Clinical Assesment Flashcards

Terms Definitions
Consistency
 
Mobility
 
Delimitation
 
Usual Age
 
Cancer

Usual Age
 
Tenderness        Often tender
 
Cervical Nodes
Pre auricular
post auricular
occipital
tonsilar
submandibular
submental
posterior cervical
superficial cervical
deep cervical
supraclavicular
Consistency  Firm or hard
 
Crepitus seen in osteoarthritis
Increased peristaltic waves in (visible peristalsis)
intestinal obstruction
-coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces suggests
-“Dry” or brown-black ulcers from gangrene may ensue.
decreased arterial perfusion
Each normal electrical impulse starts in the sinus node or Sinoatrial node or SA node- (a group of specialized cardiac cells located in the right atrium near the junction of the vena cava.) The sinus node acts as the cardiac pacemaker and automatically d
An imperforate hymen occasionally delays menarche. Be sure to check for this possibility when menarche seems unduly late in relation to the development of a girl's breasts and pubic hair.
 Heberden's nodes palpated at the DIP joints are called Heberden's nodes seen in In osteoarthritis 
 nodes palpated at the PIP joints are called Bouchard's nodes seen in In osteoarthritis 
Percussion Dullness in both flanks prompts further assessment for
ascites
Oily residue, sometimes frothy or floating, occurs with steatorrhea, or fatty diarrheal stools, from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.
asymmetric diminished pulses in 
arterial occlusion from atherosclerosis or embolism
Right  Ventricular Impulse
Hyperkinetic

Examples of Causes
Diameter
Amplitude
Duration
Location
Examples of Causes-Anxiety, hyperthyroidism, severe anemia
Location-3rd, 4th, or 5th left interspaces
Diameter- not useful
Amplitude-More forceful
Duration-normal
Cardiac Base
2
1)-2nd ICS, RSB
2)-2nd ICS, LSB
Increased transmission of voice sounds suggests that air-filled lung has become
airless.
Tuberculous Epididymitis
The chronic inflammation of tuberculosis produces a firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens.
Urethral caruncle-
prolapse of the urethral mucosa
“Swan neck” deformity:

“Boutonniere deformity”:
“Swan neck” deformity: hyperextension of the PIP joint with fixed flexion of the DIP joint
“Boutonniere deformity”: persistent flexion of the PIP joint with hyperextension of the DIP joint
Facial asymmetry associated with TMJ syndrome.

-Typical features are unilateral chronic pain with chewing, jaw clenching, or teeth grinding, often associated with stress (may also present as headache).
Pain with chewing also in trigeminal neuralgia, te
1-w/ constipation consider medications such as 
2-Constipation occurs with what diseases? (6)
1-anticholinergic agents, calciumchannel blockers, iron supplements, and opiates.
 
2-diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson's disease, and systemic sclerosis.
Indicators of oropharyngeal dysphagia include
drooling, nasopharyngeal regurgitation, and cough from aspiration in muscular or neurologic disorders affecting motility; gurgling or regurgitation of undigested food occur in structural conditions like Zenker's diverticulum
Symptoms of blood loss such as lightheadedness or syncope depend on the rate and volume of bleeding and are rare until blood loss exceeds 500 ml
1-Varicose veins appear  
2-Their walls may feel  
 
 
Many varicose veins can be seen in the leg
1-dilated and tortuous.
2-somewhat thickened.
intima
-Surrounds the lumen of all blood vessels  a -single continuous lining of endothelial cells with remarkable metabolic properties.Intact endothelium synthesizes regulators of thrombosis like prostacyclin, plasminogen activator, and heparin-like molecules.
It produces prothrombotic molecules such as Von Willebrand factor and plasminogen activator inhibitor. It modulates blood flow and vascular reactivity through synthesis of vasoconstrictors like endothelin and angiotensin-converting enzyme and vasodilators such as nitric oxide and prostacyclin.
-The intimal endothelium also regulates immune and inflammatory reactions through elaboration of interleukins, adhesion molecules, and histocompatibility antigens.



Important Areas of Examination

THE LEGS
(vascular)


Size, symmetry, skin color


Femoral pulse and inguinal lymph nodes


Popliteal, dorsalis pedis, and posterior tibial pulses


Peripheral edema
PAD Symptoms
1-Fatigue, aching, numbness, or pain that limits walking or exertion in the legs

2-Any poorly healing or nonhealing wounds of the legs or feet
3- Any pain at rest in the lower leg or foot and changes when standing or supine
4- Abdominal pain after meals and associated “food fear” and weight loss
1- the right ventricle occupies most of the
2-This chamber and the pulmonary artery form a wedgelike structure behind and to the left of the 
1. anterior cardiac surface. 
2-sternum, 
Palpitations involve
-an unpleasant awareness of the heartbeat
-irregular heart beats
1-A brief middiastolic apical impulse indicates an  2-an impulse just before the systolic apical beat itself indicates an
1- S3
2-S4.
There may be dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium. Such epidermoid cysts are common, frequently multiple, and benign
Genital Herpes Simplex

Appearance: Small scattered or grouped vesicles, 1-3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks.


Causative organism: Usually Herpes simplex virus 2 (90%), a double-stranded DNA virus. Incubation: 2 to 7 days after exposure.


Primary episode may be asymptomatic; recurrence usually less painful, of shorter duration.


Associated with fever, malaise, headache, arthralgias; local pain and edema, lymphadenopathy.


Need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution); candidiasis.
A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and rather fragile. When only the tip is seen, it cannot be differentiated clinically from a polyp originating
Uterine enlargement suggests
pregnancy, uterine myomas (fibroids), or malignancy
Prostatitis
Acute bacterial prostatitis, presents with  
The gland feels
More than 80% of infections are caused by
In men younger than 35, consider
.Acute bacterial prostatitis, presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain.
 The gland feels tender, swollen, “boggy,” and warm. Examine it gently.
More than 80% of infections are caused by gram-negative aerobes such as E. coli, Enterococccus, and Proteus.
In men younger than 35, consider sexual transmission of Neisseria gonorrhea and Chlamydia trachomatis.
Restrictions of internal and external rotation and Restricted abduction of hip is common in
 hip osteoarthritis
Patients may complain of unpleasant abdominal fullness after light or moderate meals, or early satiety- (the inability to eat a full meal) Consider?
 diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, gastric cancer; early satiety in hepatitis.
icterus
In some patients, you will be struck by jaundice or icterus, the yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. Normally the hepatocytes conjugate, or combine, unconjugated bilirubin with other substances, making the bile water soluble, and then excrete it into the bile. The bile passes through the cystic duct into the common bile duct, which also drains the extrahepatic ducts from the liver.
Asymmetric blood pressures seen in 
-coarctation of the aorta  
-dissecting aortic aneurysm
1-Sudden arterial occlusion from embolism or thrombosis causes
 2-The limb distal to the occlusion becomes
3- If collateral circulation is good, only 
1-pain and numbness or tingling.
2-cold, pale, and pulseless. 
3-numbness and coolness may result.
Raynaud's Disease and Phenomenon
-Raynaud's disease:Episodic spasm of the small arteries and arterioles; no vascular occlusion
-Raynaud's phenomenon:Syndrome secondary to other conditions such as collagen vascular disease, arterial occlusion, trauma, drugs
-Distal portions of one or more fingers. Pain is usually not prominent unless fingertip ulcers develop. Numbness and tingling are common.
-pain gets worse w/ Exposure to cold, emotional upset and better w/ Warm environment
-Color changes in the distal fingers: severe pallor (essential for the diagnosis) followed by cyanosis and then redness
nodes of the arm
epitrochlear nodes- These are located on the medial surface of the arm approximately 3 cm above the elbow and they drain the distal portion of the arm.
 
(-most of the arm(proximal portion) is drained by the axillary nodes)
Increased JVP  suggests? 4
right-sided congestive heart failure or, less commonly, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction
asymmetric increased fremitus in
unilateral pneumonia from increased transmission
Leaning forward, This position may reveal an asymmetry of the breast or nipple not otherwise visible. Retraction of the nipple and areola suggests an underlying cancer
an underlying cancer
Scrotal Edema
Pitting edema may make the scrotal skin taut; seen in congestive heart failure or nephrotic syndrome.
A bulge that appears on straining suggests
a hernia
Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is most often a result of sexually transmitted infection of the fallopian tubes (salpingitis) or of the tubes and ovaries (salpingo-oophoritis). It is caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and other organisms. Acute disease is associated with very tender, bilateral adnexal masses, although pain and muscle spasm usually make it impossible to delineate them. Movement of the cervix produces pain. If not treated, a tubo-ovarian abscess or infertility may ensue.
Internal hemorrhoids are
enlargements of the normal vascular cushions located above the pectinate line. Here, they are not usually palpable. Sometimes, especially during defecation, internal hemorrhoids may cause bright-red bleeding. They may also prolapse through the anal canal and appear as reddish, moist, protruding masses, typically located in one or more of the positions illustrated.
 The knee should be extended at heel strike and flexed at all other phases of swing and stance.
Abdominal masses may be categorized in several ways:
physiologic (pregnant uterus)
inflammatory (diverticulitis of the colon)
vascular (an abdominal aortic aneurysm), neoplastic (carcinoma of the colon)
 obstructive (a distended bladder or dilated loop of bowel)
Ascites from increased hydrostatic pressure in
cirrhosis, congestive heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction; from decreased osmotic pressure in nephrotic syndrome, malnutrition. Also in ovarian cancer.
Increased pulsation seen in 
aortic aneurysm or of increased pulse pressure
Nodes of the Leg
(superficial, palpable system)
 horizontal group-  chain high in the anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the external genitalia (but not the testes), the anal canal and perianal area, and the lower vagina.
 
 vertical group- clusters near the upper part of the saphenous vein and drains a corresponding region of the leg. 
capillary leak syndrome
in which protein leaks into the interstitial space, seen in burns, angioedema, snake bites, and allergic reactions
intermittent claudication.
pain or cramping in the legs during exertion that is relieved by rest within 10 minutes
he retrograde filling (Trendelenburg) test,
steps

-Start with the patient supine. Elevate one leg to about 90° to empty it of venous blood.
-Next, occlude the great saphenous vein in the upper thigh
 -Ask the patient to stand. While you keep the vein occluded, watch for venous filling in the leg. Normally the saphenous vein fills from below, taking about 35 seconds 

-After the patient stands for 20 seconds, release the compression and look for sudden additional venous filling. Normally there is none; competent valves in the saphenous vein block retrograde flow. Slow venous filling continues.
1-Systole is the period of 
2-pressure in the left ventricle rises from less than
1-ventricular contraction
 
2- 5 mm Hg in its resting state to a normal peak of 120 mm Hg
In diastole, left ventricular pressure continues to drop and falls below left atrial pressure. The mitral valve opens. This event is usually silent, but may be audible as a pathologic?
opening snap (OS) if valve leaflet motion is restricted, as in mitral stenosis.
-right after S2
Ventricular Premature Contractions
Rhythm. A beat of ventricular origin comes earlier than the next expected normal beat. A pause follows, and the rhythm resumes.Heart Sounds. S1 may differ in intensity from the S1 of the normal beats, and S2 may be decreased. Both sounds are likely to be split.
A right-sided heart with a normally placed liver and stomach is usually associated with
congenital heart disease.
Clubbing of the nails in
lung abscesses, malignancy, congenital heart disease
Deeply pigmented, velvety axillary skin suggests
acanthosis nigricans—one form is associated with internal malignancy.
Erectile dysfunction may be from
psychogenic causes, especially if early morning erection is preserved;
also from decreased testosterone, decreased blood flow in the hypogastric arterial system, or impaired neural innervation
Epidermoid Cyst
A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. These are yellowish in color. Look for the dark punctum marking the blocked opening of the gland.
Cancer of the Rectum
Asymptomatic carcinoma of the rectum makes routine rectal examination important for adults. Illustrated here is the firm, nodular, rolled edge of an ulcerated cancer
Generalized symptoms (fever, chills, etc.) are common in
 rheumatoid arthritis, systemic lupus erythematosus (SLE), PMR, and other inflammatory arthritides. High fever and chills suggest an infectious cause.
Chronic Rheumatoid Arthritis
lSwelling and thickening of the MCP and PIP joints
lROM limited, fingers deviated toward the ulnar side
lInterosseous muscle atrophy
l“Swan neck” deformity: hyperextension of the PIP joint with fixed flexion of the DIP joint
l“Boutonniere deformity”: persistent flexion of the PIP joint with hyperextension of the DIP joint
 large dull areas in percussion suggets
 
Pregnant uterus, ovarian tumor, distended bladder, large liver or spleen
Tenderness over the liver suggests
inflammation, as in hepatitis, or congestion, as in heart failure.
Thin, pencil-like stool occurs in an?
obstructing “apple-core” lesion of the sigmoid colon
Many patients with chronic upper abdominal discomfort or pain complain primarily of heartburn, acid reflux, or regurgitation. If patients report these symptoms more than once a week, they are likely to have
gastroesophageal reflux disease (GERD) until proven otherwise.
Conditions such as muscular atrophy can also cause 
different circumferences in the legs.
Persistent splitting results from
delayed closure of the pulmonic valve or early closure of the aortic valve.
a series of precordial crackles synchronous with the heart beat, not with respiration. Best heard in the left lateral position, it is due to
mediastinal crunch or (Hamman's Sign) due to mediastinal emphysema (pneumomediastinum).
The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure in the spermatic cord suggests
a hydrocele of the cord.
Carcinoma of the Vulva
An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma.
An anorectal fistula is an
 inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface (as shown here) or into another viscus. An abscess usually antedates such a fistula. Look for the fistulous opening or openings anywhere in the skin around the anus.
Conditions that impair range of motion include
arthritis, tenosynovitis, Dupuytren's contracture
Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by
food such as alcohol, chocolate, citrus fruits, coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or lying supine.
Increased abdominal pain on either maneuver (a positive Rovsing's sign and referred rebound tenderness) constitutes a positive
psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
1- A diminished or absent pulse indicates  
2- Chronic arterial occlusion, usually from atherosclerosis, causes 3
1-partial or complete occlusion proximally; for example, at the aortic or iliac level, all pulses distal to the occlusion are typically affected.
 
2-intermittent claudication , postural color changes , and trophic changes in the skin .
Pitting edema results from several conditions:
-when legs are dependent from prolonged standing or sitting, which leads to increased hydrostatic pressure in the veins and capillaries; -congestive heart failure leading to decreased cardiac output;
-nephrotic syndrome,
-cirrhosis, or malnutrition leading to low albumin and decreased intravascular colloid oncotic pressure; 
 -drug use.
Finally, although not often heard in normal adults, a fourth heart sound, S4, marks ?
-when is it heard
-whats the pathology
 
-atrial contraction.
-It immediately precedes S1 of the next beat
-also reflects a pathologic change in ventricular compliance.
Atrial Fibrillation and Atrial Flutter With Varying AV Block
Rhythm. The ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may seem regular.Heart Sounds. S1 varies in intensity.
What produces the first heart sound, S1.
Closure of the mitral valve, During systole,
 
 
During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, shutting the mitral valve. 
If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed,
suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue
Paget's Disease of the Nipple
This uncommon form of breast cancer usually starts as a scaly, eczemalike lesion that may weep, crust, or erode. A breast mass may be present. Suspect Paget's disease in any persisting dermatitis of the nipple and areola. Can present with invasive breast cancer or ductal carcinoma in situ
Torsion of the Spermatic Cord
Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection. Torsion, most common in adolescents, is a surgical emergency because of obstructed circulation.
Tumor of the Testisearly stage
late stage
early-Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy.
Late-As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.
Three to five years after menopause, ovaries are atrophic and usually nonpalpable. In postmenopausal women, investigate a palpable ovary for possible
ovarian cyst or ovarian cancer.
Pelvic pain, bloating, increased abdominal size, and urinary tract symptoms are more common in women with ovarian cancer
Retroversion of the Uterus
Retroversion of the uterus refers to a tilting backward of the entire uterus, including both body and cervix. It is a common variant occurring in approximately 20% of women. Early clues on pelvic examination are a cervix that faces forward and a uterine body that cannot be felt by the abdominal hand. In moderate retroversion, the body may not be palpable with either hand. In marked retroversion, the body can be felt posteriorly, either through the posterior fornix or through the rectum. A retroverted uterus is usually both mobile and asymptomatic. Occasionally, such a uterus is fixed and immobile, held in place by conditions such as endometriosis or pelvic inflammatory disease.
Prolapse of the Rectum
On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, appearing as a doughnut or rosette of red tissue. A prolapse involving only mucosa is relatively small and shows radiating folds, as illustrated. When the entire bowel wall is involved, the prolapse is larger and covered by concentrically circular folds.
1-Stiffness and limited motion after inactivity, sometimes called gelling, seen in
 
2-stiffness lasting 30 minutes or more after inactivity seen in
 
Stiffness also with fibromyalgia and polymyalgia rheumatica (PMR)
1-Stiffness and limited motion after inactivity, sometimes called gelling, seen in degenerative joint disease but usually lasts only a few minutes;
 
2-stiffness lasting 30 minutes or more after inactivity seen in rheumatoid arthritis
 
Stiffness also with fibromyalgia and polymyalgia rheumatica (PMR)
Localized tenderness or pain with adduction of arm accross chest suggests?
 
whats the name of this test?
inflammation or arthritis of the acromioclavicular joint. But sensitivity and specificity of tenderness is
 
“crossover test.”
1-Monoarticular Pain (in one joint) suggests
 
2-Lateral hip pain near the greater trochanter suggests
1-Monoarticular Pain (in one joint) suggests trauma, monoarticular arthritis, possible tendinitis, or bursitis.
 
2-Lateral hip pain near the greater trochanter suggests trochanteric bursitis
The pain of appendicitis classically begins near, then shifts to?
begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it.
 
 
Older patients report this pattern less frequently than younger ones
Note that an aortic valve murmur may radiate to the neck and sound like a?
carotid bruit
 
Listen to the carotids at the neck w/ the bell, low pitch sounds
1-Of the two components of the S2, which is louder and softer
2-where are A2 and P2 heard
 
3- where do you search for splitting of the S2.
 
1)-A2 is normally louder, reflecting the high pressure in the aorta. 
-P2, is relatively soft, reflecting the lower pressure in the pulmonary artery. 
 
2)- A2 is heard throughout the precordium.
-P2 is heard best in its own area—the (LSB) 2nd and 3rd left interspaces close to the sternum. It is here that you should search for splitting of the S2.
3)-LSB
Abnormal retraction of the lower interspaces during inspiration. Supraclavicular retraction is often present
Severe asthma, COPD, or upper airway obstruction
Spermatocele and Cyst of the Epididymis
A painless, movable cystic mass just above the testis suggests a spermatocele or an epididymal cyst. Both transilluminate. The former contains sperm, and the latter does not, but they are clinically indistinguishable.
 Flex the patient's shoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally.
 
name of test?
Pain during this maneuver is a positive test indicating possible rotator cuff tear.
 
Test Hawkin's impingement sign.
Pain with pressure or fist percussion of kidney suggests
pyelonephritis but may also have a musculoskeletal cause.


If pain or diminished pulses suggest arterial insufficiency, look for postural color changes by 
(sitting exam)


-ask the patient to sit up with legs dangling down. Compare both feet, noting the time required for:
• Return of pinkness to the skin, normally about 10 seconds or less
• Filling of the veins of the feet and ankles, normally about 15 seconds
(any longer, abnormal)
1- S1 is decreased in 
2- S2 is decreased in
1- first-degree heart block
2- aortic stenosis.
The term heart failure is now preferred over “congestive heart failure” because?
not all patients have volume overload on initial presentation
Swelling above and adjacent to the patella suggests
 
Thickening, bogginess, or warmth in these areas indicate
synovial thickening or effusion in the knee joint.
 
synovitis or nontender effusions from osteoarthritis
Pain may also be referred to the abdomen from
3
the chest, spine, or pelvis, thus complicating the assessment of abdominal pain
If edema is present, look for possible causes in the peripheral vascular system. 
3
These include (1) recent deep venous thrombosis, (2) chronic venous insufficiency from previous deep venous thrombosis or incompetence of the venous valves, and (3) lymphedema. Note the extent of the swelling. How far up the leg does it go
When measuring JUGULAR VENOUS PRESSURE (JVP)
1. what is normal and abnormal hight
2. what positions do u measure in
1-JVP measured at more than 4 cm above the sternal angle, or more than 9 cm above the right atrium, is considered elevated or abnormal
 
2-30 degrees 60 and 90
Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include
a very thick chest wall; an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor
with the McMurray test if
A click or pop along the medial joint with valgus stress, external rotation, and leg extension
suggests a probable tear of the posterior portion of the medial meniscus. The tear may displace meniscal tissue, causing “locking” on full knee extension.A McMurray sign and locking make a medial meniscus tear more likely.
Cancer of the prostate is suggested by
an area of hardness in the gland. A distinct hard nodule that alters the contour of the gland may or may not be palpable. As the cancer enlarges, it feels irregular and may extend beyond the confines of the gland. The median sulcus may be obscured. Hard areas in the prostate are not always malignant. They may also result from prostatic stones, chronic inflammation, and other conditions
If you suspect edema, measure the legs to identify the edema. Compare one side with the other. A difference of more than ___________________ suggests edema.
 1 cm just above the ankle or 2 cm at the calf is unusual in normal people and
Tenderness
 
Number
 
Shape
 
Number              Single or multiple
 
Tenderness      Usually nontender
 
Flatness-eg Large pleural effusion
Dullness- Lobar pneumonia
Resonance-Simple chronic bronchitis or norm
Hyperresonance-COPD, pneumothorax
Tympany(loud w/ high pitch)-Large pneumothorax
Consistency      Soft to firm, usually elastic
 

Prepatellar bursitis (“housemaid's knee”) from excessive kneeling.

Anserine bursitis from running, valgus knee deformity, fibromyalgias, osteoarthritis.
A popliteal or “baker's” cyst from distention of the gastrocnemius semimembranosus bursa
An obstructed, distended gallbladder may form an oval mass below the edge of the liver and merge with it. It is dull to percussion.


Acute Arterial Occlusion


-Embolism or thrombosis, 
-Sudden onset of distal pain, usually involving the foot and leg
-Coldness, numbness, weakness, absent distal pulses
A sustained low-amplitude (hypokinetic) apical impulse may result from
dilated cardiomyopathy.
1-Dyspareunia-

2- Vaginismus refers to
1-Dyspareunia- pain during sex
 
2- Vaginismus- refers to an involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during intercourse painful or impossible.
Tenderness and effusion suggest synovitis of the glenohumeral joint.
If the margins of the capsule and synovial membrane are palpable, a moderate to large effusion is present.
Minimal degrees of synovitis at the glenohumeral joint cannot be detected on
Tenderness in ischiogluteal bursitis or “weaver's bottom”—because of the adjacent sciatic nerve, this may mimic sciatica
angina from inferior wall coronary ischemia along the diaphragm may present as
heartburn
Rebound tenderness suggests
peritoneal inflammation, if appendicitis
A loud P2 suggests .
pulmonary hypertension
Louder, clearer voice sounds are called
bronchophony
Chancroid

Appearance: Red papule or pustule initially, then forms a painful deep ulcer with ragged non-indurated margins; contains necrotic exudate, has a friable base.


Causative organism: Haemophilus ducreyi, an anaerobic bacillus. Incubation: 3 to 7 days after exposure.


Painful inguinal adenopathy; suppurative boboes in 25% of patients.


Need to distinguish from: primary syphilis; genital herpes simplex; lymphomogranuloma venerium, granuloma inguinale from Klebsiella granulomatis (both rare in U.S.).

Menopause usually occurs between 48 and 55 years, 
If your patient is perimenopausal, with onset of variable cycle length, ask about such vasomotor symptoms as hot flashes, flushing, and sweating. Sleep disturbances are also common. After menopause, th
“No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovagina
bacterial vaginosis
Remember that tenderness in the costovertebral angles may signify kidney infection rather than a musculoskeletal problem.
1-Extra-articular structures include-
 



2-Extra-articular disease typically involves-
1-Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin.


 

2-Extra-articular disease typically involves selected regions of the joint and types of movement
color of stools
1-melena,

2-hematochezia
1-black tarry stools
2-stools that are red or maroon-colored
1-Bulging flanks suggests?
2-suprapubic bulge suggests?
1-ascites-fluid wave test
 
2- a distended bladder or pregnant uterus; hernias
 regurgitation
Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching
Anorexia is?
loss or lack of appetite.
 
Find out if it arises from intolerance to certain foods or reluctance to eat because of anticipated discomfort. Check for associated symptoms of nausea and vomiting
Hematemesis may accompany
esophageal or gastric varices, gastritis, or peptic ulcer disease.
Neuropathic Ulcer
-This condition develops in pressure points of areas with diminished sensation;
-seen in diabetic neuropathy, neurologic disorders, and Hansen disease.
-Surrounding skin is calloused. There is no pain, so the ulcer may go unnoticed. In uncomplicated cases, there is no gangrene. Associated signs include decreased sensation and absent ankle jerks
Compartment Syndrome
-Pressure builds from trauma or bleeding into one of the four major muscle compartments between the knee and ankle (Each compartment is enclosed by fascia and thus cannot expand)
-Tight, bursting pain in calf muscles, usually in the anterior tibial compartment, sometimes with overlying dusky red skin.
-Pain lasts Several hours if acute (pressure must be relieved to overt necrosis). During exercise if chronic.
-Aggravates pain-Acute:anabolic steroids; surgical complication; crush injury.Chronic:occurs with exercise
-Relives pain-Acute: surgical incision to relieve pressure
Chronic:avoiding exercise; ice elevation
 
-Tingling, burning sensations in calf; muscles may feel tight, full, numbness, paralysis if unrelieved
Pulsus Alternans
-The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular
 
 -Pulsus alternans indicates left ventricular failure and is usually accompanied by a left-sided S3.
The level identified by first hearing Korotkoff sounds is the highest systolic pressure during the respiratory cycle. The level identified by hearing sounds throughout the cycle is the lowest systolic pressure. A difference between these levels of more th
Louder, clearer whispered sounds are called
whispered pectoriloquy
Acute Epididymitis
An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. It occurs chiefly in adults. Coexisting urinary tract infection or prostatitis supports the diagnosis.
Other Symptoms
Pruritus; vaginal soreness; pain on urination (from skin inflammation); dyspareunia
dyspareunia (Superficial pain) suggests-
dyspareunia (deeper pain) may be from
 
dyspareunia (Superficial pain) suggests- local inflammation, atrophic vaginitis, or inadequate lubrication;
dyspareunia (deeper pain) may be from pelvic disorders or pressure on a normal ovary.
The cause of vaginismus may be physical or psychological
positive Lachman Test
knee at 15 degrees with FWD excursion suggests
ACL tear
1- Articular structures include-
 



2-Articular disease typically involves swelling and tenderness of
1- Articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone.


 

2-Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion.
if Involuntary rigidity (muscular spasm) typically persists during Light Palpation.
even with the relaxing breathing methods
It indicates peritoneal inflammation.
Parietal pain
-It is a steady, aching pain
-usually more severe than visceral pain 
 -more precisely localized over the involved structure.
-It is typically aggravated by movement or coughing. -Patients with this type of pain usually prefer to lie still
 
originates from inflammation in the parietal peritoneum.
1-GERD  atypical respiratory symptoms
2-Some patients may have “alarm symptoms,” such as
1-cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness and chronic sore throat
 
2-difficulty swallowing (dysphagia), pain with swallowing (odyophagia), recurrent vomiting, evidence of gastrointestinal bleeding, weight loss, anemia, or risk factors for gastric cancer
Prominent veins in an edematous arm suggest 
venous obstruction.

“Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetr
Suggests atherosclerotic peripheral arterial disease
A fully described murmur might be: a “medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th left interspace, with radiation to the apex”
Preload
refers to the load that stretches the cardiac muscle before contraction. The volume of blood in the right ventricle at the end of diastole,
 
-Right ventricular preload is increased by increasing venous return to the right heart.
-Physiologic causes include inspiration and the increased volume of blood flow from exercising muscles.
-The increased blood volume in a dilated right ventricle of congestive heart failure also increases preload.
-Causes of decreased right ventricular preload include exhalation, decreased left ventricular output, and pooling of blood in the capillary bed or the venous system.
Right  Ventricular Impulse
Volume Overload


 

Examples of Causes
Diameter
Amplitude
Duration
Location
Examples of Causes-Atrial septal defect
Location-Left sternal border,
Diameter- not useful
Amplitude-More forceful
 
Lateral displacement of the trachea in
pneumothorax- contra 
pleural effusion-contra
atelectasis-ipsi
Breast cancer is the most common cause of cancer in women worldwide, accounting for more than 10% of cancers in women. In the United States a woman born now has a 12%, or 1 in 8, lifetime risk of developing breast cancer. The probability of diagnosis over
Common scrotal swellings include
indirect inguinal hernias, hydroceles, and scrotal edema
Genital Herpes
Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as shown. Recurrent infections usually are confined to a small local patch.
1-Primary dysmenorrhea results from
2-Causes of secondary dysmenorrhea include
1-Primary dysmenorrhea results from increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline
2-Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps
Chronic Tophaceous Joint
 
lMay mimic RA and OA
lJoint involvement is usually not symmetric as in RA
lAcute (huge)inflammation present
lKobby swellings around the joints ulcerated and discharge white chalklike urates
When the knee joint contains a large effusion, suprapatellar compression ejects fluid into the spaces adjacent to the patella. A palpable fluid wave signifies a positive “balloon sign.” A returning fluid wave into the suprapatellar pouch confirms an e
Referred pain
Referred pain is felt in more distant sites, which are innervated at approximately the same spinal levels as the disordered structures.
 
Referred pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from the initial site. It may be felt superficially or deeply but is usually well localized
Splenomegaly is eight times more likely when the spleen is palpable. Causes include
portal hypertension, hematologic malignancies, HIV infection, and splenic infarct or hematoma
An exaggerated, widened femoral pulse suggests a
 femoral aneurysm, a pathologic dilatation of the artery.
Deep Venous Thrombosis (DVT)
Clot formation in a deep vein
 
Possible swelling of the foot and calf, local calf tenderness
 
wlakin makes it worse elevation of feet makes it better
The Allen test 
-The patient should rest with hands in lap, palms up.
-Ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers.
-Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale (Extending the hand fully may cause pallor and a falsely positive test)
-Release your pressure over the ulnar artery. If the ulnar artery is patent, the palm flushes within about 3 to 5 seconds.(Persisting pallor indicates occlusion of the ulnar artery or its distal branches)
-Patency of the radial artery may be tested by releasing the radial artery while still compressing the ulnar artery.
“base of the heart”


a clinical term that refers to the superior aspect of the heart at the right and left 2nd interspaces next to the sternum.
 
Varying S1
S1 varies in intensity (1) in complete heart block, when atria and ventricles are beating independently of each other and (2) in any totally irregular rhythm (e.g., atrial fibrillation). .
Middiastolic and presystolic murmurs reflect
turbulent flow across the atrioventricular valves
Breath Sounds-Bronchial or bronchovesicular over the involved area


Transmitted Voice Sounds-Spoken words louder, clearer (bronchophony), Spoken “ee” heard as “ay” (egophony) Whispered words louder, clearer (whispered pectoriloquy)


Tactile
Airless Lung, as in Lobar Pneumonia
Abnormal Contours
Look for any variation in the normal convexity of each breast, and compare one side with the other. Special positioning may again be useful. eg- marked flattening of the lower outer quadrant of the left breast.

1-Phimosis is

2-Paraphimosis is

1-Phimosis is a tight prepuce that cannot be retracted over the glans.
 

2-Paraphimosis is a tight prepuce that, once retracted, cannot be returned. Edema ensues.
Secondary Syphilis (Condyloma Latum)
Slightly raised, round or oval, flat-topped papules covered by a gray exudate suggest condylomata lata. These constitute one manifestation of secondary syphilis and are contagious.
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. (Or in a female, uterine cervix nontender.) Stool brown and hemoccult negative.”
OR
“Perirecta


EXAMPLES OF ABNORMALITIES
Raises concern of proctitis from infectious cause




EXAMPLES OF ABNORMALITIES
Raises concern of prostate cancer
The MCPs are often boggy or tender in
rheumatoid arthritis
Test thumb abduction by asking the patient to raise the thumb straight up as you apply downward resistance.
Weakness on thumb abduction is a positive test—the abductor pollicis longus is innervated only by the median nerve. Weak thumb abduction, hand s
carpal tunnel disease
Studies suggest that neuropeptides like 5-hydroxytryptophan and substance P mediate
interconnected symptoms of pain, bowel dysfunction, and stress

Distinguishing an Abdominal Mass From a Mass in the Abdominal Wall.
An occasional mass is in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdom
1-remains palpable when the pt flexes
 
2-is obscured by muscular contraction.
If you suspect arterial insufficiency, feel for the 
brachial pulse. Flex the patient's elbow slightly, and palpate the artery just medial to the biceps tendon at the antecubital crease. The brachial artery can also be felt higher in the arm in the groove between the biceps and triceps muscles.
abdominal aortic aneurysm (AAA)
1-when is it present
2-risk factors 6
-aaa is present when the infrarenal aortic diameter exceeds 3.0 cm (mortality rates increase over 5.5 cm)
-2-smokers
-CAD
-PAD
-Fam History
-HTN
-elevated cholesteol
1- A sustained, high-amplitude apical impulse that is normally located suggests

2- If such an impulse is displaced laterally, consider
1-left ventricular hypertrophy from pressure
overload (as in hypertension).
 
2-volume overload.
 
(JVP) venous pressure may appear elevated on expiration only and the internal jugular veins collapse on inspiration, this suggests?
In patients with obstructive lung disease,
 
(This finding does not indicate congestive heart failure)
Extra Sounds in Systole
Such as ejection sounds or systolic clicks
Thickening and prominent pores suggest
breast cancer
(Thickening of the skin and unusually prominent pores may accompany lymphatic obstruction)
Excoriations or itchy, small, red maculopapules suggest
pediculosis pubis (lice or “crabs”). Look for nits or lice at the bases of the pubic hairs.

G =


P =

Pregnantcy

G = gravida, or total number of pregnancies


P = para, or outcomes of pregnancies. After P, you will often see the notations F (full-term), P (premature), A (abortion), and L (living child).
Normal Prostate Gland
As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure approximately 2.5 cm long.
The median sulcus can be felt between the two lateral lobes.
Only the posterior surface of the prost
As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure approximately 2.5 cm long. The median sulcus can be felt between the two lateral lobes. Only the posterior surface of the prostate is palpable. Anterior lesions, including those that may obstruct the urethra, are not detectable by physical examination.
Thenar atrophy seen in _______________from _______________

hypothenar atrophy seen in
Thenar atrophy in median nerve compression from carpal tunnel syndrome

 
hypothenar atrophy in ulnar nerve compression.
Is there odynophagia, or pain on swallowing Consider
esophageal ulceration from radiation, caustic ingestion, or infection from Candida, cytomegalovirus, herpes simplex, or HIV.

Can be pill-induced (aspirin, nonsteroidal anti-inflammatory agents).
Attributes favoring an enlarged kidney over an enlarged spleen include
 preservation of normal tympany in the left upper quadrant and the ability to probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders.
Decreased or absent pedal pulses (assuming a warm environment) with normal femoral and popliteal pulses suggest 
occlusive disease in the lower popliteal artery or its branches—often seen in diabetes mellitus.
FLUID EXCHANGE AND THE CAPILLARY BED
-Blood circulates from arteries to veins through the capillary bed
-Blood pressure (hydrostatic pressure) within the capillary bed, especially near the arteriolar end, forces fluid out into the tissue spaces.
-As blood continues through the capillary bed toward the venous end, its hydrostatic pressure falls, and another force gains dominance. This is the colloid oncotic pressure of plasma proteins, which pulls fluid back into the vascular tree.
-Lymphatic capillaries, which also play an important role in this equilibrium, remove excessive fluid, including protein, from the interstitial space.
-Lymphatic dysfunction or disturbances in hydrostatic or osmotic forces can all disrupt this equilibrium. The most common clinical result is the increased interstitial fluid known as edema 
Thrills may accompany loud, harsh, or rumbling murmurs as in? 4
aortic stenosis, patent ductus arteriosus, ventricular septal defect, and, less commonly, mitral stenosis
The jugular venous hum
which is common in children, may still be heard through young adulthood
A second, more important example is the cervical systolic murmur or bruit, which may be innocent in children but suspicious for arterial obstruction in adults
1- Small, thready, or weak pulse seen in 
2- bounding pulse seen in 
1-cardiogenic shock
2- aortic insufficiency
 
Occasionally in severe obstructive pulmonary disease, the patient is unable to force enough air through the narrowed bronchi to produce wheezing. The resulting .
silent chest is ominous and warrants immediate attention
1-A mobile mass that becomes fixed when the arm relaxes is attached to 
2- if fixed when the hand is pressed against the hip, it is attached to
1-the ribs and intercostal muscles;
2- the pectoral fascia
Carcinoma of the Penis
An indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious
A poorly developed scrotum on one or both sides suggests
cryptorchidism (an undescended testicle).
Prolapse of the Uterus
In first-degree prolapse-
In second-degree prolapse-
In third-degree prolapse (procidentia)-
Prolapse of the UterusProlapse of the uterus results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. In progressive stages, the uterus becomes retroverted and descends down the vaginal canal to the outside:

In first-degree prolapse, the cervix is still well within the vagina.


In second-degree prolapse, it is at the introitus.


In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus
Amenorrhea followed by heavy bleeding suggests
a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation
1-Change in bowel pattern, especially stools of thin pencil-like caliber, may warn of 
2-Blood in the stool may be from
3-mucus may accompany
1-Change in bowel pattern, especially stools of thin pencil-like caliber, may warn of colon cancer.
2-Blood in the stool may be from polyps or cancer, also from gastrointestinal bleeding or local hemorrhoids;
3-mucus may accompany villous adenoma


Ligaments are ropelike bundles of collagen fibrils that connect-




Tendons are collagen fibers connecting-




Bursae are-


Ligaments are ropelike bundles of collagen fibrils that connect bone to bone.

 





Tendons are collagen fibers connecting muscle to bone.









Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures.
Brownish or blackish vomitus with a “coffee grounds” appearance suggests
blood altered by gastric acid. Coffee-grounds emesis or red blood is termed hematemesis



An enlarged epitrochlear node may arise from 


Epitrochlear nodes are difficult or impossible to identify in most normal people.
local or distal infection or may be associated with generalized lymphadenopathy.
Listen to what anatomy here?
 
1)- 2nd intercostal space right sternal border(2nd, ICS, RSB)
2)- 2nd intercostal space left sternal border(2nd, ICS, LSB)
1)-(2nd, ICS, RSB)- sounds from the aortic valve
 
2)- (2nd, ICS, LSB)- sounds from the pulmonic valve
1-A markedly dilated failing heart may have a
1-hypokinetic apical impulse that is displaced far to the left.
 
A large pericardial effusion may make the impulse undetectable.
Wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure. They are often audible at the mouth as well as through the chest wall. Causes of wheezes throughout the chest include
asthma, chronic bronchitis, COPD, and congestive heart failure (cardiac asthma). In asthma, wheezes may be heard only in expiration or in both phases of the respiratory cycle. Rhonchi suggest secretions in the larger airways. In chronic bronchitis, wheezes and rhonchi often clear with coughing.
Adnexal masses most commonly result from
disorders of the fallopian tubes or ovaries. Three examples—often hard to differentiate—are described. In addition, inflammatory disease of the bowel (such as diverticulitis), carcinoma of the colon, and a pedunculated myoma of the uterus may simulate an adnexal mass.
Which joints of the hands are affected in rheumatoid arthritis?
 
what else happenes
 
In rheumatoid arthritis, symmetric deformity in the PIP, MCP, and wrist joints,
-with ulnar deviation
Risk factors for abdominal aortic aneurysm (AAA) are
age 65 years or older, history of smoking, male gender, and a first-degree relative with a history of AAA repair
Deep and Superficial Venous System (Legs).
-The deep veins of the legs carry approximately 90% of venous return from the lower extremities. They are well supported by surrounding tissues.


-In contrast, the superficial veins are subcutaneous, with relatively poor tissue support


Afterload refers to the degree of vascular resistance to ventricular contraction. Sources of resistance to left ventricular contraction include the tone in the walls of the aorta, the large arteries, and the peripheral vascular tree (primarily the smal
-refers to the degree of vascular resistance to ventricular contraction.
-Sources of resistance to left ventricular contraction include the tone in the walls of the aorta, the large arteries, and the peripheral vascular tree (primarily the small arteries and arterioles), as well as the volume of blood already in the aorta.
A lung affected by COPD often displaces the upper border of the
liver downward. It also lowers the level of diaphragmatic dullness posteriorly.
1-Pain, swelling, loss of active and passive motion, “locking,” deformity seen in
2-loss of active but not passive motion, tenderness outside the joint, absence of deformity often seen in
1-Pain, swelling, loss of active and passive motion, “locking,” deformity seen in articular joint pain;

 
2-loss of active but not passive motion, tenderness outside the joint, absence of deformity often seen in nonarticular pain
Only about half of livers with an edge below the right costal margin are palpable, but when the edge is palpable it suggests
the likelihood of hepatomegaly roughly doubles
Ulcers of the Ankles and Feet in Arterial Insufficiency
-This condition occurs in the toes, feet, or possibly areas of trauma (e.g., the shins).
 -Surrounding skin shows no callus or excess pigment, although it may be atrophic.
-Pain often is severe unless neuropathy masks it. -Gangrene may be associated, along with decreased pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency.
Pressure on the carotid sinus may cause a
 
where is the carotid sinus located?
reflex drop in pulse rate or blood pressure
 
Avoid pressing on the carotid sinus, which lies at the level of the top of the thyroid cartilage.
A wheeze that is entirely or predominantly inspiratory is called .
 
high-pitched wheeze
stridor. It is often louder in the neck than over the chest wall. It indicates a partial obstruction of the larynx or trachea, and demands immediate attention
Listen for bruits over the aorta, the iliac arteries, and the femoral arteries. Bruits confined to systole are relatively common, however bruits w/ both systolic and diastolic components strongly suggests
renal artery stenosis as the cause of hypertension
 Ask the patient to place arms at the side and flex the elbows to 90° with the thumbs turned up. Provide resistance as the patient presses the forearms outward. Weakness during this maneuver is a positive test indicating
Weakness during this maneuver is a positive test indicating possible rotator cuff tear or bicipital tendinitis
 
Test infraspinatus strength
1-If you find a large scrotal mass and suspect that it may be a hernia, ask the patient to lie down. The mass may return to the abdomen by itself. If so, __________
2-Can you get your fingers above the mass in the scrotum?


If you can, suspect a ____
1-If you find a large scrotal mass and suspect that it may be a hernia, ask the patient to lie down. The mass may return to the abdomen by itself. If so, it is a hernia. If not:
• Can you get your fingers above the mass in the scrotum?


If you can, suspect a hydrocele.



• Listen to the mass with a stethoscope for bowel sounds.


Bowel sounds may be heard over a hernia, but not over a hydrocele.
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