Patient Assessment Ii: Final Exam

Front 1

Gall Bladder Pain

Back 1

Complains of RUQ pain which radiates around to the inferior border to the right scapula; frequently preceded by a fatty meal

Front 2

Pancreas Pain (Pancreatitis, Pancreatic Cancer)

Back 2

Complains of epigastric pain which radiates straight through to the back; sometimes relieved by sitting up and leaning forward, but no activity triggered

Front 3

Hiatial Hernia (GERD) (Chest Pain Pattern)

Back 3

Complains of substernal pain possibly accompanied by SOB; frequently exacerbated by a large meal and/or a recumbent posture

Front 4

Pleurisy (Chest Pain Pattern)

Back 4

Complains of sharp well localized chest pain in the area of involvement; "Scheppelman's" and when bends away from painful site (and therefore, certain movements will trigger it); may be a sequela to chest trauma, influenza or metastatic cancer

Front 5

Musculoskeletal (Tietze's, Rib Fracture, Subluxation) (Chest Pain Pattern)

Back 5

Complains of well localized pain which can be reproduced by palpation of the painful area and/or the subluxated joint

Scheppelman's and when bends towards painful site (and therefore certain movements will trigger it); may be sequela to trauma or over use

Front 6

Cadiac (Chest Pain Pattern)

Back 6

Complains of diffuse retrosternal pressure which can radiate to left shoulder, arm and hand (mostly in males), both shoulders, arms and jaw (mostly in females) or midscapular region

Front 7

Cardiac (Chest Pain Pattern) if Angina Pectoris

Back 7

Usually preceded by activity, duration is usually less than 20 minutes and pain is relieved by rest or NTG
- May exhibit Levine's sign (fist put to the chest)

Front 8

Cardiac (Chest Pain Pattern) if MI

Back 8

Usually not preceded by activity, usually more severe, duration is more than 20 minutes, and pain is unrelieved by rest or NTG
- May exhibit Levine's sign (first put to chest)

Front 9

Tendon Xathoma

Back 9

Stony hard slightly yellowish masses boundt o the extensor tendons of the fingers; pathognomonic for familial hypercholesterolemia

Front 10

Eruptive Xathoma

Back 10

Small (1-3mm) yellowish papules on an erythematous base frequently found on the abdomen, buttocks, elbows knees and back; indicate acute elevations of serum triglycerides; will recede after triglyercides return normal

Front 11

Splinter Hemorrhages

Back 11

Small reddish brown lines in the nail bed; classically associated with SBE

Front 12

Earlobe Crease (Lichenstein's Sign)

Back 12

An oblique crease, frequently bilateral, seen in patient's over 50 years old with severe CAD

Front 13

Xanthelasma

Back 13

Yellowish plaques on the eyelids and periorbital region which indicate hyperlipoproteinemia

Front 14

Arcus senilis

Back 14

Whitish ring at the perimeter of the cornea suggestive of hypercholesterolemia in patient's younger than 50 years old

Front 15

Palatal Petechiae

Back 15

Associated with SBE

Front 16

High Arched Palate

Back 16

Seen with Marfan's Syndrome (along with arachnodactyly, displacement of lens and tall stature with long arms and legs); frequently accompanied by cardiac problems including aortic regurgitation or stenosis)

Front 17

JVD

Back 17

Indicative of increase in CVP; seen with right sided heart failure

Front 18

Dependent Edema

Back 18

Indicative of increase in peripheral venous pressure; seen with right sided heart failure

Front 19

How is dependent edema assessed?

Back 19

At the dorsum of the feet and the shin area on ambulatory patient's and in the sacral area for bedridden patient's

These are grade

Front 20

Grading of Dependent Edema

Back 20

1+: slight pitting, no visible distortion, disappears rapidly
2+: deeper than 1+, but no readily detectable distortion, disappears within 10-15 seconds
3+: pit is noticeably deep and lasts longer than a minute, dependent extremity looks swollen and fuller
4+: pit is very deep, lasts as long as 2-5 minutes, dependent extremity is grossly distorted

Front 21

Decreased Kyphosis

Back 21

Frequently associated with an S1 split best auscultated at the tricuspid valve (and assumed to be a normal variant)

Front 22

Thrills

Back 22

Palpatory evidence of the presence of a murmur (turbulent flow through a heart valve)

Feels like irregular vibrations under your fingers

Front 23

Asymmetry of Pulsations

Back 23

Suggestive of atherosclerosis

Front 24

Tenderness during palpation of the temporal artery

Back 24

Suggestive of temporal arteritis (giant cell arteritis); usually seen in >50 year olds with a history of polymyalgia rheumatica and a recent onset of ipsilateral H/A; refer out as it may cause blindness

Front 25

Coldness in Extremities

Back 25

If universal, suggests left sided heart failure; if in just one limb, suggests local arterial problem

Front 26

Apical Rate > Radial Rate

Back 26

Suggests a ventricular origin of pulse irregularity

- This can also be noted with atrial fibrillation and CHF (both of which cause ineffecitve perfusion by the left ventricle)

Front 27

S1 is louder than S2 at which sites?

Back 27

Mitral and Triscuspid

Front 28

S2 is louder than S2 at which sites?

Back 28

Aortic and Pulmonic

Front 29

S1 conicides with which pulse?

Back 29

Carotid artery pulse

Front 30

Which Heart Sound?
- Caused by closure of AV valves
- Signals the beginning of systole
- May not a split as a normal variant

Back 30

S1 Heart Sound

Front 31

Which Heart Sound?
- Caused by closure of the semilunar valves
- Signals the beginning of systole
- May note a split

Back 31

S2 Heart Sound

Front 32

Physiological S2 Split

Back 32

A2 closes before P2 during inspiration (due to more negative pressure in the thoracic cavity during inspiration causing a delay in right ventricular emptying and pulmonic closure); NORMAL

Front 33

Paradoxical S2 Split

Back 33

P2 closes before pathologically delayed A2 (noted during expiration); suggests left BBB, aortic stenosis, patent ductus arteriosis

Front 34

Fixed S2 Split

Back 34

A2 always closes before pathologically delayed P2 (unaffected by respiration); suggests right CHF or atrial septal defect

Front 35

Which Heart Sound?
- Heard in early diastole
- Due to immediate forceful ventricular filling
- Usually a dull low pitched sound best heard when patient is supine
- Normal in children/aerobically trained athletes
- Abnormal in older adults (suggests CHF), may be seen in conjunction with hyperthyroidism, anemia and pregnancy

Back 35

S3 (Gallop Rhythm)

Front 36

Which Heart Sound?
- Heard in late diastole
- Due to blood volume being too great for ventricular size
- Usually a very soft, very low pitched sound

Back 36

S4 (Pre-Systolic Sound)

Front 37

S4 Heart Sound is pathologically seen with what?

Back 37

- Diseases of decreased ventricular compliance (CAD, cardiomyopathy) or causes of same (aortic stenosis, systemic HTN)
- Also seen with pregnancy (due to hypervolemia)

Front 38

Which Heart Sound?
- Heard in early diastole
- Due to high pressure needed to open a stenotic mitral valve
- Usually sharp and high pitched with a snapping quality

Back 38

Opening Snap
(Mitral Stenosis)

Front 39

Which Heart Sound?
- Heard in early systole
- Due to high pressures needed to open a stenotic aortic valve
- Usually short and high pitched with a click quality

Back 39

Ejection Click
(Aortic Stenosis)

Front 40

Which Heart Sound?
- Heard in mid to late systole
- Due to ballooning of the AV valve leaflets into the atrium as pressure builds during systole
- Usually short and high pitched with a click quality

Back 40

Mid-Systolic Click
(Mitral Valve Prolapse)
- Frequently followed by a systolic murmur)

Front 41

Grading of Murmurs

Back 41

Grade I: barely audible in a quiet room
Grade II: clearly audible, but faint
Grade III: moderately loud, easy to hear
Grade IV: loud, associated with a thrill
Grade V: very loud, heard with parts of the stethoscope off the chest wall, associated with a thrill
Grade VI: loudest, heard with entire stethoscope lifted just off the chest wall

Front 42

Systolic Pressure

Back 42

The blood pressure measured during the period of ventricular contraction; influenced by aortic distensibility, stroke volume and velocity of ejection

Front 43

Diastolic Pressure

Back 43

The blood pressure measured during the period of ventricular filling; influenced by total peripheral resistance and heart rate

Front 44

Pulmonary Hypertension

Back 44

Pulmonary artery pressure > 30/15 mm Hg

Front 45

Pulmonary hypertension is indicative of what?

Back 45

- Pulmonary embolus/thrombus
- Left sided heart failure
- Extensive disease of the lung parenchyma

Front 46

Systemic Hypertension

Back 46

Persistent levels of BP in which systolic pressure is > 140 and diastolic pressure > 90

Front 47

Pulse Pressure

Back 47

Difference between systolic and diastolic pressure
(Systolic - Diastolic = PP)

Front 48

Etiology of essential/primary hypertension?

Back 48

Unknown

Front 49

Etiology of secondary hypertension?

Back 49

Specific cause
- Renal arterial or parenchymal disease, drug side effects, endocrine disorders, tumors, pregnancy

Front 50

"White Coat" Hypertension

Back 50

Elevation of BP noted solely during doctor/hospital visits in an otherwise normotensive patient

Front 51

Orthostatic (Postural) Hypotension

Back 51

Drop in systolic pressure > 15 mmHg and/or a drop in diastolic pressure >5-10 mmHg as patient moves from lying to sitting and/or standing

Front 52

What percent of the population will develop hypertension?

Back 52

20%

Front 53

Define: Atherosclerotic Occlusive Arterial Disease

Back 53

Disease due to fibromuscular or endothelial thickening of the arterial walls leading to a decrease in arterial lumen size

Front 54

What percent is needed for a decrease in lumen size before the patient will complain of symptomotology?

Back 54

60 - 80% decrease in lumen size

Front 55

Define: Thoracic Aortic Aneurysm

Back 55

Localized sac or dilation of that portion of the aorta located in the thoracic cage

Front 56

Define: Abdominal Aortic Aneurysm

Back 56

Localized sac or dilation of that portion of the aorta located in the abdomen

Front 57

Define: Buerger's Disease (Thromoangiitis Obliterans)

Back 57

Recurring inflammation in the arteries and veins of lower and upper extremities resulting in thrombus formation and vessel occlusion; usually starts in smaller arteries and spreads to larger ones; cause is unknown

Front 58

Define: Raynaud's Disease

Back 58

Form of intermittent arteriolar vasoconstriction that results in coldness, pain, pallor and occasionally ulcerations of the fingertips; cause unknown

Front 59

Define: DVT

Back 59

Formation of a clot in the wall of a vein; most common site is ileofemoral vein, popliteal vein or small veins of the calf

Front 60

Risk factors of DVT?

Back 60

Virchows Triad
- Injury to vein endothelium
- Hypercoagulability
- Circulatory stasis

Front 61

Define: Varicose Veins

Back 61

Abnormally dilated, tortuous superficial veins caused by incompetent valves, increased venous pressure and/or decreased tone of veins

Front 62

Abdominal Pain Pattern: Appendicitis

Back 62

Begins periumbilically and then refers to RLQ (older texts refer specifically to McBurney's point)

Front 63

Abdominal Pain Pattern: Diverticulitis

Back 63

Usually LLQ (as most frequently affects sigmoid colon)' sometimes referred to as "left sided appendicitis"

Front 64

Abdominal Pain Pattern: Renal Colic (2° to Renal Stone)

Back 64

Intense flank pain and/or inguinal pain referring to groin (and in males, the scrotum); as a general rule, a stone high in the ureter will give inguinal pain and those low in the ureter will give more upper abdominal/flank pain; patient will frequently writhe in search of a comfortable position (which will not be found)

Front 65

Abdominal Pain Pattern: Ruptured Abdominal Aortic Aneurysm

Back 65

Moderately severe lower abdominal pain radiating to the back

Front 66

Abdominal Pain Pattern: Small Bowel Obstruction

Back 66

Periumbilical/Colic pain

Front 67

Abdominal Pain Pattern: Large Bowel Obstruction

Back 67

Lower abdominal colic/pain

Front 68

Abdominal Pain Pattern: Ruptured Ectopic Pregnancy

Back 68

Severe lower abdominal pain of sudden onset

Front 69

Cullen's sign

Back 69

Periumbilical bruising suggestive of intraabdominal bleeding (example: ruptured spleen, ruptured ectopic pregnancy); may also be seen with acute pancreatitis

Front 70

Turner's Sign (Grey Tuner's Sign)

Back 70

Flank bruising seen with pancreatitis

Front 71

Abdominal Contour Findings: Fat

Back 71

Most common cause; umbilicus may appear appear sunken; percussion is normal; lift fatty apron which may be present to examine the intertrigous area of inflammation or hernia

Front 72

Abdominal Contour Findings: Gas

Back 72

Causes increase in tympany, distension becomes more marked in large vs. small bowel obstruction

Front 73

Abdominal Contour Findings: Pregnancy

Back 73

Percussive note will be periumbically dull with flank tympany; listen for fetal heart using a fetoscope of doptone unit

Front 74

Abdominal Contour Findings: Ascities

Back 74

Percussive note will be periumbilical tympany with flank dullness; will be associated with a bulging flanks (which are dull to percussion)

Front 75

Abdominal Contour Findings: Grossly Distended Bladder

Back 75

will cause post-micturation suprapubic percussive dullness

Front 76

Abdominal Contour Findings:Large Solid Pelvic Tumor

Back 76

Displaces air filled bowel superiorly causing inferior dullness and superior tympany; usually due to ovarian tumor or uterine myomata

Front 77

Abdominal Contour Findings: Umbilical Hernia

Back 77

Most common in infants and usually close spontaneously within a year or two; in an adult, may be seen with pregnancy and long standing ascites

Front 78

Abdominal Contour Findings: Incisional Hernia

Back 78

Protrusion through a surgical scar; smaller defects are at greater risk than are large ones for complications (as bowel and vessels can be caught up in small ones, but self reduce in larger ones)

Front 79

Abdominal Contour Findings: Epigastric Hernia

Back 79

Small midline protrusion through a defect in the linea alba located somewhere between the xiphoid process and the umbilicus; best noted when patient performs a "crunch" and examiner runs a fingerpad down the lineal alba to feel it

Front 80

Abdominal Contour Findings: Diastasis Recti

Back 80

Separation of the two rectus abdominis muscles through which abdominal contents bulge forming a midline ridge when patient performs a "crunch" usually associated with multipartiy, obesity and COPD; clinically insignificant

Front 81

Abdominal Contour Findings: Lipoma

Back 81

Common benign fatty tumors usually located in the squamous tissues anywhere in the body; usually soft and often lobulated and relatively

Front 82

Suprapubic Distension

Back 82

Symmetrical distension may be noted with a very full bladder (suggestive of cystitis, neurogenic bladder and prostate problems)

Front 83

Periorbital Edema and/or Facial Puffiness

Back 83

May be seen with nephrotic conditions (including glomerulonephritis, pyelonephritis, nephrotic syndrome)

Front 84

Renal Frost (Uremic Frost)

Back 84

Powdery deposits on the skin (especially the face) of urea and uric acid salts (due to uremia seen with renal failure)

Front 85

Ammonia odor to the breath

Back 85

Noted with renal failure

Front 86

Hypospadias

Back 86

Congenital defect in which the urethral meatus is located on the ventral surface of the penis

Front 87

Epispadias

Back 87

Rare congenital defect in which the urethral meatus is located on the dorsal surface of the penis

Front 88

Peyronie Disease

Back 88

A disease of unknown etiology characterized by a fibrous band in the corpus cavernosum and non-tender hard plaques just beneath the skin on the dorsum of the penis causing deviation of the penis during an erection; depending upon the extent, erections may be painful and intromission impossible

Front 89

Phimosis

Back 89

A condition where the foreskin is advanced and fixed so tightly that it is impossible to retract over the glans

Front 90

Paraphimosis

Back 90

A condition where the foreskin is retracted and fixed; this retraction impedes circulation and venous drainage to the glans causing swelling

Front 91

Balanitis

Back 91

An inflammation of the glans due to bacterial or fungal infections most frequently seen in men with poorly controlled diabetes mellitus and candidal infections; one of the components of Reiter's syndrome

Front 92

Priapism

Back 92

Prolonged, painful penile erection, usually idiopathic in nature, but frequently associated with leukemia, sickle cel anemia and spinal trauma

Front 93

Purulent Penile Discharge

Back 93

Suggests STD (especially chlamydia or gonorrhea); frequently will crust over during sleep

Front 94

Carcinoma of Penis

Back 94

Appears as an indurated nodule or ulcer that is usually non-tender; almost exclusively seen in men who were not circumcised in childhood who practice poor hygiene

Front 95

Syphilitic Chancre

Back 95

Usually appears as an oval or round, dark, red, painless erosion or ulcer with an indurated base; non-tender enlarged vertical lymph nodes are typically associated

Front 96

Venereal/Genital Herpes

Back 96

A cluster of small vesciles followed by shallow, painful, non-indurated ulcers on red bases

Front 97

Genital Warts (Condyloma Acuminatum)

Back 97

Rapidly growing lesions that are moist and often malodorous due to infection with HPV

Front 98

Lymphogranuloma venereum

Back 98

Initial lesion is a painless erosion at or near the coronal sulcus of the penis; later, inguinal lymph nodes become involved

Front 99

Molluscum contagiosum

Back 99

Lesions are pearly gray, smooth and dome shaped with discrete margins; usually occurring on the glans penis

Front 100

Condylomata lata

Back 100

Lesion of secondary syphilis

Front 101

Hydrocele

Back 101

A non-tender fluid filled mass that occupies the space within the tunica vaginalis; mass remains in the scrotum and does not enter the inguinal canal; it transilluminates

Front 102

Spermatocele

Back 102

A painless mobile cystic mass just above the testis; it transilluminates

Front 103

Varicoele

Back 103

Varicose veins of the spermatic cord (usually on the left); slowly collapses as scrotum is elevated in the supine patient; palpation findings are described as a "bag of worms"

Front 104

Orchitis

Back 104

An acute inflammation of the testis that is painful, tender and edematous; frequently a complication of mumps; leads to testicular atrophy 50% of the time

Front 105

Epididymitis

Back 105

An acute inflammation of the epididymis cauisng marked tenderness of the epididymis; commonly associated with UTI

Front 106

Testicular Torsion

Back 106

A twisting of the testicle on its spermatic cord, producing an acutely tender and swollen testis that is drawn upward in the scrotum; scrotum becomes red and edematous; not associated with a UTI; most common in adolescents; surgical emergency

Front 107

Testicular Tumor

Back 107

A neoplasm arising from the testicle appearing as an irregular, non-tender fixed mass on the testis that does not transilluminate

Front 108

Anorectal Fistula

Back 108

An inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface; usually preceded by an abscess

Front 109

Anal Fissure

Back 109

Very painful oval ulceration of the anal canal, found most commonly in the midline posteriorly, less commonly in the midline anteriorly

Front 110

Pilonidal Cyst

Back 110

Fairly common congenital abnormality located in the midline superficial to the coccyx or the lower sacrum; sinus tract opening may develop and be surrounded by a ring of erythema and show a tuft of hair; benign except that sinus may become abscessed

Front 111

Hemorrhoids- Varicose Veins

Back 111

External: if they originate below anorectal line and are covered by anal skin
Internal: if they originate above the anorectal junction and are covered by rectal mucosa; either can cause hematochezia

Front 112

Rectal Prolapse

Back 112

Prolapse of the rectal mucosa through the anus appearing as a donut of rosette of red tissue; frequently occurs upon straining for a bowel movement

Front 113

Direct Inguinal Hernia

Back 113

Herniation of the abdominal contents directly THROUGH the external ring

Front 114

Indirect Inguinal Hernia

Back 114

Herniation of the abdominal contents DOWN the inguinal hernia

Front 115

Femoral Hernia

Back 115

Herniation of the abdominal contents BELOW the inguinal ligament

Front 116

Prostatitis

Back 116

An acute, febrile condition caused by bacterial infection. The gland is very tender, swollen, firm and warm

Front 117

Benign Prostatic Hypertrophy (BPH)

Back 117

Symmetrical benign enlargement of the prostate seen in the 50s which can cause urinary symptoms including frequency, hesitancy and change in urine stream force. The gland is enlarged, smooth and firm though slightly elastic

Front 118

Prostate Cancer

Back 118

Suggested by an alteration in the contour of the prostate. The gland is hard and non-tender with irregular nodules and occasional obliteration of the median sulcus

Front 119

Scrotal structures which do not transilluminate

Back 119

Vascular structures, tumors, blood, hernias, normal testicle

Front 120

Scrotal structures which do transilluminate

Back 120

Hydrocele, spermatocele

Front 121

Pediculosis pubis

Back 121

Excoriations and erythematous areas noted with little dark spots adherent to pubic hair near the roots (amy also note in eyebrows and eyelashes)

Front 122

Contact Dermatitis

Back 122

Red, swollen vesicles that may weep and then crust over or scale; may note regional excoriations due to scratching; frequently result from reaction to a feminine hygiene product or synthetic fabric underwear

Front 123

Herpes Genitalis (HSV Type II)

Back 123

Clusters of shallow, small, painful vesicles on red bases on genital area and inner thigh; rupture in 1 - 3 days leaving painful ulcers; associated signs include inguinal edema and lymphadenopathy

Front 124

Syphilitic Chancre

Back 124

Begins as a small, solitary silvery papule that erodes to a red round or oval, superficial ulcer with a yellowish discharge; palpation yields a non-tender lesion which can be lifted like a button between your thumb and finger; asociated signs include non-tender inguinal lymphadenopathy

Front 125

Condylomata accuminata

Back 125

Pink or flesh colored soft, pointed moist warty papules appearing in cauliflower-like patches around the vulva, introitus, anus, cervix and vagina due to infection with HPV; presence increases risk for cervical cancer

Front 126

Condylomata lata

Back 126

Flat, moist papular growth that is seen in secondary syphilis

Front 127

Carcinoma of the Vulva

Back 127

An ulcerated or raised red vulvar lesion

Front 128

Abscess of Bartholin's Gland

Back 128

A tense, swollen, hot, reddened very tender abscess in the posterior part of the labia; may seen purulent discharge (spontaneous or expressed) and erythema around the duct opening; may be 2° to gonorrhea or chlamydia or other organisms

Front 129

Urethral Caruncle

Back 129

Small, deep red, benign tumor visible at the posterior part of the urethral meatus which may bleed on contact; usually asymptomatic but associated symptoms may include pain with urination, frequency, hematuria and/or dyspareunia

Front 130

Cystocele

Back 130

Bulge of the bladder into the anterior wall of the vagina due to weakened pelvic floor; better visualized as patient bears down; associated symptoms may include stress incontinence and feeling of pressure in the vagina

Front 131

Rectocele

Back 131

Bulge of the rectal wall into the posterior wall of the vagina due to weakened pelvic floor; better visualized as patient bears down; associated symptoms may include constipation and/or feelings of pressure in the vagina

Front 132

Uterine Prolapse

Back 132

Protrusion of the uterus into the vagina; better visualized as patient bears down (though may also occur when standing)

Front 133

Trichomonas vaginitis

Back 133

Profuse amount of yellowish, green or grey possible frothy malodorous discharge; associated pruritus

Front 134

Candida vaginitis

Back 134

White and curdy thick nonmalodorous discharge; associated pruritus

Front 135

Bacterial vaginosis

Back 135

Minimal to moderate amount of grey or white thin malodorous (fishy or musty smelling) discharge; no pruritus

Front 136

Atrophic vaginitis

Back 136

Variable in color, consistency and amount (may even be bloody, rarely profuse); associated pruritus; associated with decreased estrogen after menopause

Front 137

Chadwick's Sign

Back 137

Bluish discoloration of the cervix suggestive of pregnancy (appears at approximately 6th-8th week)

Front 138

Cervical Erosion

Back 138

Rim of cervical os appears red and eroded with no ulceration of tissue; usually due to mucopurulent cervical discharge

Front 139

Cancer of the Cervix

Back 139

Irregular cauliflower-like growth with ulceration and induration (seen late in disease, early need Pap smear to distinguish from normal cervix)

Front 140

Cervical Polyp

Back 140

Bright red, soft pedunculated benign growth that emerges from the os

Front 141

Fetal exposure to DES

Back 141

Red, granular patches of columnar epithelium covering all or most of the cervix; other findings include a transverse ridge; protuberant anterior lip (Cock's Comb deformity)