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CHAPTER 2: HEAD and NECK

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• The Eye

• The Ear

• Nose and Throat

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THE EYE

SYMPTOMS:

• SUDDEN LOSS of VISION: Potential Causes

o AMAUROSIS FUGAX: Temporary, monocular, ischemic blindness.

Painless

Caused bu ipsilateral Carotid stenosis or emboliation o! the retinal artery.

o RETINAL DETACHMENT: "lashin# li#hts, !loatin# halos, and blurry $ision

before the blindness is indicati$e o! retinal detachment.

o UVEITIS: %n!lammation o! u$eal tract && iris, ciliary body, and choroid.

'l(ays pain!ul

'ssociated (ith multiple diseases: connecti$e tissue diseases,

histoplasmosis, sarcoidosis, tuberculosis.

• GRADUAL LOSS of VISION: Potential Causes

o CATARACTS: Opacities o! the lens, occurrin# (ith a#e.

o GLAUCOMA: %ncreased intraocular pressure.

%t is the most common reason for loss of vision over age 50.

o MACULAR DEGENERATION: Secondary to )iabetes, and e*pected to cause

$isual blindness.

Diab!i" R!ino#a!$%.

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o OPTIC NERVE COMPRESSION: Caused by an intracranial neoplasm, or

pituitary adenoma.

o OPTIC NEUROPATHY &O#!i" N'(i!i)*: M'+!i#+ S"+(o)i), and dru#s such

as Ethambutol, Methanol, can all cause optic neuritis and #radual blindness.

o PRES,YOPIA: +radual loss o! ability o! 'ccommodation !or near&$ision,occurrin# (ith a#e.

o CORTICAL ,LINDNESS: %n!arct o! the Occipital obe can lead to cortical

blindness. Patient (ill ha$e binocular blindness, but (ill retain the pupillary light

reflex (hich is una!!ected.

• DIPLOPIA: )ouble $ision.

o Mono"'+a( Di#+o#ia: Should su##est corneal or lens problem.

o ,ino"'+a( Di#+o#ia: %ndicati$e o! cranial ner$e palsy or ocular muscle problems,

or a brainstem problem.

o M%a)!$nia G(a-i) &MG*: )iplopia (ithout pain is o!ten the presentin#

complaint in M+.

• EYE PAIN:

o The cornea is inner$ated by the O#$!$a+.i" N(-/ CN V0.

o Possible causes o! eye pain

CNS problems a!!ectin# CN -: Menin#itis, ca$ernous sinus thrombosis,

aneurysms, mi#raine

'd/acent structures: sinus problems

Eye problems 0 in!lammations: Con/uncti$itis, stye, chalaion

o P$o!o#$obia: Eye pain upon e*posure to li#ht, indicati$e o!

• SCOTOMATA: Speci!ic islands or spots o! impaired $ision1 an impaired $isual !ield.

EYELIDS:

•

PTOSIS: )roopy eyelids1 !ailure o! lids to open !ully.o Caused by !ailure o! levator palpebrae, inner$ated by CN %%%, or !ailure o! Tarsal

Muscle, inner$ated by sympathetics.

o Some causes: 2orner3s Syndrome, Myasthenia +ra$is, Encephalitis

• LID LAG: E$idence o! (hite sclera bet(een the iris and upper lid mar#in. This is

normally not !ound.



o %t is a si#n o! G(a-1) Di)a)

• STYE: Small abscess caused by in!ection o! sebaceous glands of Zeis.

• CHALAION: 'cute in!lammation o! the meibomian gland.

SCLERA:

• SCLERITIS: %n!lammation o! the sclera, $isible as bro(n 0 red in!iltrates in sclera on

#ross e*amination. "ound in autoimmune and colla#en $ascular diseases, such as SLE/RA.

• ,LUE SCLERA: Patho#nomonic o! Osteogenesis Imperfecta.

o Results !rom $ery thin sclera in (hich the choroid sho(s throu#h.

• ,RO3N SCLERA: "ound in disorder l!aptonuria 4metabolic disorder5

• YELLO3 SCLERA: "ound in "aundice. %t should raise the 6uestion o! li$er disease or

hemolytic anemia.

EXOPHTHALMOS: Eyes /uttin# out past eyelids. ' si#n o! +ra$e3s disease, acrome#aly, and

ca$ernous sinus thrombosis.

CORNEA:

• KERATOCON4UNCTIVITIS &KERATITIS* SICCA: "ound in S567(n1) S%nd(o.,

resultin# !rom autoantibodies a#ainst sali$ary #lands resultin# in no sali$ary secretion.

o Classic triad o! symptoms (ith S/7#ren3s Syndrome:

8eratitis Sicca 4dry eyes5

9erostomia 4dry mouth5

Rheumatoid 'rthritis

• INTERSTITIAL KERATITIS: ' si#n o! con#enital syphilis.

o H'!"$in)on1) T(iad: Triad o! interstitial eratitis, dea!ness, and notched teeth is

classical e$idence !or con#enital syphilis.

• ARCUS SENILIS: +ray band o! opacity around the cornea.

• KAYSER8FLEISCHER RINGS: Copper in )escemet3s Membrane.

o Circular bands o! bro(nish pi#ment on lateral and medial mar#ins o! cornea.

o "ound in 3i+)on1) Di)a)

• PINGUECULAE: Small, yello(ish ele$ations o! the con/uncti$ae, (hich appear bro(n

in +aucher3s disease. %t is caused by hyaline de#eneration o! con/uncti$al tissue.



• ANISOCORIA: Un9'a+ #'#i+), caused by miosis or mydriasis o! one pupil.

PUPILS:

• MARCUS GUNN PUPIL: ' pupil that dilates 4rather than constricts5 as li#ht s(in#s

to(ard it.o %t indicates either se$ere macular disease or optic ner$e disease in the a!!ected

eye.

• PUPILLARY REFLEXES:

o Ab)n! Di("! Rf+: %ndicates a problem (ith the a!!erent branch 4Tri#eminal

-5 o! the re!le*.

o Ab)n! Con)n)'a+ Rf+: %ndicates a problem (ith the e!!erent branch 4CN %%%,

Edin#er&;estphal Nucleus5 o! the a!!ected eye.

•

CONVERGENCE: 'bility o! eyes to !ocus in(ard and accommodate !or near $ision.

o Impaired convergence is seen (ith +ra$e3s )isease.

• ARGYLL RO,ERTSON PUPIL: %ndicates a !orm o! CNS Syphilis, Tab) Do()a+i).

o ;ea or absent direct pupillary re!le*.

o #ormal response to accommodation.

o "ailure o! pupillary dilation (ith pain!ul stimulation or a!ter atropine

administration.

• ADIE1S PUPIL: Similar to 'r#yll Robertson Pupil.

o ;ea or absent direct pupillary re!le*.

o Impaired or absent accommodation.

o Eye appears lar#er than the other eye on inspection.

• MYDRIASIS: 'bnormal dilation o! pupil, can occur in )iabetes.

• MIOSIS: 'bnormal constriction o! pupil, seen in 2orner3s syndrome.

o

HORNER1S SYNDROME: ost sympathetics !rom the Superior Cer$icalPle*us. $tosis, Miosis, nhydrosis.

NYSTAGMUS: Nysta#mus is normal (hen looin# in the periphery !or e*tended times. 'll

other nysta#mus is abnormal.

• Causes: abyrinthitis, MS, ;ernice&8orsao!!, Meniere3s )isease



EXTRAOCULAR PALSIES:

• In!(na+ S!(abi).'): Eye points in, due to dener$ation o! the bducens, %# &I .

• E!(na+ S!(abi).'): Eye points out and do(n, due to dener$ation o! the Oculomotor,

%# III.

o Eye points out because o! in!luence o! 'bducens 4CN -%5

o Eye points do(n because o! in!luence o! Trochlear 4CN %-5 &&&&&&< Superior

Obli6ue muscle.

VISUAL FIELD DEFICITS:

• ,ITEMPORAL HEMIANOPSIA: oss o! peripheral $ision1 tunnel $ision, occurs (ith

Pituitary Tumor.

• HOMONYMOUS HEMIANOPSIA: oss o! same $isual !ield in both eyes. Occurs due

to lesion in Optic Tract.

• ;UADRANT HEMIANOPSIA: esion in the optic radiations.

FUNDUSCOPIC INSPECTION:

• RED REFLEX: %ts absence indicates a cataract.

• -ESSES:

o The $eins are normally sli#htly bi##er than the arteries.

o ARTERIO8VENOUS &AV* NICKING: H%#(!n)ion narro(s the arteries and

creates indentations in the $eins, (here arteries cross the $eins.

• MACULA: )immer, darer area in !undoscope, containin# the !o$ea.

• OPTIC DISC: Out o! (hich $essels tra$el. The bri#htest area o! !undoscope.

• RET%NOP'T2OO+%ES:

o DIA,ETIC RETINOPATHY: Sho(s $a(d 'da!) on the retina, (hich are

lipid laden. They are dense, (ell&de!ined creamy (hite spots.

Co!!on 3oo+ E'da!) are poorer de!ined and can occur (ith

hypertension.

o PAPILLEDEMA: S(ellin# o! retinal $essels, !rom impaired $enous return in the

eye &&&&&&< $enous distension.

$apilledema is caused by increased intracranial pressure.

Causes: =rain tumors, mali#nant hypertension, hydrocephalus.

's opposed to $appilitis, there is no loss o! $ision.



o HYPERTENSION: Chan#es in retina are #raded thru >. 'n abnormally hi#h

-0' ratio can be !ound, indicatin# $enous distension.

S!a7 I: 'rteriolar narro(in# but no '-&nicin#.

S!a7 II: "ocal spasm, AV8ni"<in7.

S!a7 III: 2emorrha#es and e*udates

S!a7 IV: Pa#i++d.a/ O#!i" di)" d.a 4due to ischemia5 and

hemorrha#e, (hich can lead to retinal detachment.

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THE EAR

TINNITUS: Rin#in# in ear.

VERTIGO:

• Ob5"!i- V(!i7o: The earth is mo$in# around you.

• S'b5"!i- V(!i7o: You are mo$in# in space.

RINNE TEST: Test !or conductive hearing loss by comparin# air conduction to bone

conduction.

• "irst hold tunin# !or ri#ht near auricle, then place it o$er the Mastoid Process.

• NORM': %t should sound louder near the auricle, because air conduction should be

better than strai#ht bone conduction.

• '=NORM': %! it sounds louder o$er the mastoid process instead, that indicates a

conductive hearing loss in the middle ear.

3E,ER TEST: Place tunin# !or o$er head. %t should be heard e6ually in both ears.

•

ONE E'R %S O?)ER: %! one ear is louder, than there is either conducti$e hearin# lossin that ear or sensorineural hearin# loss in the other ear.

MENIERE1S DISEASE: Triad o! tinnitus, $erti#o, and sensorineural hearin# loss. May see

nausea, $omitin#, nysta#mus.




,ENIGN POSITIONAL VERTIGO: Transient attacs o! $erti#o, induced by mo$ements o!

the head and trun. Symptoms can be induced by ha$in# the patient merely thin about the

mo$ements.

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NOSE and THROAT

NOSE:

• EPISTAXIS: =loody nose.

o T(an)in! E#i)!ai): May occur (ith !orce!ul nose&blo(in#, sneein#, nose&

picin#, !acial trauma.

o R"'((n! E#i)!ai): )i!!erential dia#nosis @ hypertension, coa#ulopathies, renal

!ailure, cirrhosis, $(di!a(% $.o(($a7i" !+an7i"!a)ia.

• RHINOPHYMA: Se$ere acne rosacea !ound in association (ith sin hypertrophy and

con#estion o! subcutaneous tissue, around the nose.

THROAT:

• SOAR THROAT: %n!ection mononucleosis, strep&throat 4streptococcal pharyn#itis5.

• HOARSENESS: aryni#itis, aryn#eal cancer, hypothyroidism, smoin# &&&&&&<

broncho&#enic carcinoma.

A,NORMAL TASTE:

• H%#o7')ia: %mpaired ability to taste. Seen in ?R%3s, #lossitis, stomatitis.

• D%)7')ia: ?npleasant taste. )i!!erential dia#nosis:

o Medications: .!(onida=o+

o -itamin and mineral de!iciencies: inc depletion

o

Chyronic hypercalcemia, hyperparathyroidism.o -iral hepatitis

TONGUE:

• MACROGLOSSIA: ar#e ton#ue can occur (ith amyloidosis and acrome#aly.

• GLOSSITIS: %n!lammation on sides, base, and underside o! ton#ue.




o -itamin and mineral de!icincies

o Medications: metronidaole, phenytoin

o %n!ections: candidiasis

o Pernicious 'nemia

o Cytoto*ic dru#s, radiotherapy.

MOUTH EXAMINATION:

• ORAL ULCERS: Recurrent oral ulcers di!!erential dia#nosis:

o R"'((n! a#$!$o') '+"() 4caner soars5: Common, !re6uently associated (ith

%n!lammatory =o(el )isease.

o %n!ections: HSV80, 2erpes Aoster, tuberculosis, histoplasmosis, syphillis.

o Trauma

o Cytoto*ic dru#s

o Rare: Erythema Multi!orme, ;e#ener3s +ranulomatosis, Ste$ens&Bohnson

Syndrome, Reiter3s Syndrome

• SYN)ROMES:

o PEUT84EGHER1S SYNDROME: Melanin spots on lips are !ound.

o OLIVER83E,ER8RENDU SYNDROME: T+an7i"!a)ia, $ascular lesion

!ormed by dilation o! small #roup o! blood $essels.

• KOPLIK1S SPOTS: ;hite spots on the buccal mucosa, indicati$e o! the .a)+).

• STRA3,ERRY TONGUE: Erythema o! ton#ue, occurs (ith )"a(+! f-(.

CHAPTER >: RESPIRATORY SYSTEM


P?MON'RY SYMPTOMS:

• COUGH:

o Possible Causes o! Cou#h:

Pulmonary 0 Mechanical causes: A)!$.a, %rritants, aspiration





%n!ectious: T'b("'+o)i)/ Hi)!o#+a).o)i)/ Pn'.onia

Temperature: %nhalin# cold air

P'+.ona(% E.bo+i)./ #'+.ona(% d.a?

Non&Pulmonary: e*ternal ear canal irritation.

o )etails:

S.o<(1) Co'7$ usually occurs in mornin# and is producti$e.

A)!$.a!i" Co'7$ usually is non&producti$e.

• SPUTUM: %t is al(ays abnormal.

o PRO)?CT%-E CO?+2S are seen in:

Chronic =ronchitis, Smoer3s cou#h

,(on"$i"!a)i): chronically dilated bronchioles.

ar#e $olume o! sputum, (hich separates into t(o or three layers

upon standin#.

Tumors: =ronchoal$eolar Carcinoma

%n!ections: Pneumonia, tuberculosis, un# 'bscess

;ill usually see %++o@ o( 7(n sputum.

Pulmonary Edema

• HEMOPTYSIS:

o C'?SES:

Most common: ,(on"$i!i)/ ,(on"$o7ni" Ca("ino.a/ Pn'.o"o""a+Pn'.onia

More rare in!ections:

T'b("'+o)i): '#e o$er D, cracles, !e( other symptoms

Coccidiomycosis, 2istoplasmosis

Other Tumors: ;ei#ht loss, ci#arettes, anore*ia

Rare %mmune )isorders: +oodpasture3s Syndrome, ;e#ener3s

+ranulomastosis

P'+.ona(% E.bo+i).:



2i#h -0 Ratio. ots o! $entilation, poor per!usion. E*cessi$e

dead space.

"riction rub, accentuated PF.

Pleuritic chest pain.

o MASSIVE HEMOPTYSIS @ DD m in F> hrs. ?sually associated (ith

b(on"$i"!a)i), and may be indicati$e o! +'n7 "an"( or #'+.ona(%a)#(7i++o)i).

• PLEURITIC CHEST PAIN: Chest pain upon breathin#.

o P?MON'RY C'?SES: =ronchitis, pneumonia, pulmonary embolism,

tuberculosis, lun# carcinoma.

o NON&P?MON'RY C'?SES:

Ti!=1) S%nd(o. &Co)!o"$ond(i!i)*: Super!icial chest pain (ith localtenderness.

T(a"$i!i) presents (ith retrosternal chest pain, made (orse by cou#hin#.

• DYSPNEA: )i!!icult, labored breathin#.

o )i!!erential )ia#nosis: ' laundry list o! possible causes

Pulmonary )isease: COP), cancer, asthma, chronic or acute bronchitis,

emphysema, pneumonia, pulmonary emboli, pneumothora*

Cystic "ibrosis: S(eat test

Cardiac causes: C2", Pulmonary edema, PN)

2ematolo#ic: 'nemia, CO&Poisonin#

Metabolic: 8etoacidosis

Salicylate poisonin#

o Symptoms: )yspnea may be mased by !a"$%#na 4shallo(, rapid breathin#5.

H%#(#na is not tachypnea && it is hyper$entilation 4not labored

breathin#5 usually caused by metabolic acidosis and is unrelated todyspnea. )istin#uish the t(o (ith pulmonary !unction studies.

• ORTHOPNEA: )yspnea (ith onset occurrin# (hile lyin# do(n, and (hich is

immediately corrected upon restoring upright position.

o )i!!erential )ia#nosis: Con7)!i- Ha(! Fai+'( or COPD

'lso bilateral paralysis o! diaphra#ms.



• PAROXYSMAL NOCTURNAL DYSPNEA &PND*: )yspnea at ni#ht, created by lyin#

do(n, but (hich does not immediately improve upon standing up. Patient !eels acutely

air&hun#ry and !re6uently (aes up at ni#ht. Ni#ht s(eats common.

o )i!!erential )ia#nosis: A"'! P'+.ona(% Ed.a secondary to "on7)!i- $a(!fai+'(.

• 3HEEING: 2i#h&pitched musical breath sound usually heard on e*piration, but can

be heard on inspiration.

o C'?SE) by air rushin# past a constricted air(ay, constricted by secretions,

mucous, edema, neuro#enic, a tumor, or an aspirated !orei#n body.

o A)!$.a: ;heein# is characteristic o! asthma.

Si+n! A)!$.a is asthma (ithout (heein#.

o STRIDOR: 2i#h&pitched sound occurrin# (ith inspiration.

Stridor portends total air'ay obstruction, a medical emer#ency.

o A"'! E#i7+o!!i!i): (. Influen)a in!ection in ids. Stridor is characteristic. 2a$e

a chest&tube nearby be!ore e*aminin# epi#lottis to pre$ent 4or treat imminent5aspiration.

• CYANOSIS:

o Cn!(a+ C%ano)i): "ace, lips, ton#ue. Results !rom systemic hypo*ia due to poor

per!usion or $entilation in the lun#s.

o P(i#$(a+ C%ano)i): May be !ound in e*tremities, ears, chees, etc. Can becaused by cold&induced $asoconstriction 4Raynaud3s Phenomenon5 or poor

circulation 4shoc, C2"5.

o )i!!erential )ia#nosis: Pulmonary hypo$entilation, COP)

Cardiac causes: Shunt 4Tetralo#y o! "allot5, pulmonary edema 4cor

pulmonale5

• RHINORRHEA: Nasal dischar#e

• CORYA: Nasal dischar#e caused by a $iral upper respiratory tract in!ection.

"'M%Y 0 SOC%' 2%STORY:

• Pre$ious Tuberculosis in!ection, PP) test.

• Poor dental hy#iene is a ris !or a lun# abscess.

• En$ironmental e*posures re$ealed in social history

o Tra$el



o Psittacosis: E*posure to birds

o e#ionellosis: E*posure to (ater, air&conditioners

• Tobacco use

E9TR'P?MON'RY E9'M%N'T%ON:

• HALITOSIS: Some possible causes

o %ampylobacter $ylori coloniation o! stomach

o un# abscess or bronchiectasis 4!oul&smellin#, !ecal breath&odor5

o Necrotic lesions o! mouth or throat

o Aener3s )i$erticulum

• C+'bbin7 o! !in#ernails:

o Con#enital 2eart )isease: Chronic hypo*ia o! -S) or Tetralo#y, in ids.

o 'dults: Systemic hypo*ia, lun# cancer, bronchiectasis, .)o!$+io.a.

• C$.o)i): Con/uncti$al edema. 2yperthyroidism or obstruction o! S-C.

,REATHING:

• ,(ad%#na: Slo( breathin# rate

o %nsulin Coma

o )ru#&induced respiratory depression

• Ta"$%#na: Rapid, shallo( breathin#, caused by pleuritic chest pain or diseases that

immobilie the lun#.

• H%#(#na: Rapid, deep breathin#1 hyper$entilation.

o )iabetic etoacidosis compensation 4to lo(er PCOF5

o KUSSMAUL RESPIRATIONS: Central hyper$entilation, deep rapid breaths

characteristic o! )iabetic hyper#lycemic coma.

• CHEYNE8STOKES RESPIRATION: Cyclic alternations bet(een apnea andhyperpnea, in (hich PCOF !luctuates and is unstable. %t occurs (hen the respiratory

centers o! the brain become insensitive to changes in %O*

o 'SSOC%'TE) )%SE'SES: Con#esti$e 2eart "ailure 4C2"5, ?remia,

Menin#itis, Pneumonia.

• ,IOT1S ,REATHING: 'ta*ic breathin#1 unpredictable and irre#ular respirations.



o Caused by menin#itis or other cerebral dys!unction.

• SLEEP APNEA: Obesity, leadin# to air(ay obstruction at ni#ht and chronic !ati#ue

durin# the day. Treat (ith CP'P.

%NSPECT%ON:

• ='C8 S%)E:

o ,'ffa+o H'.#: "atty deposit o$erlyin# CG, characteristic o! Cushin#3s Syndrome

o ,a((+ C$)!: Chronically in!lated lun#s characteristic o! COP).

o K%#$o)i): E*cessi$e anterior cur$ature o! spine, as in hunchbac.

Cause: normal or !rom a#in#, o)!o#o(o)i).

o S"o+io)i): ateral cur$ature o! spine.

May be detected by patient bendin# !or(ard and notin# une$en para$ertebral bac muscles.

o Lo(do)i): E*cessi$e posterior cur$ature o! spine. =o(in# o! lumbar and cer$ical

spines to#ether.

o Gibb') Dfo(.i!%: Sharp chan#e o! an#le o! spine instead o! #radual chan#e.

Characteristic o! Pott3s )isease, or -ertebral Tuberculosis

• "RONT S%)E

o P"!') Ca(ina!'. &Pi7on C$)!*: Sternum placed !or(ard, increased

anteroposterior chest measurement.

"ound in Ma(fan1) S%nd(o./ Ri"<!)

o P"!') E"a-a!'. &F'nn+8C$)!*: o(er end o! sternum is depressed in(ard.

May also be !ound in Mar!an3s Syndrome or Ricets.

o F+ai+ C$)!: Caused by multiple !ractures ribs. One side o! chest mo$es

parado*ically relati$e to the other side o! the chest.

PALPATION: 'ssess chest e*cursion by placin# !in#ers at costo$ertebral an#le and ha$in#

patient inhale.

• S'b"'!ano') E.#$%).a: 'ir in subcutaneous space. Can occur in tracheostomy

patients, or people (ith 'R)S (ho ha$e an endotracheal tube.• O+i-(1) Si7n: Tracheal tu# (hen patient li!ts his chin up.

o %ndicati$e o! 'ortic 'neurysm, pullin# trachea do(n(ard by pressure o! le!t main

bronchus.



• Ta"!i+ F(.i!'): -ibration on lun#s (hen you ha$e patient say Hninety&nineH

o %ncreased !remitus is !ound (ith pulmonary consolidation in pneumonia.

o "remitus cannot be heard belo( the le$el o! !luid in emphysema or pleural

e!!usion, because the !luid stops the sound !rom bein# transmitted !urther.

PNEUMOTHORAX: Trachea 'ill shift to'ard opposite side as the pneumothorax. The side o!

the pneumothora* ac6uires positi$e pressure, thus trachea de$iates to the other side.

• T(a"$a+ D-ia!ion: Tracheal de$iation can be caused by other thin#s than

pneumothora*.

o P+'(a+ Eff')ion/ E.#$%).a may also cause trachea to de$iate to the opposite

side.

o A!+"!a)i) o! lun# may cause trachea to de$iate to(ard same side as diseased

lun#.

• Tn)ion Pn'.o!$o(a: Medical emer#ency in (hich air enters the pleural ca$ity and is

trapped durin# e*piration

o Intrathoracic pressure builds to values higher than atmospheric pressure,

compresses the lun#, and may displace the mediastinum and its structures to(ard

the opposite side, (ith conse6uent disad$anta#eous e!!ects on blood !lo(.

PERCUSSION:

• R)onan": Normal breath sound

• H%#(()onan": %ncreased resonance o$er thora*.

o May be !ound in Emphysema or Pneumothora*.

• T%.#an%: Percussion o! #astric air&bubble or air&!illed bo(el. %ncreased resonance.

• D'++n)): )ecreased resonance, normally !ound o$er li$er, spleen, and belo( lun#.

o Causes: Emphysema, Pneumonia (ith consolidation, pleural e!!usion.

• F+a!n)): E*treme dullness (ith !e( or no rin#in# tones.

o Pleural e!!usions, massi$e pulmonary consolidations (ith tumor, pneumonia.

AUSCULTATION:

• +eneral Properties:

o Stethoscope Sounds: ?se the bell side to listen to breath sounds.

Press li#htly: hear lo(&pitched sounds.





• A!+"!a)i): =ronchial plu# &&&&&&< decreased lun# $olume &&&&&&< hi#her lun# density

&&&&&&< lun# mass is pulled to(ard chest (all by ne#ati$e pressure

o Tracheal de$iation to(ard a!!ected side

o cracles, maybe

o no breath sounds

• ,(on"$i"!a)i): Chronic bronchial dilation.

o Caused by fre+uent pulmonary infections or pneumonia.

o ar#e amounts o! sputum (ill be e*pectorated (hen patient lies prone han#in#

to(ard !loor.

• ,(on"$i!i): 'cute 4in!ectious5 or chronic 4smoer3s5

•

,(on"$io+i!i): Common in in!ants and children.

• L'n7 Can"(

• Co( P'+.ona+

• C(o'#: 8ids under I years old. Rapid, staccato cou#hs.

o )i!!erential )ia#nosis is bet(een in!lammatory Croup or Spasmodic Croup.

• C%)!i" Fib(o)i)

• P+'(a+ Eff')ion: ullness on percussion. ecreased fremitus. Reduced breath sounds.

• E.#$%).a

• E#i7+o!!i!i): %n iddies, don3t inspect the pharyn* (ithout a chest tube nearby.

• Pn'.onia

CHAPTER : MUSCULOSKELETAL


EPIDEMIOLOGY:

• COMMON M?SC?OS8EET' )%SE'SES =Y '+E:

o Childhood: Bu$enile R', Rheumatic "e$er

o Youn# adult: Reiter3s Syndrome, SE

o Middle '#e: "ibrositis





o Old '#e: Osteoarthritis

• COMMON M?SC?OS8EET' )%SE'SES =Y SE9:

o Male: +out

o "emale: SE, R'

• COMMON M?SC?OS8EET' )%SE'SES =Y R'CE::

o =lac: Sarcoidosis, SE

o ;hite: Polymyal#ia Rheumatica

SYMPTOMS:

• REITER1S SYNDROME:

o Symptoms: Con5'n"!i-i!i)/ U(!$(i!i)/ A(!$(i!i).

o Si#ns:

K(a!od(.a ,+nno(($a7ia: Rash on palms and soles.

Ci("ina! ,a+ani!i): Circular rash on penis.

Sa')a7 fin7(): S(ellin# o! the tendon sheath o! the hands.

• PSORIATIC ARTHRITIS: 'rthritis occurrin# (ith Psoriasis.

o Si#ns:

Sa')a7 fin7(): S(ellin# o! the tendon sheath o! the hands.

)%P /oints may be in!lamed unilaterally.

• GOUT:

o Symptoms:

Poda7(a: Se$ere #outy pain at the base o! the #reat toe.

• RHEUMATIC FEVER :

o Symptoms:

Mi7(a!o(% Pain: Typical !indin#. Pain mo$in# !rom /oint to /oint.

o 4on) C(i!(ia: )ia#nostic criteria !or Rheumatic "e$er. T(o ma/or criteria, or

one ma/or and t(o minor criteria are re6uired.

Ma5o( C(i!(ia:



Ca(di!i): Myocarditis, Pericarditis

Po+%a(!$(i!i)

C$o(a: Purposeless mo$ements o! $arious muscle #roups

E(%!$.a Ma(7ina!'.: Pin, circular rash on trun on pro*imalarms.

S'b"'!ano') Nod'+): +ranulomatous nodules on e*tensor

sur!aces, o!ten associated (ith cardiac in$ol$ement.

Mino( C(i!(ia:

2istory, Symptoms:

2istory o! pre$ious rheumatic !e$er or rheumatic heart

disease.

'rthral#ia

"e$er

abs:

'cute phase reactants: increased ESR, C&Reacti$e Protein,

leuocytosis.

EC+ abnormalities

Recent streptococcal in!ection.

• GONORRHEA/ DISSEMINATED &Gono"o""a+ A(!$(i!i)*:

o Symptoms:

Mi7(a!o(% Pain: Typical !indin#. Pain mo$in# !rom /oint to /oint.

• RHEUMATOID ARTHRITIS:

o Symptoms:

Mo(nin7 )!iffn)): Pain in the mornin#, (hich tends to loosen up as the

day pro#resses.

Fa!i7': )urin# the day, !ati#ue sets in. The earlier the !ati#ue sets in, the

(orse is the R'.

o Si#ns: The proximal 4P%P and MCP5 /oints are characteristically more in$ol$ed

than the )%P /oints.

Syno$ial Thicenin# && s(ellin# o! /oints.



Entire phalan* may de$iate laterally or medially.

,o'!onni( Dfo(.i!%/ S@an8N"< Dfo(.i!%/ U+na( D-ia!ion: Characteristic de!ormities o! hands and (rists seen in Rheumatoid'rthritis.

• OSTEOARTHRITIS: )e#enerati$e arthritis.

o Symptoms:

Pain usually #ets (orse as the day pro#resses, leadin# to !ati#ue in the

a!ternoon.

o Si#ns: The distal 4)%P5 /oints are characteristically more in$ol$ed than the P%P

/oints.

)istal phalan* may de$iate laterally.

Hb(dn1) Nod): =ony o$er#ro(ths on the dorsum o! the )%P /oints,typical o! osteoarthritis.

• SYSTEMIC LUPUS ERYTHEMATOSUS &SLE*: )ia#nostic Criteria. > o! at any

time is dia#nostic.

o Malar Rash

o )iscoid rash

o Photosensiti$ity

o

Oral ulcers

o 'rthritis

o Serositis 4pleuritis, pericarditis5

o Renal disorder

o Neurolo#ic disorder 4seiures, psychosis5

o 2ematolo#ic 4anemia, leuopenia, lymphopenia, thrombocytopenia5.

o %mmunolo#ic 4ele$ated anti&)N', E&Prep, or biolo#ical !alse positi$e !or

Syphilis 4RPR55

o 'ntinuclear 'ntibody 4'N'5

TERMS:

• K%#$o)i): 'nterior cur$ature o! the spine. Normally !ound in thoracic area, characteried

by e*tensi$e !le*ion.



• Lo(do)i): Posterior cur$ature o! the spine, normally !ound in cer$ical and lumbar areas.

• S"o+io)i): ateral cur$ature o! the spine.

• Va('): Medial de$iation.

• Va+7'): ateral de$iation.

SYMPTOMS:

• P'%N:

o +enerally, the deeper the musculoseletal structure, the more di!!use the pain.

Pain !rom bone is deep or borin# pain.

Pain !rom periosteum is more localied.

o Re!erred pain: )on3t !or#et the )d* o! C') in shoulder pain.

o A(!$(a+7ia: )e!ined as /oint pains (ithout ob/ecti$e si#ns o! in!lammation. %t is

caused by many processes, both in!lammatory and non&in!lammatory.

o A(!$(i!i): Boint in!lammation.

• ST%""NESS:

• ;E'8NESS:

o 3a<n)): oss o! stren#th, due to mechanical or neurolo#ical impairment.

o

Fa!i7': Poor endurance.

%NSPECT%ON

P'P'T%ON: May !ind the !ollo(in# abnormalities on palpation:

• S(ellin#

o Syno$ial thicenin# 4 pannus !ormation5 is characteristic o! R'.

o S(ellin# o! tendon&sheath 4sausa#e&shaped di#it5 occurs in Reiter3s Syndrome and

Psoriatic 'rthritis.

o Eff')ion): "luid is most commonly !ound in the nee.

• )e!ormity

o Gan7+ia: "luid&!illed cysts !ound alon# /oint capsules, usually in the (rist.

o R$'.a!oid Nod'+): "irm nodules !ound on e*tensor sur!aces o! bony

prominences. They contain mononuclear cells and !ibrosis.



o Go'!% To#$i: Boint nodules associated (ith urate deposits.

o ,'()i!i): %n!lammation o! the bursa in the nee or elbo(.

• Erythema and ;armth: Especially in in!lammatory or in!ectious processes.

• imitation o! Ran#e o! Motion:

• Tenderness: The sub/ecti$e sensation o! pain upon pressure.

o +radin#:

B: No tenderness

0: Patient says it is tender

2: Patient says it is tender and (inces

>: Patient says it is tender, (inces, and pulls bac

: Patient (ill not allo( palpation.

• Boint noises or locin#:

'?SC?T'T%ON:

• C(#i!'): +ratin# or #rindin# sensation !elt by patient, or heard by e*aminer. Rubbin# o!

bones due to de#eneration o! articular cartila#e.

• C(a"<in7/ Sna##in7: Snappin# o! /oints is usually not patholo#ic, unless it occurs

repeatedly.

• C+i"<in7: May indicate an abnormality (hen it occurs in TMB /oint.

M?SCE STREN+T2: +raded on a scale !rom J to D.

• : "ull stren#th

• : Stren#th a#ainst #ra$ity and added resistance.

• >: Stren#th only a#ainst #ra$ity, not added resistance.

• 2: Muscle contraction occurs, but not su!!icient to o$ercome #ra$ity.

• 0: Muscle contracts (ith little or no mo$ement.

• B: No muscle contraction.

R'N+E O" MOT%ON

• A"!i- Ran7 of Mo!ion: -oluntary mo$ement

• Pa))i- Ran7 of Mo!ion: E*aminer mo$es the /oint.



• Gonio.!(: )e$ice used to measure an#les, to assess the ran#e o! motion o! a /oint.

• Un)!ab+ 4oin!: E*cessi$e /oint motion 4e*cessi$e e*tension5 o! the nee may be seen in

osteoarthritis.

2E') E9'M:

• TMB 'bnormalities are caused by dental malocclusion, trauma to the /a(, R'.

NEC8 4CER-%C' SP%NE5:

• 'rthritis may limit rotation or lateral !le*ion o! the nec.

S2O?)ER:

• Ro!a!o( C'ff In5'(%: Pain or spasm in mid&abduction is a si#n o! rotator cu!! in/ury.

This is due to de#eneration in the subacromial bursa, resultin# in !riction bet(een thesupraspinatus muscle and acromial process at mid&abduction.

o 'rm can3t rise abo$e about KD, the e*tent to (hich the )eltoid can abduct it.

• Ad$)i- Ca#)'+i!i) &F(o=n S$o'+d(*: ?nilateral di!!use, dull, achin# pain.

o Tenderness is di!!use.

• AC D7n(a!i- A(!$(i!i): Maybe !rom trauma. %t hurts upon mo$ement o! scapula.

• ,i"i#i!a+ Tndini!i) &I.#in7.n! S%nd(o.*: %n!lammation o! the tendon o! the

supraspinatus muscle.

• Ca+"ifi" Tndini!i): Prolon#ed in!lammation o! the supraspinatus tendon, (ith resultin#calci!ication.

E=O;:

• Tnni) E+bo@: Tender and in!lamed +a!(a+ #i"ond%+, resultin# !rom repeated

e*tension. Patient (ill e*perience pain (hen ased to e*tend the elbo( a#ainst

resistance.

• Go+f(1) E+bo@: %n!lammation o! the .dia+ #i"ond%+. Typically sho(s pain (hen

ased to li!t (ith the palms !acin# up(ard 4$olar aspect5.

;R%ST:

• )iseases:

o DE;UERVAIN1S TENOSYNOVITIS: %n$ol$es the e*tensor tendon o! the

thumb. 's patient to apply pressure (ith thumb a#ainst the !ore!in#er, and pain

(ill result.

o GANGLION: Cyst caused by herniated syno$ium into so!t tissues.



o CARPAL TUNNEL SYNDROME: Compression o! median ner$e throu#h

carpal tunnel.

P$a+n1) T)!: 's patient to !le* each (rist at KD !or one minute. Positi$e

test occurs i! numbness and tin#lin# o$er median distribution results.

Tin+1) Si7n: Tin#lin# shots o! pain o$er median ner$e upon percussion o! the (rist.

o DUPUYTREN1S CONTRACTURE: "ibrous contraction o! the palmar

aponeurosis.

May be !ound in R', alcoholism, or !amilial.

• Si#ns:

o ,o'"$a(d1) Nod): S(ellin# o! the P%P /oints, (hich is less common than

s(ellin# o! the )%P /oints.

o Hb(dn1) Nod): =ony o$er#ro(ths on the dorsum o! the )%P /oints, typical o!

osteoarthritis.

o ,o'!onni( Dfo(.i!%: "le*ion contracture o! the P%P /oint, (ith

hypere*tension o! the )%P /oint. Caused by in/ury or R'.

o S@an N"< Dfo(.i!%: 2ypere*tended P%P /oints and !le*ed )%P /oints. May

accompany R'.

SP%NE:

• SCOLIOSIS: ateral cur$ature o! spine. ;hen bendin# o$er, muscular prominences on

one side o! the bac is more prominent than the other side.

• S!(ai7$! ,a"< S%nd(o.: ac o! normal thoracic yphosis.

• Do@a7(1) H'.#: Mared yphosis o! dorsal spine in elderly (omen.

• An<%+o)in7 S#ond%+i!i): R'&lie disease a!!ectin# the lo(er spine and sacroiliac /oints.

• L'.bo)a"(a+ S!(ain: o(er bac pain !rom obesity and or poor posture.

• H(nia!d N'"+') P'+#o)'):

• S"ia!i"a:

2%P:

• %! one le# is shorter than the other as measured !rom 'S%S to anle, hip disease is liely.

• T(nd+nb'(7 T)!: 2a$e patient stand on one !oot. The contralateral hip should pull

up(ard. %! it doesn3t, and the same hip on (hich patient is standin# instead pulls

do(n(ard, then that is a positi$e test and is indicati$e o! hip disease.



• An!a+7i" Gai!: ;alin# !unny 4limpin#5 in order to a$oid pain in the hip.

8NEE:

• ,a<(1) C%)!: E*tension o! the syno$ium into the popliteal space. "elt on posterior nee.

•

O)7ood8S"$+a!!( Di)a): Partial separation o! the 6uadriceps !emoris tendon at thetibial tuberosity, main# the tibial tuberosity s(ollen and tender. Seen in adolescents.

• Gn' Va+7'): 8noc need. 8nees bend in(ard.

• Gn' Va('): =o(le##ed. 8nees bend out(ard.

• Gn' R"'(-a!'.: E*cessi$e e*tension o! the nee.

'N8E and "EET:

• ,'nion: S(ellin# o! the #reat toe. ?sually $al#us is seen too.

• F+a! Foo! & pes planus*: Rela*ation o! lon#itudinal arches, resultin# in !lattenin# o! thearch o! the !oot. Patients tend to (ear do(n the soles o! their shoes on the medial side.

• Hi7$ A("$) & pes cavus*: 2a$e e*cessi$e (ear on their soles at the base o! the heal and

under the metatarsal heads.

• H+ S#'(: Tenderness may happen at the insertion o! the plantar lon#itudinal tendon on

the calcaneous.

• Mo(!on N'(o.a: Pinchin# o! !ibrous neuromas bet(een metatarsal heads, resultin#

se$ere burnin# pain.

CHAPTER 0B: NEUROLOGICAL


NE?ROO+%C SYMPTOMS:

• HEADACHE:

o MIGRAINE HEADACHE: O!ten preceded by aura, and associated (ith

(eaness, numbness, and paresthesias.

o

TENSION HEADACHE: ?sually is !rontal or occipital. Tends to be recurrent.

o CLUSTER HEADACHE: %n males, occurrin# at ni#ht, F&I hours a!ter !allin#

asleep. Symptoms are intense unilateral orbital pain 4o$er one eye5, (ith

lacrimation, rhinorrhea, !lushin#. ?sually lasts about hour.

o C'?SES o! SECON)'RY 2E')'C2E:





Mnin7i).'): Sti!! nec. %! it occurs (ith the H(orst headache o! my

li!e,H then you should be suspicious o! )'ba(a"$noid $.o(($a7.

P(o5"!i+ Vo.i!in7: 2eadache (ith pro/ectile $omitin#, occurrin# in

mornin#, usually means increased intracranial pressure.

T(an)in! +o)) of Con)"io')n)): 2eadache accompanied by transientloss o! consciousness should raise 6uestion o! )!(o<.

• SYNCOPE and OSS o! CONSC%O?SNESS:

• SE%A?RES:

o Types o! Seiures:

Co.#+ Pa(!ia+ Si='(): Patients commonly ha$e !eelin#s o! !ear or

de/a $u associated (ith comple* partial seiures.

G(and Ma+ Si='(): Tonic&clonic, o!ten (ith loss o! autonomic control.

P!i! Ma+ Si='(): astin# !or a short period o! time && only a !e(

seconds.

o C'?SES o! SE%A?RE:

'dolescents 4F&FD5: %diopathic 4E#i+#)%5, Trauma, )ru# and alcohol

(ithdra(al

Youn# 'dults 4FD&IJ5: Trauma, alcoholism, brain tumor

Older adults 4IJL5: b(ain !'.o(, C-', metabolic disorders, electrolyteimbalances 4$%#ona!(.ia, hypo#lycemia, uremia5.

• C2'N+ES in -%S%ON:

o A.a'(o)i) F'7a: Transient, painless loss o! $ision in one eye, due to ischemic

chan#es in retina. ?sually due to "a(o!id a(!(% )!no)i) or some !orm o! retinal

artery occlusion.

Other symptoms, such as (eaness, paresthesias, o!ten accompany the

'maurosis "u#a*.

o

R!(ob'+ba( N'(i!i): Occurs in M'+!i#+ S"+(o)i) and may cause transient losso! $ision in one eye.

• C2'N+ES in 2E'R%N+:

• C2'N+ES in SPEEC2:

o D%)a(!$(ia: )i!!iculty in articulatin# (ords.



o D%)#$onia: )i!!iculty speain# due to impaired phonation ability.

o A#$a)ia: %nability to produce 4.o!o( a#$a)ia5 or understand 4("#!i- a#$a)ia5

meanin#!ul speech.

• P'R'YS%S or ;E'8NESS: Pa()i) is intermittent (eaness.

o C'?SES o! Paresis:

Myasthenia +ra$is 4!ati#able (eaness5

H%#o<a+.ia can result in periodic paralysis.

T(an)in! i)"$.i" a!!a"<) &TIA1)*: Recurrent Transient (eanesses in

an upper e*tremity, accompanied by numbness and paresthesia.

Peripheral neuropathies

Polymyositis or dermatomyositis.

• N?M=NESS and P'REST2ES%':

o 2ypocalcemia, hypoma#nesemia

o 2yper$entilation syndrome

o Paraneoplastic syndrome.

o Medications: isoniaid, metronidaole.

• C2'N+ES in MOO) and SEEP P'TTERN:

• 'CO2O and )R?+ ?SE, SE9?' 2%STORY:

o S'a+ $i)!o(%: %n the neuro e*am, may in6uire about it to e$aluate ris o! 2%-

encephalopathy.

o 'lcoholism mani!ests a lot o! neurolo#ical symptoms 4;ernice, beriberi,

peripheral neuropathies5.

NE?ROO+%C E9'M:

• 'SSESSMENT o! MOTOR "?NCT%ON: Sometimes pluses and minuses can be used !or

e$en !iner #radin#.

o B: No contraction1 paralysis

o 0: Trace o! contraction.

o 2: Mo$es i! #ra$ity is eliminated.

o >: Mo$es a#ainst #ra$ity.



o : Mo$es a#ainst #ra$ity and a#ainst some resistance.

o : Normal stren#th.

• Motor 'bnormalities:

o H%)!(ia: To test (hether (eaness in the le# is !rom hysteria or is or#anic, put ahand on both limbs and ha$e the patient li!t one limb a#ainst the hand3s resistance.

%! the cause o! motor (eaness is or#anic, then e*aminer should !eel the

other le# mo$e the opposite direction in compensation.

%! it is hysteria, then the other le# remains still.

o Fa)"i"'+a!ion): T(itchin#s in restin# muscles. May be normal i! they are

occasional or precipitated by cold. They may be a si#n o! A.%o!(o#$i" La!(a+S"+(o)i) &ALS* i! they are accompanied by (eaness.

o Ti"): Normal mo$ements o! muscle #roups 4such as (inin# or #rinnin#5occurrin# in$oluntarily, as in Tourette3s Syndrome.

o T!an%: %n$oluntary muscle spasms.

Causes: Tetanus, hypocalcemia, hypoma#nesemia, hyper$entilation

syndrome.

C$-o)!<1) Si7n: Tap o$er !acial ner$e anterior to ear, and loo !or

contraction o! the !acial muscles, especially shuttin# o! eyes.

T(o'))a'1) P$no.non: %n!late a blood&pressure cu!! to systolic

pressure and maintain !or &F minutes. %nduction o! carpal&pedal spasmindicates latent tetany.

o T(.o(): Oscillatin# mo$ements caused by in$oluntary contractions o! muscle

#roups.

• SENSORY E-'?'T%ON

o P(i#$(a+ N'(o#a!$i) tend to occur in hand-and-glove distribution && at the

distal ends o! the e*tremities.

o P'%N: ?pon pinpric, patient may e*perience $%#a+7)ia 4reduced pain5,

hyperal#esia, or anal#esia 4no pain5.

o %+2T TO?C2:

H%#)!$)ia %mpaired li#ht touch sensation. 'lso related to li#ht&touch

are hyperesthesia, paresthesia, and anesthesia 4no li#ht touch5.

o Sn)o(% E!in"!ion: %n #a(i!a+ +ob +)ion), i! you put a pinpric on both sides

o! the body o! a patient simultaneously, the patient (ill not percei$e the pric on



the a!!ected side o! the lesion. %! the pins are placed se6uentially, then the patient

still retains normal sensation on both sides.

• STEREO+NOS%S: =ein# able to identi!y ob/ects (ith your eyes closed.

• CERE=E'R "?NCT%ON:

o D%)(7ia: %mproper coordinated !unction o! a muscle #roup.

o D%).!(ia: %nability to properly #ua#e the distance bet(een t(o points. Tested

(ith !in#er&to&nose mo$ements.

o D%)diado"$o<in)ia: %nability to do rapid alternatin# mo$ements.

o S"annin7 S#"$: Prolon#ed separation o! syllables, o!ten seen (ith cerebellar

dys!unction.

o +'%T )isturbances:

Cerebellar esions: Central cerebellar lesion sho(s unsteady #ait, but

con$entional cerebellar si#ns may be normal.

Po)!(io( Co+'.n) L)ion): oss o! proprioception results in unsteady

#ait 'hen eyes are closed , but relati$ely normal #ait (hen eyes are open.

F)!ina!in7 Gai!: Parinsonian #ait, shu!!lin# (al.

o Ro.b(7 T)!: Patient can3t maintain balance (ith le#s ti#ht to#ether, (ith eyes

closed.

o

Ti!'ba!ion: =ody tremor (hen standin# or (alin#, si#n o! cerebellar disease.

RE"E9ES:

• )eep Tendon Re!le*es:

o ?pper E*tremity:

,i"#) Rf+: Elbo( !le*ion.

T(i"#) Rf+: "orearm e*tension.

,(a"$io(adia+i) Rf+: Tap distal radius &&&&&&< !le*ion and partial

supination o! the !orearm.

o o(er E*tremity:

Pa!++a( Rf+: Contraction o! uadriceps 4stron#est muscles in body5

and e*tension o! le#.

S'#(a#a!++a( Rf+: 'bo$e the nee1 same response.





• 'bsence o! Super!icial Re!le*es: ?nilateral suppression o! super!icial re!le*es o!ten

results !rom upper motor lesions subse6uent to a C-'.

• P(i.i!i- Rf+): Presence o! primiti$e re!le*es is o!ten a si#n o! f(on!a+ +ob lesions.

o S'"< Rf+: +ently tap or rub the upper li!t &&&&&&< elicit a re!le*i$e sucin# or

pucerin# response.

o G(a)# Rf+: Stroe the patient3s palm, causin# him to #rasp your !in#ers. '

positi$e test occurs (hen the patient does not let #o o! your !in#ers.

o Pa+.o.n!a+ Si7n: Rub the thenar eminence &&&&&&< elicit re!le*i$e contraction

o! the muscles o! the chin.

CRANIAL NERVE EVALUATION:

• CN I: OLFACTORYo

TEST: 2a$e patient identi!y ob/ects by smell.

o '=NORM':

2ead trauma (ith !racture o! cribri!orm plate

Neoplasm in anterior !ossa: menin#ioma

• CN II: OPTIC

o TEST: -isual acuity, !unduscopic e*am

o '=NORM': ots o! causes o! blindness

• CN III: OCULOMOTOR

o TEST:

2a$e patient mo$e eyes throu#h all !ields o! $ision. %ntact I rd ner$e means

that eyes can mo$e medially, superiorly, and in!eriorly.

P'#i++a(% Rf+: Chec !or pupillary response to li#ht in same eye and

contralateral eye.

P!o)i): Ptosis may occur due to Ird ner$e palsy.

o '=NORM':

?nilateral CN&%%% Palsy: Subarachnoid hemorrha#e resultin# !rom

aneurysm, diabetes, atherosclerosis.

2orner3s Syndrome: ?sually occurs !rom b(on"$o7ni" "a("ino.a

4Pan"oa)! T'.o(5 impin#in# on the Superior Cer$ical +an#lion.



• CN IV: TROCHLEAR

o TEST:

o '=NORM':

• CN V: TRIGEMINAL

o TEST:

Sensory: Chec corneal re!le*. Test !acial sensation (ith eyes closed.

Motor: 2a$e patient clench teeth and palpate masseter muscle.

o '=NORM':

ost Corneal Re!le*: Tumor o! the cerebellopontine an#le.

Ti" Do'+o'(': %rritati$e lesions o! the CN - sensory roots.

Spasm o! muscles o! mastication: tetanus, ad$erse reaction to

Phenothiaines.

• CN VI: A,DUCENS

o TEST: oo laterally.

o '=NORM':

)iabetes, atherosclerosis, increased %CP, neoplasm.

• CN VII: FACIALo TEST: 2a$e patient smile, blin, !ro(n, (rinle !orehead.

o '=NORM': ,++1) Pa+)%

Cn!(a+ L)ion of VII: The supratrochlear muscles are spared, as they

recei$e bilateral inner$ation !rom both !acial ner$es. =elo( the eyes, the

contralateral side (ill be paralyed.

P(i#$(a+ L)ion of VII: There is an entire !acial hemiple#ia, (ith the

paralysis occurrin# on the contralateral side.

• CN VIII: VESTI,ULOCOCHLEAR

o TEST: Standard hearin# and $estibular tests.

o '=NORM': ' $ariety o! disorders

• CN IX: GLOSSOPHARYNGEAL



o TEST: 2a$e patient open mouth and say H'aahhh.H

o '=NORM': See -a#us N. belo(.

• CN X: VAGUS

o TEST: 2a$e patient open mouth and say H'aahhh.H

o '=NORM':

'ortic 'neurysm, =roncho#enic Carcinoma may dama#e the recurrent

laryn#eal ner$e.

?$ula (ill de$iate to(ard the dama#ed side.

• CN XI: SPINAL ACCESSORY

o TEST: 2a$e patient shru# shoulders.

o '=NORM': Polymyositis

• CN XII: HYPOGLOSSAL

o TEST: 2a$e patient stic out ton#ue.

o '=NORM':

MENT' ST'T?S E9'M:

• ST'TE o! CONSC%O?SNESS: The +las#o( Coma Scale

•

OR%ENT'T%ON

• '=%%TY to COOPER'TE

• MOO)

• T2O?+2T PROCESS

• MEMORY !or RECENT and REMOTE E-ENTS

• '=%%TY to 2'N)E CONCEPTS and PRO-ER=S

• PR'CT%C' S8%S

• SPEEC2 PRO=EMS and RECO+N%T%ON o! 'P2'S%'

P'T%ENTS (ith '=NORM' NE?ROO+%C' ST'T?S:

• 'PPRO'C2 to the COM'TOSE P'T%ENT:

• 'PPRO'C2 to the )E%R%O?S P'T%ENT:



• 'PPRO'C2 to the P'T%ENT (ith PER%P2ER' NE?ROP'T2Y:

• 'PPRO'C2 to the P'T%ENT (ith S%+NS o! MEN%N+E' %RR%T'T%ON:

CHAPTER : CARDIAC


C'R)%'C SYMPTOMS, 2%STORY:

• CHEST PAINo ANGINA &ISCHEMIC CARDIAC PAIN*: S6ueein#, crushin#, stran#lin#,

constrictin# pain in center o! chest. Pain may radiate to le!t shoulder, le!t arm,

ri#ht shoulder, /a(.

S!ab+ &T%#i"a+* An7ina: 'n#ina upon e!!ort, or an#ina induced by

increased blood pressure or increased heart&rate. 'n#ina is relie$ed bynitro#lycerin, althou#h nitro#lycerin is not speci!ic to this type o! an#ina.

L-in1) Si7n: Patient maes !ist and holds it up to his chest, to

describe the pain.

S"ond8@ind P$no.non: %! patient repeats same acti$ity a!ter

the attac, he may not !eel the attac a#ain the second time.

3a+<8!$(o'7$ An7ina: The pain subsides as patient continues the

acti$ity.

A!%#i"a+ An7ina: 'typical presentation o! typical an#ina.

typical ymptoms/ Sharp or stabbin# pain, rather than crushin#

pain.

typical %auses/ 'n#ina (ith chan#e in position, !or e*ample,

rather than an#ina strictly upon e!!ort.

ngina +uivalents/ Other symptoms that are caused by

myocardial ischemia.

E*ertional dyspnea.

Nausea, indi#estion.

)iiness, s(eatin#.





Un)!ab+ An7ina: 'n#ina e$en at rest, or an#ina that has recently #otten

(orse. %t is associated (ith sharply increased ris !or myocardial in!arct(ithin > months.

An7ina D"'bi!') is a speci!ic term !or an#ina occurrin# at rest.

Va(ian! An7ina &P(in=.!a+ An7ina*: $aradoxic angina occurrin#durin# rest but usually not durin# e*ercise. %t is caused by "o(ona(%a(!(% )#a).. %t can be hard to spot because it can coe*ist (ith typicalan#ina.

Characteristic EC+ !indin#s can help distin#uish $ariant an#ina

!rom typical an#ina.

Nitro#lycerin (ill probably still relie$e pain, as it rela*es coronary

arteries.

M%o"a(dia+ Infa("!: Typical presentation @ 1nstable angina lasting

longer than 25 minutes, that is not relieved by nitroglycerin.

Silent M%3s and M%3s (ith atypical presentation do occur.

o NON&%SC2EM%C C'R)%'C P'%N:

Mi!(a+ Va+- P(o+a#): ?sually asymptomatic, but may present (ith an

intermittent, sharp, sticin# pain o$er le!t precordium.

P(i"a(di!i): The patient feels relief by shallo' breathing and by sitting

up and leaning for'ard.

Di))"!in7 An'(%).: Sudden, se$ere tearin# pain, radiatin# to theabdomen, nec, or bac, dependin# on (here the aneurysm is #oin#.

o PE?R%T%C 4P?MON'RY5 C2EST P'%N: 'lso see pulmonary study #uide.

P'+.ona(% E.bo+i).: May be asymptomatic, or the patient may !eel a

dull ti#htness i! the embolus is lar#e enou#h.

Pa(o%).a+ D%)#na is the most common symptom o! pulmonary

embolism.

P+'(i)%: Pain upon breathin#. May be caused by pulmonary embolism,

pneumonia, bronchitis, or pleural e!!usion.

P'+.ona(% H%#(!n)ion: )yspnea is a more common symptoms than

pleuritic pain.

Pn'.o!$o(a: Pain may be con!used (ith pain o! an M%.

Mdia)!ina+ E.#$%).a: "ree air in the mediastinum produces chest

ti#htness and dyspnea.



Ha..an1) Si7n: Crunchin#, raspin# sound heard synchronous

(ith the heartbeat, indicati$e o! mediastinal emphysema.

o +'STRO%NTEST%N' C2EST P'%N:

E)o#$a7a+ S#a).: Substernal chest pain and dyspha#ia.

E)o#$a7a+ Rf+' &GERD*: Chest pain relie$ed by antacids.

Ga++)!on Co+i": Colicy R? pain radiatin# to bac and to ri#ht

shoulder. Occasionally it may be con!used (ith an#ina.

o C2EST ;' P'%N:

TIETE1S SYNDROME &COSTOCHONDRITIS*: %n!lammation o!

Costochondral /oints. Pain is o!ten localied and can be elicited by

palpatin# the sternum o$er the in$ol$ed ribs.

HERPES OSTER : Pain may precede the appearance o! the rash. =oth pain and rash !ollo( dermatomal distribution.

DACOSTA1S SYNDROME: Psycho#enic pain usually localied to the

cardiac ape*. May be associated (ith an*iety.

May also see palpitations, hyper$entilation, dyspnea, (eaness,

depression, or other si#ns o! an*iety.

V(!b(a+ Co+'.n Di)a): %t may occasionally lead to anterior chest

pain.

• DYSPNEA: 'ir hun#er or di!!iculty breathin# may be associated (ith cardiac diseases.

o EXERTIONAL DYSPNEA: )yspnea on e*ertion is a common symptom o! mild

or se$ere Con7)!i- Ha(! Fai+'(.

o DYSPNEA a! REST:

P'+.ona(% causes o! dyspnea 4PE, COP), pneumothora*5 o!ten occur at

rest. ;ith cardiac problems, dyspnea usually does not occur at rest, or it is

o$ershado(ed by an#ina.

Ani!% D%)#na: )i!!iculty breathin# due to an*iety occurs only at rest.

o ORTHOPNEA: )yspnea occurrin# (ith patient in the supine position.

Orthopnea is a si#n o! Con7)!i- Ha(! Fai+'( that is more severe than that

associated (ith e*ertional dyspnea.

C'?SE: Supine position increases pulmonary blood !lo( &&&&&&<

e*acerbate pulmonary con#estion and pulmonary edema. The problem is

relie$ed by resumin# a more upri#ht position.



T@o8Pi++o@/ T$(8Pi++o@ O(!$o#na: Terms to describe the se$erity o!

the orthopnea. Three pillo( is (orse than t(o&pillo(.

o PAROXYSMAL NOCTURNAL DYSPNEA &PND*: Similar to orthopnea,

e*cept it has sudden onset and occurs only a!ter the patient has been lyin# do(nat rest !or at least an hour.

?nlie orthopnea, %t is not relie$ed immediately by sittin# up.

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

o PULMONARY EDEMA: Pulmonary edema is usually a mani!estation o! le!t&

$entricular heart !ailure. Peripheral edema associated (ith C2" is a mani!estation

o! ri#ht&sided heart !ailure 4Cor Pulmonale5.

SYMPTOMS: Se$ere symptoms. E*treme an*iety, dyspnea, air hun#er,

cold s(eats, !ear o! impendin# death.

S%+NS: Pin, !rothy sputum, and bubbly breath sounds.

o VALVULAR HEART DISEASE: Mi!(a+ S!no)i) is associated (ith dyspnea.

o CON+EN%T' 2E'RT )%SE'SES:

T!(a+o7% of Fa++o!: E*ertional dyspnea is common.

Vn!(i"'+a( S#!a+ Df"!: Tachypnea and s(eatin#. ate cyanosis.

o C'R)%'C &$s& P?MON'RY )YSPNE':

o

OT2ER C'?SES O" S2ORTNESS O" =RE'T2:

K')).a'+ R)#i(a!ion: %ntense hyper$entilation 4respiratory alalosis5

occurrin# (ith Diab!i" K!oa"ido)i), as a compensatory mechanism to

relie$e the metabolic acidosis.

• PALPITATIONS: 'n unpleasant a(areness o! one3s o(n heart&beat. O!ten described as

!lutterin#, or sippin# a beat.

o Pa(o%).a+ A!(ia+ Ta"$%"a(dia: May cause palpitations (ith an instantaneous

onset.

o

P(.a!'( Vn!(i"'+a( Con!(a"!ion) &PVC1)*: May be e*perienced as palpitations or a sipped beat. The premature contraction is !ollo(ed by a

compensatory pause, to allo( !or $entricular !illin#.

• FATIGUE: Non&speci!ic !indin# o!ten !ound (ith heart disease.

o "'T%+?E C'?SE) =Y 2E'RT )%SE'SE: %t usually occurs later in the day or

in the e$enin#. "ati#ue early in the mornin# is usually not associated (ith heart

disease, unless the patient (as aroused !rom REM sleep.



The heart disease #ets (orse, as the patient e*periences onset o! !ati#ue

earlier in the day.

o OT2ER C'?SES O" "'T%+?E: ots. Chronic illness o! many types, anemia,

psycholo#ical causes.

• SYNCOPE: "aintin#, transient loss o! consciousness.

o VASOVAGAL EVENTS: Most common cause o! syncope, it is caused by

e*cessi$e stimulation o! the -a#us ner$e &&&&&&< e*cessi$e bradycardia and

reduced blood&!lo( to the brain.

Ani!%: %t is usually associated (ith acute an*iety or e*cessi$e emotion.

The -a#al hyperacti$ity is thou#ht to be a hypersensiti$e response to

sympathetic out!lo(.

o CARDIOVASCULAR CAUSES:

A(($%!$.ia):

STOKES8ADAMS SYNDROME: Syncope caused by reduced

cardiac output secondary to an arrhythmia.

=oth se$ere tachycardia and bradycardia can reduce cardiac

output, leadin# to syncope. Se$ere tachycardia reduces cardiac

output by reducin# $entricular !illin# time.

Ca(dia" O'!f+o@ T(a"! Ob)!('"!ion:

Ao(!i" S!no)i) may lead to syncope.

M%o.a), beni#n myocardial tumors, may cause out!lo(

obstruction and lead to syncope.

T!(a+o7% of Fa++o! is associated (ith !aintin# attacs.

M%o"a(dia+ I)"$.ia

Ca(o!id Sin') S%n"o#: (ypersensitivity of the %arotid inus in elderly

men is common cause o! syncope.

I.#ai(d Va)o.o!o( Rf+): %mpairment o! =aroreceptors. Syncope is

associated (ith orthostatic hypotension.

D"(a)d ,+ood Vo+'.

o FLUID REMOVAL:

Mi"!'(i!ion S%n"o#: Syncope occurrin# (ith micturition but at no other

time. 'ssociated (ith remo$al o! !luid !rom the body.



o POST8TUSSIVE SYNCOPE: Syncope a!ter a bout o! cou#hin#, or a!ter the

-alsal$a maneu$er, may occur in patients (ith COP).

• HEMOPTYSIS: Mi!(a+ Va+- S!no)i) is a cardiac disease that may cause hemoptysis.

Mitral Stenosis &&&&&&< pulmonary $enous con#estion &&&&&&< may lead to hemoptysis.

• EDEMA:

o Pi!!in7 Ed.a is a common si#n o! Con#esti$e 2eart "ailure.

o P()a"(a+ Ed.a may be !ound in bed&ridden patients, and may lead to decubitus

ulcers.

o Ana)a("a: Se$ere #eneralied edema and ascites, as seen in se$ere C2", li$er

cirrhosis, or nephrotic syndrome.

o L%.#$d.a may be caused "ilariasis or a tumor obstructin# a lymphatic $essel.

• CYANOSIS: Presence o! e*cessi$e deo*y#enated hemo#lobin in the blood. %t becomes$isible (hen the concentration o! deo*y#enated hemo#lobin e*ceeds J # 0 d && a hi#her

rate o! desaturation than is !ound in the venous blood o! normal people.

o Cn!(a+ C%ano)i): -isible in the lips, !ace, con/uncti$ae, ton#ue. %t is caused by

primary systemic hypoxia due to impaired o*y#enation o! blood. E9'MPES:

T!(a+o7% of Fa++o! or the late sta#es o! other con#enital heart de!ects

Vnoa(!(ia+ )$'n!

o P(i#$(a+ C%ano)i) &A"(o"%ano)i)*: -isible in the !in#ers and toes, earlobes,

nose. %t is caused by locali)ed hypoxia due to poor circulation, reduced blood&!lo(, C2", shoc.

+ENER' P2YS%C' E9'M: Many con#enital disorders are associated (ith $arious heartde!ects. See Table >&J, pa#e JD !or complete list. 'lso see Table o! Physical "indin#s !or a

complete list o! physical !indin#s.

• T2E "'CE:

• T2E EYES:

• T2E MO?T2:

• T2E S8%N:

o R$'.a!i" F-(: Characteristically you (ill see E(%!$.a Ma(7ina!'. and

S'b"'!ano') Nod'+).

• T2E T2OR'9:

• T2E '=)OMEN:



• T2E E9TREM%T%ES:

o C+'bbin7 o! !in#ers and toes is a classic !indin# o! C%ano)i). May also be seen

(ith in!ecti$e endocarditis or other conditions.

,LOOD PRESSURE:

• P'P'T%ON:

• AUSCULTATION &Ko(o!<off So'nd)*:

o P$a) 0: Clear tappin# sounds representin# systolic pressure.

o P$a) 2: So!ter tones

o P$a) >: ouder once a#ain.

o P$a) : Mu!!led Tones.

o P$a) : Tones cease. )iastolic Pressure. )iastolic pressure may actually behi#her than estimated by auscultation.

• %NTERPRET'T%ON:

o A')"'+!a!o(% Ga#: Period o! silence that may occur bet(een Phase and Phase

F. The be#innin# and end o! the 'uscultatory +ap may be mistaen !or )iastolicor Systolic blood pressure, respecti$ely.

C'?SES: -enous distension or se$ere 'ortic Stenosis.

o O(!$o)!a!i" H%#o!n)ion: ?pon standin#, normal decrease in systolic blood

pressure is J&J mm 2#1 anythin# more is Orthostatic 2ypotension. )iastolic pressure normally remains constant or increases sli#htly.

o Obese Patient: ?se a lar#e cu!!.

o 2ypertension:

Coa("!a!ion of !$ Ao(!a (ill result in a systolic pressure that is 6uite

hi#h in the arm, but much lo(er in the le#.

4UGULAR VENOUS PULSES:

• Cn!(a+ Vno') P())'( &CVP*: ?se the ri#ht %nternal Bu#ular to estimate C-P because

it is strai#hter.

o ME'S?REMENT:

;ith patient sittin# up, cla$icles are D cm abo$e ri#ht atrium, thus C-P @

/u#ular $enous distension abo$e cla$icles L D cm.



;ith patient ele$ated ID, sternal 'n#le o! ouis is normally about J cm

abo$e ri#ht atrium, and %nternal Bu#ular should be $isible about I cmdirectly $ertical 4use a ruler5, abo$e the sternal 'n#le o! ouis.

o RESP%R'T%ON: C-P should decrease (ith inspiration and increase (ith

e*piration.

KUSSMAUL1S SIGN: Parado*ical chan#e in C-P durin# inspiration

4and increase instead o! decrease5, caused by a restriction in !illin# o! the

ri#ht $entricle, such as pericardial e!!usion.

HEPATO4UGULAR REFLEX: Normally, it should only sho( a

transient increase in C-P. ;ith Cor Pulmonale, the increased C-P ismaintained throu#hout.

• 4UGULAR VENOUS 3AVES:

o a83a-: Ri#ht atrial contraction, correspondin# to pea !illin# o! the /u#ular $ein.

' lar#e a&(a$e is characteristic o! pulmonary hypertension.

' #iant a&(a$e is characteristic o! a total heart bloc.

No a&(a$e is characteristic o! atrial !ibrillation.

o 8D)"n!: "ollo(s a&(a$e, as atrium rela*es. )ecreased /u#ular $ein !illin#.

"irst heart sound is heard durin# the

o "83a-: Occurs (ith contraction o! the $entricles. ?sually not $isible at bedside.

C'ROT%) P?SE occurs durin# this, (hich is ri#ht a!ter the a&(a$e and

also durin# the *&descent.

o -83a-: Passi$e phase o! atrial !illin# durin# $entricular systole.

o %8D)"n!: =rie! decreases in /u#ular $ein pressure a!ter the Tricuspid $al$e

opens 4be#innin# o! Systole5.

ARTERIAL PULSES:

• Normal Pulses: Radial, =rachial, Carotid, "emoral, Popliteal, Posterior Tibial, )orsalis

Pedis.• Rhythm 'bnormalities:

o Sin') A(($%!$.ia: The pulse accelerates (ith inspiration.

o Premature Contractions:



A!(ia+ P(.a!'( Con!(a"!ion) &APC*: Normally do not disturb the

cycle.

Vn!(i"'+a( P(.a!'( Con!(a"!ion) &PVC*: They are !ollo(ed by a

compensatory pause, and a ne( rhythm is established.

o P'+) Dfi"i!: ;ith A!(ia+ Fib(i++a!ion L Ta"$%"a(dia/ the radial pulse may not be e6ual to the cardiac apical pulse. T(o rapid beats in a ro( may not allo(

su!!icient $entricular !illin# !or the systole to be transmitted to the periphery. The

lapse bet(een apical and radial pulse is the pulse de!icit.

o ,i7.ina+ P'+): T(o consecuti$e heartbeats closely coupled, (ith subse6uent

pause be!ore the ne*t beat.

• -olume 'bnormalities:

o H%#(<in!i" P'+): uic up stroe and !ull $olume, seen (ith hypertension,

an*iety.

o Co((i7an1) P'+): ' bris pulse (ith lar#e $olume, or HCollapsin#H pulse, seen in

'ortic Re#ur#itation.

D'(o=i= M'(.'( should be heard across the !emoral artery

simultaneous (ith the collapsin# pulse.

o ;'in"<1) P'+): -isible capillary pulsations in the nail&bed. 'nother si#n o!

'ortic %nsu!!iciency.

o P'+)') ,i)f(in): =i!id pulse. T(o distinct impulses (ith each heartbeat. Seen

in:

'ortic Re#ur#itation

2ypertrophic Cardiomyopathy.

o P'+)') A+!(an): One pulse !eels lar#e, the ne*t one small. )ue to decreased

cardiac contractility and carries a poor pro#nosis.

o P'+)') Pa(ado'): ;eaenin# o! the pulse (ith inspiration more than normal.

Systolic pressure normally decreases by less than D mm 2#. Parado*ical

pulse occurs (hen decrease is #reater than D mm 2#.

%ndicati$e o! constricti$e cardiac disease: Pericardial e!!usion, constricti$e

pericarditis.

• +radin# Pulses: Scale o! D to >

o Scale:

B @ no pulse



> @ normal pulse

@ boundin# pulse

o In!(.i!!n! C+a'di"a!ion: Temporary (eaenin# o! lo(er e*tremities due to

arterial insu!!iciency.

o L(i"$1) S%nd(o.: 'therosclerosis o! abdominal 'orta, reducin# !lo( to lo(er

e*tremities and leadin# to impotence.

o Ta<a%a)'1) Di)a): Pulseless disease && no pulse in arms, due to pro#ressi$e

obliterati$e arteritis.

T2E PRECOR)%?M:

• Ao(!i" Va+-: Second ri#ht interspace 4upper ri#ht && on the opposite side because the

'orta bends o$er to(ard the ri#ht side5.

•

P'+.oni" -al$e: Second le!t interspace 4upper le!t && on opposite side because thePulmonary arteries bi!urcate behind the 'orta.5

• T(i"')#id Va+-: o(er parasternum 4centrally located5

• Mi!(a+ Va+-: 'pe*

• E(b1) Poin!: Place to listen to ri#ht&sided patholo#ies, at the third le!t interspace.

PALPATION PERCUSSION:

• Poin! of Mai.a+ I.#'+) &PMI*: Should be at the ape*.

o %! it is located more centrally and do(n, that is indicati$e o! COPD due to barrelchest and constantly in!lated lun#s, displacin# the heart centrally 4ri#ht&sidedshi!t5.

o Ri#ht -entricular 2ypertrophy can shi!t the PM% posteriorly, as the ri#ht&

$entricular mass mass the le!t&$entricular PM%, main# it di!!icult to palpate.

• S$o"<: 'n impulse o! a heart sound transmitted to the e*aminin# hand.

• Ha- Lif!: "orce!ul, systolic thrust that mo$es the palpatin# hand up a little.

• T$(i++: ' palpable murmur. ' palpable $ibration that by definition is accompanied by an

audible murmur.

STETHOSCOPE: +et a #ood one. The shorter the tube, the better. )ouble&barreled tubes are

better than sin#le&barrel.

• DIAPHRAGM: 2i#h&pitched 4primarily systolic5 sounds, and press !irmly.

• ,ELL: o(&pitched 4primarily diastolic5 sounds, and press li#htly.



HEART SOUNDS:

• NORMAL HEART SOUNDS: Normal order o! e$ents @ M0/ T0/ A2/ P2

o S0: Closin# o! Mitral 4M5 and Tricuspid 4T5 $al$es.

S is loudest near the ape*.

O?) S: Occurs (ith hi#her cardiac output, such as !e$er, e*ercise,

thyroto*icosis.

SO"T S: Occurs (ith impaired myocardial contraction, C2", mitral

re#ur#itation.

o S2: Closin# o! 'ortic 4'F5 and Pulmonic 4PF5 $al$es.

SP%TT%N+: Normally, ortic closes before $ulmonic, due to hi#her

pressure in 'orta.

3id S#+i!!in7: %NSP%R'T%ON normally increases the inter$al bet(een 'F and PF, (hich is attributed to increased pulmonary

blood !lo(, and decreased pulmonary $ascular resistance.

%NTENS%TY: ' loud SF usually is attributed to the 'ortic $al$e 4'F5, and

o!ten occurs (ith hypertension.

• THIRD HEART SOUND &S>*: Considered normal in in!ants and children.

o C'?SE: Slo(in# o! $elocity o! blood, or $ibrations !rom turbulent blood&!lo(

durin# $entricular !illin#, especially at the be#innin#.

o POS%T%ON: Patient should be in le!t lateral decubitus position !or ma*imalauscultation o! SI.

o Ga++o#: SI sound plus tachycardia, #i$in# the sound o! a #allopin# horse.

o ET%OO+%ES: Cardiac disease (hich causes increased ventricular volume, such

as:

Mitral and Tricuspid Re#ur#itation

Con#esti$e 2eart "ailure

o O#nin7 Sna# &OS*: =rie! clic heard (hen mitral $al$e opens at the be#innin#o! diastole 4around SI5. 'ssociated (ith Mitral Stenosis

o Kn!'"<%: S, SF, SI to#ether ha$e this appro*imate rhythm.

• FOURTH HEART SOUND &S*: l'ays pathological .

o C'?SE: Contraction o! the atria at the end o! diastole &&&&&&< turbulent blood !lo(

(hich is audible as S>.



ecreased ventricular compliance is the most common etiolo#y o! S>

sound.

o ET%OO+%ES:

e!t&Sided: hypertension, aortic stenosis, an#ina pectoris.

Ri#ht&Sided: pulmonary hypertension, pulmonic stenosis.

o Tnn)): S>, S, SF sounds to#ether ha$e this appro*imate rhythm.

• SUMMATION GALLOP: SI L S> L Tachycardia, as seen in chronic hypertension

leadin# to C2".

• SYSTOLIC SOUNDS and CLICKS:

o E5"!ion So'nd): Can be innocent, or caused by abnormal 'ortic $al$es or a

dilated 'orta.

o Mi!(a+ Va+- P(o+a#) &MVP*: ;ill result in a mid or late systolic clic, as the

mitral lea!let protrudes bac into the atrium durin# $entricular contraction.

• NON&-'-?'R SO?N)S:

o P("o(dia+ Kno"< : Results !rom "on)!(i"!i- #(i"a(di!i) and can be heard o$er

the internal /u#ular at the base o! the nec.

C'?SE: thicened pericardium limits e*pansion o! $entricles durin# rapid

!illin# phase o! diastole, resultin# in bacup o! blood.

o

P(i"a(dia+ F(i"!ion R'b: Caused by #(i"a(dia+ ff')ion, and can be heardo$er a limited area in le!t parasternal space.

More e*tensi$e pericardial e!!usion may eliminate the rub, as the

pericardium #ets completely separated !rom the epicardium.,

2E'RT M?RM?RS: +eneral Properties

• Timin#

• ocation

• Con!i#uration: Crescendo 0 )ecrescendo

• %ntensity:

o G(ad I: =arely audible by an e*pert.

o G(ad III: Moderately loud (ith palpable thrill.

o G(ad VI: So loud it can be heard (ithout the stethoscope main# complete

contact (ith the sin.



• "re6uency

• uality

• TR'NSM%SS%ON: ;here does the sound transmit to This is characteristic !or certain

patholo#ies and can be dia#nostic.

SYSTOLIC MURMURS: Cardiac disorders and their associated !indin#s.

• AORTIC STENOSIS: iamond-shaped systolic e3ection murmur .

o ocation: O$er the 'ortic $al$e, at the second ri#ht intercostal space.

o Transmission: to the carotids bilaterally.

• PULMONIC STENOSIS: iamond-shaped systolic e3ection murmur .

o ocation: Second or third le!t parasternal interspace.

• HYPERTROPHIC O,STRUCTIVE CARDIOMYOPATHY: iamond-shapedmidsystolic murmur .

o P'T2OO+Y o! )%SE'SE:

Septal re#ion o! le!t $entricle is thicened &&&&&&< e!t -entricular

2ypertrophy.

)urin# systole, anterior lea!let o! mitral $al$e is abnormal.

%mpaired rela*ation o! the le!t $entricle durin# diastole.

o SO?N): Similar to 'ortic Stenosis, but it does not transmit to the Carotids.

o E9'M%N'T%ON TEC2N%?ES: The murmur becomes louder as left

ventricular volume is reduced. This is parado*ic beha$ior as compared to most

murmurs

Hand7(i# &&&&&&< increase in le!t $entricular $olume &&&&&&< decreased

murmur . This occurs because the septal obstruction is relati$ely lesssi#ni!icant.

Va+)a+-a Man'-(: Murmur becomes louder in the late&sta#e o! the

-alsal$a Maneu$er, rather than so!ter as in most murmurs.

Murmur becomes 6uieter (hen the patient s6uats && also parado*ical

beha$ior.

• MITRAL VALVE PROLAPSE: %! it occurs (ith mitral re#ur#itation, a late systolic

murmur (ill be heard a!ter the midsystolic clic.

o E*amination Techni6ue: ie cardiomyopathy, reduce le!t $entricular $olume

&&&&&&< louder murmur 4and an earlier clic5.



• HOLOSYSTOLIC MURMURS: They indicate that blood is !lo(in# do(n a pressure

#radient (hen it shouldn3t be, as in insu!!iciencies.

o C'?SES: Mitral re#ur#itation, Tricuspid re#ur#itation, -entricular septal de!ect.

• MITRAL REGURGITATION: The most common cause !or (olosystolic Murmur .

o Causes: 'nythin# that maes the mitral $al$e incompetent, or mitral lea!lets

dama#e:

-e#etations

papillary muscle dys!unction

shortened chordae tendineae

o Concurrent !eatures o! Mitral Re#ur#itation:

e!t -entricular 2ypertrophy &&&&&&< Shi!ted PM%

SI #allop

• VENTRICULAR SEPTAL DEFECT: =est heard at lo(er le!t parasternal border 4Erb3s

point5

• TRICUSPID REGURGITATION: (olosystolic murmur

o May result !rom %- dru# use &&&&&&< endocarditis, or Rheumatic $al$ular disease.

• OT2ER M?RM?RS:

o STRAIGHT ,ACK SYNDROME: Systolic e/ection murmur.

o Inno"n! M'(.'()

o Vno') H'.: 2eard abo$e the cla$icles in normal indi$iduals.

o Ma..a(% So'ff+: 2i#h pitched continuous !lo( heard o$er base o! heart in

pre#nancy.

DIASTOLIC MURMURS: Cardiac disorders and associated !indin#s.

• AORTIC INSUFFICIENCY: =lo(in# or ecrescendo diastolic murmur .

o Many causes: in!ectious, rheumatic, dissectin# aortic aneurysm.

o C2" maes the murmur so!ter.

o 'ssociated !indin#s:

Co((i7an1) 3a!( Ha..( P'+): Collapsin# pulse, (ith little up stroe

or do(nstroe.



de Musset3s Si#n: to and !ro head mo$ement synchronous (ith the

heartbeat.

;'in"<1) P'+): capillary pulsation o! !in#ertips.

D'(o=i=1) Si7n: "emoral artery systolic and diastolic bruits.

Hi++1) Si7n: =lood pressure in the le#s bein# hi#her than it is in the arms.

Normal di!!erence @ FD mm 2#

'ortic %nsu!!iciency @ >D&D mm 2#.

• PULMONIC INSUFFICIENCY: ecrescendo diastolic murmur .

o GRAHAM STEELL1S MURMUR : P'+.ona(% H%#(!n)ion as the cause o!

pulmonic hypertension 4due to dilation o! pulmonic lea!lets5.

Prominent a8@a- is !ound concurrent (ith the murmur.

Pa(adoi"a+ S#+i!!in7 also occurs.

• MITRAL STENOSIS: Middiastolic murmur

o C'?SE: Chronic R$'.a!i" Ha(! Di)a) is most common cause.

• TRICUSPID STENOSIS: Middiastolic murmur

• RHEUMATIC FEVER :

o Ca(% Coo.b) M'(.'( is the characteristic murmur occurrin# durin# the

acute sta#e o! Rheumatic "e$er. %t is a blubberin# middiastolic murmur heard atape*. The murmur disappears a!ter acute disease has subsided.

o Middiastolic murmur o! mitral stenosis mi#ht then remain as a se6uel.

• PATENT DUCTUS ARTERIOSUS:

o Con!in'o') M'(.'(): Murmurs occurrin# throu#hout the cardiac cycle, caused

by blood continually !lo(in# !rom hi#her pressure to lo(er pressure. Can beheard (ith Patent )uctus 'rteriosus.

TECHNI;UES FOR ENHANCING AUSCULTATION:

• INSPIRATION: Normally you should see splittin# o! SF (ith inspiration. PF occurs later

and mo$es !urther a(ay !rom 'F.

o Pa(adoi" S#+i!!in7: SF splittin# is decreased instead o! increased (ith

inspiration.

Lf! ,'nd+8,(an"$ ,+o"< causes parado*ic splittin#. %n this condition,

under normal circumstances, 'F already occurs after PF 4instead o! be!ore5,



because o! the le!t&sided heart&bloc. Thus, (ith inspiration, PF actually

mo$es closer to 'F and you see parado*ic splittin#.

• EXHALATION: Can be used to e$aluate right-sided heart murmurs.

o The intensity o! most ri#ht&sided heart murmurs (ill decrease (ith e*halation,

(hile le!t&sided murmurs remain unchan#ed.

• MLLER1S MANEUVER : 2a$e patient pinch the nostrils shut (ith one hand and suc

hard on a !in#er (ith the other.

o MEC2'N%SM: This creates prolon#ed n7a!i- in!(a!$o(a"i" #())'(. That

shift blood from the systemic to the pulmonary circulation, (hich ampli!ies and prolon#s the murmurs !ound (ith inspiration. %t maes it easier to hear inspiratory

murmurs.

• VALSALVA MANEUVER : 2a$e patient hold breath and bear do(n !or FD seconds. Can

be used to e$aluate le!t&sided heart murmurs.

o MEC2'N%SM: This creates a prolon#ed #o)i!i- in!(a!$o(a"i" #())'(. That

shifts blood from the pulmonary to the systemic circulation && the e*act opposite as

Mller3s Maneu$er.

o T%ME CO?RSE: Most le!t&side murmurs !irst #ro( louder, and then #ro( so!ter.

"irst D&J seconds: %nitially, cardiac output increases, and the intensity o!

le!t&sided murmurs increase accordin#ly.

'!ter D&J seconds: Cardiac then be#ins to decrease, as $enous return

!rom the lun#s decreases. Most le!t&sided murmurs then #ro( so!ter a#ain.

o E9CEPT%ONS: T(o conditions sho( di!!erent characteristics than abo$e:

H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: e!t&$entricular

hypertrophy and resultant cardiomyopathy, due to hypertension. ;ith thiscondition, the late&phase o! the murmur actually increases or may be heard

!or the !irst time.

Mi!(a+ Va+- P(o+a#): ate&phase murmur usually increases rather than

decreases, and may be heard !or the !irst time.

• STANDING !o S;UATTING: 2a$e patient s6uat do(n and breathe normally, and then

stand. S6uattin# increases stroe $olume, and standin# decreases it a#ain.

o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: 's patient s6uats, this murmur

should be decreased.

o Mi!(a+ R7'(7i!a!ion: Occasionally decreases.

• S;UATTING !o STANDING:



o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: 's the patient stands bac, this

murmur should increase.

o Mi!(a+ R7'(7i!a!ion: Occasionally increases.

• PASSIVE LEG ELEVATION:

o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: Murmur should decrease, as le!t

$entricular $olume increases and the le!t $entricle enlar#es.

• ISOMETRIC HANDGRIP: ?sin# a hand#rip !or minutes increases peripheral

$ascular resistance.

o )ECRE'SE) %NTENS%TY: 2ypertrophic Obstructi$e Cardiomyopathy, 'ortic

Stenosis 4about ID o! cases5.

o %NCRE'SE) %NTENS%TY: -entricular Septal )e!ect, 'ortic Re#ur#itation,

Mitral Re#ur#itation.

o CONTR'%N)%C'T%ONS: )o not do this test on people (ith myocardial

ischemia, $entricular arrhythmias, or unstable an#ina

• TRANSIENT ARTERIAL OCCLUSION: Place blood pressure cu!! on both arms and

occlude blood&!lo( !or FD seconds.

o %NCRE'SE) %NTENS%TY: Mitral Re#ur#itation, -entricular Septal )e!ect. Most

other murmurs are una!!ected.

• AMYL NITRATE: 2a$e patient inhale amyl nitrate &&&&&&< decreased TPR. 'uscultate

sounds J&ID seconds later.

o )ECRE'SE) %NTENS%TY: Mitral Re#ur#itation, -entricular Septal )e!ect.

o %NCRE'SE) %NTENS%TY: Ri#ht&sided murmurs, aortic stenosis, hypertrophic

obstructi$e cardiomyopathy.

CHAPTER : A,DOMEN


2%STORY T'8%N+:

• A,DOMINAL PAINo C2'R'CTER O" P'%N

PUD: =urnin# or #na(in# pain, epi#astric, may radiate to the bac.





Precipitated by lon# periods o! no !ood or sippin# meals.

O!ten !eel pain early in mornin#, (hich is relie$ed by intae o!

!ood or antacids.

GERD: =urnin#, epi#astric or *iphisternal. Radiates to the retrosternum.

Precipitated by o$er&eatin#, bendin# o$er, or bein# in a reclined

position.

o OC'T%ON O" P'%N:

o R')%'T%ON O" P'%N

Renal Colic o!ten radiates to the #roin.

+allbladder pain o!ten radiates to bac, scapula, or ri#ht shoulder.

Splenic pain o!ten radiates to bac.

Pancreatic pain o!ten radiates to bac.

o "'CTORS PREC%P%T'T%N+ 'N) RE%E-%N+ T2E P'%N

o P'T%ENT 'SSESSMENT O" P'%N SE-ER%TY: Scale o! D to D.

o COMP'R%SON ;%T2 OT2ER TYPES O" P'%N

• ANOREXIA:

o )i!!erential dia#nosis:

Neoplasms

Chronic Renal "ailure

Psychiatric: 'nore*ia ner$osa, depression

%n!ections: 2epatitis, many chronic in!ections.

o Po+%#$a7ia: Seen in hyperthyroidism, malabsorption syndromes, especially

pancreatic insu!!iciency.

•

NAUSEA AND VOMITING:

o D+a%d Ga)!(i" E.#!%in7: %t is a common cause o! nausea. Possible causes o!

delayed #astric emptyin#:

Pyloric Outlet Obstruction: ?lcers, pyloric stenosis, Crohn3s )isease,

neoplasms.



Neuromuscular: Scleroderma, $a#otomy, demyelinatin# diseases 4MS5,

Polio

Metabolic: Diab!i" 7a)!(o#a()i), $%#o!$%(oidi).?

)ru#s: 'nti&choliner#ics, #an#lionic blocers, opiates

Psychiatric: 'nore*ia Ner$osa

o P(o5"!i+ Vo.i!in7: Special $omitin# that can si#ni!y increased intracranial

pressure 4%CP5.

o R7'(7i!a!ion: -omitin# (ithout nasea. Causes:

O$ereatin#.

'chalasia.

)elayed #astric emptyin#

Esopha#eal rin#s and (ebs.

• DYSPHAGIA:

o Odn%o#$a7ia: Pain!ul di!!iculty s(allo(in#.

o Common Causes:

CVA/ )!(o<

Parinson3s

Re!lu* Esopha#itis

Esopha#eal rin#s and (ebs

'chalasia

Esopha#eal Tumors

Candidiasis

• DIARRHEA: E*cretion o! more than IDD # o! stool per day.

o A"'! Dia(($a:

%n!ectious +astroenteritis: higella, almonella, %ampylobacter, in$asi$e

. %oli

Symptom Cluster: "e$er, myal#ia, chills, nausea, $omitin#,

diarrhea, crampin# abdominal pain.



actose %ntolerance

'ntibiotic&associated 4loss o! normal !lora5

%n!lammatory bo(el

o S!oo+ In"on!inn": Recurrent de!ecation in pants is not diarrhea and has a $erylimited di!!erential dia#nosis, all relatin# to ana+ )#$in"!( d%)f'n"!ion:

)iabetes Mellitus

Pre$ious rectal or perirectal sur#ery.

Errant episiotomy !rom a traumatic childbirth.

o C$(oni" dia(($a:

)ietary habits 4co!!ee5

Parasitic in!ection: #iardiasis, amebiasis.

%n!lammatory bo(el disease

• CONSTIPATION: F bo(el mo$ements per (ee is normal in some people.

o A"'! Con)!i#a!ion: Recent change in bo(el habits. Causes:

)ru#s: anticholiner#ics, psycho&acti$e dru#s, many others.

H%#o!$%(oidi).

H%#(#a(a!$%(oidi).

)ecreased !ood intae, decreased !luid intae.

Chronic debilitatin# disease 4post&stroe5.

o Hi()"$)#('n71) Di)a): '#an#lionic Me#acolon

i!elon# constipation

Ocassional passa#e o! enormous stools

'bsence or mared dimunition o! #an#lion cells in rectal tissue

Mared colonic distension.

o Idio#a!$i" C$(oni" Con)!i#a!ion may be caused by a de!ect in the pel$is !loor

in (omen, in (hich they contract the anal sphincter, rather than rela* it, (hende!ecatin#.

• HEMATEMESIS



o Possible Causes:

P?) or erosi$e +astritis

Ma++o(%83i)) Ta( o! esopha#us

Esopha#eal $arices, portal hypertension

• HEMATOCHEIA and MELENA

o HEMATOCHEIA: Occult blood in stool.

Possible Causes

Co+o("!a+ "a("ino.a

Inf"!io') n!(i!i): higella, almonella, %ampylobacter, in$asi$e .

%oli may all cause hematocheia.

2emorrhoids

Chronic di$erticular disease

o MELENA: Passa#e o! blac or $ery dar stool, re!lectin# heme breado(n

products in stool.

Other causes o! blac stool 4other than occult blood5: %ron&containin#

dru#s, bismuth&containin# dru#s, charcoal, lots o! blac cherries.

o Ma(oon8Co+o(d S!oo+) are indicati$e o! massi$e blood loss 4F to I units o!

blood5. ?sually (ill see unstable $ital si#ns. oo !or complications o! P?),

such as per!orated ulcer.

INSPECTION:

• PROTU,ERANT OR DISTENDED A,DOMENo Pa(!ia+ ,o@+ Ob)!('"!ion: )istended abdomen plus peristaltic mo$ements

heard o$er the distension is practically dia#nostic.

o P)'do"%)i)/ P)'do#(7nan"%: ;oman (ho (ants to be pre#nancy de$elops a

distended abdomen psycho#enically.

o %ncreased air in bo(el causin# abdominal distension:

Mechanical !actors, carcinoma or adhesions

'dynamic paralytic ileus.

o A)"i!): Most common cause is alcoholic cirrhosis leadin# to portal hypertension.



F+'id 3a-: Press do(n abdomen and create a !luid (a$e. %t is indicati$e

o! ascites.

P'dd+ Si7n: 2a$e patient lie prone and then #et on hands and nees, to

#et all ascites to #o to a dependent position. Then !lic and auscultate the

abdomen, listenin# !or chan#es in intensity o! sounds. Positi$e test

indicates ascites.

C$%+o') A)"i!) is mily 4lipid5 loo to transudate, indicatin# lymphatic

bloca#e. Occurs (ith intraabdominal lymphomas and 2od#in3s disease.

'scites can be assessed by auscultation by assessin# shi!tin# dullness

(hen patient chan#es position.

• GREY TURNER1S SIGN: Ecchymoses on the abdomen, an unusual place !or

ecchymoses. %t occurs in f'+.inan! a"'! #an"(a!i!i) and carries a #ra$e pro#nosis.

• 4AUNDICE: Most common causes

o -iral 2epatitis

o 'lcoholic i$er )isease

o )ru#&induced /aundice

o Chronic acti$e li$er disease

o Choledocolithiasis

o Pancreatic carcinoma

o Metastatic li$er disease

• A,DOMINAL HERNIAS

o 'natomical Types o! 2ernias:

In7'ina+ H(nia): Most common hernia.

Di("! In7'ina+ H(nia: 2ernia directly penetrates the in#uinal

trian#le. %t creates a bul#e ri#ht abo$e 4superior and medial to5 thein#uinal li#ament.

Indi("! In7'ina+ H(nia: 2ernia passes through the inguinal

canal , and creates a bul#e in the ri#ht o$er the in#uinal li#ament,

as it passes throu#h the in#uinal rin#.

%n men, o!ten herniates into scrotum.

F.o(a+ H(nia: Second most common. 2i#h ris o! stran#ulation, FD

o! cases.



Ob!'(a!o( H(nia: ?nusual, occurin# in elderly, thin, emaciated (omen.

Protrusion o! peritoneal sac throu#h Obturator "oramen.

Symptom: Pain, paresthesia do(n anterior thi#h, due to

compression o! !emoral ner$e.

U.bi+i"a+ H(nia: May occur in people (ith chronic increasedintraabdominal pressure: Multiparous (omen and COP).

S#i7+ian H(nia: Occurs bet(een ubilicus and pubic symphysis.

?nusual.

o Reducability:

Rd'"ib+: The contents o! the hernia can be easily displaced.

I((d'"ib+/ In"a("(a!d: The contents o! the hernia cannot be displaced

and are stuc there.

S!(an7'+a!d: 'n incarcerated hernia that has cut o!! its blood supply,

resultin# in tissue necrosis and #an#rene.

PERCUSSION:

• T%.#an%: %ncreased tympany is heard upon percussion o! the abdomen in cases o!

#a(!ia+ bo@+ ob)!('"!ion.

• Normal i$er Span: D&F cm in men, Q& cm in (omen.

'?SC?T'T%ON:

• PERISTALTIC SOUNDS:

o 'bsent =o(el Sounds: %leus

o %ncreased =o(el Sounds: +astroenteritis.

o ,o(bo(%7.i: 2i#h&pitched bo(el sounds indicatin# small bo(el obstruction.

• SUCCUSSION SPLASH: 'udible presence o! increased amount o! !luid in stomach.

o Normal a!ter a lar#e meal.

o %! it occurs a!ter !astin#, then it is indicati$e o! #%+o(i" ob)!('"!ion?• A,DOMINAL ,RUITS: Caused by calci!ication o! aorta, celiac compression, and

alcoholic hepatitis.

• PERITONEAL FRICTION RU,S: 2earin# a peritoneal !riction rub o$er the li$er is

indicati$e o! li$er metastasis or primary hepatoma.

P'P'T%ON:



• LIVER :o H#a!o.7a+%:

Primary or metastatic 2epatoma.

'lcoholic li$er disease 4!atty li$er5.

Se$ere C2".

%n!iltrati$e diseases o! li$er lie amyloidosis.

Myeloproli!erati$e )isorders: CM, Myelo!ibrosis.

• SPLEEN

o S#+no.7a+%:

%n!ections

euemias

Portal hypertension

• GALL,LADDER

o Co'(-o)i(1) La@: +allbladder is palpable in FJ o! cases o! #an"(a!i""a("ino.a, due to painless distension.

o M'(#$%1) Si7n: R? pain a##ra$ated by inspiration, indicati$e o! a"'!"$o+"%)!i!i).

• KIDNEYS:

o Enlar#ed 8idneys: Polycystic 8idney )isease, hypernephroma, renal cysts,

hydronephrosis.

o P!o!i" Kidn%: Normal&sied idney displaced in!eriorly into abnormal position1

pel$ic idney.

• AORTA: Pulsatile mass in midline is su##esti$e o! 'ortic 'neurysm.

• MASSES and ,O3EL LOOPS

• FEMORAL PULSES and DISTAL AORTA: )ecreased or absence !emoral pulses can be !ound in se$eral disorders:

o )issectin# 'ortic 'neurysm

o Coarctation o! 'orta

o Se$ere atherosclerotic peripheral $ascular disease



o L(i"$1) S%nd(o.: Occlusion o! the distal 'orta.

Symptom Tetrad: bsent femoral pulses, intermittent claudication, gluteal

pain, impotence.

• RECTAL EXAM

'C?TE '=)OM%N' P'%N:

• LOCALIING PAIN !o INTRAA,DOMINAL SITES• INVOLUNTARY GUARDING AND MUSCLE RIGIDITY:

o P(fo(a!d '+"(

o P(fo(a!d bo@+

o P(i!oni!i)

• DIRECT AND INDIRECT TENDERNESS

o Rbo'nd Tnd(n)): Tenderness on sudden release o! pressure. ' reliable si#n

o! peritoneal in!lammation.

o 4a( Tnd(n)): '$oidance o! sudden mo$ements due to abdominal pain. 'lso a

si#n o! peritoneal in!lammation.

'=)OM%N' P'%N SYN)ROMES:

• 'C?TE '=)OM%N' P'%N

o )i!!erential )ia#nosis:

%n!ectious: 'ppendicitis, cholecystitis, pancreatitis, hepatitis,

+astroenteritis, )i$erticulitis.

Crohn3s )isease

,o@+ #(fo(a!ion: Peritoneal si#ns should be present. Patient doesn3t

(ant to mo$e.

,o@+ ob)!('"!ion: Patient can3t stay still and eeps mo$in# around to #et

com!ortable.

Colic: Renal or biliary colic.

)issectin# 'bdominal 'ortic 'neurysm.

o )iabetic 8etoacidosis and other metabolic disorders can simulate an acute

abdomen.

• C2RON%C '=)OM%N' P'%N



o PEPTIC ULCER DISEASE: +na(in#, burnin#, achin#.

Pain partially relie$ed by eatin# !ood.

Chronicity, Rhythmicity, Periodicity

o CHOLELITHIASIS and ,ILIARY COLIC:

Paro*ysms o! sharp colicy R? pain, o!ten radiatin# to bac, ri#ht mid&

abdomen.

%ntolerance to #reasy !oods may be !ound.

?ltrasound is usually dia#nostic.

o DELAYED GASTRIC EMPTYING:

O!ten accompanied by nausea, emesis, and early satiety.

Pain is 'orsened by eatin#.

o CHRONIC PANCREATITIS:

Caused by alcoholism.

May be e*acerbated by eatin#

o PANCREATIC CARCINOMA

;ei#ht loss, abdominal pain, anore*ia, (eaness 0 !ati#ue, diarrhea

common

Pain is $ariable in 6uality, and o!ten ameliorated by sittin# in nee&chest

position.

o LACTASE DEFICIENCY

o IRRITA,LE ,O3EL SYNDROME: 'bdominal discom!ort (ith no

demonstrable or#anic cause.

)e!ecation relie$es the pain.

• 'NTER%OR '=)OM%N' ;' P'%N

o Neuromas, 2erpes Aoster, 2ernias.

o Ti#htenin# o! abdominal (all should aggravate symptoms, indicatin# abdominal&

(all pain. %! ti#htenin# o! abdominal (all relie$ed symptoms or (ere done as a#uardin# action, then that (ould be $isceral pain.

CHAPTER : MALE GENITALIA




SYMPTOMS:

• )YS?R%': ?ncom!ortable or pain!ul urination

o Pain (ith urination: ?rethritis, urethral obstruction, prostatitis.

o Pain !elt after urination: b+add( "a+"'+'), prostatitis.

• "RE?ENCY o! ?R%N'T%ON:

• ?R+ENCY:

• NOCT?R%':

• POY?R%':

• ?R%N'RY %NCONT%NENCE:

• 2EM'T?R%':

o Ti. of H.a!'(ia:

4eginning o! micturition: urethral or prostatic source. =lood is ori#inatin#

near the meatus.

Throughout micturitiuon: renal source. =lood is di!!usely present in urine.

nd o! micturition: bladder source. =lood is ori#inatin# !rom bladder.

o Pain+)) H.a!'(ia: Thin no#+a).) 4renal or bladder5, renal tuberculosis,acute #lomerulo&nephritis.

• O%+?R%', 'N?R%': Renal !ailure.

o O+i7'(ia: F>&hr urine output less than >DD ml

o An'(ia: F>&hr urine output less than DD ml

• PNE?M'T?R%': Passa#e o! air or stool throu#h urinary tract. %t indicates the presence

o! !istula tracts connectin# the +% and ?+ tracts, such as a!ter sur#ery or (ith

in!lammatory bo(el disease.

• PROST'T%SM: No direct relationship e*ists bet(een $oidin# habits and !eelin#s o!

ur#ency, and the sie o! =eni#n Prostatic 2yperplasia.

• PEN%E P'%N, ?CERS, )%SC2'R+E:

o P$i.o)i): Constriction o! the penis, causin# pain in uncircumcised penises.

• OSS o! %=%)O, %MPOTENCE:





• %N"ERT%%TY:

• SCROT' S;E%N+, TEST%C?'R P'%N: Testicular pain is usually caused by

torsion, hydrocele, $aricocele, or spermatocele. Testicular tumors are usually painless

'hen they present.

P2YS%C' E9'M:

• PEN%S

o ,a+ani!i): %n!lammation o! the #lans penis. Causes:

)iabetes mellitus

%n!ections: %andida, Trichomonas

)ru# reactions

Reiter3s Syndrome

o P%(oni1) Di)a): ateral de$iation o! penis, caused by unilateral in!lammation

o! a corpus ca$ernosum.

• SCROT?M

o A!(o#$i" T)!): Caused by orchitis, trauma, "$(oni" a+"o$o+i)., "i(($o)i).

o H%d(o"+: T(an)i++'.ina!ion o! a scrotal mass (ill illumiunate a hydrocele. %! a

pain!ul mass is present, transilluminate it.

• PROST'TE

• %N+?%N' C'N'S and +RO%N: See abdominal study #uide.

• RECT' E9'M

Date post:	05-Jul-2018
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Abdominal Px

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