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535 Cards in this Set
- Front
- Back
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Primary Headaches |
Headaches that include migraine, tension, cluster, and chronic daily headaches |
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Secondary Headaches |
Headaches that arise from underlying structural, systemic, or infectious causes such as meningitis or subarachnoid hemorrhage and may be life-threatening |
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Thunderclap Headaches |
Type of headache that reaches maximal intensity over several minutes in 70% of patients with subarachnoid hemorrhage, and are often preceded by a sentinel leak headache from a vascular leak into the subarachnoid space |
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Subarachnoid hemorrhage or meningitis |
If headache is severe and of sudden onset, what should you consider as the cause? |
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Migraine and tension headaches |
What type of headaches are episodic and tend to peak over several hours? |
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Tumor, abscess, or mass lesion |
New and persisting, progressively severe headaches raise concerns of what? |
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Migraine and cluster headaches |
Unilateral headache occurs in what? |
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Temporal areas |
Where do tension headaches often arise? |
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Retro-orbital |
Where do cluster headaches often arise? |
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Migraine, brain tumors, subarachnoid hemorrhage |
nausea and vomiting can occur because of what? |
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Visual aura, such as spark photopsias (flashes of light), fortifications (zig-zag arcs of light), and scotomata (area of visual loss with surrounding normal vision) |
What symptoms are common with migraines? |
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Acute sinusitis or mass lesion due to changing intracranial pressure |
valsalva maneuver may increase pain from what? |
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hyperopia (farsightedness) or presbyopia (aging vision) |
vision difficulty with close work suggests what? |
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myopia (nearsightedness) |
vision difficulty with distances indicates what? |
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vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion |
If sudden unilateral visual loss is painless what should you consider? |
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corneal ulcer, uveitis, traumatic hyphema, acute glaucoma, and optic nephritis |
If sudden unilateral visual loss is painful what should you consider? |
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Medications that change refraction such as cholinergics, anticholinergics, and steroids |
If sudden bilateral and painless vision loss occurs, what should you consider? |
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chemical or radiation exposures |
If sudden bilateral and painful vision loss occurs, what should you consider? |
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cataracts or macular degeneration |
Gradual bilateral vision loss usually arises from what? |
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nuclear cataract and macular degenration |
Slow central vision loss occurs in what? |
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open-angle glaucoma |
Peripheral vision loss occurs in what? |
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hemianopsia and quadrantic defects |
One-sided vision loss occurs in what? |
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vitreous floaters |
Moving specks or strands in the vision area suggest what? |
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lesions in the retina or visual pathways |
fixed defects, or scotomas, in the vision area suggest what? |
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detachment of vitreous from retina |
Flashing lights or new vitreous floaters in the vision area suggest what? |
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in lesions in the brainstem or cerebellum, or weakness or paralysis of one or more extraocular muscles |
When is diplopia seen? |
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palsy of cranial nerve III or VI |
Horizontal diplopia occurs because of what? |
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palsy of cranial nerve III or IV |
Vertical diplopia occurs because of what? |
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a problem in the cornea or lens |
Diplopia in one eye with the other closed suggests what? |
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Sensorineural hearing loss |
Type of hearing loss where people have particular trouble understanding speech, often complaining that others mumble; noisy environments make hearing worse |
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Conductive hearing loss |
Noisy environments may help this type of hearing loss |
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Aminoglycosides, aspirin, NSAIDs, quinine, and furosemide |
What medications may affect hearing? |
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otitis externa |
Pain occurs in the external ear canal in what? |
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otitis media |
If there is a respiratory infection, pain in the inner ear occurs in what? |
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acute or chronic otitis media |
Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated ear drum is present in what? |
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Meniere's disease |
When tinnitus is associated with hearing loss and vertigo this suggests what? |
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vertigo |
What represents vestibular disease? |
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benign positional vertigo, labyrinthitis, and Meniere's disease |
Vertigo is usually from peripheral causes in the inner ear such as what? |
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Central neurologic causes in the cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor. Also consider migraine |
Vertigo associated with ataxia, diplopia and dysarthria signal what? |
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viral infections, allergic rhinitis ("hay fever") and vasomotor rhinitis |
What are the causes of rhinorrhea? |
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allergic rhinitis |
seasonal onset or environmental triggers of rhinorrhea and nasal congestion suggest what? |
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excessive use of decongestant or use of cocaine |
When does drug-induced rhinitis occur? |
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Acute bacterial sinusitis |
unlikely until viral URI symptoms persist more than 7 days; both purulent drainage and facial pain should be present for diagnosis |
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oral contraceptives, resperpine, guanethidine, alcohol, cocaine |
What drugs may induce nasal stuffiness? |
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deviated nasal septum, nasal polyp, foreign body, granuloma (Wegener's), or carcinoma |
What might cause nasal congestion on only one side? |
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Trauma (especially nose-picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies |
Local causes of epistaxis include what? |
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Anticoagulents, NSAIDs, and coagulopathies |
What drugs can contribute to epistaxis? |
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Fever history, tonsillar exudates, swollen tender anterior cervical adenopathy, and absence of cough |
What symptoms indicate streptococcal and Fusobacterium necrophorum pharynigitis (bacterial infection)? |
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Nutritional deficiency |
Sore smooth tongue indicates what? |
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gingivitis |
Bleeding gums are most often cause by what? |
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voice overuse and acute viral larygitis |
If voice hoarseness is acute, what are the most likely causes? |
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hypothyroidism, reflux, vocal cord nodules, head and neck cancers, and neurologic disorders like parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis |
If voice hoarseness lasts more that two weeks, what causes should be considered? |
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pharyngitis |
Enlarged tender lymph nodes commonly accompany what? |
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increased function, decreased function, or normal function |
Goiter may do what to thyroid function? |
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Hypothyroidism |
Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest what? |
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Hyperthyroidism |
Intolerance to heat, increased sweating, palpatations, and involuntary weight loss suggest what? |
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Cataracts |
Clouding of the optic lens is caused by what? |
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Macular degeneration |
Mottling of the macula, variations in retinal pigmentation, subretinal hemorrhage or exudates are caused by what? |
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Glaucoma |
Change in color and size of the optic disc is caused by what? |
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hydrocephalus or Paget's disease of bone |
An enlarged skull may signify what? |
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head trauma |
Palpable tenderness or step-offs of the skull may be present after what? |
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Glaucoma, optic neuropathy, optic neuritis, and glioma |
Causes of anterior pathway defects include what? |
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stroke and chiasmal tumor |
Causes of posterior pathway defects include what? |
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Left temporal hemianopsia |
When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze ,what is present? |
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Glaucoma, optic neuritis, and papilledema |
An enlarged blind spot occurs in conditions affecting the optic nerve such as what? |
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Down syndrome |
Upstarting palpebral fissure are seen in what? |
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Blepharitis |
Red inflamed lid margins are seen in what? |
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Conjunctival inflammation and corneal irrtation |
Increased production of tears may be caused by what? |
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ectropion and nasal lacrimal duct obstruction |
Impaired tear drainage may be caused by what? |
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Sjogren's syndrome |
Eye dryness may occur from impaired secretion seen in what? |
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Nodualr episcleritis, rheumatoid arthritis, and lupus erythematosus |
Local eye redness is seen in what? |
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Acute narrow-angle glaucoma |
A sudden increase in intraocular pressure when drainage of the aqueous humor is blocked |
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Open-angle glaucoma |
The common form of glaucoma where the normal spatial relation between iris and cornea is preserved and the iris is fully lit |
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Miosis |
Refers to contriction of the pupils |
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Mydriasis |
Refers to dilation of the pupils |
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Argyll Roberton and tonic (Adie's) pupils |
Testing the near reaction is helpful in diagnosing what? |
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A deviation from normal ocular alignment |
Asymmetry of the corneal reflections indicates what? |
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In lid lag of hyperthyroidism |
When is a rim of sclera visible above the iris with downward gaze? |
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In paralysis of CN VI |
When are they eyes conjugate in right lateral gaze but not in left lateral gaze? |
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proptosis |
abnormal protrusion of the eyeballs |
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orbital tumor or retrobulbar hemorrhage from trauma |
If unilateral proptosis is present, what should you consider? |
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hyperthyroidism |
When does poor eye convergence occur? |
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head injury and coma, in which continuing observations of pupillary reactions are essential and any suspicion of narrow-angle glaucoma |
What are contraindications for mydriatic drops? |
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Opacity of the lens (cataract) or possibly of the vitreous. Less commonly a detached retina or in children, a retinoblastoma |
What causes absence of a red reflex? |
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Light rays from a distance do not focus on the retina |
What happens to light rays in a refractive error? |
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They focus anterior to the retina |
What happens to light rays in myopia? |
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They focus posterior to the retina |
What happens to light rays in hyperopia? |
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They look larger than normal |
How do retinal structures look in a myopic eye? |
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Chronic open-angle glaucoma |
What does an enlarged physiologic cup suggest? |
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With intracranial pressures that change the pressure gradient between cerebral spinal fluid pressure and intraocular pulse pressure in the optic disc |
When does loss of SVPs (spontaneous venous pulsations) in they eye occur? |
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Dry atrophic (more common but less severe) and wet exudative, or neovascular |
What are the different types of macular degeneration (an important cause of poor central vision in older adults)? |
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conductive hearing loss |
Hearing disorders of the external and middle ear cause what type of hearing loss? |
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infection (otitis externa), trauma, squamous cell carcinoma, and benign bony growths such as exostoses or osteomas |
What are hearing disorders of the external ear? |
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Congenital conditions, benign cholesteatomas and otosclerosis, tumors, and perforation of the typanic membrane |
What are hearing disorders of the middle ear? |
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sensorineural hearing loss |
Disorders of the inner ear cause what kind of hearing loss? |
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congenital and hereditary conditions, presbycusis, viral infections such as rubella and cytomegalovirus, Meniere's disease, noise exposure, and acoustic neuroma |
What are hearing disorders of the inner ear? |
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Painful in acute otitis externa but not in otitis media |
movement of the auricle and tragus is painful in what? |
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otitis media |
Tenderness behind the ear may be present in what? |
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Exostoses (nonmalignant overgrowths which may obscure the drum) |
Nontender nodular swellings covered by normal skin deep in the ear canal suggests what? |
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acute otitis externa |
When is the ear canal often swollen, narrowed, moist, pale, and tender (may be reddened)? |
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chronic otitis externa |
When is the skin of the ear canal often thickened, red, and itchy? |
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acute purulent otitis media |
When is the ear drum red and bulging? |
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serous effusion |
When is the ear drum amber? |
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retracted drum |
An unusually prominent short process and a prominent handle that looks more horizontal suggests what? |
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serous effusion, a thickened drum, or purulent otitis media |
What might decrease mobility of the ear drum? |
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Higher frequency hearing loss (more likely to miss consonants) |
Older adults which presbycusis have hearing loss of what frequency? |
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The impaired ear |
In unilateral conductive hearing loss sound is heard in (lateralized to) which ear? |
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otosclerosis otitis media, perforation of the eardrum, and cerumen |
What are explanations unilateral conductive hearing loss? |
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The good ear |
In unilateral sensorineural hearing loss, sound is heard in which ear? |
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heard through bone as long as or longer than it is through air |
In conductive hearing loss, is sound heard longer through bone or through air? |
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heard longer through air |
In sensorineural hearing loss, is sound heard longer through bone or through air? |
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local infection such as a furuncle |
What does tenderness of the nasal tip or alae suggest? |
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reddened and swollen |
In viral rhinitis, how does the nasal mucosa appear? |
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pale, bluish, or red |
In allergic rhinitis, how does the nasal mucosa appear? |
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trauma, surgery, and intranasal use of cocaine or amphetamines |
What are causes of septal perforation? |
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nasal polyps |
pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses |
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allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis |
What conditions are conductive to polyps |
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acute sinusitis |
Local tenderness, together with symptoms such as pain, fever, and nasal discharge suggest what? |
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denture sore mouth |
Bright red edematous mucosa underneath a denture suggests what? |
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Gingivitis |
Gum redness and swollen interdental papillae are characteristics of what? |
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lead poisoning |
When is a black line in the gums seen? |
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Torus palatinus |
A benign midline lump on the roof of the mouth |
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lesion of CN XII |
Asymmetric protrusion of the tongue suggests what? |
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CN X paralysis |
What causes the soft palate to fail to rise and the uvula to deviate to the opposite side? |
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streptococcal pharyngitis |
When are tonsillar exudates common? |
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Possible metastasis from a thoracic or an abdominal malignancy |
What does an enlargement of a supraclavicular node, especially on the left, suggest? |
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HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis |
When is general lymphadenopathy seen? |
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Retrosternal goiter |
May cause hoarseness, shortness of breath, stridor, or dysphagia from tracheal compression |
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Soft in Grave's Disease. Firm in Hashimoto's thyroiditis and malignancy. Tender in thyroiditis. |
When is the thyroid gland soft? Firm? Tender? |
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Hyperthyroidism |
When may a localized systolic or continuous bruit be heard? |
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Obstructed nasolacrimal duct |
Discharge of mucopurulent fluid from puncta suggests what? |
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Women |
Is ostheoarthritis more common in women or men? |
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Articular disease |
Typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion due either to stiffness or to pain |
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Extra-articular disease |
Typically involves selected regions of the joint and types of movement |
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Musculoligamentous injury, disc herniation, vertebral collapse, spinal cord metastases, and, rarely, epidural abscess |
For midline back pain, what should you assess for? |
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muscle strain, sacroilitis, trochanteric bursitis, sciatica, and hip arthritis; also for renal conditions like pyelonephritis or stones |
For pain off the midline of the back, what should you assess for? |
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Sciatica |
Radicular gluteal and posterior leg pain in the S1 distribution that increases with cough or vals |
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Spinal Stenosis |
Leg pain that resolves with rest and/or lumbar forward flexion occurs in what? |
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Cauda equina syndrome from S2-4 midline disc or tumor |
If there is bowel or bladder dysfunction, especially if there is saddle anesthesia or perineal numbness what should be considered? |
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Spinal nerve compression, most commonly C7 followed by C6; foraminal impingement from degenerative joint changes |
Radicular back pain arises from what? |
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Injury, monoarticular arthritis, possible tendinitis, or bursitis |
What does pain in one joint suggest? |
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Trochanteric bursitis |
Lateral hip pain near the greater trochanter suggests what? |
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Rheumatic fever or gonococcal arthritis |
Migratory pattern of spread (of joint pain) is seen in what? |
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Rheumatoid arthritis |
Progressive additive pattern (of joint pain) with symmetric involvement is seen in what? |
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Women |
Are inflammatory arthritides more common in men or women? |
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In inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tensosynovitis); also in sprains from stretching or tearing of ligaments |
When does extra-articular pain occur? |
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acute septic arthritis or gout; in children consider osteomyelitis in bone contiguous to a joint |
What does severe pain of rapid onset in a red, swollen joint suggest? |
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septic arthritis; also consider gout or possible rheumatic fever |
Fever, chills, warmth and redness of a joint are seen in what? |
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Articular joint pain |
Pain, swelling, loss of active and passive motion, or "locking" of a joint suggests what? |
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Nonarticular pain |
Loss of active but not passive motion and tenderness outside the joint are seen in what? |
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Degenerative joint disease |
Stiffness and limited motion after inactivity, sometimes called gelling, occurs in what? |
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Rheumatoid arthritis and other inflammatory arthritides; fibromyalgia and polymyalgia rheumatica (PMR) |
Stiffness lasting 30 minutes or more is present in what? |
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Rheumatoid arthritis, systemic lupus erythematosus (SLE), PMR, and other inflammatory arthritides |
Generalized systemic symptoms accompanied by joint pain are common in what? |
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An infectious cause |
High fever and chills accompanied by joint pain suggest what? |
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Hepatic and renal disease |
Osteoporosis is common in what diseases? |
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Trauma, septic arthritis, or gout |
Acute involvement of only one joint suggests what? |
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Rheumatoid arthritis |
Type of arthritis that is typically polyarticular and symmetrical |
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Subcutaneous nodules- rheumatoid arthritis or rheumatic fever; Effusions-Trauma; Crepitus over inflamed joints- osteoarthritis; Crepitus over inflamed tendon sheaths- Tenosynovitis |
When are subcutaneous nodules around joints present? When is effusion present? When is crepitus over inflamed joints present? Over inflamed tendon sheaths? |
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Arthritis, inflammation of tissues around a joint, fibrosis in or around a joint, fibrosis in or around joint, or bony fixation (ankylosis) |
When is decreased range of motion present? |
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Knee trauma |
When does ligamentous laxity of the ACL occur? |
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Rheumatoid arthritis |
When is muscle atrophy or weakness seen? |
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Synovitis |
What does palpable bogginess or doughiness of the synovial membrane indicate? |
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Arthritis, tendinitis, bursitis, osteomyelitis |
When is increased warmth around a joint seen? |
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Arthritis or infection |
What does diffuse tenderness and warmth over a thickened synovium suggest? |
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Injury |
What does focal tenderness around a joint suggest? |
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septic or gouty arthritis, or possibly rheumatoid arthritis |
Redness over a tender joint suggests what? |
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TMJ syndrome |
Symptoms include facial asymmetry, unilateral chronic pain with chewing, jaw clenching, or teeth grinding, often associated with stress; patients may also present with headache |
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TMJ syndrome, trigeminal neuralgia, and temporal arteritis |
When does pain with chewing occur? |
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poor occlusion, meniscus injury, or synovial swelling from trauma |
When is palpable crepitus or clicking present? |
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Scoliosis |
This may cause elevation of one shoulder |
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Anterior dislocation of the shoulder |
When does the rounded lateral aspect of the shoulder appear flattened? |
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Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine |
What can occur within 2 to 3 weeks of a rotator cuff tear? |
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Subacromial or subdeltoid bursitis, degenerative changes, or calcific deposits in the rotator cuff |
localized tenderness around the subacromial and subdeltoid bursae and the sits muscles arises from what? |
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Bursal tear that communicates with the articular cavity. |
Swelling around the subacromial and subdeltoid bursae and the sits muscles suggests what? |
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Sprains, tears, and tendon rupture of the rotator cuff, most commonly the supraspinatus |
When are tenderness over the SITS muscle insertions and inability to abduct the arm above shoulder level are seen in what? |
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snyovitis of the glenohumeral joint |
Tenderness and effusion of the shoulder suggest what? |
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bursitis, capsulitis, rotator cuff tears or sprains, and tendinitis |
Restricted range of motion of the shoulder occurs in what? |
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inflammation or arthritis of the acromioclavicular joint |
Localized shoulder tenderness or pain with adduction suggests what? |
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Rotator cuff disorder or adhesive capsulitis |
Difficulty with the Apley scratch test suggests what? |
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Possible inflammation or rotator cuff tear |
Pain during the Neer's impingement sign indicates what? |
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Possible inflamation or rotator cuff tear |
Pain during the Hawkin's impingement sign indicates what? |
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Possible rotator cuff tear |
Weakness while testing supraspinatus strength indicates what? |
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Rotator cuff tear or bicipital tendinitis |
Weakness while testing infraspinatus strength indicates what? |
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Inflammation of the long head of the biceps tendon and possible rotator cuff tear |
Pain while testing forearm supination indicates what? |
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Rotator cuff tear |
When testing the "drop-arm" sign, if the patient cannot hold the arm fully abducted at shoulder level or cannot control lowering the arm, this indicates what? |
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olecranon bursitis |
When is swelling over the olecranon process found? |
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arthritis |
When does inflammation or synovial fluid occur in the elbow? |
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common in lateral epicondylitis (tennis elbow) and less common in medial epicondylitis (pitcher's or golfer's elbow) |
When is tenderness distal to the epicondyle seen? |
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posterior dislocation of the elbow and supracondylar fracture |
When is the olecranon displaced posteriorly? |
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Fracture, intra-articular effusion, and hemarthrosis |
After injury, preservation of active range of motion and full elbow extension makes what diagnoses highly unlikely? |
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Flexor tendon damage |
When is abnormal finger alignment seen? |
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arthritis or infection |
Diffuse swelling in the hands and wrists is common in what? |
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Ganglion |
Local swelling in the hands or wrists suggests what? |
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Osteoarthritis |
When should you look for Herberden's nodes at the DIP joints and Bouchard's nodes at the PIP joints? |
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Rheumatoid Arthritis |
When is there symmetric deformity in the PIP, MCP, and wrist joints, and ulnar deviation? |
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Carpal tunnel syndrome |
Thenar atrophy occurs in median nerve compression from what? |
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Ulnar nerve compression |
Hypothenar atrophy occurs in median nerve compression from what? |
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Thickening of the palmar fascia |
Flexion contractures in the ring, fifth, and third fingers, or Dupuytren's contractures, areise from what? |
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Colles' fracture (from a fall) |
Tenderness over the distal radius occurs in what? |
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Rheumatoid arthritis |
Swelling and/or tenderness of the hands and wrists suggests what if it is bilateral and of several weeks' duration? |
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Quervain's tenosynovitis and gonococcal tenosynovitis |
Tenderness over the extensor and abductor tendons of the thumb at the radial syloid suggest what? |
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Scaphoid fracture (most common injury of the carpal bones) |
Tenderness over the "snuffbox" suggests what? |
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Avascular necrosis |
Poor blood supply puts the scaphoid bone at risk for what? |
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Rheumatoid arthritis; posttraumatic arthritis |
The MCPs are often boggy or tender in what? Pain with compression of the MCPs also occurs in what? |
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Rheumatoid arthritis |
PIP changes are seen in what? |
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Osteoarthritis |
When are Bouchard's nodes seen? |
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Carpometacarpal arthritis |
When does pain at the base of the thumb occur? |
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osteoarthritis; psoriatic arthritis |
Hard dorsolateral nodules on the DIP joints, or Heberden's nodes, are common in what? DIP joints are also involved in what other type of arthritis? |
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Tenosynovitis or inflammation of the tendon sheaths |
Tenderness and swelling of the wrists and hands are seen in what? |
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De Quervain's tenosynovitis |
What type of tenosynovitis involves the extensor and abductor tendons of the thumb as they cross the radial styloid? |
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Arthritis, tenosynovitis, and Dupuytren's contracture |
What conditions impair range of motion of the wrist? |
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Repetitive motion with wrists flexed, pregnancy, rheumatoid arthritis, diabetes, or hypothryoidism |
Onset of carpal tunnel syndrome is often related to what? |
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carpal tunnel syndrome |
Decreased sensation in the median nerve distribution characterizes what? |
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Weakness of the finger flexors and/or intrinsic muscles of the hand. It may also result from degenerative joint changes |
Decreased hand grip strength is a positive test for what? |
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de Quervain's tenosynovitis |
Wrist pain and grip weakness occur in what? |
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arthritis, carpal tunnel syndrome, epicondylitis, and cervical radiculopathy |
There is decreased grip strength in what? |
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de Quervain's tenosynovitis from inflammation of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheaths |
Pain during Finkelstein's test indicates what? |
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Carpal tunnel syndrome |
Weakness on thumb abduction increases the likelihood of what? |
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Carpal tunnel syndrome |
Aching and numbness when testing Tinel's sign increases the likelihood of what? |
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Carpal tunnel syndrome |
Numbness and tingling when testing Phalen's sign increases the likelihood of what? |
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Arthritis, muscle strain, or other underlying pathology that should be pursued |
What does neck stiffness signal? |
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Torticollis from contraction of the sternocleidomastoid muscle |
Lateral deviation and rotation of the head suggests what? |
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fracture or dislocation if preceded by trauma, underlying infection, or arthritis |
Tenderness of the vertebra suggests what? |
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Arthritis, especially at the facet joints between C5 and C6 |
Tenderness of the facet joints that lie between the cervical vertebrae about 1 inch lateral to the spinous processes of C2-C7 occurs in what? |
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In spondylolisthesis, or forward slippage of one vertebra, which may compress the spinal cord |
When do vertebral step-offs occur? |
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|
sacroilitis and ankylosing spondylitis |
What may produce tenderness over the sacroiliac joint? |
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osteoporosis, infection, or malignancy |
Pain on percussion of the spine may arise from what? |
|
|
Scoliosis; Sprengel's deformity of the scapula, from the attachment of an extra bone or band between the upper scapula and C7; "winging" of the scapula, from loss of innervation of the serratus anterior muscle by the long thoracic; and contralateral weakness of the trapezius |
Unequal shoulder heights occur in what? |
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unequal lengths of the legs, scoliosis, hip abduction or adduction |
Unequal heights of the iliac crests, or pelvic tilt, suggest what? |
|
|
herniated lumbar disc |
When is "listing" of the trunk to one side seen? |
|
|
Spina bifida |
Birthmarks, port-wine stains, hairy patches, and lipomas often overlie bony defects such as what? |
|
|
Neurofibromatosis |
Cafe-au-lait spots, skin tags, and fibrous tumors are common in what? |
|
|
Degenerative and inflammatory processes of muscles overuse, prolonged contraction from abnormal posture, or anxiety |
Spasm of the paravertebral muscles occurs in what? |
|
|
A herniated disc or mass lesion impinging on the contributing nerve roots |
Sciatic nerve tenderness suggests what? |
|
|
Herniated intervertebral discs, most common at L1-S1 or L4-L5 |
What may produce tenderness of the spinous processes, the intervertebral joints, the paravertebral muscles, the sacrosciatic notch, and the sciatic nerve? |
|
|
Rheumatoid arthritis and herniated intervertebral discs |
What may cause tenderness of the intervertebral joints? |
|
|
Kidney infection |
Tenderness in the constovertebral angle may signify what? |
|
|
Stiffness from arthritis, pain from trauma, overuse, or muscle spasm such as torticollis |
Limitations in range of motion of the neck can arise from what? |
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|
Possible risk for subluxation and high cervical cord compression and needs prompt additional assessment |
Tenderness at C1-C2 in rheumatoid arthritis suggests possible risk for what? |
|
|
muscle spasm or ankylosing spondylitis |
Persistence of lumbar lordosis suggests what? |
|
|
osteoarthritis and ankylosing spondylitis |
Decreased spinal mobility is common in what? |
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|
cerebellar disease or foot problems |
A wide gait base suggests what? |
|
|
Hip dislocation, arthritis, leg length discrepancy, or abductor weakness |
What can cause the pelvis to drop on the opposite side producing a waddling gait? |
|
|
Lack of knee flexion |
What makes the leg functionally longer, interrupts the smooth pattern of gait with circumduction of the extremity, or swinging the leg out to the side? |
|
|
paravertebral spasm |
Loss of lordosis may reflect what? |
|
|
flexion deformity of the hip |
Excess lordosis suggests what? |
|
|
abduction or adduction deformities and scoliosis |
Changes in apparent leg length are seen in what? |
|
|
hip fracture |
Leg shortening and external rotation suggest what? |
|
|
Sacroilitis |
Sacroiliac joint tenderness suggests what? |
|
|
synovitis of the hip joint, arthritis, bursitis, or possibly psoas abscess |
Tenderness in the groin are may be from what? |
|
|
Trochanteric bursitis |
Focal tenderness over the trochanter confirms what? |
|
|
localized tendinitis or muscle spasm from referred hip pain, and iliotibial band tendinitis |
Tenderness over the posterolateral surface of the greater trochanter occurs in what? |
|
|
ischiogluteal bursitis |
Called "weaver's bottom" and may mimic sciatica because of the adjacent sciatic nerve |
|
|
Flexion deformity of the hip |
Type of deformity of the hip where as the opposite hip is flexed (with the thigh against the chest), the affected hip does not allow full hip extension, and the affected thigh appears flexed |
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|
An increase, rather than flattening, in lumbar lordosis and an anterior pelvic tilt |
Flexion deformity of the hip may be masked by what? |
|
|
Hip osteoarthritis |
Restricted hip abduction is common in what? |
|
|
arthritis |
Restriction of internal and external rotation are sensitive indicators of hip disease such as what? |
|
|
Arthritis, anterior knee pain, and patellar dislocation |
Problems with patellar tracking, for example in patients with shallower knee grooves, especially women, can lead to what? |
|
|
Patellar tracking; anterior knee pain |
In women, quadriceps contraction tends to have a more lateral pull (Q angle) that alters what and contributes to what? |
|
|
quadriceps weakness or abnormal patellar tracking |
Stumbling or "giving way" of the knee during heel strike suggests what? |
|
|
Limb paralysis or hamstring tightness |
When is flexion contracture (inability to fully extend the knee) seen? |
|
|
prepatellar bursitis; infrapatellar bursitis; anserine bursitis |
Swelling over the patella suggest what? Over the tibial turcle? Or if more medial? |
|
|
Osteoarthritis |
This is likely when there are tender bony ridges along the joint margins of the knee, genu varum deformity, and stiffness lasting 30 minutes or less. Crepitus may also be present. |
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|
trauma |
A medial meniscus tear with point trauma is more common after what? |
|
|
partial or complete tear of the patellar tendon |
Tenderness over the tendon or inability to extend the knee suggests what? |
|
|
Chondromalacia or degenerative patella (the patellofemoral syndrome) |
Pain with patellar compression and with patellar movement during quadriceps contraction suggests what? |
|
|
synovial thickening or effusion in the knee joint |
Swelling above and adjacent to the patella suggests what? |
|
|
excessive kneeling |
Prepatellar bursitis ("housemaid's knee") arises from what? |
|
|
running, valgus knee deformity, fibromyalgias, osteoarthritis |
Anserine bursitis arises from what? |
|
|
distention of the gastrocnemius semimembranosus bursa from underlying arthritis or trauma |
A popliteal or "baker's" cyst arises from what? |
|
|
ruptured Achilles tendon |
A defect in the gastrocnemius and soleus muscles on the posterior surface of the lower leg with tenderness and swelling suggests what? |
|
|
Achilles tendinitis |
Tenderness and thickening of the tendon above the calcaneus, sometimes with a protuberant posterolateral bony process of the calcaneus, suggests what? |
|
|
Rupture of the Achilles tendon |
Absence of plantar flexion is a positive test indicating what? Sudden severe pain "like a gun shot wound," an ecchymosis from the calf into the heel, and a flat-footed gait with absence of "toe-off" may also be present. |
|
|
osteoarthritis |
Crepitus of the knee with flexion and extension suggests what? |
|
|
A probable tear of the posterior portion of the medial meniscus. The tear may displace meniscal tissue, causing "locking" on full knee extension. |
When doing the McMurray test, a click or pop along the medial joint with valgus stress, external rotation, and leg extension suggests what? |
|
|
ligamentous laxity and a partial tear of the medial collateral ligament |
When doing the Abduction (or Valgus) stress test, pain or a gap in the medial joint line points to what? |
|
|
Ligamentous laxity and a partial tear of the lateral collateral ligament |
When doing the Adduction (or Varus) stress test, pain or a gap in the lateral joint line points to what? |
|
|
ACL tear |
A forward jerk showing the contours of the upper tibia is a positive anterior drawer sign. This makes what diagnoses 11.5 times more likely? |
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|
ACL tear |
Significant forward excursion when doing the Lachman Test indicates what? |
|
|
Injured PCL |
In a positive posterior drawer sign the proximal tibia falls back. What is the most likely diagnoses? |
|
|
arthritis, ligamentous injury, or infection of the ankle |
Localized tenderness of the ankle is often present in what? |
|
|
plantar fasciitis, seen in prolonged standing or heel-strike exercise and also in rheumatoid arthritis, and gout |
Focal heel tenderness on palpation of the plantar fascia suggests what? |
|
|
posterior tibial tendinitis; flat feet |
Tenderness along the posterior medial malleolus suggests what and causes what? |
|
|
ankle fracture (known as Ottawa ankle rule) |
After trauma, inability to bear weight after four steps and tenderness over the posterior aspects of either maleolus, especially the medial malleolus, is suspicious for what? |
|
|
Rheumatoid arthritis |
Tenderness on compression of the forefoot is an early sign of what? |
|
|
Gout |
Acute inflammation of the first metatarsophalangeal joint suggests what? |
|
|
trauma, arthritis, vascular compromise |
Pain and tenderness called metatarsalgia, occurs in what? |
|
|
Morton's neuroma |
Tenderness over the third and fourth metatarsal heads on the plantar surface signals what? |
|
|
Acute snyovitis |
Pain in the metatarsophalangeal joints suggests what? |
|
|
chronic synovitis and claw-toe deformity |
Instability of the metatarsophalangeal joints occurs in what? |
|
|
sharp, burning, or shooting foot pain |
Diabetic patients with small fiber neuropathy report what? |
|
|
numbness and tingling or even no sensation at all |
Diabetics with large fiber neuropathy experience what? |
|
|
Mass lesions from brain tumors or abscess |
Dull headache increased by coughing and sneezing, especially in the same location, occurs in what? |
|
|
Pulsatile or throbbing, One-day duration or lasts 4 to 72 hours if untreated, Unilateral, Nausea or vomiting, Disabling or intensity causing interruption of daily activity |
What are the POUND features of migraine? |
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|
Presynscope from arrhythmia, orthostatic hypotension, vasovagal stimulation, or side effects from blood pressure and other medications |
Feeling light-headed, weak in the legs, or about to faint points to what? |
|
|
Vertebrobasilar transient ischemic attack or stroke. Also consider posterior fossa tumor and vertebrobasilar or hemicranial migraine |
Ataxia, diplopia, and dysarthria are suspicious for what? |
|
|
Transient ischemic attack and stroke |
Abrupt onset of motor and sensory deficits occurs in what? |
|
|
Guillain-Barre syndrome |
Progressive subacute onset of distal lower extremity weakness suggests what? |
|
|
Metastatic cord lesions and lumbar disc disease |
Chronic, more gradual, onset of weakness in the lower extremities can be seen in what? |
|
|
Central (ischemic, thrombotic, or mass lesions) and peripheral (range from nerve injury to the neuromuscular junction disorders, to myopathies, or intrinsic muscle diseases) |
Focal or asymmetric weakness has many causes such as what? |
|
|
myopathies from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders like myositis and dermatomyositis |
Proximal limb weakness, usually symmetric and without sensory loss occurs in myopathies from what? |
|
|
Myasthenia gravis |
In this neuromuscular junction disorder there is proximal typically asymmetric weakness that gets worse with effort (fatigability), often with associated bulbar symptoms such as diplopa, ptosis, dysarthria, and dysphagia |
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|
Polyneuropathy, as in diabetes |
Bilateral predominantly distal weakness suggests what? |
|
|
Local nerve compression or "entrapment," seen in hand numbness in distributions specific to the median, ulnar, or radial nerve; nerve root compression with dermatomal sensory loss from vertebral bone spurs or herniated discs; or central lesions from stroke or multiple sclerosis |
What are the different levels that sensory changes may arise at? |
|
|
painful sensory neuropathies from conditions like diabetes |
Burning pain from light touch or pinprick occurs in what? |
|
|
Polyneuropathies, especially from diabetes |
A pattern of stocking, then glove, sensory loss occurs in what? |
|
|
Mononeuritis multiplex, seen in diabetes and rheumatoid arthritis |
Multiple patchy areas of sensory loss in different limbs suggests what? |
|
|
seizures, "neurocardiogenic" or vasovagal syncope, orthostatic hypotension, and cardiac disease including arrhythmias, especially ventricular tachycardia and bradyarrhythmias |
Causes of syncope or fainting include what? |
|
|
a prodrome of nausea, diaphoresis, and pallor triggered by a fearful or unpleasant event, then vagally mediated hyptension, often with slow onset and offset |
In vasovagal syncope, a common cause of syncope, what should you look for? |
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|
Sudden onset and offset, reflecting loss and recovery of cerebral perfusion |
In syncope from arrhythmias, what should you look for? |
|
|
head trauma; alcohol, cocaine, and other drugs; withdrawal from alcohol, benzodiazepines, and barbituates; metabolic insults from low or high glucose or low calcium or sodium; acute stroke; and meningitis or encephalitis |
Common causes of acute symptomatic seizures include what? |
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|
Tonic-clonic motor activity, bladder or bowel incontinence, and postictal state. Unlike syncope, tongue biting or bruising of limbs may occur. |
What are characteristics of generalized seizures? |
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|
Epilepsy |
This seizure disorder is more common in infants and older adults. The baseline neurologic exam is frequently normal. Usually begins in childhood or adolescence; adult seizures are usually partial. |
|
|
Parkinson disease |
Low-frequency unilateral resting tremor, rigidity, and bradykinesia typify what disease? |
|
|
Essential tremors |
High-frequency, bilateral, upper extremity tremors that occur with both limb movement and sustained posture; head, voice, and leg tremor may also be present. |
|
|
pregnancy, renal disease, and iron deficiency |
Reversible causes of restless legs syndrome include what? |
|
|
Sinus conditions, head trauma, smoking, aging, and the use of cocaine, and in parkinson disease |
When does loss of smell occur? |
|
|
papilledema; optic atrophy; glaucoma |
When does optic disc bulging and blurred margins occur? Optic disc pallor? Cup enlargement? |
|
|
Horner's syndrom and simple anisocoria |
If both pupils react to light and anisocoria worsens in darkness, the small pupil has abnormal pupillary dilation which is seen in what? |
|
|
local problems with glasses or contacts lenses, cataracts, astigmatism, or ptosis |
Monocular diplopia is seen in what? |
|
|
CN III, IV, VI neuropathy, eye muscle disease from myasthenia gravis, trauma, thyroid opthalmopathy, and internuclear opthalmoplegia |
Binocular diplopa is seen in what? |
|
|
cerebellar disease, especially with gait ataxia and dysarthria, and vestibular disorders, and in internuclear opthalmoplegia |
When is nystagmus seen? |
|
|
3rd nerve palsy, Horner's syndrome, or myasthenia gravis |
Ptosis suggests what? |
|
|
Masseter and lateral pterygoind weakness |
Difficulty clenching the jaw or moving it to the opposite side occurs in what? |
|
|
CN V pontine lesions; bilateral hemispheric disease |
When palpating the temporal muscles and masseter muscles, unilateral weakness is seen in what? Bilateral weakness is seen in what? |
|
|
Ipsilateral facial and body sensory loss from contralateral cortical or thalamic lesion; ipsilateral face but contralatral body sensory loss |
Cranial nervous system patterns from stroke include what? From brainstem lesions? |
|
|
Peripheral nerve disorders like trigeminal neuralgia |
Isolated facial sensory loss occurs in peripheral nerve disorders like what? |
|
|
Absent blinking in lesions of CN V or VII. Absent blinking and sensorineural hearing loss in acoustin neuroma |
Absent blinking when testing the corneal reflex suggests what? |
|
|
facial weakness |
Flattening of the nasolabial fold and drooping of the lower eyelid suggests what? |
|
|
Both upper and lower face |
A peripheral injury to CN VII, also seen in Bell's palsy, affects which parts of the face? |
|
|
Mainly the lower face |
A central lesion to CNVII affects which parts of the face? |
|
|
conductive hearing loss |
Excess cerumen, otosclerosis, and otitis media cause what type of hearing loss |
|
|
sensorineural hearing loss |
Presbyacusis from aging comonly reflects what type of hearing loss? |
|
|
Vocal cord paralysis; paralysis of the palate |
Voice hoarsness occurs in what? Nasal voice occurs in what? |
|
|
Pharygeal or palatal weakness |
Difficulty swallowing suggests what? |
|
|
The palate fails to rise |
What happens when there is a bilateral lesion of CN X? |
|
|
One side of the palate fails to rise and, together with the uvula, is pulled toward the normal side |
What happens when there in unilateral paralysis of CN X? |
|
|
lesion of CN IX and perhaps CN X |
Unilateral absence of the gag reflex suggests what? |
|
|
a peripheral nerve disorder |
Trapezius weakness with atrophy and fasciculations indicates what? |
|
|
The shoulder droops and the scapula is displaced downward and laterally |
What happens in trapezius muscle paralysis? |
|
|
Raising the head off the pillow |
A supine patient with bilateral weakness of the sternomastoids has difficulty doing what? |
|
|
Amyotrophic lateral sclerosis and polio |
Tongue atrophy and fasciculations occur in what? |
|
|
The protruded tongue deviates transiently in a direction away from the side of the cortical lesion, toward the side of weakness |
In a unilateral cortical lesion, what happens? |
|
|
Mono- or hemiparesis from stroke |
Abnormal body position alerts you to what? |
|
|
median and ulnar nerve damage |
Localized atrophy of the thenar and hypothenar eminences occurs in what? |
|
|
Disease of the peripheral motor unit |
Fasciculations with atrophy and muscle weakness suggest what? |
|
|
Disease of the peripheral nervous system, cerebellar disease, or the acute stages of spinal cord injury |
Decrease muscle resistance suggests what? |
|
|
muscle hypotonia or flaccidity, usually from a disorder of the peripheral motor system |
Marked floppines of a muscle indicates what? |
|
|
Spasticity |
Velocity dependent increased tone that worsens at the extremes of range. Seen in central corticospinal tract diseases, is rate dependent, and increases with rapid movement. |
|
|
Rigidity |
Increased resistance throughout the range of movement and in both directions; it is not rate dependent. |
|
|
Weakness or paresis |
Impaired muscle strength is called what? |
|
|
peripheral nerve disease, from radial nerve damage, and in central nervous system disease, producing hemiplegia, seen in stroke or multiple sclerosis |
Weakness of extension of the wrist is seen in what? |
|
|
cervical radiculopathy, de Quervain's tenosynovitis, carpal tunnel syndrom, arthritis, and epicondylitis |
A weak grip is seen in what? |
|
|
Ulnar nerve disorders |
Weak finger abduction is seen in what? |
|
|
Median nerve disorders such as carpal tunnel syndrome |
Weak opposition of the thumb is seen in what? |
|
|
Myopathy; polyneuropathy, or disorder of the peripheral nerves |
When testing adduction at the hips, symmetric weakness of the proximal muscles suggests what? Symmetric weakness of distal muscles? |
|
|
nystagmus, dysarthria, hyoptonia, and ataxia |
In cerebellar disease, what should you look for? |
|
|
cerebellar disease |
Dysdiadochokinesis occurs in what? |
|
|
Cerebellar disease |
In this type of disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. In the finger to nose test, the finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement. |
|
|
Cerebellar disease. |
What disease causes incoordination that worsens with eyes closed? |
|
|
Cerebllar or vestibular disease |
Repetitive and consistent deviation to one side during the finger to nose test, referred to as past pointing, that is worse with the eyes closed suggests what? |
|
|
The heel may overshoot the knee and then oscillate from side to side down the shin. When position sense is lost, the heel is lifted too high and the patient tries to look. With eyes closed, performance is poor. |
When performing the heel-to shin test, if cerebellar disease is present, what happens? When position sense is lost, what happens? |
|
|
cerebellar disease, loss of position sense, or intoxication |
What might cause ataxia (a gait that lacks coordination, with reeling and instability)? |
|
|
Ataxia not previously obvious |
Tandem walking may reveal what? |
|
|
Distal muscular weakness in the legs |
Walking on toes and heels may reveal what? |
|
|
Corticospinal tract damage |
Inability to heel-walk is a sensitive test for what? |
|
|
weakness, lack of position sense, or cerebellar dysfunction |
Difficulty hopping may be due to what? |
|
|
proximal weakness (extensors of the hip), weakness of the quadriceps (the extensor of the knee), or bothD |
Difficulty in doing shallow knee bend suggests what? |
|
|
Proximal muscle weakness involving the pelvic girdle and legs |
What causes difficulty rising from a sitting position without arm support and stepping up on a sturdy stool? |
|
|
Ataxia from dorsal column disease and loss of position sense, and cerebellar ataxia |
What are possible causes of a positive Romberg Test? |
|
|
Corticospinal tract lesion originating in the contralateral hemisphere |
What is a cause of a positive pronator drift test? |
|
|
loss of position sense; cerebellar incoordination |
In the pronator drift test, a sideward or upward drift, sometimes with searching, writhing movements of the hands suggests what? If the arm returns to its original position but overshoots and bounces, what does this suggest? |
|
|
a lesion in the opposite cerebral hemisphere; a spinal cord lesion |
A hemisensory loss pattern suggests what? A sensory level suggest what? |
|
|
polyneuropathy |
Symmetric distal sensory loss suggests what? |
|
|
The "glove and stocking" sensory loss of a polyneuropathy, often seen in alcoholism and diabetes |
If sensory loss is bilateral, it suggests what? |
|
|
Absence of pain; decreased sensitivity to pain; increased sensitivity to pain |
Analgesia refers to what? hypalgesia? hyperalgesia? |
|
|
Absence of touch sensation; decreased sensitivity; increased sensitivity |
Anesthesia refers to what? Hypesthesia? Hyperesthesia? |
|
|
Vibration sense |
What is often the first sense to be lost in a peripheral neuropathy? |
|
|
Diabetes and alcoholism, posterior column disease such as tertiary syphilis or vitamin B12 deficiency |
What are common causes of vibration sense loss? |
|
|
Estimating the level of a cord lesion |
Testing vibration sense in the trunk may be useful in what? |
|
|
tabes dorsalis, multiple sclerosis, or B12 deficiency from posterior column disease, and in peripheral neuropathy from diabetes |
Loss of position sense is seen in what? |
|
|
disease of the sensory cortex |
When touch and position sense are normal or only slightly impaired, a disproportionate decrease in, or loss of, discriminative sensations suggest what? |
|
|
posterior column disease |
Stereognosis, number identification, and two-point discrimination are impaired in what? |
|
|
The inability to recognize objects placed in the hand |
Astereognosis refers to what? |
|
|
a lesion in the sensory cortex |
The inability to recognize numbers, or graphesthesia, suggests what? |
|
|
lesions of the sensory cortex |
In two-point discrimination, what can increase the distance between two recognizable points? |
|
|
lesions of the sensory cortex |
What impairs the ability to localize points accurately? |
|
|
lesions of the sensory cortex (the stimulus on the side opposite the damaged cortex is extinguished) |
When simultaneously stimulating corresponding areas on both sides of the body, what may cause only one stimulus to be recognized? |
|
|
In central nervous system lesions along the descending corticospinal tract |
Hyperactive reflexes (hyperreflexia) is seen in what? |
|
|
In diseases of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves |
Hypoactive or absent reflexes (hyporeflexia) is seen in what? |
|
|
In the ankle reflex |
The slowed relaxation phase of reflexes in hypothyroidism is often easily seen and felt in which reflex? |
|
|
Central nervous system disease |
Sustained clonus indicates what? |
|
|
central and peripheral nerve disorders |
Abdominal reflexes may be absent when? |
|
|
Central nervous system lesion in the corticospinal tract, unconscious states from drug or alcohol intoxication or in the postical period following a seizure |
What may cause a positive Babinski Test? |
|
|
Lesion in the S2-3-4 reflex arc, is seen in cauda equina lesions |
Loss of the anal reflex suggests what? |
|
|
resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve (Brudzinski's sign), or the sciatic nerve (Kernig's sign) |
Inflammation in the subarachnoid space causes what? |
|
|
Acute bacterial meningitis, subarachnoid hemorrhage, severe meningeal inflammation |
Neck stiffness with resistance to flexion is seen in what? |
|
|
Flexion of both the hips and knees |
What happens in a positive Brudzinski's sign? |
|
|
Pain and increased resistance to extending the knee |
What happens in a positive Kernig's sign? |
|
|
a painful radiculopathy with associated muscle weakness and dermatomal sensory loss, usually from a herniated disc |
Compression of the spinal nerve root as it passes through the vertebral foramen causes what? |
|
|
L5-S1 where the spine angles sharply anterior |
More than 95% of disc herniations occur where? |
|
|
Pain radiating into the ipsilateral leg |
What happens in a positive straight-leg test for lumbosacral radiculopathy? |
|
|
lumbosacral radiculopathy, sciatic neuropathy, or both |
Foot dorsiflexion can increase leg pain in what conditions? |
|
|
Increased pain when the contralateral healthy leg is raised |
What happens in a positive crossed straight-leg-raising sign? |
|
|
liver disease, uremia, and hypercapnia |
Sudden, brief, nonrhythmic flexion of the hands and fingers indicates asterixis. This is seen in what? |
|
|
weakness of the serratus anterior muscle, seen in musular dystrophy or injury to the long thoracic nerve |
Winging of the scapula suggests what? |
|
|
At 24 hours- absent corneal response, absent pupillary response, absent withdrawal response to pain, no motor response; at 72 hours- no motor response |
What are five clinical signs that strongly predict death or poor outcome? |
|
|
structural lesions from stroke, abscess, or tumor mass |
What may lead to asymmetrical pupils and loss of light reaction? |
|
|
"look at the lesion" in the affected hemisphere |
In structural hemispheric lesions, where do the eyes look? |
|
|
"look away" from the affected hemisphere |
In irritative lesions from epilepsy or early cerebral hemorrhage, where do the eyes look? |
|
|
lesion of the midbrain or pons |
In a comatose patient with absence of doll's eye movements, the ability to move both eyes to one side is lost, this suggests what? |
|
|
Brainstem injury |
When testing the oculovestibular reflex, no response to stimulation suggests what? |
|
|
corticospinal tract lesion |
When applying a painful stimulus, if there is no response on one side, what does this suggest? |
|
|
Usually flaccid at first. The limp hand drops to form a right angle with the wrist. |
What is the hemiplegia of sudden cerebral accidents like? |
|
|
The flaccid leg falls more rapidly into extension, with external rotation at the hip |
In acute hemiplegia, what happens to the flaccid leg? |
|
|
The internal inguinal ring where the spermatic cord exits the abdomen |
Where do indirect inguinal hernias develop? |
|
|
More medially from weakness in the floor of the inguinal canal and are associated with straining and heavy lifting |
Where do direct inguinal hernias arise? |
|
|
Femoral hernias |
This type of hernia is more likely to present as an emergency with bowel incarceration or strangulation |
|
|
psychogenic causes such as depression, endocrine dysfunction, or side effects of medications |
What might cause lack of libido? |
|
|
Psychogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes |
What are causes of erectile dysfunction? |
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Medications, surgery, neurologic deficits, or lack of androgen |
What are possible causes of reduced or absent ejaculation? |
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psychogenic causes |
What is typically the cause of lack of orgasm with ejaculation? |
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Gonorrhea; gonococcal urethritis from chlamydia |
Yellow penile discharge is seen in what? White discharge? |
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Disseminated gonorrhea |
Rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms, occur in what? |
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syphilitic chancre, herpes; human papillomavirus (HPV); mumps, orchitis, scrotal edema, testicular cancer; testicular torsion, epipdidymitis, orchitis |
When should you look for ulcer on the penis or scrotum? Warts?Swelling? Pain? |
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gonorrhea, chlamydia, syphilis, and herpes |
Infections from oral-penile transmission include what? |
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Anal intercourse |
Symptomatic or asymptomatic proctitis may follow what? |
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Phimosis |
A tight prepuce that cannot be retracted over the glans |
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Paraphimosis |
A tight prepuce that, once retracted, cannot be returned. Edema ensues. |
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Balanitis |
Inflammation of the glans |
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Balanoposthitis |
Inflammation of the glans and prepuce |
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lice (crabs) or, sometimes, scabies |
Pubic or genital excoriations suggest what? |
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Hypospadias |
A congenital, ventral displacement of the meatus on the penis |
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gonococcal urethritis; nongonococcal urethritis |
When does profuse yellow discharge from the penis occur? Scanty white or clear discharge? |
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Urethral stricture or possibly a carcinoma |
Induration along the ventral surface of the penis suggests what? |
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Periurethral inflammation secondary to a urethral stricture |
Tenderness in an inundated area of the penis suggests what? |
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cryptorchidism (an undescended testicle) |
A poorly developed scrotum on one or both sides suggests what? |
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indirect inguinal hernias, hydroceles, scrotal edema, and, rarely, testicular carcinoma |
Common scrotal swellings include what? |
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acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia |
Tender, painful scrotal swelling is present in what? |
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hydrocele of the cord |
A cystic structure in the spermatic cord suggests what? |
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varicocele |
If while palpating the spermatic cord, multiple tortuous veins are palpable and even visible, what might this indicate? |
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Thickened or beaded |
If the vas deferens are chronically infected, how might they feel? |
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light up with a red glow or transilluminate |
If a light is shined on a testis containing a hydrocele, how will it appear? |
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Sagging of the pelvic floor, widening the urogenital hiatus, and prolapse the pelvic organs |
Weakness of the levator ani may cause what? |
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stress incontinence |
Loss of urethral support contributes to what? |
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rectoceles and enteroceles |
Weakness of the perineal body from childbirth predisposes to what? |
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Increased protaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline |
Primary dymenorrhea results from what? |
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endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps |
What are causes of secondary dysmenorrhea? |
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pregnancy, lactation, menopause, low body weight from any cause, stress, chronic illness, and hypothalamic pituitary-ovarian dysfunction |
What are causes of secondary amenorrhea? |
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pregnancy, cervical or vaginal infection or cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal contraception or replacement therapy |
What are causes of abnormal bleeding in women? |
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cervical polyps or cancer, or, in an older woman, atrophic vaginitis |
Postcoital bleeding suggests what? |
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endometrial cancer, hormone replacement therapy, and uterine and cervical polyps |
Causes of postmenopausal bleeding include what? |
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a threatened abortion or dysfunctional uterine bleeding related to a lack of ovulation |
Amenorrhea followed by heavy bleeding suggests what? |
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lack of estrogen, medical illness, and psychiatric conditions |
Sexual dysfunction in a woman may be caused by what? |
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local inflammation, atrophic vaginitis, or inadequate lubrication; pelvic disorders or pressure on a normal ovary |
Superficial pain with intercourse suggests what? Deeper pain? |
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pelvic inflammatory disease, ruptured ovarian cyst, and appendicitis |
What are the most common causes of acute pelvic pain in women? |
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pain from ovulation at midcycle |
What is mittelschmerz? |
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Endometriosis, adenosis, fibroids |
What are common causes of chronic pelvic pain? |
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history of sexual abuse |
Chronic pelvic pain is a red flag for what? |
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familial or related to chronic illness; abnormal function of the hypothalamus, anterior pituitary gland, or ovaries |
Why might someone experience delayed puberty? |
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Pediculosis pubis (lice or "crabs") |
When examining the external genitalia, excoriations or itchy, small, red maculopapules suggest what? |
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endometriosis involving the uterosacral ligaments |
When may lateral displacement of the cervix be present? |
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|
urethritis, cervicitis, pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain |
Chlamydial infection is linked to what? |
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Candida, trichomonas vaginalis, bacterial vaginosis |
Vaginitis with discharge can result from what? |
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|
DES exposure in utero and HPV infection |
What are risk factors for vaginal cancer? |
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|
Anterior vaginal wall defects such as cystoceles; rectoceles |
Using the lower blade of the speculum as a retractor during bearing down helps expose what? Use of the upper blade helps expose rectoceles |
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Pelvic inflammatory disease, ectopic pregnancy, and appendicitis |
Cervical motion tenderness and/or adnexal tenderness suggest? |
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Pregnancy, uterine myomas (fibroids), or malignancy |
Uterine enlargement suggests what? |
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|
Myomas |
Nodules on the uterine surfaces suggest what? |
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|
Ovarian cyst or ovarian cancer |
In postmenopausal women, a palpable ovary may indicate what? |
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|
tubo-ovarian abscess, salpingitis or inflammation of the fallopian tubes from PID, or ectopic pregnancy |
Adnexal masses can also arise from what? |
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|
Pelvic floor spasm, interstitial cystitis, vulvodynia, and urethral spasm |
Pelvic floor muscle overrecruitment with tightening, vaginal wall tenderness, and referred pain may be found in pelvic pain from what? |
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|
Pelvic floor spasm |
Trigger point tenderness in pelvic floor muscles can be seen in what? |
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|
endometriosis |
Nodularity, thickening of the uterosacral ligaments, and pain with uterine movement occur in what? |
|
|
Indirect inguinal hernia; femoral hernia |
What is the most common hernia in women? The second most common? |
|
|
infection with Chlamydia trachomatis or Neisseria gonorrhoeae |
Urethritis in women may arise from what? |
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Colon cancer; polyps, cancer, gastrointestinal bleeding, or local hemorrhoids; villous adenoma |
Change in bowel pattern, especiall stools of thin pencil-like shape, may warn of what? Blood in the stool? Mucus? |
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|
Itching, anorectal pain, tenesmus, or discharge or bleeding from infection or rectal abscess |
Proctitis may be indicated by what? |
|
|
gonorrhea, chlamydia, lymphogranuloma venereum, receptive anal intercourse, ulcerations of herpes simplex, chancre of primary syphilis |
Causes of proctitis include what? |
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|
Pinworms |
Rectal itching in younger patients may be from what? |
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|
HPV, condylomata lata in secondary syphilis |
Genital warts may occur from what? |
|
|
proctitis and Crohn's disease |
When can anal fissures be found? |
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|
feeling of discomfort or heaviness in the prostate area at the base of the penis, malaise, fever, or chills |
What symptoms may suggest possible prostatitis? |
|
|
hemorrhoids, vereneal warts, herpes, syphilitic chancre, and carcinoma |
Anal and perianal lesions include what? |
|
|
anal fissure from large, hard stools, inflammatory bowel disease, or STIs |
A linear crack or tear in the anus suggests what? |
|
|
Pruritus ani |
What should you consider if there is swollen, thickened, fissured perianal skin with excoriations? |
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|
anxiety, inflammation, or scarring; neurologic diseases, such as S2-4 cord lesions |
Anal sphincter tightness may occur with what? Laxity? |
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|
inflammation, scarring, or malignancy |
Induration of the anus may be caused by what? |
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|
peritoneal metastases; peritoneal inflammation |
What does a rectal "shelf" indicate? Rectal tenderness? |
|
|
Galactorrhea |
The inappropriate discharge of milk-containing fluid from the breasts; abnormal if it occurs 6 or more months after childbirth or cessation of breast-feeding. |
|
|
Local infection or inflammatory carcinoma |
Redness of the breast may be caused by what? |
|
|
Cancer |
Flattening of the normally convex breast suggests what? |
|
|
underlying cancer |
Asymmetry in directions in which nipples point suggests what? |
|
|
Paget's disease of the breast |
Rash or ulceration of the breast occurs in what? |
|
|
Nipple retraction; A retracted nipple may also be broadened and thickened, suggesting an underlying cancer |
Recent or fixed flattening or depression of the nipple suggests what? |
|
|
An underlying cancer |
Dimpling or retraction of the breasts when the arms are over the head, hands pressed against the hips, or leaning forward suggests what? |
|
|
Posttraumatic fat necrosis or mammary duct ectasia |
Dimpling or retraction of the breasts may be caused by what benign lesions? |
|
|
Mammary duct ectasia, a benign but sometimes painful condition of dilated ducts with surrounding inflammation, sometimes with associated masses |
Tender breast cords suggest what? |
|
|
cancer |
Hard, irregular, poorly circumscribed breast nodules, fixed to the skin or underlying tissues, strongly suggests what? |
|
|
the ribs and intercostal muscles; pectoral fascia |
A mobile breast mass that becomes fixed when the arm relaxes is attached to what? If fixed when the hand is pressed against the hip? |
|
|
An underlying cancer |
Thickening of the nipple and loss of elasticity suggest what? |
|
|
an imbalance of estrogens and androgens, sometimes drug related |
Gynecomastia arises from what? |
|
|
hidradenitis suppurative |
Sweat gland infection is called what? |
|
|
acanthosis nigricans (one form is associated with internal malignancy) |
Deeply pigmented, velvety axillary skin suggests what? |
|
|
Nonpuerperal galactorrhea; hypothyroidism, pituitary prolactinoma, and drugs that are dopamine agonists, including many psychotropic agents and phenothiazines |
Milky discharge unrelated to a prior pregnancy and lactation is called what? What are the causes? |
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|
intraductal papilloma, ductal carcinoma in situ, or Paget's disease of the breast |
Spontaneous unilateral bloody discharge from one or two breast ducts warrants further evaluation for what? |
|
|
Supine hypotensive syndrome |
When a pregnant woman lies supine, compression of the descending aorta and inferior vena cava interferes with venous return from the lower extremities and pelvic vessels, causing the paint to feel dizzy and faint. What is this called? |
|
|
hyperemesis gravidarum |
Losses in excess of 5% of pre-pregnancy weight are considered excessive and represent what? |
|
|
Gestational hypertension |
SBP >140 or DBP >90 first documented after 20 weeks of pregnancy without proteinuria |
|
|
Preeclampsia |
SBP >140 or DBP >90 after 20 weeks of pregnancy with proteinuria |
|
|
preeclampsia |
Facial edema after 20 gestational weeks may reflect what? |
|
|
Poor pregnancy outcomes |
Dental problems in pregnancy are associated with what? |
|
|
possible infection, asthma, pulmonary embolus, or peripartum cardiomyopathy |
Dyspnea accompanied by increased respiratory rate, cough, rales, or respiratory distress duiring pregnancy raises concerns of what? |
|
|
anemia |
Murmurs in pregnancy may signal what? |
|
|
error in calculating gestational age, fetal death or severe morbidity, or false pregnancy |
If fetal movement cannot be felt after 24 weeks, what should be considered? |
|
|
preterm labor |
Before 37 weeks, regular uterine contractions with or without pain and bleeding are abnormal and suggest what? |
|
|
multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma; low level of amniotic fluid, missed abortion, intrauterine growth retardation, or fetal anomaly |
If fundal height during pregnancy is 4 cm larger than expected, what should be considered? 4 cm smaller? |
|
|
Fewer week's gestation than expected, fetal demise, false pregnancy, or observer error |
Lack of audible fetal heart tones may indicate what? |
|
|
Multiple gestation |
After 24 weeks, auscultation of more than one FHR in different locations with varying rates suggests what? |
|
|
Sustained dips in FHR and lack of beat-to-beat variability |
What characteristics of fetal heart rate warrant investigation with a formal FHR monitor? |
|
|
preterm labor |
Cervical opening or shortening (effacement) prior to 37 weeks gestation may indicate what? |
|
|
uterine leiomyomata, or fibroids, or a bicornuate uterus, one with two distinct cavities separated by a septum |
An irregularly shaped uterus suggests what? |
|
|
ectopic pregnancy |
Adnexal tenderness or masses early in gestation require ultrasound evaluation to rule out what? |
|
|
deep vein thrombosis |
In pregnancy, unilateral severe edema with calf tenderness warrants evaluation for what? |
|
|
preeclampsia |
Hyperreflexia during pregnancy may signal what? |
|
|
depression, Parkinson's disease, or alzheimer's disease |
Flat or impoverished affect occurs in what? |
|
|
medications, autonomic disorders, diabetes, prolonged bed rest, volume depletion, amyloidosis, and cardiovascular disorders |
What are causes of orthostatic hypertension? |
|
|
lower respiratory infection, heart failure, and COPD exacerbation |
Respiratory rate >25 or equal to 25 breaths per minutes in an older adult indicates what? |
|
|
depression, alcoholism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, social isolation, poor dentition, and poverty |
When is undernutrition seen? |
|
|
Pressure sores |
These may develop from obliteration of arteriolar and capillary blood flow to the skin or from shear forces during movement across sheets or when lifted upright incorrectly. |
|
|
Cigarette smoking, exposure to UV-B light, high alcohol intake, diabetes, medications (including steroids), and trauma |
What are risk factors for cataracts? |
|
|
cerebral microvasular disease and cognitive impairment |
Retinal microvascular disease is linked to what? |
|
|
dilation of the left ventricle from heart failure or cardiomyopathy; hypertension |
In older adults and S3 suggests what? S4? |
|
|
Aortic stenosis |
Delay present during simultaneous palpation (but not compression) of the brachial and radial pulses denotes what? |
|
|
Parkinson's disease |
Persistent blinking after glabellar tap and difficulty walking heel-to-toe are common in what? |
