascitesis mil-y )lipid+ loo- to transudate, indicating lymphatic bloc-age."ccurs %ith intraabdominal lymphomas and &odg-in:s disease.

Ascites can be assessed by auscultation by assessing shifting dullness %hen patient

changes position.

G*EY T3*NE*"S SIGN2


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Indirect Ing#ina$ Hernia$ &erniapasses through the inguinal canal, and createsa bulge in the right o/er the inguinal ligament, as it passes through the inguinalring.

#n men, often herniates into scrotum.

Femora$ Hernia$ Second most common. &igh ris- of strangulation, O of cases.

.)t#rator Hernia$ Unusual, occuring in elderly, thin, emaciated %omen. Protrusion ofperitoneal sac through "bturator Foramen. Symptom$ Pain, paresthesia do%n anterior thigh, due to compression of femoral

ner/e.

3m)i$ica$ Hernia2May occur in people %ith chronic increased intraabdominal pressure$Multiparous %omen and !"PD.

Spige$ian Hernia$ "ccurs bet%een ubilicus and pubic symphysis. Unusual.o Reducability$

*ed#ci)$e21he contents of the hernia can be easily displaced. Irred#ci)$e, Incarcerated21he contents of the hernia cannot be displaced and are stuc-

there.

Strang#$ated2An incarcerated hernia that has cut off its blood supply, resulting in tissuenecrosis and gangrene.

PE*C3SSI.N$

T%mpan%$ #ncreased tympany is heard upon percussion of the abdomen in cases of partia$ )o/e$o)str#ction.

ormal (i/er Span$ *2* cm in men, 42** cm in %omen.

AUS!U(1A1#"$

PE*ISTALTIC S.3NDS$o Absent 6o%el Sounds$ #leus

o #ncreased 6o%el Sounds$ 'astroenteritis.

o Bor)or%gmi$ &igh2pitched bo%el sounds indicating small bo%el obstruction. S3CC3SSI.N SPLASH$ Audible presence of increased amount of fluid in stomach.

o ormal after a large meal.

o #f it occurs after fasting, then it is indicati/e of p%$oric o)str#ction ABD.0INAL B*3ITS$ !aused by calcification of aorta, celiac compression, and alcoholic hepatitis. PE*IT.NEAL F*ICTI.N *3BS$ &earing a peritoneal friction rub o/er the li/er is indicati/e of

li/er metastasis or primary hepatoma.


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PA(PA1#"$

LIE*$o Hepatomega$%2

Primary or metastatic &epatoma.

Alcoholic li/er disease )fatty li/er+. Se/ere !&F.

#nfiltrati/e diseases of li/er li-e amyloidosis.

Myeloproliferati/e Disorders$ !M(, Myelofibrosis.

SPLEENo Sp$enomega$%2

#nfections

(eu-emias

Portal hypertension

GALLBLADDE*o Co#r+osier"s La/$ 'allbladder is palpable in KO of cases of pancreatic carcinoma, due to

painless distension.o 0#rp(e%"s Sign2RU@ pain aggra/ated by inspiration, indicati/e of ac#te c(o$ec%stitis.

8IDNEYS$o


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o Perforated #$cero Perforated )o/e$o Peritonitis

DI*ECT AND INDI*ECT TENDE*NESSo *e)o#nd Tenderness21enderness on sudden release of pressure. A reliable sign of peritoneal

inflammation.o 7ar Tenderness$ A/oidance of sudden mo/ements due to abdominal pain. Also a sign of

peritoneal inflammation.

A6D"M#A( PA# SDR"M fatigue, diarrhea common


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Pain is /ariable in 7uality, and often ameliorated by sitting in -nee2chest position.

o LACTASE DEFICIENCYo I**ITABLE B.4EL SYND*.0E$ Abdominal discomfort %ith no demonstrable organic

cause.

Defecation relie/es the pain.

A1


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o Pain$ess Hemat#ria21hin- neop$asms)renal or bladder+, renal tuberculosis, acute glomerulo2nephritis.

"(#'UR#A, AUR#A$ Renal failure.

o .$ig#ria$ C2hr urine output less than C mlo An#ria$ C2hr urine output less than * ml

P


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CHAPTE* 2 FE0ALE GENITALIADownload a copy of this study guide

SMP1"MS$

PAS1 S1"R$

o Gra+ida2umber of pregnancieso Para2umber of li/e deli/erieso umber of planned and spontaneous abortions.

A6"RMA(#1#


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Premat#re o+arian fai$#re$ Menopause occurring before age 0K. !an be causedoophoritis )mumps /irus+, or may be idiopathic.

Polycystic "/ary Syndrome

As(erman"s S%ndrome2Amenorrhea caused by intrauterine adhesions)synechiae+ that obliterate part of the uterine ca/ity. 1his can occur subse7uent to

/igorous di$atation and c#rettage DC!of the endometrium.o H%pomenorr(ea2Decrease in /olume of flo% or duration of periods.o 0enorr(agia, H%permenorr(ea2Abnormally hea/y /olume of flo% or abnormally long

periods. Most common causes$ Uterine fibroids )leiomyomas+, P#D,


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Endometriosis2Dysmenorrhea, dyspareunia, infertility. "ften ha/e chronic pel/ic pain,associated %ith the location of the ectopic glandular tissue.

Pain of endometriosis tends to be constant, and tends to radiate to coccyx, lo%er

bac-. "nset of disease is usually bet%een K and C. Undifferentiated dysmenorrhea

often presents younger than age K. UR#AR 1RA!1 #F

pregnancy or in other circumstances.

Goode$$"s Sign$ 6luish discoloration and softening of the cer/ix. Bra'ton Hic&s Contractions$ Painless uterine contractions occurring after the 4th%ee- 9#ic&ening$ 1he first fetal mo/ement of %hich the patient is a%are. ormally occurs at

*4 %ee-s during first pregnancy, and at *I %ee-s in subse7uent pregnancies.

o H%datidiform 0o$e2Signs of a molar pregnancy$ Uterus increases rapidly in siBe shortly after implantation.

Persistent /aginal bleeding, no fetal mo/ement, and no fetal heart tones by * %ee-s.

ausea and /omiting more intense than usual.

'rape li-e clusters of tissues may be expelled through the /agina.

A6"RMA(#1#


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?A'#A( D#S!&AR'< and #1!'

o P(%sio$ogic Disc(arge2!lear or %hite discharge occurring at midcycle.o Trichomonas Vaginalis:

Discharge$ 'ray, foamy discharge ha/ing bad odor.

Mucosa$ Red, stra%berry cer/ix.

!onfirm$ !onfirm %ith /et-mo#nt)saline suspension microscopy+.o Gonorr(ea$

Discharge$ Profuse mucoid discharge %ith foul odor.

Mucosa$ Red, tender mucosa.

!onfirm$ !onfirm %ith culture.

o Gardnerella Vaginalis:Also called Non-specific +aginitis. !o2infection %ith anaerobes usuallyalso occurs.

Discharge$ 'ray or %hite, fishy odor

Mucosa$ ormal

!onfirm$ C$#e ce$$sG large epithelial cells %ith many coccobacilli adherent to them.o C($am%dia$

Discharge$ (ittle, yello%, mucous and pus in cer/ical canal. Mucosa$ !er/ical erosion.

!onfirm$ FA stain of smear sho%s e$ementar% )odies.o Candida Albicans:east infection.

Discharge$ hite, cottage2cheese li-e

Mucosa$ hite patches stuc- to a red base.

!onfirm$ 9"& preparation, loo- for pse#do(%p(a.o Atrop(ic aginitis2


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CHAPTE* J2 03SC3L.S8ELETAL


EPIDE0I.L.GY$ !"MM" MUS!U("S9


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o Symptoms$

Podagra2Se/ere gouty pain at the base of the great toe. *HE30ATIC FEE*$

o Symptoms$

0igrator% Pain$ 1ypical finding. Pain mo/ing from 3oint to 3oint.

o 7ones Criteria2Diagnostic criteria for Rheumatic Fe/er. 1%o ma3or criteria, or one ma3or andt%o minor criteria are re7uired.

0a6or Criteria$ Carditis$ Myocarditis, Pericarditis Po$%art(ritis C(orea$ Purposeless mo/ements of /arious muscle groups Er%t(ema 0arginat#m$ Pin-, circular rash on trun- on proximal arms. S#)c#taneo#s Nod#$es$ 'ranulomatous nodules on extensor surfaces, often

associated %ith cardiac in/ol/ement.

0inor Criteria$ &istory, Symptoms$

&istory of pre/ious rheumatic fe/er or rheumatic heart disease. Arthralgia

Fe/er

(abs$

Acute phase reactants$ increased


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.STE.A*TH*ITIS$ Degenerati/e arthritis.o Symptoms$

Pain usually gets %orse as the day progresses, leading to fatigue in the afternoon.

o Signs$ 1he distal)D#P+ 3oints are characteristically more in/ol/ed than the P#P 3oints.

Distal phalanx may de/iate laterally.

He)erden"s Nodes26ony o/ergro%ths on the dorsum of the D#P 3oints, typical ofosteoarthritis.

SYSTE0IC L3P3S E*YTHE0AT.S3S SLE!2Diagnostic !riteria. C of ** at any time isdiagnostic.

o Malar Rash

o Discoid rash

o Photosensiti/ity

o "ral ulcers

o Arthritis

o Serositis )pleuritis, pericarditis+

o Renal disorder

o eurologic disorder )seiBures, psychosis+o &ematologic )anemia, leu-openia, lymphopenia, thrombocytopenia+.

o #mmunologic )ele/ated anti2DA, (


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o Art(ra$gia2Defined as 3oint pains %ithout ob3ecti/e signs of inflammation. #t is caused by manyprocesses, both inflammatory and non2inflammatory.

o Art(ritis$ ;oint inflammation. S1#FF S%elling

o Syno/ial thic-ening )pannusformation+ is characteristic of RA.

o S%elling of tendon2sheath )sausage2shaped digit+ occurs in Reiter:s Syndrome and Psoriatic

Arthritis.

o Eff#sions2Fluid is most commonly found in the -nee. Deformity

o Gang$ia$ Fluid2filled cysts found along 3oint capsules, usually in the %rist.o *(e#matoid Nod#$es$ Firm nodules found on extensor surfaces of bony prominences. 1hey

contain mononuclear cells and fibrosis.

o Go#t% Top(i$ ;oint nodules associated %ith urate deposits.o B#rsitis$ #nflammation of the bursa in the -nee or elbo%.


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Crepit#s2'rating or grinding sensation felt by patient, or heard by examiner. Rubbing of bones due todegeneration of articular cartilage.

Crac&ing, Snapping2Snapping of 3oints is usually not pathologic, unless it occurs repeatedly. C$ic&ing2May indicate an abnormality %hen it occurs in 1M; 3oint.

MUS!(< S1R


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AC Degenerati+e Art(ritis$ Maybe from trauma. #t hurts upon mo/ement of scapula. Bicipita$ Tendinitis Impingement S%ndrome!2#nflammation of the tendon of the supraspinatus

muscle.

Ca$cific Tendinitis2Prolonged inflammation of the supraspinatus tendon, %ith resulting calcification.


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Do/ager"s H#mp2 Mar-ed -yphosis of dorsal spine in elderly %omen. An&%$osing Spond%$itis2RA2li-e disease affecting the lo%er spine and sacroiliac 3oints. L#m)osacra$ Strain2(o%er bac- pain from obesity and or poor posture. Herniated N#c$e#s P#$pos#s2 Sciatica2

P$

#f one leg is shorter than the other as measured from AS#S to an-le, hip disease is li-ely.

Trende$en)#rg Test2&a/e patient stand on one foot. 1he contralateral hip should pull up%ard. #f itdoesn:t, and the same hip on %hich patient is standing instead pulls do%n%ard, then that is a positi/e testand is indicati/e of hip disease.

Anta$gic Gait$ al-ing funny )limping+ in order to a/oid pain in the hip.

9


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CHAPTE*

associated %ith complex partial seiBures.

Grand 0a$ Sei5#res21onic2clonic, often %ith loss of autonomic control. Petit 0a$ Sei5#res$ (asting for a short period of time 22 only a fe% seconds.

o !AUS


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!&A'

extremity, accompanied by numbness and paresthesia. Peripheral neuropathies

Polymyositis or dermatomyositis.

UM6


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o ;2Mo/es if gra/ity is eliminated.o @2Mo/es against gra/ity.o 2Mo/es against gra/ity and against some resistance.o 2ormal strength.

Motor Abnormalities$

o H%steria21o test %hether %ea-ness in the leg is from hysteria or is organic, put a hand on bothlimbs and ha/e the patient lift one limb against the hand:s resistance. #f the cause of motor %ea-ness is organic, then examiner should feel the other leg mo/e

the opposite direction in compensation.

#f it is hysteria, then the other leg remains still.

o Fascic#$ations21%itchings in resting muscles. May be normal if they are occasional orprecipitated by cold. 1hey may be a sign of Am%otrop(ic Latera$ Sc$erosis ALS!if they areaccompanied by %ea-ness.

o Tics$ ormal mo/ements of muscle groups )such as %in-ing or grinning+ occurringin/oluntarily, as in 1ourette:s Syndrome.

o Tetan%$ #n/oluntary muscle spasms.

!auses$ 1etanus, hypocalcemia, hypomagnesemia, hyper/entilation syndrome. C(+oste&"s Sign21ap o/er facial ner/e anterior to ear, and loo- for contraction of the

facial muscles, especially shutting of eyes.

Tro#ssea#"s P(enomenon2#nflate a blood2pressure cuff to systolic pressure andmaintain for *2 minutes. #nduction of carpal2pedal spasm indicates latent tetany.

o Tremors$ "scillating mo/ements caused by in/oluntary contractions of muscle groups. S


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o D%smetria2#nability to properly guage the distance bet%een t%o points. 1ested %ith finger2to2nose mo/ements.

o D%sdiadoc(o&inesia2#nability to do rapid alternating mo/ements.o Scanning Speec(2Prolonged separation of syllables, often seen %ith cerebellar dysfunction.o 'A#1 Disturbances$

!erebellar (esions$ !entral cerebellar lesion sho%s unsteady gait, but con/entionalcerebellar signs may be normal.

Posterior Co$#mns Lesions$ (oss of proprioception results in unsteady gait when eyesare closed, but relati/ely normal gait %hen eyes are open.

Festinating Gait2Par-insonian gait, shuffling %al-.o *om)erg Test2Patient can:t maintain balance %ith legs tight together, %ith eyes closed.o Tit#)ation26ody tremor %hen standing or %al-ing, sign of cerebellar disease.

R


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o !orneal Reflex

o Pupillary (ight Reflex

o 'ag Reflex

Abnormal Reflexes$

o Ba)ins&i Sign2Stro-e bottom of the foot 222222= fanning )e/ersion+ of big toe.

o C(addoc&"s *ef$e'2 hen the external malleolar s-in area is irritated, extension of the great toeoccurs in cases of organic disease of the corticospinal reflex paths.o .ppen(eim"s Sign$ Scratch inner side of leg 222222= extension of toes. Sign of cerebral irritation.o Gordon"s Sign$ S7ueeBe the calf muscles and note the response of the great toe. Fanning or

extension is considered abnormal.

o Hoffman"s Sign$ Flexion of the terminal phalanx of the thumb and of the second and thirdphalanges of one or more of the fingers %hen the /olar surface of the terminal phalanx of the

fingers is flic-ed.

#t is significant for pyramidal tract disease %hen it is unilateral. #f it is bilateral than the

meaning is uncertain.

Absence of Superficial Reflexes$ Unilateral suppression of superficial reflexes often results from upper

motor lesions subse7uent to a !?A. Primiti+e *ef$e'es2Presence of primiti/e reflexes is often a sign of fronta$ $o)elesions.

o S#c& *ef$e'2'ently tap or rub the upper lift 222222= elicit a reflexi/e suc-ing or puc-eringresponse.

o Grasp *ef$e'2Stro-e the patient:s palm, causing him to grasp your fingers. A positi/e testoccurs %hen the patient does not let go of your fingers.

o Pa$momenta$ Sign2Rub the thenar eminence 222222= elicit reflexi/e contraction of the musclesof the chin.

C*ANIAL NE*E EAL3ATI.N$

CN I2 .LFACT.*Yo 1


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&a/e patient mo/e eyes through all fields of /ision. #ntact 0 rdner/e means that eyes can

mo/e medially, superiorly, and inferiorly. P#pi$$ar% *ef$e'2!hec- for pupillary response to light in same eye and contralateral

eye. Ptosis2Ptosis may occur due to 0rdner/e palsy.

o A6"RMA($ Unilateral !2### Palsy$ Subarachnoid hemorrhage resulting from aneurysm, diabetes,

atherosclerosis. &orner:s Syndrome$ Usually occurs from )ronc(ogenic carcinoma)Pancoast T#mor+

impinging on the Superior !er/ical 'anglion.

CN I2 T*.CHLEA*o 1


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o 1

PA1#


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PHYSICAL DIAGN.SIS FINAL E:A0 ST3DY G3IDEDownload a copy of this study guide

C(apter ;2 Head and Nec& C(apter @2 *espirator% C(apter 2 Cardiac C(apter 2 T(e A)domen C(apter 2 0a$e Genita$ia C(apter 2 Fema$e Genita$ia C(apter J2 0#sc#$os&e$eta$ C(apter


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Al%ays painful

Associated %ith multiple diseases$ connecti/e tissue diseases, histoplasmosis,

sarcoidosis, tuberculosis.

o G*AD3AL L.SS of ISI.N$ Potential !auses CATA*ACTS2"pacities of the lens, occurring %ith age.

GLA3C.0A2#ncreased intraocular pressure. #t is the ost coon reason for loss of vision over age !".

0AC3LA* DEGENE*ATI.N2Secondary to Diabetes, and expected to cause /isualblindness.

Dia)etic *etinopat(%. .PTIC NE*E C.0P*ESSI.N$ !aused by an intracranial neoplasm, or pituitary

adenoma.

.PTIC NE3*.PATHY .ptic Ne#ritis!20#$tip$e Sc$erosis, and drugs such as


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o PT.SIS2 Droopy eyelids8 failure of lids to open fully. !aused by failure of levator palpebrae, inner/ated by ! ###, or failure of Tarsal $uscle,

inner/ated by sympathetics.

Some causes$ &orner:s Syndrome, Myasthenia 'ra/is,


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Found in 4i$son"s Diseaseo PING3EC3LAE2Small, yello%ish ele/ations of the con3uncti/ae, %hich appear bro%n in

'aucher:s disease. #t is caused by hyaline degeneration of con3uncti/al tissue.

o ANIS.C.*IA23ne?#a$ p#pi$s, caused by miosis or mydriasis of one pupil.

P3PILS$

o 0A*C3S G3NN P3PIL2A pupil that dilates )rather than constricts+ as light s%ings to%ard it. #t indicates either se/ere macular disease or optic ner/e disease in the affected eye.

o P3PILLA*Y *EFLE:ES$ A)sent Direct *ef$e'2#ndicates a problem %ith the afferent branch )1rigeminal ?*+ of

the reflex. A)sent Consens#a$ *ef$e'2#ndicates a problem %ith the efferent branch )! ###,


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o E'terna$ Stra)ism#s2


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Stage I$ Papi$$edema, .ptic disc edema)due to ischemia+ and hemorrhage,%hich can lead to retinal detachment.


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N.SE$

o EPISTA:IS26loody nose. Transient Epista'is$ May occur %ith forceful nose2blo%ing, sneeBing, nose2pic-ing,

facial trauma.

*ec#rrent Epista'is2Differential diagnosis G hypertension, coagulopathies, renalfailure, cirrhosis, (ereditar% (emorr(agic te$angiectasia.o *HIN.PHY0A2Se/ere acne rosacea found in association %ith s-in hypertrophy and

congestion of subcutaneous tissue, around the nose.

TH*.AT$

o S.A* TH*.AT$ #nfection mononucleosis, strep2throat )streptococcal pharyngitis+.o H.A*SENESS$ (arynigitis, (aryngeal cancer, hypothyroidism, smo-ing 222222= broncho2genic

carcinoma.

ABN.*0AL TASTE$

o H%pog#esia$ #mpaired ability to taste. Seen in UR#:s, glossitis, stomatitis.o D%sg#esia$ Unpleasant taste. Differential diagnosis$

Medications$ metronida5o$e ?itamin and mineral deficiencies$ Binc depletion

!hyronic hypercalcemia, hyperparathyroidism.

?iral hepatitis

T.NG3E$

o 0AC*.GL.SSIA2(arge tongue can occur %ith amyloidosis and acromegaly.o GL.SSITIS2#nflammation on sides, base, and underside of tongue.

?itamin and mineral deficincies

Medications$ metronidaBole, phenytoin

#nfections$ candidiasis

Pernicious Anemia

!ytotoxic drugs, radiotherapy.

0.3TH E:A0INATI.N$


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o .*AL 3LCE*S2Recurrent oral ulcers differential diagnosis$ *ec#rrent ap(t(o#s #$cers)can-er soars+$ !ommon, fre7uently associated %ith

#nflammatory 6o%el Disease.

#nfections$ HS-


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!hronic 6ronchitis, Smo-er:s cough

Bronc(iectasis$ chronically dilated bronchioles. (arge /olume of sputum, %hich separates into t%o or three layers upon

standing.

1umors$ 6ronchoal/eolar !arcinoma

#nfections$ Pneumonia, tuberculosis, (ung Abscess ill usually see %e$$o/ or greensputum.

Pulmonary


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Metabolic$ 9etoacidosis

Salicylate poisoning

Symptoms$ Dyspnea may be mas-ed by tac(%pnea)shallo%, rapid breathing+. H%perpneais not tachypnea 22 it is hyper/entilation )not labored breathing+

usually caused by metabolic acidosis and is unrelated to dyspnea. Distinguish the

t%o %ith pulmonary function studies.o .*TH.PNEA2Dyspnea %ith onset occurring %hile lying do%n, and %hich is iediately

corrected upon restoring upright position. Differential Diagnosis$ Congesti+e Heart Fai$#re or C.PD

Also bilateral paralysis of diaphragms.

o PA*.:YS0AL N.CT3*NAL DYSPNEA PND!2Dyspnea at night, created by lying do%n,but %hich does not iediately iprove upon standing up. Patient feels acutely air2hungry and

fre7uently %a-es up at night. ight s%eats common. Differential Diagnosis$ Ac#te P#$monar% Edema secondary to congesti+e (eart

fai$#re.o 4HEE=ING2 &igh2pitched musical breath sound usually heard on expiration, but can be heard

on inspiration. !AUS


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o Pre/ious 1uberculosis infection, PPD test.

o Poor dental hygiene is a ris- for a lung abscess.

o


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!aused by meningitis or other cerebral dysfunction.

o SLEEP APNEA$ "besity, leading to air%ay obstruction at night and chronic fatigue during theday. 1reat %ith !PAP.

#SP

!ause$ normal or from aging, osteoporosis. Sco$iosis2(ateral cur/ature of spine.

May be detected by patient bending for%ard and noting une/en para/ertebral

bac- muscles.

Lordosis$


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Fremitus cannot be heard belo% the le/el of fluid in emphysema or pleural effusion,

because the fluid stops the sound from being transmitted further.

PNE30.TH.*A:2Trachea will shift toward opposite side as the pneuothora#. 1he side of thepneumothorax ac7uires positi/e pressure, thus trachea de/iates to the other side.

o Trac(ea$ De+iation$ 1racheal de/iation can be caused by other things than pneumothorax. P$e#ra$ Eff#sion, Emp(%semamay also cause trachea to de/iate to the opposite side. Ate$ectasisof lung may cause trachea to de/iate to%ardsaeside as diseased lung.

o Tension Pne#mot(ora'2Medical emergency in %hich air enters the pleural ca/ity and istrapped during expiration

Intrathoracic pressure builds to values higher than atospheric pressure, compresses the

lung, and may displace the mediastinum and its structures to%ard the opposite side, %ith

conse7uent disad/antageous effects on blood flo%.

PE*C3SSI.N$

o *esonance2ormal breath soundo H%perresonance2#ncreased resonance o/er thorax.

May be found in


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esic#$ar So#nds2Soft, lo%2pitched, airy, s%ishing, heard belo% the le/el of thebronchi.

o C*AC8LES *ALES, C*EPITATI.NS!2Soft, short, high2pitched fine sounds. !AUS


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o L#ng Cancero Cor P#$mona$eo Cro#p29ids under 0 years old. Rapid, staccato coughs.

Differential Diagnosis is bet%een inflammatory !roup or Spasmodic !roup.

o C%stic Fi)rosis

o P$e#ra$ Eff#sion$Dullnesson percussion.Decreased freitus. Reduced breath sounds.o Emp(%semao Epig$ottitis$ #n -iddies, don:t inspect the pharynx %ithout a chest tube nearby.o Pne#monia

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CHAPTER 4: CARDIAC

!ARD#A! SMP1"MS, S1"R$

o CHEST PAIN ANGINA ISCHE0IC CA*DIAC PAIN!$ S7ueeBing, crushing, strangling,

constricting pain in center of chest. Pain may radiate to left shoulder, left arm, right

shoulder, 3a%. Sta)$e T%pica$! Angina$ Angina upon effort, or angina induced by increased

blood pressure or increased heart2rate. Angina is relie/ed by nitroglycerin,although nitroglycerin is not specific to this type of angina.

Le+ine"s Sign$ Patient ma-es fist and holds it up to his chest, to describethe pain.

Second-/ind P(enomenon2#f patient repeats same acti/ity after theattac-, he may not feel the attac- again the second time.

4a$&-t(ro#g( Angina$ 1he pain subsides as patient continues theacti/ity.

At%pica$ Angina$ Atypical presentation of typical angina. &typical Syptos/Sharp or stabbing pain, rather than crushing pain.

&typical *auses/Angina %ith change in position, for example, rather than

angina strictly upon effort.
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&ngina 0uivalents/"ther symptoms that are caused by myocardial

ischemia.

embolism. P$e#ris%$ Pain upon breathing. May be caused by pulmonary embolism,

pneumonia, bronchitis, or pleural effusion. P#$monar% H%pertension$ Dyspnea is a more common symptoms than pleuritic

pain.

Pne#mot(ora'$ Pain may be confused %ith pain of an M#. 0ediastina$ Emp(%sema$ Free air in the mediastinum produces chest tightness

and dyspnea.


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Hamman"s Sign2!runching, rasping sound heard synchronous %ith theheartbeat, indicati/e of mediastinal emphysema.

'AS1R"#1


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Unli-e orthopnea, #t is not relie/ed immediately by sitting up.

Patient is usually able to return to sleep, e/entually.

P3L0.NA*Y EDE0A$ Pulmonary edema is usually a manifestation of left2/entricular heart failure. Peripheral edema associated %ith !&F is a manifestation of

right2sided heart failure )!or Pulmonale+.

SMP1"MS$ Se/ere symptoms.


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An'iet%$ #t is usually associated %ith acute anxiety or excessi/e emotion. 1he?agal hyperacti/ity is thought to be a hypersensiti/e response to sympatheticoutflo%.

CA*DI.ASC3LA* CA3SES$ Arr(%t(mias$

ST.8ES-ADA0S SYND*.0E2Syncope caused by reduced cardiacoutput secondary to an arrhythmia. 6oth se/ere tachycardia and bradycardia can reduce cardiac output,

leading to syncope. Se/ere tachycardia reduces cardiac output by reducing

/entricular filling time.

Cardiac .#tf$o/ Tract .)str#ction$ Aortic Stenosismay lead to syncope. 0%'omas, benign myocardial tumors, may cause outflo% obstruction and

lead to syncope. Tetra$og% of Fa$$otis associated %ith fainting attac-s.

0%ocardia$ Isc(emia Carotid Sin#s S%ncope$Hypersensitivity of the *arotid Sinus in elderly enis

common cause of syncope. Impaired asomotor *ef$e'es$ #mpairment of 6aroreceptors. Syncope is

associated %ith orthostatic hypotension. Decreased B$ood o$#me

FL3ID *E0.AL$ 0ict#rition S%ncope2Syncope occurring %ith micturition but at no other time.

Associated %ith remo/al of fluid from the body.

P.ST-T3SSIE SYNC.PE$ Syncope after a bout of coughing, or after the ?alsal/amaneu/er, may occur in patients %ith !"PD.

o HE0.PTYSIS$ 0itra$ a$+e Stenosisis a cardiac disease that may cause hemoptysis. Mitral

Stenosis 222222= pulmonary /enous congestion 222222= may lead to hemoptysis.o EDE0A$

Pitting Edemais a common sign of !ongesti/e &eart Failure. Presacra$ Edemamay be found in bed2ridden patients, and may lead to decubitus ulcers. Anasarca2Se/ere generaliBed edema and ascites, as seen in se/ere !&F, li/er cirrhosis,

or nephrotic syndrome.

L%mp(edemamay be caused Filariasis or a tumor obstructing a lymphatic /essel.o CYAN.SIS$ Presence of excessi/e deoxygenated hemoglobin in the blood. #t becomes /isible

%hen the concentration of deoxygenated hemoglobin exceeds K g > d( 22 a higher rate of

desaturation than is found in the venous bloodof normal people.


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Centra$ C%anosis$ ?isible in the lips, face, con3uncti/ae, tongue. #t is caused bypriarysysteic hypo#iadue to impaired oxygenation of blood.


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!AUS


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%-Descent$ 6rief decreases in 3ugular /ein pressure after the 1ricuspid /al/e opens)beginning of Systole+.

A*TE*IAL P3LSES$

o ormal Pulses$ Radial, 6rachial, !arotid, Femoral, Popliteal, Posterior 1ibial, Dorsalis Pedis.o Rhythm Abnormalities$

Sin#s Arr(%t(mia21he pulse accelerates %ith inspiration. Premature !ontractions$

Atria$ Premat#re Contractions APC!2ormally do not disturb the cycle. entric#$ar Premat#re Contractions PC!21hey are follo%ed by a

compensatory pause, and a ne% rhythm is established.

P#$se Deficit2ith Atria$ Fi)ri$$ationL Tac(%cardia, the radial pulse may not be e7ualto the cardiac apical pulse. 1%o rapid beats in a ro% may not allo% sufficient /entricular

filling for the systole to be transmitted to the periphery. 1he lapse bet%een apical and

radial pulse is the pulse deficit.

Bigemina$ P#$se21%o consecuti/e heartbeats closely coupled, %ith subse7uent pausebefore the next beat.

o ?olume Abnormalities$

H%per&inetic P#$se2@uic- up stro-e and full /olume, seen %ith hypertension, anxiety. Corrigan"s P#$se2A bris- pulse %ith large /olume, or J!ollapsingJ pulse, seen in Aortic

Regurgitation. D#ro5ie5 0#rm#rshould be heard across the femoral artery simultaneous %ith

the collapsing pulse.

9#inc&e"s P#$se2?isible capillary pulsations in the nail2bed. Another sign of Aortic#nsufficiency.

P#$s#s Bisferiens26ifid pulse. 1%o distinct impulses %ith each heartbeat. Seen in$ Aortic Regurgitation &ypertrophic !ardiomyopathy.

P#$s#s A$terans2"ne pulse feels large, the next one small. Due to decreased cardiaccontractility and carries a poor prognosis.

P#$s#s Parado'#s2ea-ening of the pulse %ith inspiration more than normal. Systolic pressure normally decreases by less than * mm &g. Paradoxical pulse

occurs %hen decrease is greater than * mm &g. #ndicati/e of constricti/e cardiac disease$ Pericardial effusion, constricti/e

pericarditis.

o 'rading Pulses$ Scale of to C


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Scale$

G no pulse @G normal pulse G bounding pulse

Intermittent C$a#dication$ 1emporary %ea-ening of lo%er extremities due to arterial

insufficiency. Leric(e"s S%ndrome2Atherosclerosis of abdominal Aorta, reducing flo% to lo%er

extremities and leading to impotence.

Ta&a%as#"s Disease2Pulseless disease 22 no pulse in arms, due to progressi/e obliterati/earteritis.

1&< PR

PALPATI.N PE*C3SSI.N$

o Point of 0a'ima$ Imp#$se P0I!2Should be at the apex. #f it is located more centrally and do%n, that is indicati/e of C.PDdue to barrel chest

and constantly inflated lungs, displacing the heart centrally )right2sided shift+. Right ?entricular &ypertrophy can shift the PM# posteriorly, as the right2/entricular mass

mas-s the left2/entricular PM#, ma-ing it difficult to palpate.o S(oc&2An impulse of a heart sound transmitted to the examining hand.o Hea+e Lift2Forceful, systolic thrust that mo/es the palpating hand up a little.o T(ri$$2A palpable murmur. A palpable /ibration that by definitionis accompanied by an audible

murmur.

STETH.SC.PE$ 'et a good one. 1he shorter the tube, the better. Double2barreled tubes are betterthan single2barrel.

o DIAPH*AG0$ &igh2pitched )primarily systolic+ sounds, and press firmly.


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o BELL$ (o%2pitched )primarily diastolic+ sounds, and press lightly.

HEA*T S.3NDS$

o N.*0AL HEA*T S.3NDS$ ormal order of e/ents G 0


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Right2Sided$ pulmonary hypertension, pulmonic stenosis.

Tennessee2SC, S*, S sounds together ha/e this approximate rhythm.o S300ATI.N GALL.P2S0 L SC L 1achycardia, as seen in chronic hypertension leading to

!&F.o SYST.LIC S.3NDS and CLIC8S$

E6ection So#nds2!an be innocent, or caused by abnormal Aortic /al/es or a dilatedAorta. 0itra$ a$+e Pro$apse 0P!2ill result in a mid or late systolic clic-, as the mitral

leaflet protrudes bac- into the atrium during /entricular contraction.

o "2?A(?U(AR S"UDS$

Precordia$ 8noc&$ Results from constricti+e pericarditisand can be heard o/er theinternal 3ugular at the base of the nec-.

!AUS


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(ocation$ "/er the Aortic /al/e, at the second right intercostal space.

1ransmission$ to the carotids bilaterally.

o P3L0.NIC STEN.SIS$Diaond3shaped systolic e4ection urur. (ocation$ Second or third left parasternal interspace.

o HYPE*T*.PHIC .BST*3CTIE CA*DI.0Y.PATHY$Diaond3shaped idsystolic

urur. PA1&"("' of D#Svolue is reduced.1his is paradoxic beha/ior as compared to most murmurs Handgrip222222= increase in left /entricular /olume 222222= decreased urur.

1his occurs because the septal obstruction is relati/ely less significant. a$sa$+a 0ane#+er$ Murmur becomes louderin the late2stage of the ?alsal/a

Maneu/er, rather than softer as in most murmurs. Murmur becomes 7uieter %hen the patient s7uats 22 also paradoxical beha/ior.

o 0IT*AL ALE P*.LAPSE$ #f it occurs %ith mitral regurgitation, a late systolic murmur%ill be heard after the midsystolic clic-.


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ST*AIGHT BAC8 SYND*.0E$ Systolic e3ection murmur. Innocent 0#rm#rs eno#s H#m$ &eard abo/e the cla/icles in normal indi/iduals. 0ammar% So#ff$e$ &igh pitched continuous flo% heard o/er base of heart in pregnancy.

DIAST.LIC 03*03*S$ !ardiac disorders and associated findings.

o A.*TIC INS3FFICIENCY$ 6lo%ing orDecrescendo diastolic urur. Many causes$ infectious, rheumatic, dissecting aortic aneurysm.

!&F ma-es the murmur softer.

Associated findings$

Corrigan"s 4ater Hammer P#$se$ !ollapsing pulse, %ith little up stro-e ordo%nstro-e.

de Musset:s Sign$ to and fro head mo/ement synchronous %ith the heartbeat.

9#inc&e"s P#$se$ capillary pulsation of fingertips. D#ro5ie5"s Sign$ Femoral artery systolic and diastolic bruits. Hi$$"s Sign$ 6lood pressure in the legs being higher than it is in the arms.

ormal difference G mm &g

Aortic #nsufficiency G C2I mm &g.

o P3L0.NIC INS3FFICIENCY$Decrescendo diastolic urur. G*AHA0 STEELL"S 03*03*$ P#$monar% H%pertensionas the cause of

pulmonic hypertension )due to dilation of pulmonic leaflets+.

Prominent a-/a+eis found concurrent %ith the murmur. Parado'ica$ Sp$ittingalso occurs.

o 0IT*AL STEN.SIS$$iddiastolic urur !AUS


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TECHNI93ES F.* ENHANCING A3SC3LTATI.N$

o INSPI*ATI.N$ ormally you should see splitting of S %ith inspiration. Poccurs later andmo/es further a%ay from A.

Parado'ic Sp$itting2S splitting is decreasedinstead of increased %ith inspiration.

Left B#nd$e-Branc( B$oc&causes paradoxic splitting. #n this condition, undernormal circumstances, Aalready occurs afterP)instead of before+, because ofthe left2sided heart2bloc-. 1hus, %ith inspiration, Pactually mo/es closer to A

and you see paradoxic splitting.o E:HALATI.N$ !an be used to e/aluate right3sidedheart murmurs.

1he intensity of most right2sided heart murmurs %ill decrease%ith exhalation, %hile left2

sided murmurs remain unchanged.

o 0LLE*"S 0ANE3E*$ &a/e patient pinch the nostrils shut %ith one hand and suc- hard ona finger %ith the other.

M

murmurs found %ith inspiration. #t ma-es it easier to hear inspiratory murmurs.o ALSALA 0ANE3E*$ &a/e patient hold breath and bear do%n for seconds. !an be

used to e/aluate left2sided heart murmurs. M

blood fro the pulonary to the systeic circulation22 the exact opposite as MNller:sManeu/er.

1#M< !"URS


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0itra$ *eg#rgitation2"ccasionally decreases.o S93ATTING to STANDING$

H%pertrop(ic .)str#cti+e Cardiom%opat(%2As the patient stands bac-, this murmurshould increase.

0itra$ *eg#rgitation2 "ccasionally increases.

o PASSIE LEG ELEATI.N$ H%pertrop(ic .)str#cti+e Cardiom%opat(%2Murmur should decrease, as left

/entricular /olume increases and the left /entricle enlarges.

o IS.0ET*IC HANDG*IP2Using a handgrip for * minutes increases peripheral /ascularresistance.

D


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!&ARA!1 PA1#


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Delayed gastric emptying


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Hirsc(spr#ng"s Disease2Aganglionic Megacolon (ifelong constipation

"cassional passage of enormous stools

Absence or mar-ed dimunition of ganglion cells in rectal tissue

Mar-ed colonic distension.

Idiopat(ic C(ronic Constipationmay be caused by a defect in the pel/is floor in%omen, in %hich they contract the anal sphincter, rather than relax it, %hen defecating.

o HE0ATE0ESIS Possible !auses$

PUD or erosi/e 'astritis

0a$$or%-4eiss Tearof esophagus


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Adynamic paralytic ileus.

Ascites$ Most common cause is alcoholic cirrhosis leading to portal hypertension. F$#id 4a+e2Press do%n abdomen and create a fluid %a/e. #t is indicati/e of

ascites.

P#dd$e Sign$ &a/e patient lie prone and then get on hands and -nees, to get all

ascites to go to a dependent position. 1hen flic- and auscultate the abdomen,listening for changes in intensity of sounds. Positi/e test indicates ascites.

C(%$o#s Ascitesis mil-y )lipid+ loo- to transudate, indicating lymphaticbloc-age. "ccurs %ith intraabdominal lymphomas and &odg-in:s disease.

Ascites can be assessed by auscultation by assessing shifting dullness %hen

patient changes position.

o G*EY T3*NE*"S SIGN2


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3m)i$ica$ Hernia2May occur in people %ith chronic increased intraabdominalpressure$ Multiparous %omen and !"PD.

Spige$ian Hernia$ "ccurs bet%een ubilicus and pubic symphysis. Unusual. Reducability$

*ed#ci)$e21he contents of the hernia can be easily displaced.

Irred#ci)$e, Incarcerated21he contents of the hernia cannot be displaced andare stuc- there. Strang#$ated2An incarcerated hernia that has cut off its blood supply, resulting in

tissue necrosis and gangrene.

PE*C3SSI.N$

o T%mpan%$ #ncreased tympany is heard upon percussion of the abdomen in cases of partia$)o/e$ o)str#ction.

o ormal (i/er Span$ *2* cm in men, 42** cm in %omen.

AUS!U(1A1#"$

o PE*ISTALTIC S.3NDS$ Absent 6o%el Sounds$ #leus

#ncreased 6o%el Sounds$ 'astroenteritis.

Bor)or%gmi$ &igh2pitched bo%el sounds indicating small bo%el obstruction.o S3CC3SSI.N SPLASH$ Audible presence of increased amount of fluid in stomach.

ormal after a large meal.

#f it occurs after fasting, then it is indicati/e of p%$oric o)str#ctiono ABD.0INAL B*3ITS$ !aused by calcification of aorta, celiac compression, and alcoholic

hepatitis.

o PE*IT.NEAL F*ICTI.N *3BS$ &earing a peritoneal friction rub o/er the li/er is indicati/eof li/er metastasis or primary hepatoma.

PA(PA1#"$

o LIE*$ Hepatomega$%2

Primary or metastatic &epatoma.

Alcoholic li/er disease )fatty li/er+.

Se/ere !&F.


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#nfiltrati/e diseases of li/er li-e amyloidosis.

Myeloproliferati/e Disorders$ !M(, Myelofibrosis.

o SPLEEN Sp$enomega$%2

#nfections

(eu-emias Portal hypertension

o GALLBLADDE* Co#r+osier"s La/$ 'allbladder is palpable in KO of cases of pancreatic carcinoma,

due to painless distension.

0#rp(e%"s Sign2RU@ pain aggra/ated by inspiration, indicati/e of ac#te c(o$ec%stitis.o 8IDNEYS$


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*e)o#nd Tenderness21enderness on sudden release of pressure. A reliable sign ofperitoneal inflammation.

7ar Tenderness$ A/oidance of sudden mo/ements due to abdominal pain. Also a sign ofperitoneal inflammation.

A6D"M#A( PA# SDR"M fatigue, diarrhea common

Pain is /ariable in 7uality, and often ameliorated by sitting in -nee2chest position.


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LACTASE DEFICIENCY I**ITABLE B.4EL SYND*.0E$ Abdominal discomfort %ith no demonstrable

organic cause.

Defecation relie/es the pain.

o A1


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.$ig#ria$ C2hr urine output less than C ml An#ria$ C2hr urine output less than * ml

o P


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CHAPTER 7: FEMALE GENITALIA

SMP1"MS$

o PAS1 S1"R$

Gra+ida2umber of pregnancies Para2umber of li/e deli/eries umber of planned and spontaneous abortions.

o A6"RMA(#1#


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subse7uent to /igorous di$atation and c#rettage DC!of theendometrium.

H%pomenorr(ea2Decrease in /olume of flo% or duration of periods. 0enorr(agia, H%permenorr(ea2Abnormally hea/y /olume of flo% or abnormally long

periods.

Most common causes$ Uterine fibroids )leiomyomas+, P#D,


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"nset of disease is usually bet%een K and C. Undifferentiated

dysmenorrhea often presents younger than age K.o UR#AR 1RA!1 #F

occur during pregnancy or in other circumstances.

Goode$$"s Sign$ 6luish discoloration and softening of the cer/ix. Bra'ton Hic&s Contractions$ Painless uterine contractions occurring after the

4th%ee-.

9#ic&ening$ 1he first fetal mo/ement of %hich the patient is a%are. ormallyoccurs at *4 %ee-s during first pregnancy, and at *I %ee-s in subse7uent

pregnancies. H%datidiform 0o$e2Signs of a molar pregnancy$

Uterus increases rapidly in siBe shortly after implantation.

Persistent /aginal bleeding, no fetal mo/ement, and no fetal heart tones by *

%ee-s.

ausea and /omiting more intense than usual.

'rape li-e clusters of tissues may be expelled through the /agina.

o A6"RMA(#1#


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o ?A'#A( D#S!&AR'< and #1!'

P(%sio$ogic Disc(arge2!lear or %hite discharge occurring at midcycle. Trichomonas Vaginalis:

Discharge$ 'ray, foamy discharge ha/ing bad odor.

Mucosa$ Red, stra%berry cer/ix.

!onfirm$ !onfirm %ith /et-mo#nt)saline suspension microscopy+. Gonorr(ea$

Discharge$ Profuse mucoid discharge %ith foul odor.

Mucosa$ Red, tender mucosa.

!onfirm$ !onfirm %ith culture.

Gardnerella Vaginalis:Also called Non-specific +aginitis. !o2infection %ith anaerobesusually also occurs.

Discharge$ 'ray or %hite, fishy odor

Mucosa$ ormal

!onfirm$ C$#e ce$$sG large epithelial cells %ith many coccobacilli adherent tothem.

C($am%dia$ Discharge$ (ittle, yello%, mucous and pus in cer/ical canal.

Mucosa$ !er/ical erosion.

!onfirm$ FA stain of smear sho%s e$ementar% )odies. Candida Albicans:east infection.

Discharge$ hite, cottage2cheese li-e

Mucosa$ hite patches stuc- to a red base.

!onfirm$ 9"& preparation, loo- for pse#do(%p(a. Atrop(ic aginitis2


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CHAPTER 9: MSCLOSKELETAL

EPIDE0I.L.GY$

o !"MM" MUS!U("S9


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o *HE30ATIC FEE*$ Symptoms$

0igrator% Pain$ 1ypical finding. Pain mo/ing from 3oint to 3oint. 7ones Criteria2Diagnostic criteria for Rheumatic Fe/er. 1%o ma3or criteria, or one

ma3or and t%o minor criteria are re7uired.

0a6or Criteria$ Carditis$ Myocarditis, Pericarditis Po$%art(ritis C(orea$ Purposeless mo/ements of /arious muscle groups Er%t(ema 0arginat#m$ Pin-, circular rash on trun- on proximal arms. S#)c#taneo#s Nod#$es$ 'ranulomatous nodules on extensor surfaces,

often associated %ith cardiac in/ol/ement.

0inor Criteria$ &istory, Symptoms$

&istory of pre/ious rheumatic fe/er or rheumatic heart disease.

Arthralgia

Fe/er (abs$

Acute phase reactants$ increased


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o .STE.A*TH*ITIS$ Degenerati/e arthritis. Symptoms$

Pain usually gets %orse as the day progresses, leading to fatigue in the afternoon.

Signs$ 1he distal)D#P+ 3oints are characteristically more in/ol/ed than the P#P 3oints.

Distal phalanx may de/iate laterally.

He)erden"s Nodes26ony o/ergro%ths on the dorsum of the D#P 3oints, typical ofosteoarthritis.

o SYSTE0IC L3P3S E*YTHE0AT.S3S SLE!2Diagnostic !riteria. C of ** at any time isdiagnostic.

Malar Rash

Discoid rash

Photosensiti/ity

"ral ulcers

Arthritis

Serositis )pleuritis, pericarditis+

Renal disorder

eurologic disorder )seiBures, psychosis+ &ematologic )anemia, leu-openia, lymphopenia, thrombocytopenia+.

#mmunologic )ele/ated anti2DA, (


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Referred pain$ Don:t forget the Ddx of !AD in shoulder pain.

Art(ra$gia2Defined as 3oint pains %ithout ob3ecti/e signs of inflammation. #t is causedby many processes, both inflammatory and non2inflammatory.

Art(ritis$ ;oint inflammation.o S1#FFo S%elling

Syno/ial thic-ening )pannusformation+ is characteristic of RA.

S%elling of tendon2sheath )sausage2shaped digit+ occurs in Reiter:s Syndrome and

Psoriatic Arthritis. Eff#sions2Fluid is most commonly found in the -nee.

o Deformity

Gang$ia$ Fluid2filled cysts found along 3oint capsules, usually in the %rist. *(e#matoid Nod#$es$ Firm nodules found on extensor surfaces of bony prominences.

1hey contain mononuclear cells and fibrosis.

Go#t% Top(i$ ;oint nodules associated %ith urate deposits. B#rsitis$ #nflammation of the bursa in the -nee or elbo%.

o


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o Crepit#s2'rating or grinding sensation felt by patient, or heard by examiner. Rubbing of bonesdue to degeneration of articular cartilage.

o Crac&ing, Snapping2Snapping of 3oints is usually not pathologic, unless it occurs repeatedly.o C$ic&ing2May indicate an abnormality %hen it occurs in 1M; 3oint.

MUS!(< S1R


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1enderness is diffuse.

o AC Degenerati+e Art(ritis$ Maybe from trauma. #t hurts upon mo/ement of scapula.o Bicipita$ Tendinitis Impingement S%ndrome!2#nflammation of the tendon of the

supraspinatus muscle.

o Ca$cific Tendinitis2Prolonged inflammation of the supraspinatus tendon, %ith resulting

calcification.


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SP#


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o 0orton Ne#roma2Pinching of fibrous neuromas bet%een metatarsal heads, resulting se/ereburning pain.

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CHAPTER !": NEROLOGICAL

Grand 0a$ Sei5#res21onic2clonic, often %ith loss of autonomic control. Petit 0a$ Sei5#res$ (asting for a short period of time 22 only a fe% seconds.

!AUS


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oung Adults )20K+$ 1rauma, alcoholism, brain tumor

"lder adults )0KL+$ )rain t#mor, !?A, metabolic disorders, electrolyteimbalances )(%ponatremia, hypoglycemia, uremia+.

o !&A'

extremity, accompanied by numbness and paresthesia.

Peripheral neuropathies

Polymyositis or dermatomyositis.

o UM6


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o ASS


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side of the lesion. #f the pins are placed se7uentially, then the patient still retains normal

sensation on both sides.

o S1


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C$ !lonus

o Superficial Reflexes$

Upper Abdominal$ #psilateral contraction of abdominal muscles on the stro-ed side.

(o%er Abdominal$ #psilateral contraction of abdominal muscles on the stro-ed side.

!remasteric$ Stro-e inner thigh 222222= ele/ation of testes.

o 6rainstem Reflexes$ !orneal Reflex

Pupillary (ight Reflex

'ag Reflex

o Abnormal Reflexes$

Ba)ins&i Sign2Stro-e bottom of the foot 222222= fanning )e/ersion+ of big toe. C(addoc&"s *ef$e'2 hen the external malleolar s-in area is irritated, extension of the

great toe occurs in cases of organic disease of the corticospinal reflex paths. .ppen(eim"s Sign$ Scratch inner side of leg 222222= extension of toes. Sign of cerebral

irritation. Gordon"s Sign$ S7ueeBe the calf muscles and note the response of the great toe. Fanning

or extension is considered abnormal. Hoffman"s Sign$ Flexion of the terminal phalanx of the thumb and of the second and

third phalanges of one or more of the fingers %hen the /olar surface of the terminalphalanx of the fingers is flic-ed.

#t is significant for pyramidal tract disease %hen it is unilateral. #f it is bilateral

than the meaning is uncertain.o Absence of Superficial Reflexes$ Unilateral suppression of superficial reflexes often results from

upper motor lesions subse7uent to a !?A.

o Primiti+e *ef$e'es2Presence of primiti/e reflexes is often a sign of fronta$ $o)elesions. S#c& *ef$e'2'ently tap or rub the upper lift 222222= elicit a reflexi/e suc-ing or

puc-ering response. Grasp *ef$e'2Stro-e the patient:s palm, causing him to grasp your fingers. A positi/e

test occurs %hen the patient does not let go of your fingers. Pa$momenta$ Sign2Rub the thenar eminence 222222= elicit reflexi/e contraction of the

muscles of the chin.

C*ANIAL NE*E EAL3ATI.N$

o CN I2 .LFACT.*Y 1


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&ead trauma %ith fracture of cribriform plate

eoplasm in anterior fossa$ meningioma

o CN II2 .PTIC 1


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Centra$ Lesion of II$ 1he supratrochlear muscles are spared, as they recei/ebilateral inner/ation from both facial ner/es. 6elo% the eyes, the contralateralside %ill be paralyBed.

Perip(era$ Lesion of II21here is an entire facial hemiplegia, %ith the paralysisoccurring on the contralateral side.

o CN III2 ESTIB3L.C.CHLEA* 1


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o APPR"A!& to the !"MA1"S< PA1#

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17466593 Physical Diagnosis Information Overview[1]

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