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161 Cards in this Set

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  • Back
Habit history
TACOS - tobacco, alcohol, caffeine, occupation, street drug use
Plan for treatment
MOTHRR
Medication
OMM
Testing (lab, radiology)
Holistic approach (non pharmacologic heat, ice, physical therapy)
Referral to specialists
Return to office
Describe clinical (close-ended) interviews
Interviewer = "director" of interview
Very focused questions - designed to allow specific information
Interviewer is expert in the information
Narrowly defined time constraints
Describe ethnographic (open-ended) interviews
Interviewer = facilitator
Open ended questions - designed to allow respondent to talk
More open time constraints
Best time to do breast exam
week or two after menses
Risk factors for breast cancer
- Prior cancer
- Family history
- Early menarche
- Late or no pregnancy
- Exposure to radiation
Redness of breast could indicate _
Infection or inflammatory carcinoma
What do you look for when you inspect breast
- Appearance of skin - color, thickening of skin or unusually prominent pores
- Size and symmetry of breasts, some difference is normal
- Contour of breasts - look for masses, dimpling or flattening - compare one breast with another.
What do you look for in inspection of nipples
- Size and shape - occassionally nipple is inverted - depressed below areolar surface, longstanding inversion is usually normal variant
- Direction in which point ( normal outward and downward)
- Any rashes or ulcerations
- Discharge
Recent or short term retraction of the breast means _
malignancy
What do you notice on palpation of the breast
- Consistency of tissue
- Tenderness
- Nodules - feel for any lump or mass
Isolated axillary adenopathy means _ while general adenopathy (cervical, clavicular) means _
- Breast CA
- HIV, lymphoma
Indications for pelvic exam in female
- Menstrual irregularities such as amenorrhea, excessive bleeding or dysmenorrhea
- Unexplained abdominal pain
- Vaginal discharge
- Prescribing of oral contraceptives
- Bacterial and cytological studies in sexually active females
- The patients own desire for assesment
2 types of speculum
GRAVES - rounded, better suited for sexually active females
PENDERSON - narrow bladed - useful in virgin or elderly woman, may be more comfortable for other women as well
Excoriations or small red maculopapules on genitalia mean _
PEDICULOSIS PUBIS
Where do you take smears for pap staining - 2 spaces - _
From endocervical canal and ectocervix
Pain on bimanual exam suggests _
PID
Excoriations on male genitalia suggest _
scabies
Syphillis lesion is called _ while painful multiherpetic lesion is called _
Chancre
Chancroid
Angiokeratoma
pinpoint dark red raised lesion on scrotum in men over 50 - common, normal
Smegma
- Cheesy white material under foreskin - normal
Phimosis
Condition where foreskin cannot be retracted
Balanoposthitis
Inflammation of glans and prepuce
Balanitis
Inflammation of the glans penis alone
Hypospadias
Meatus opens in ventral surface of penis
Epispadias
Less common, meatus on dorsal surface of penis
Peyronies Disease
Non tender induration or fibrotic area under skin of shaft of the penis
Paraphimosis
Condition which notes the inability to replace foreskin when its retracted behind corona
Varicocele
Common enlargement of spermatic cord due to dilation of pinpiniform plexus , usually on left side
Abdominal exam order
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
5. Rectal exam
Cullens sign
- Ecchymoses in periumbilical area could be a sign of intrabdominal bleeding from ectopic pregnancy and pancreatitis
Grey Turner sign
- Ecchymoses on flank - sign of acute pancreatitis
High pitch tingling bowel sound means _
Intestinal obstruction
Absent bowel sounds mean _
Bowel obstruction, perforation
Normal liver size
4-8 cm in midsternal line
6-12 cm in right midclavicular line
Thrill
Turbulence of vascular flow, vibratory sensation when palpating aorta
Aortic dissection
- Tearing or ripping abdominal pain that radiates to the back, expansile pulsations
- Normal aorta shouldnt be more then 2.5 cm wide
Two tests to assess ascites
- Fluid wave - press down on abdomen and create fluid wave
- Shifting dullness - percuss to identify areas of dullness and tympany, have patient roll away from you - percuss again for dullness and tympany - if dullness has shifted to areas of prior tympany - patient may have ascites
Psoas sign
- Test for appendicitis
- Place hand above patients right knee, ask patient to flex hip against resistance
- Increased abdominal pain - positive psoas sign
Obturator sign
- Test for appendicitis
- Raise pt's right leg with knee flexed, rotate leg internally at hip
- Increased abdominal pain - positive obturator sign
Rovsings sign
- Test for appendicitis
- Palpation of the LLQ will result in the pain of RLQ.
Describe acute cholecystitis
- Fatty food tolerance
- RUQ pain with radiation to right scapula
Murphys sign checks for _
Acute cholecystitis
Hematochezia
Bright red blood per rectum - from colon
Melena
Black tarry like stools
First Cranial nerve testing
Test the sense of smell by presenting the patient with familiar and non-irritating odors. Be sure each nasal passage is open. The patient should close both eyes. Ask patient to identify substances such as coffee, vanilla and soap
Second cranial nerve testing
- Test visual acuity
- Inspect optic fundi with special attention to optic discs
- Determine visual fields
- Test for extinction of vision on one side
How do you test III, IV and VI CN
Test extraocular movements in the six cardinal fields of gaze and look for loss of conjugate movements. Check convergence. Identify any nystagmus including direction of quick and slow components
Look for ptosis of upper eyelids
How do you test V CN
Motor - while palpatin masseter and temporalis muscles ask patient to clench teeth
Sensory - use safety pin or other suitable object and ask patient about sensation (sharp or dull) in areas of forehead, below eyes and on lateral chin
Test for light touch with patients eyes closed with wisp of cotton
Test corneal reflex with fine wisp of cotton
How do you test CN VII
Inspect face for asymmetry at rest and during conversation
Ask patient to raise eyebrows, close eyes against resistance, smile, frown, show upper and lower teeth and puff out both cheeks.
How do you test CN VIII
Assess hearing. If impaired test for lateralization and compare air and bone conduction.
How do you test IX and X CN's
Listen to patients voice.
Is there difficulty in swallowing?
Ask patient to say ah as you watch movements of soft palate and pharynx
Warn patient and test GAG REFLEX by stimulating the back of the throat on each side
How do you test XI CN
From behind look for atrophy or fasciculation in trapezius muscle
Ask patient to shrug both shoulders upward against your hands
How do you test XII CN
Listen to articulation of spoken word
Inspect tongue fo atrophy or fasciculation - with tongue extended look for symmetry atrophy or lateral deviation.
Ask patient to move tongue from side to side. You may need to assess tongue strength in each direction by resisting movement with your gloved finger.
Tandem walking
Walk heel to toe in straight line
A gait that lacks coordination is called )
Ataxic
Ataxia occurs due to _
Cerebellar disease or intoxication
Rhomberg test
Have patient stand with feet together and eyes open - then close both eyes and stand for 20-30 seconds without support - normally only minimal swaying occurs
Pronator drift suggests _
Mild hemiparesis
Drifting or weakness suggests
Hemiparesis or shoulder girdle disease
Absence of strength of muscle is called _
Paralysis or plegia
Impaired muscle strength is called _
Paresis
Increased resistance of muscle is called _ Higher form of resistance is called _
Spasticity
Rigidity
Describe grading of muscle strength
0- no muscular contraction detected
1- barely detectable flicker or trace of contraction
2- active movement of body part with gravity eliminated
3 -active movement against gravity
4- active movement against gravity and some resistance
5- active movement against full resistance without fatigue bormal muscle strength
Describe grading of reflexes
+4 - very brisk, hyperactive, often associated with clonus
+3 - brisker than average, possibly but not indicative of disease
+2- average, normal
+1 - somewhat diminished, low normal
0 - no response
Describe biceps reflex
Patients arm flexed at elbow with palm down. Place thumb or finger firmly on biceps tendon. Strike with reflex hammer - observe flexion at elbow and watch for and feel contraction of biceps
Describe triceps reflex
Flex patients arm at elbow with palm toward body and pull it slightly across chest. Strike triceps tendon above elbow. Watch for contraction of triceps at the extension of elbow
Brachioradialis reflex
Patients hand should rest on abdomen or lap with forearm partially pronated. Strike radius about 1-2 inches above wrist. Watch for flexion and supination of forearm
Abdominal reflexes
Test abdominal reflexes by lightly but briskly sroking each side of abdomen above and below the umbilicus. With a key or something else, stroke in a downward and medial manner from sides of abdomen. Note contraction of abdominal muscles and deviation of umbilicus toward stimulus.
Knee reflex
Knee is flexed with patient sitting or lying down. Briskly tap patella tendon below the patella. Note contraction of quadriceps with extension of knee. A hand on anterior thigh helps you feel reflex
Babinski reflex
Dorsiflexion of the big toe with fanning of the other toes - indicates upper motor neuron disease, also caused by drug, alcoholic intoxication
Sustained clonus indicates _
Upper motor neuron disease
Analgesia
Loss of sensation of pain
Hypalgesia
Decreased sensation of pain
Hyperalgesia
Increased sensation of pain
Anesthesia
Absense of touch sensation
Hyperesthesia
Increased sensitivity to pain
Stereognosis
Ability to identify an object by the feel of it, place familiar object in patients hand and ask to close eyes
Chaddock reflex
Same as Babinski reflex but stroking on the side of the foot, not bottom
Graphesthesia - what it is and what indicates
Ability to perceive number drawn on hand - activity of higher cortical area
Jendrassik maneuver
If reflex is weak or absent - clench teeth which distracts patient and accentuates reflex
Which nerves responsible for corneal reflex
V and VII
Vestibulo-ocular reflex
Comatose patients - eye should follow turn of the head
Components of cardiac exam
- Heart
- Lungs
- Neck
- Feet
- Pulses
Jugular veins distention indicate _
right heart failure
Carotid bruits is sign of _
carotid stenosis
Blowing murmur is a sign of _ Rumbling murmur is a sign of _
Stenosis
Regurgitation
Which murmurs are more common
Systolic - diastolic murmurs are hard to hear
Heart murmurs are caused by _
Turbulent flow - clogged valves and leaky valves
Aortic valve is auscultated where
2nd intercostal space, right sternal border
Pulmonic valve is auscultated where
2nd intercostal space, left sternal border
Tricuspid valve is auscultated where
5th intercostal space, left sternal border
Mitral valve is auscultated where
5th intercostal space mid clavicular line
Name systolic murmurs
Aortic stenosis and mitral regurgitation
Name diastolic murmurs
Mitral stenosis and aortic insufficiency
Where is point of maximal impact located
5th ICS mide clavicular line
WHat happens in cardiomegaly
Heart drops down and out - 6th ICS and anterior axillary line
Why does chest pain come on exertion in angina
Oxygen demand increases and you get supply/demand imbalance
Describe angina
Crushing substernal pain which radiates to the left arm, associated with shortness of breath, nausea, vomitting, diaphoresis. Pain comes on exertion and is relieved by rest
Describe common symptoms of CHF
Shortness of breath, awakening at night unable to breath, needing to sleep on 3 pillows and ankle swelling. Jugular vein distention.
In CHF which heart fails
L ventricle doesnt pump blood - later get both right and left heart failure
What is the most common cause of right heart failure
Left heart failure
What is the difference between symptom and sign
Symptom - subjective, sign - what you observe
Why do people with heart problems lean to catch their breath
Pectoralis major - accessory muscle - leaning allows flipping origin and insertion - helps breathing
Two types of chest pain
Pleuritic and non-pleuritic
Pleuritic - chest pain that gets worse when you take deep breath
Non pleuritic = angina pain
2 patterns of respiration
Cheyne-Stokes - irregular - alternating rapid and shallow breaths
Kussmaul - deep big expirations - elimination of CO2/acid
Dullness on percussion of lungs means _
fluind in lungs (blood), pneumonia - fluid in parenchyma
Hyperresonance in lungs on percussion means _
Pneumothorax
COPD - what do you find
Diminished breath sounds, hyperresonant percussion
Pulmonary embolism
Blood clot in pulmonary artery
Pleural space
Potential space between visceral and parietal pleura
Hallmark of asthma
Wheezing
How does pneumonia usually present
Productive cough, fever, chills, blood streaked sputum
Why do people with COPD breathe through pursed lips
Generating resistance
Macule
Well circumscribed flat discoloration which may be red, blue, brown or hypopigmented
Example - freckles
Its absolutely flat and if you run fingers over it you wont be able to feel it
Papule
Solid raised lesion which is less then 1 cm in diameter
- Can have variety of shapes - flat, umbilicated, domed
- Can be associated with scales or crusts
Example - molluscum contagiosum - dome shaped umbilicated papules
Nodule
Solid raised lesion more then 1 cm in diameter - can be in epidermis, dermis or subcutaneous tissue
Tumor
Solid mass of skin or subcutaneous tissue - larger then nodule - can be benign or malignant
If ulcerated or erodes skin - worse prognosis
Example - basal cell skin carcinoma
Plaque
Solid raised flat topped lesion more then 1 cm in diameter
Psoriasis plaque - prototypical plaque disease
Wheel
Area of edema in upper epidermis - elevated, palpable, usually disappears in less then 24 hours, also called hives
Example - allergy, urticaria
Vesicle
Raised lesion filled with clear fluid less then 1 cm in diameter'
Example - poison ivy contact dermatitis, herpes lesions, usually linear pattern
Bullae
Circumscribed fluid filled lesions more then 1 cm in diameter
Pustule
Circumscribed elevated lesions that contain pus
Example - streptococcal skin infection
Scales
Secondary lesion caused by desquamation of the skin
Crust
Secondary lesion - collection of dried cellular debris, can occur after herpetic lesions resolve
Fissure
Secondary lesion - linear crack through the skin, can extend to dermis
Erosion
Focal loss of epidermis
Ulcer
Focal loss of epidermis and dermis, erosions can evolve into ulcers
Atrophy
Depression of skin due to thinning of epidermis - striae or stretch marks - can be due to systemic injection of steroids. Adolescents can have striae due to excessive growth - can also be observed with radiation dermatitis or from old insulin injections which are not used any more
Scar
Permanent fibrotic change of skin due to injury to dermis
Burrow
Lesion that occurs due to infestation of skin and making tunnels in skin by scabies or other parasites
Most common causes of death during first year of life
Congenital and chromosomal - 20%
Short gestation and low birth weight - 16%
Sudden infant death syndrome - 8.1 %
Maternal complications of pregnancy - 5.4 %
Which screening test is used to assess development of the baby
Denver Developmental Screening test
Mnemonic for history taking in adolescents
HEADS
Home environment
Education and Employment
Activities (peers)
Drugs (also alcohol and tobacco included here)
Sexuality and Suicide
APGAR score is taken when
At 1 min and 5 minutes
Plethora in baby means _
Palor means
Plethora - very red
Palor - very white
Mongolian spots
Flat birthmarks in baby that can be confused with bruises and suggest abuse
Port wine stain
Also called nevus flammeus
Can be sign of Sturge Weber syndrome (seizure disorder)
Transient neonatal pustular melanosis
Present at birth - pustules and vesicles, resolve within month, but brown macules may persist for a while
Erythema toxicum
Common rash of babies - presents in different ways and may be confused with something more serious (herpes), will resolve on own
Cavernous hemangioma
Like strawberry nevus but more deep and may be more permanent
Milia
Common benign keratin filled cysts
Caput succedaneum
Diffuse swelling of the scalp in newborns caused by pressure of uterus or vaginal wall during delivery
Cephalohematoma
Not the same as caput succedaneum - caput is more generalized and resolves fast, while cephalohematoma becomes more obvious within first few days of life - collection of blood under periosteum.
Barlows test
Hip is flexed and thigh adducted while pushing posteriorly in line of the shaft of the femur causing femoral head to dislocate posteriorly from acetabulum
Dislocation is palpable as femoral head slips out of acetabulum
Diagnosis is confirmed with Ortolanis test
Ortolanis test
Hips are examined one at a time - flex infants hips and knees to 90 degrees, thigh is gently abducted and bringing femoral head from its dislocated posterior position to opposite acetabulum, hence reducing femoral head into acetabulum
In positive finding there is audible and palpable click as hip reduces
Sweaty feet odor from baby can indicate
Isovalericacidemia
Acetone odor from baby can indicate
Diabetic ketoacidosis
Fish odor from baby can indicate
Methionine metabolism aberration
Excessive elasticity of the skin indicates _
Ehlers Danos syndrome
If baby presents with chronic unilateral foul smelling nasal discharge suspect _
Foreign body
Stridor - what it is and what indicates
High pitched breathing sounds - indicates upper airway problem
Signs of CHF in baby
Tachycardia, tachypnea and enlarged liver. Possible feeding problems and failure to thrive
Skin condition common in young children (1-5) and caused by Strep A or S. aureus
Impetigo - contagious
Legg- Calves - Perthes disease
Idiopathic osteonecrosis of femoral head
Abnormal red reflex of the eye is present with _
Cataracts
Retinoblastoma
Retinal detachment
Chorioretinitis
How do you test for strabismus
Cover test - cover one eye at a time - observe for shifts of uncovered eye or of the covered eye after cover is quickly removed
Nasal polyps are found in _
Allergy and cystic fibrosis
Forscheimers spots are signs of _
Rubella
Koplicks spots are signs of _
Measles
Osgood Schlatter
Unilateral separation of tibial tuberosity