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CHAPTER 2: HEAD and NECK
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• The Eye
• The Ear
• Nose and Throat
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THE EYE
SYMPTOMS:
• SUDDEN LOSS of VISION: Potential Causes
o AMAUROSIS FUGAX: Temporary, monocular, ischemic blindness.
Painless
Caused bu ipsilateral Carotid stenosis or emboliation o! the retinal artery.
o RETINAL DETACHMENT: "lashin# li#hts, !loatin# halos, and blurry $ision
before the blindness is indicati$e o! retinal detachment.
o UVEITIS: %n!lammation o! u$eal tract && iris, ciliary body, and choroid.
'l(ays pain!ul
'ssociated (ith multiple diseases: connecti$e tissue diseases,
histoplasmosis, sarcoidosis, tuberculosis.
• GRADUAL LOSS of VISION: Potential Causes
o CATARACTS: Opacities o! the lens, occurrin# (ith a#e.
o GLAUCOMA: %ncreased intraocular pressure.
%t is the most common reason for loss of vision over age 50.
o MACULAR DEGENERATION: Secondary to )iabetes, and e*pected to cause
$isual blindness.
Diab!i" R!ino#a!$%.
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o OPTIC NERVE COMPRESSION: Caused by an intracranial neoplasm, or
pituitary adenoma.
o OPTIC NEUROPATHY &O#!i" N'(i!i)*: M'+!i#+ S"+(o)i), and dru#s such
as Ethambutol, Methanol, can all cause optic neuritis and #radual blindness.
o PRES,YOPIA: +radual loss o! ability o! 'ccommodation !or near&$ision,occurrin# (ith a#e.
o CORTICAL ,LINDNESS: %n!arct o! the Occipital obe can lead to cortical
blindness. Patient (ill ha$e binocular blindness, but (ill retain the pupillary light
reflex (hich is una!!ected.
• DIPLOPIA: )ouble $ision.
o Mono"'+a( Di#+o#ia: Should su##est corneal or lens problem.
o ,ino"'+a( Di#+o#ia: %ndicati$e o! cranial ner$e palsy or ocular muscle problems,
or a brainstem problem.
o M%a)!$nia G(a-i) &MG*: )iplopia (ithout pain is o!ten the presentin#
complaint in M+.
• EYE PAIN:
o The cornea is inner$ated by the O#$!$a+.i" N(-/ CN V0.
o Possible causes o! eye pain
CNS problems a!!ectin# CN -: Menin#itis, ca$ernous sinus thrombosis,
aneurysms, mi#raine
'd/acent structures: sinus problems
Eye problems 0 in!lammations: Con/uncti$itis, stye, chalaion
o P$o!o#$obia: Eye pain upon e*posure to li#ht, indicati$e o!
• SCOTOMATA: Speci!ic islands or spots o! impaired $ision1 an impaired $isual !ield.
EYELIDS:
•
PTOSIS: )roopy eyelids1 !ailure o! lids to open !ully.o Caused by !ailure o! levator palpebrae, inner$ated by CN %%%, or !ailure o! Tarsal
Muscle, inner$ated by sympathetics.
o Some causes: 2orner3s Syndrome, Myasthenia +ra$is, Encephalitis
• LID LAG: E$idence o! (hite sclera bet(een the iris and upper lid mar#in. This is
normally not !ound.
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o %t is a si#n o! G(a-1) Di)a)
• STYE: Small abscess caused by in!ection o! sebaceous glands of Zeis.
• CHALAION: 'cute in!lammation o! the meibomian gland.
SCLERA:
• SCLERITIS: %n!lammation o! the sclera, $isible as bro(n 0 red in!iltrates in sclera on
#ross e*amination. "ound in autoimmune and colla#en $ascular diseases, such as SLE/RA.
• ,LUE SCLERA: Patho#nomonic o! Osteogenesis Imperfecta.
o Results !rom $ery thin sclera in (hich the choroid sho(s throu#h.
• ,RO3N SCLERA: "ound in disorder l!aptonuria 4metabolic disorder5
• YELLO3 SCLERA: "ound in "aundice. %t should raise the 6uestion o! li$er disease or
hemolytic anemia.
EXOPHTHALMOS: Eyes /uttin# out past eyelids. ' si#n o! +ra$e3s disease, acrome#aly, and
ca$ernous sinus thrombosis.
CORNEA:
• KERATOCON4UNCTIVITIS &KERATITIS* SICCA: "ound in S567(n1) S%nd(o.,
resultin# !rom autoantibodies a#ainst sali$ary #lands resultin# in no sali$ary secretion.
o Classic triad o! symptoms (ith S/7#ren3s Syndrome:
8eratitis Sicca 4dry eyes5
9erostomia 4dry mouth5
Rheumatoid 'rthritis
• INTERSTITIAL KERATITIS: ' si#n o! con#enital syphilis.
o H'!"$in)on1) T(iad: Triad o! interstitial eratitis, dea!ness, and notched teeth is
classical e$idence !or con#enital syphilis.
• ARCUS SENILIS: +ray band o! opacity around the cornea.
• KAYSER8FLEISCHER RINGS: Copper in )escemet3s Membrane.
o Circular bands o! bro(nish pi#ment on lateral and medial mar#ins o! cornea.
o "ound in 3i+)on1) Di)a)
• PINGUECULAE: Small, yello(ish ele$ations o! the con/uncti$ae, (hich appear bro(n
in +aucher3s disease. %t is caused by hyaline de#eneration o! con/uncti$al tissue.
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• ANISOCORIA: Un9'a+ #'#i+), caused by miosis or mydriasis o! one pupil.
PUPILS:
• MARCUS GUNN PUPIL: ' pupil that dilates 4rather than constricts5 as li#ht s(in#s
to(ard it.o %t indicates either se$ere macular disease or optic ner$e disease in the a!!ected
eye.
• PUPILLARY REFLEXES:
o Ab)n! Di("! Rf+: %ndicates a problem (ith the a!!erent branch 4Tri#eminal
-5 o! the re!le*.
o Ab)n! Con)n)'a+ Rf+: %ndicates a problem (ith the e!!erent branch 4CN %%%,
Edin#er&;estphal Nucleus5 o! the a!!ected eye.
•
CONVERGENCE: 'bility o! eyes to !ocus in(ard and accommodate !or near $ision.
o Impaired convergence is seen (ith +ra$e3s )isease.
• ARGYLL RO,ERTSON PUPIL: %ndicates a !orm o! CNS Syphilis, Tab) Do()a+i).
o ;ea or absent direct pupillary re!le*.
o #ormal response to accommodation.
o "ailure o! pupillary dilation (ith pain!ul stimulation or a!ter atropine
administration.
• ADIE1S PUPIL: Similar to 'r#yll Robertson Pupil.
o ;ea or absent direct pupillary re!le*.
o Impaired or absent accommodation.
o Eye appears lar#er than the other eye on inspection.
• MYDRIASIS: 'bnormal dilation o! pupil, can occur in )iabetes.
• MIOSIS: 'bnormal constriction o! pupil, seen in 2orner3s syndrome.
o
HORNER1S SYNDROME: ost sympathetics !rom the Superior Cer$icalPle*us. $tosis, Miosis, nhydrosis.
NYSTAGMUS: Nysta#mus is normal (hen looin# in the periphery !or e*tended times. 'll
other nysta#mus is abnormal.
• Causes: abyrinthitis, MS, ;ernice&8orsao!!, Meniere3s )isease
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EXTRAOCULAR PALSIES:
• In!(na+ S!(abi).'): Eye points in, due to dener$ation o! the bducens, %# &I .
• E!(na+ S!(abi).'): Eye points out and do(n, due to dener$ation o! the Oculomotor,
%# III.
o Eye points out because o! in!luence o! 'bducens 4CN -%5
o Eye points do(n because o! in!luence o! Trochlear 4CN %-5 &&&&&&< Superior
Obli6ue muscle.
VISUAL FIELD DEFICITS:
• ,ITEMPORAL HEMIANOPSIA: oss o! peripheral $ision1 tunnel $ision, occurs (ith
Pituitary Tumor.
• HOMONYMOUS HEMIANOPSIA: oss o! same $isual !ield in both eyes. Occurs due
to lesion in Optic Tract.
• ;UADRANT HEMIANOPSIA: esion in the optic radiations.
FUNDUSCOPIC INSPECTION:
• RED REFLEX: %ts absence indicates a cataract.
• -ESSES:
o The $eins are normally sli#htly bi##er than the arteries.
o ARTERIO8VENOUS &AV* NICKING: H%#(!n)ion narro(s the arteries and
creates indentations in the $eins, (here arteries cross the $eins.
• MACULA: )immer, darer area in !undoscope, containin# the !o$ea.
• OPTIC DISC: Out o! (hich $essels tra$el. The bri#htest area o! !undoscope.
• RET%NOP'T2OO+%ES:
o DIA,ETIC RETINOPATHY: Sho(s $a(d 'da!) on the retina, (hich are
lipid laden. They are dense, (ell&de!ined creamy (hite spots.
Co!!on 3oo+ E'da!) are poorer de!ined and can occur (ith
hypertension.
o PAPILLEDEMA: S(ellin# o! retinal $essels, !rom impaired $enous return in the
eye &&&&&&< $enous distension.
$apilledema is caused by increased intracranial pressure.
Causes: =rain tumors, mali#nant hypertension, hydrocephalus.
's opposed to $appilitis, there is no loss o! $ision.
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o HYPERTENSION: Chan#es in retina are #raded thru >. 'n abnormally hi#h
-0' ratio can be !ound, indicatin# $enous distension.
S!a7 I: 'rteriolar narro(in# but no '-&nicin#.
S!a7 II: "ocal spasm, AV8ni"<in7.
S!a7 III: 2emorrha#es and e*udates
S!a7 IV: Pa#i++d.a/ O#!i" di)" d.a 4due to ischemia5 and
hemorrha#e, (hich can lead to retinal detachment.
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THE EAR
TINNITUS: Rin#in# in ear.
VERTIGO:
• Ob5"!i- V(!i7o: The earth is mo$in# around you.
• S'b5"!i- V(!i7o: You are mo$in# in space.
RINNE TEST: Test !or conductive hearing loss by comparin# air conduction to bone
conduction.
• "irst hold tunin# !or ri#ht near auricle, then place it o$er the Mastoid Process.
• NORM': %t should sound louder near the auricle, because air conduction should be
better than strai#ht bone conduction.
• '=NORM': %! it sounds louder o$er the mastoid process instead, that indicates a
conductive hearing loss in the middle ear.
3E,ER TEST: Place tunin# !or o$er head. %t should be heard e6ually in both ears.
•
ONE E'R %S O?)ER: %! one ear is louder, than there is either conducti$e hearin# lossin that ear or sensorineural hearin# loss in the other ear.
MENIERE1S DISEASE: Triad o! tinnitus, $erti#o, and sensorineural hearin# loss. May see
nausea, $omitin#, nysta#mus.
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,ENIGN POSITIONAL VERTIGO: Transient attacs o! $erti#o, induced by mo$ements o!
the head and trun. Symptoms can be induced by ha$in# the patient merely thin about the
mo$ements.
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NOSE and THROAT
NOSE:
• EPISTAXIS: =loody nose.
o T(an)in! E#i)!ai): May occur (ith !orce!ul nose&blo(in#, sneein#, nose&
picin#, !acial trauma.
o R"'((n! E#i)!ai): )i!!erential dia#nosis @ hypertension, coa#ulopathies, renal
!ailure, cirrhosis, $(di!a(% $.o(($a7i" !+an7i"!a)ia.
• RHINOPHYMA: Se$ere acne rosacea !ound in association (ith sin hypertrophy and
con#estion o! subcutaneous tissue, around the nose.
THROAT:
• SOAR THROAT: %n!ection mononucleosis, strep&throat 4streptococcal pharyn#itis5.
• HOARSENESS: aryni#itis, aryn#eal cancer, hypothyroidism, smoin# &&&&&&<
broncho&#enic carcinoma.
A,NORMAL TASTE:
• H%#o7')ia: %mpaired ability to taste. Seen in ?R%3s, #lossitis, stomatitis.
• D%)7')ia: ?npleasant taste. )i!!erential dia#nosis:
o Medications: .!(onida=o+
o -itamin and mineral de!iciencies: inc depletion
o
Chyronic hypercalcemia, hyperparathyroidism.o -iral hepatitis
TONGUE:
• MACROGLOSSIA: ar#e ton#ue can occur (ith amyloidosis and acrome#aly.
• GLOSSITIS: %n!lammation on sides, base, and underside o! ton#ue.
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o -itamin and mineral de!icincies
o Medications: metronidaole, phenytoin
o %n!ections: candidiasis
o Pernicious 'nemia
o Cytoto*ic dru#s, radiotherapy.
MOUTH EXAMINATION:
• ORAL ULCERS: Recurrent oral ulcers di!!erential dia#nosis:
o R"'((n! a#$!$o') '+"() 4caner soars5: Common, !re6uently associated (ith
%n!lammatory =o(el )isease.
o %n!ections: HSV80, 2erpes Aoster, tuberculosis, histoplasmosis, syphillis.
o Trauma
o Cytoto*ic dru#s
o Rare: Erythema Multi!orme, ;e#ener3s +ranulomatosis, Ste$ens&Bohnson
Syndrome, Reiter3s Syndrome
• SYN)ROMES:
o PEUT84EGHER1S SYNDROME: Melanin spots on lips are !ound.
o OLIVER83E,ER8RENDU SYNDROME: T+an7i"!a)ia, $ascular lesion
!ormed by dilation o! small #roup o! blood $essels.
• KOPLIK1S SPOTS: ;hite spots on the buccal mucosa, indicati$e o! the .a)+).
• STRA3,ERRY TONGUE: Erythema o! ton#ue, occurs (ith )"a(+! f-(.
CHAPTER >: RESPIRATORY SYSTEM
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P?MON'RY SYMPTOMS:
• COUGH:
o Possible Causes o! Cou#h:
Pulmonary 0 Mechanical causes: A)!$.a, %rritants, aspiration
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%n!ectious: T'b("'+o)i)/ Hi)!o#+a).o)i)/ Pn'.onia
Temperature: %nhalin# cold air
P'+.ona(% E.bo+i)./ #'+.ona(% d.a?
Non&Pulmonary: e*ternal ear canal irritation.
o )etails:
S.o<(1) Co'7$ usually occurs in mornin# and is producti$e.
A)!$.a!i" Co'7$ usually is non&producti$e.
• SPUTUM: %t is al(ays abnormal.
o PRO)?CT%-E CO?+2S are seen in:
Chronic =ronchitis, Smoer3s cou#h
,(on"$i"!a)i): chronically dilated bronchioles.
ar#e $olume o! sputum, (hich separates into t(o or three layers
upon standin#.
Tumors: =ronchoal$eolar Carcinoma
%n!ections: Pneumonia, tuberculosis, un# 'bscess
;ill usually see %++o@ o( 7(n sputum.
Pulmonary Edema
• HEMOPTYSIS:
o C'?SES:
Most common: ,(on"$i!i)/ ,(on"$o7ni" Ca("ino.a/ Pn'.o"o""a+Pn'.onia
More rare in!ections:
T'b("'+o)i): '#e o$er D, cracles, !e( other symptoms
Coccidiomycosis, 2istoplasmosis
Other Tumors: ;ei#ht loss, ci#arettes, anore*ia
Rare %mmune )isorders: +oodpasture3s Syndrome, ;e#ener3s
+ranulomastosis
P'+.ona(% E.bo+i).:
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2i#h -0 Ratio. ots o! $entilation, poor per!usion. E*cessi$e
dead space.
"riction rub, accentuated PF.
Pleuritic chest pain.
o MASSIVE HEMOPTYSIS @ DD m in F> hrs. ?sually associated (ith
b(on"$i"!a)i), and may be indicati$e o! +'n7 "an"( or #'+.ona(%a)#(7i++o)i).
• PLEURITIC CHEST PAIN: Chest pain upon breathin#.
o P?MON'RY C'?SES: =ronchitis, pneumonia, pulmonary embolism,
tuberculosis, lun# carcinoma.
o NON&P?MON'RY C'?SES:
Ti!=1) S%nd(o. &Co)!o"$ond(i!i)*: Super!icial chest pain (ith localtenderness.
T(a"$i!i) presents (ith retrosternal chest pain, made (orse by cou#hin#.
• DYSPNEA: )i!!icult, labored breathin#.
o )i!!erential )ia#nosis: ' laundry list o! possible causes
Pulmonary )isease: COP), cancer, asthma, chronic or acute bronchitis,
emphysema, pneumonia, pulmonary emboli, pneumothora*
Cystic "ibrosis: S(eat test
Cardiac causes: C2", Pulmonary edema, PN)
2ematolo#ic: 'nemia, CO&Poisonin#
Metabolic: 8etoacidosis
Salicylate poisonin#
o Symptoms: )yspnea may be mased by !a"$%#na 4shallo(, rapid breathin#5.
H%#(#na is not tachypnea && it is hyper$entilation 4not labored
breathin#5 usually caused by metabolic acidosis and is unrelated todyspnea. )istin#uish the t(o (ith pulmonary !unction studies.
• ORTHOPNEA: )yspnea (ith onset occurrin# (hile lyin# do(n, and (hich is
immediately corrected upon restoring upright position.
o )i!!erential )ia#nosis: Con7)!i- Ha(! Fai+'( or COPD
'lso bilateral paralysis o! diaphra#ms.
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• PAROXYSMAL NOCTURNAL DYSPNEA &PND*: )yspnea at ni#ht, created by lyin#
do(n, but (hich does not immediately improve upon standing up. Patient !eels acutely
air&hun#ry and !re6uently (aes up at ni#ht. Ni#ht s(eats common.
o )i!!erential )ia#nosis: A"'! P'+.ona(% Ed.a secondary to "on7)!i- $a(!fai+'(.
• 3HEEING: 2i#h&pitched musical breath sound usually heard on e*piration, but can
be heard on inspiration.
o C'?SE) by air rushin# past a constricted air(ay, constricted by secretions,
mucous, edema, neuro#enic, a tumor, or an aspirated !orei#n body.
o A)!$.a: ;heein# is characteristic o! asthma.
Si+n! A)!$.a is asthma (ithout (heein#.
o STRIDOR: 2i#h&pitched sound occurrin# (ith inspiration.
Stridor portends total air'ay obstruction, a medical emer#ency.
o A"'! E#i7+o!!i!i): (. Influen)a in!ection in ids. Stridor is characteristic. 2a$e
a chest&tube nearby be!ore e*aminin# epi#lottis to pre$ent 4or treat imminent5aspiration.
• CYANOSIS:
o Cn!(a+ C%ano)i): "ace, lips, ton#ue. Results !rom systemic hypo*ia due to poor
per!usion or $entilation in the lun#s.
o P(i#$(a+ C%ano)i): May be !ound in e*tremities, ears, chees, etc. Can becaused by cold&induced $asoconstriction 4Raynaud3s Phenomenon5 or poor
circulation 4shoc, C2"5.
o )i!!erential )ia#nosis: Pulmonary hypo$entilation, COP)
Cardiac causes: Shunt 4Tetralo#y o! "allot5, pulmonary edema 4cor
pulmonale5
• RHINORRHEA: Nasal dischar#e
• CORYA: Nasal dischar#e caused by a $iral upper respiratory tract in!ection.
"'M%Y 0 SOC%' 2%STORY:
• Pre$ious Tuberculosis in!ection, PP) test.
• Poor dental hy#iene is a ris !or a lun# abscess.
• En$ironmental e*posures re$ealed in social history
o Tra$el
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o Psittacosis: E*posure to birds
o e#ionellosis: E*posure to (ater, air&conditioners
• Tobacco use
E9TR'P?MON'RY E9'M%N'T%ON:
• HALITOSIS: Some possible causes
o %ampylobacter $ylori coloniation o! stomach
o un# abscess or bronchiectasis 4!oul&smellin#, !ecal breath&odor5
o Necrotic lesions o! mouth or throat
o Aener3s )i$erticulum
• C+'bbin7 o! !in#ernails:
o Con#enital 2eart )isease: Chronic hypo*ia o! -S) or Tetralo#y, in ids.
o 'dults: Systemic hypo*ia, lun# cancer, bronchiectasis, .)o!$+io.a.
• C$.o)i): Con/uncti$al edema. 2yperthyroidism or obstruction o! S-C.
,REATHING:
• ,(ad%#na: Slo( breathin# rate
o %nsulin Coma
o )ru#&induced respiratory depression
• Ta"$%#na: Rapid, shallo( breathin#, caused by pleuritic chest pain or diseases that
immobilie the lun#.
• H%#(#na: Rapid, deep breathin#1 hyper$entilation.
o )iabetic etoacidosis compensation 4to lo(er PCOF5
o KUSSMAUL RESPIRATIONS: Central hyper$entilation, deep rapid breaths
characteristic o! )iabetic hyper#lycemic coma.
• CHEYNE8STOKES RESPIRATION: Cyclic alternations bet(een apnea andhyperpnea, in (hich PCOF !luctuates and is unstable. %t occurs (hen the respiratory
centers o! the brain become insensitive to changes in %O*
o 'SSOC%'TE) )%SE'SES: Con#esti$e 2eart "ailure 4C2"5, ?remia,
Menin#itis, Pneumonia.
• ,IOT1S ,REATHING: 'ta*ic breathin#1 unpredictable and irre#ular respirations.
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o Caused by menin#itis or other cerebral dys!unction.
• SLEEP APNEA: Obesity, leadin# to air(ay obstruction at ni#ht and chronic !ati#ue
durin# the day. Treat (ith CP'P.
%NSPECT%ON:
• ='C8 S%)E:
o ,'ffa+o H'.#: "atty deposit o$erlyin# CG, characteristic o! Cushin#3s Syndrome
o ,a((+ C$)!: Chronically in!lated lun#s characteristic o! COP).
o K%#$o)i): E*cessi$e anterior cur$ature o! spine, as in hunchbac.
Cause: normal or !rom a#in#, o)!o#o(o)i).
o S"o+io)i): ateral cur$ature o! spine.
May be detected by patient bendin# !or(ard and notin# une$en para$ertebral bac muscles.
o Lo(do)i): E*cessi$e posterior cur$ature o! spine. =o(in# o! lumbar and cer$ical
spines to#ether.
o Gibb') Dfo(.i!%: Sharp chan#e o! an#le o! spine instead o! #radual chan#e.
Characteristic o! Pott3s )isease, or -ertebral Tuberculosis
• "RONT S%)E
o P"!') Ca(ina!'. &Pi7on C$)!*: Sternum placed !or(ard, increased
anteroposterior chest measurement.
"ound in Ma(fan1) S%nd(o./ Ri"<!)
o P"!') E"a-a!'. &F'nn+8C$)!*: o(er end o! sternum is depressed in(ard.
May also be !ound in Mar!an3s Syndrome or Ricets.
o F+ai+ C$)!: Caused by multiple !ractures ribs. One side o! chest mo$es
parado*ically relati$e to the other side o! the chest.
PALPATION: 'ssess chest e*cursion by placin# !in#ers at costo$ertebral an#le and ha$in#
patient inhale.
• S'b"'!ano') E.#$%).a: 'ir in subcutaneous space. Can occur in tracheostomy
patients, or people (ith 'R)S (ho ha$e an endotracheal tube.• O+i-(1) Si7n: Tracheal tu# (hen patient li!ts his chin up.
o %ndicati$e o! 'ortic 'neurysm, pullin# trachea do(n(ard by pressure o! le!t main
bronchus.
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• Ta"!i+ F(.i!'): -ibration on lun#s (hen you ha$e patient say Hninety&nineH
o %ncreased !remitus is !ound (ith pulmonary consolidation in pneumonia.
o "remitus cannot be heard belo( the le$el o! !luid in emphysema or pleural
e!!usion, because the !luid stops the sound !rom bein# transmitted !urther.
PNEUMOTHORAX: Trachea 'ill shift to'ard opposite side as the pneumothorax. The side o!
the pneumothora* ac6uires positi$e pressure, thus trachea de$iates to the other side.
• T(a"$a+ D-ia!ion: Tracheal de$iation can be caused by other thin#s than
pneumothora*.
o P+'(a+ Eff')ion/ E.#$%).a may also cause trachea to de$iate to the opposite
side.
o A!+"!a)i) o! lun# may cause trachea to de$iate to(ard same side as diseased
lun#.
• Tn)ion Pn'.o!$o(a: Medical emer#ency in (hich air enters the pleural ca$ity and is
trapped durin# e*piration
o Intrathoracic pressure builds to values higher than atmospheric pressure,
compresses the lun#, and may displace the mediastinum and its structures to(ard
the opposite side, (ith conse6uent disad$anta#eous e!!ects on blood !lo(.
PERCUSSION:
• R)onan": Normal breath sound
• H%#(()onan": %ncreased resonance o$er thora*.
o May be !ound in Emphysema or Pneumothora*.
• T%.#an%: Percussion o! #astric air&bubble or air&!illed bo(el. %ncreased resonance.
• D'++n)): )ecreased resonance, normally !ound o$er li$er, spleen, and belo( lun#.
o Causes: Emphysema, Pneumonia (ith consolidation, pleural e!!usion.
• F+a!n)): E*treme dullness (ith !e( or no rin#in# tones.
o Pleural e!!usions, massi$e pulmonary consolidations (ith tumor, pneumonia.
AUSCULTATION:
• +eneral Properties:
o Stethoscope Sounds: ?se the bell side to listen to breath sounds.
Press li#htly: hear lo(&pitched sounds.
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• A!+"!a)i): =ronchial plu# &&&&&&< decreased lun# $olume &&&&&&< hi#her lun# density
&&&&&&< lun# mass is pulled to(ard chest (all by ne#ati$e pressure
o Tracheal de$iation to(ard a!!ected side
o cracles, maybe
o no breath sounds
• ,(on"$i"!a)i): Chronic bronchial dilation.
o Caused by fre+uent pulmonary infections or pneumonia.
o ar#e amounts o! sputum (ill be e*pectorated (hen patient lies prone han#in#
to(ard !loor.
• ,(on"$i!i): 'cute 4in!ectious5 or chronic 4smoer3s5
•
,(on"$io+i!i): Common in in!ants and children.
• L'n7 Can"(
• Co( P'+.ona+
• C(o'#: 8ids under I years old. Rapid, staccato cou#hs.
o )i!!erential )ia#nosis is bet(een in!lammatory Croup or Spasmodic Croup.
• C%)!i" Fib(o)i)
• P+'(a+ Eff')ion: ullness on percussion. ecreased fremitus. Reduced breath sounds.
• E.#$%).a
• E#i7+o!!i!i): %n iddies, don3t inspect the pharyn* (ithout a chest tube nearby.
• Pn'.onia
CHAPTER : MUSCULOSKELETAL
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EPIDEMIOLOGY:
• COMMON M?SC?OS8EET' )%SE'SES =Y '+E:
o Childhood: Bu$enile R', Rheumatic "e$er
o Youn# adult: Reiter3s Syndrome, SE
o Middle '#e: "ibrositis
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o Old '#e: Osteoarthritis
• COMMON M?SC?OS8EET' )%SE'SES =Y SE9:
o Male: +out
o "emale: SE, R'
• COMMON M?SC?OS8EET' )%SE'SES =Y R'CE::
o =lac: Sarcoidosis, SE
o ;hite: Polymyal#ia Rheumatica
SYMPTOMS:
• REITER1S SYNDROME:
o Symptoms: Con5'n"!i-i!i)/ U(!$(i!i)/ A(!$(i!i).
o Si#ns:
K(a!od(.a ,+nno(($a7ia: Rash on palms and soles.
Ci("ina! ,a+ani!i): Circular rash on penis.
Sa')a7 fin7(): S(ellin# o! the tendon sheath o! the hands.
• PSORIATIC ARTHRITIS: 'rthritis occurrin# (ith Psoriasis.
o Si#ns:
Sa')a7 fin7(): S(ellin# o! the tendon sheath o! the hands.
)%P /oints may be in!lamed unilaterally.
• GOUT:
o Symptoms:
Poda7(a: Se$ere #outy pain at the base o! the #reat toe.
• RHEUMATIC FEVER :
o Symptoms:
Mi7(a!o(% Pain: Typical !indin#. Pain mo$in# !rom /oint to /oint.
o 4on) C(i!(ia: )ia#nostic criteria !or Rheumatic "e$er. T(o ma/or criteria, or
one ma/or and t(o minor criteria are re6uired.
Ma5o( C(i!(ia:
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Ca(di!i): Myocarditis, Pericarditis
Po+%a(!$(i!i)
C$o(a: Purposeless mo$ements o! $arious muscle #roups
E(%!$.a Ma(7ina!'.: Pin, circular rash on trun on pro*imalarms.
S'b"'!ano') Nod'+): +ranulomatous nodules on e*tensor
sur!aces, o!ten associated (ith cardiac in$ol$ement.
Mino( C(i!(ia:
2istory, Symptoms:
2istory o! pre$ious rheumatic !e$er or rheumatic heart
disease.
'rthral#ia
"e$er
abs:
'cute phase reactants: increased ESR, C&Reacti$e Protein,
leuocytosis.
EC+ abnormalities
Recent streptococcal in!ection.
• GONORRHEA/ DISSEMINATED &Gono"o""a+ A(!$(i!i)*:
o Symptoms:
Mi7(a!o(% Pain: Typical !indin#. Pain mo$in# !rom /oint to /oint.
• RHEUMATOID ARTHRITIS:
o Symptoms:
Mo(nin7 )!iffn)): Pain in the mornin#, (hich tends to loosen up as the
day pro#resses.
Fa!i7': )urin# the day, !ati#ue sets in. The earlier the !ati#ue sets in, the
(orse is the R'.
o Si#ns: The proximal 4P%P and MCP5 /oints are characteristically more in$ol$ed
than the )%P /oints.
Syno$ial Thicenin# && s(ellin# o! /oints.
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Entire phalan* may de$iate laterally or medially.
,o'!onni( Dfo(.i!%/ S@an8N"< Dfo(.i!%/ U+na( D-ia!ion: Characteristic de!ormities o! hands and (rists seen in Rheumatoid'rthritis.
• OSTEOARTHRITIS: )e#enerati$e arthritis.
o Symptoms:
Pain usually #ets (orse as the day pro#resses, leadin# to !ati#ue in the
a!ternoon.
o Si#ns: The distal 4)%P5 /oints are characteristically more in$ol$ed than the P%P
/oints.
)istal phalan* may de$iate laterally.
Hb(dn1) Nod): =ony o$er#ro(ths on the dorsum o! the )%P /oints,typical o! osteoarthritis.
• SYSTEMIC LUPUS ERYTHEMATOSUS &SLE*: )ia#nostic Criteria. > o! at any
time is dia#nostic.
o Malar Rash
o )iscoid rash
o Photosensiti$ity
o
Oral ulcers
o 'rthritis
o Serositis 4pleuritis, pericarditis5
o Renal disorder
o Neurolo#ic disorder 4seiures, psychosis5
o 2ematolo#ic 4anemia, leuopenia, lymphopenia, thrombocytopenia5.
o %mmunolo#ic 4ele$ated anti&)N', E&Prep, or biolo#ical !alse positi$e !or
Syphilis 4RPR55
o 'ntinuclear 'ntibody 4'N'5
TERMS:
• K%#$o)i): 'nterior cur$ature o! the spine. Normally !ound in thoracic area, characteried
by e*tensi$e !le*ion.
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• Lo(do)i): Posterior cur$ature o! the spine, normally !ound in cer$ical and lumbar areas.
• S"o+io)i): ateral cur$ature o! the spine.
• Va('): Medial de$iation.
• Va+7'): ateral de$iation.
SYMPTOMS:
• P'%N:
o +enerally, the deeper the musculoseletal structure, the more di!!use the pain.
Pain !rom bone is deep or borin# pain.
Pain !rom periosteum is more localied.
o Re!erred pain: )on3t !or#et the )d* o! C') in shoulder pain.
o A(!$(a+7ia: )e!ined as /oint pains (ithout ob/ecti$e si#ns o! in!lammation. %t is
caused by many processes, both in!lammatory and non&in!lammatory.
o A(!$(i!i): Boint in!lammation.
• ST%""NESS:
• ;E'8NESS:
o 3a<n)): oss o! stren#th, due to mechanical or neurolo#ical impairment.
o
Fa!i7': Poor endurance.
%NSPECT%ON
P'P'T%ON: May !ind the !ollo(in# abnormalities on palpation:
• S(ellin#
o Syno$ial thicenin# 4 pannus !ormation5 is characteristic o! R'.
o S(ellin# o! tendon&sheath 4sausa#e&shaped di#it5 occurs in Reiter3s Syndrome and
Psoriatic 'rthritis.
o Eff')ion): "luid is most commonly !ound in the nee.
• )e!ormity
o Gan7+ia: "luid&!illed cysts !ound alon# /oint capsules, usually in the (rist.
o R$'.a!oid Nod'+): "irm nodules !ound on e*tensor sur!aces o! bony
prominences. They contain mononuclear cells and !ibrosis.
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o Go'!% To#$i: Boint nodules associated (ith urate deposits.
o ,'()i!i): %n!lammation o! the bursa in the nee or elbo(.
• Erythema and ;armth: Especially in in!lammatory or in!ectious processes.
• imitation o! Ran#e o! Motion:
• Tenderness: The sub/ecti$e sensation o! pain upon pressure.
o +radin#:
B: No tenderness
0: Patient says it is tender
2: Patient says it is tender and (inces
>: Patient says it is tender, (inces, and pulls bac
: Patient (ill not allo( palpation.
• Boint noises or locin#:
'?SC?T'T%ON:
• C(#i!'): +ratin# or #rindin# sensation !elt by patient, or heard by e*aminer. Rubbin# o!
bones due to de#eneration o! articular cartila#e.
• C(a"<in7/ Sna##in7: Snappin# o! /oints is usually not patholo#ic, unless it occurs
repeatedly.
• C+i"<in7: May indicate an abnormality (hen it occurs in TMB /oint.
M?SCE STREN+T2: +raded on a scale !rom J to D.
• : "ull stren#th
• : Stren#th a#ainst #ra$ity and added resistance.
• >: Stren#th only a#ainst #ra$ity, not added resistance.
• 2: Muscle contraction occurs, but not su!!icient to o$ercome #ra$ity.
• 0: Muscle contracts (ith little or no mo$ement.
• B: No muscle contraction.
R'N+E O" MOT%ON
• A"!i- Ran7 of Mo!ion: -oluntary mo$ement
• Pa))i- Ran7 of Mo!ion: E*aminer mo$es the /oint.
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• Gonio.!(: )e$ice used to measure an#les, to assess the ran#e o! motion o! a /oint.
• Un)!ab+ 4oin!: E*cessi$e /oint motion 4e*cessi$e e*tension5 o! the nee may be seen in
osteoarthritis.
2E') E9'M:
• TMB 'bnormalities are caused by dental malocclusion, trauma to the /a(, R'.
NEC8 4CER-%C' SP%NE5:
• 'rthritis may limit rotation or lateral !le*ion o! the nec.
S2O?)ER:
• Ro!a!o( C'ff In5'(%: Pain or spasm in mid&abduction is a si#n o! rotator cu!! in/ury.
This is due to de#eneration in the subacromial bursa, resultin# in !riction bet(een thesupraspinatus muscle and acromial process at mid&abduction.
o 'rm can3t rise abo$e about KD, the e*tent to (hich the )eltoid can abduct it.
• Ad$)i- Ca#)'+i!i) &F(o=n S$o'+d(*: ?nilateral di!!use, dull, achin# pain.
o Tenderness is di!!use.
• AC D7n(a!i- A(!$(i!i): Maybe !rom trauma. %t hurts upon mo$ement o! scapula.
• ,i"i#i!a+ Tndini!i) &I.#in7.n! S%nd(o.*: %n!lammation o! the tendon o! the
supraspinatus muscle.
• Ca+"ifi" Tndini!i): Prolon#ed in!lammation o! the supraspinatus tendon, (ith resultin#calci!ication.
E=O;:
• Tnni) E+bo@: Tender and in!lamed +a!(a+ #i"ond%+, resultin# !rom repeated
e*tension. Patient (ill e*perience pain (hen ased to e*tend the elbo( a#ainst
resistance.
• Go+f(1) E+bo@: %n!lammation o! the .dia+ #i"ond%+. Typically sho(s pain (hen
ased to li!t (ith the palms !acin# up(ard 4$olar aspect5.
;R%ST:
• )iseases:
o DE;UERVAIN1S TENOSYNOVITIS: %n$ol$es the e*tensor tendon o! the
thumb. 's patient to apply pressure (ith thumb a#ainst the !ore!in#er, and pain
(ill result.
o GANGLION: Cyst caused by herniated syno$ium into so!t tissues.
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o CARPAL TUNNEL SYNDROME: Compression o! median ner$e throu#h
carpal tunnel.
P$a+n1) T)!: 's patient to !le* each (rist at KD !or one minute. Positi$e
test occurs i! numbness and tin#lin# o$er median distribution results.
Tin+1) Si7n: Tin#lin# shots o! pain o$er median ner$e upon percussion o! the (rist.
o DUPUYTREN1S CONTRACTURE: "ibrous contraction o! the palmar
aponeurosis.
May be !ound in R', alcoholism, or !amilial.
• Si#ns:
o ,o'"$a(d1) Nod): S(ellin# o! the P%P /oints, (hich is less common than
s(ellin# o! the )%P /oints.
o Hb(dn1) Nod): =ony o$er#ro(ths on the dorsum o! the )%P /oints, typical o!
osteoarthritis.
o ,o'!onni( Dfo(.i!%: "le*ion contracture o! the P%P /oint, (ith
hypere*tension o! the )%P /oint. Caused by in/ury or R'.
o S@an N"< Dfo(.i!%: 2ypere*tended P%P /oints and !le*ed )%P /oints. May
accompany R'.
SP%NE:
• SCOLIOSIS: ateral cur$ature o! spine. ;hen bendin# o$er, muscular prominences on
one side o! the bac is more prominent than the other side.
• S!(ai7$! ,a"< S%nd(o.: ac o! normal thoracic yphosis.
• Do@a7(1) H'.#: Mared yphosis o! dorsal spine in elderly (omen.
• An<%+o)in7 S#ond%+i!i): R'&lie disease a!!ectin# the lo(er spine and sacroiliac /oints.
• L'.bo)a"(a+ S!(ain: o(er bac pain !rom obesity and or poor posture.
• H(nia!d N'"+') P'+#o)'):
• S"ia!i"a:
2%P:
• %! one le# is shorter than the other as measured !rom 'S%S to anle, hip disease is liely.
• T(nd+nb'(7 T)!: 2a$e patient stand on one !oot. The contralateral hip should pull
up(ard. %! it doesn3t, and the same hip on (hich patient is standin# instead pulls
do(n(ard, then that is a positi$e test and is indicati$e o! hip disease.
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• An!a+7i" Gai!: ;alin# !unny 4limpin#5 in order to a$oid pain in the hip.
8NEE:
• ,a<(1) C%)!: E*tension o! the syno$ium into the popliteal space. "elt on posterior nee.
•
O)7ood8S"$+a!!( Di)a): Partial separation o! the 6uadriceps !emoris tendon at thetibial tuberosity, main# the tibial tuberosity s(ollen and tender. Seen in adolescents.
• Gn' Va+7'): 8noc need. 8nees bend in(ard.
• Gn' Va('): =o(le##ed. 8nees bend out(ard.
• Gn' R"'(-a!'.: E*cessi$e e*tension o! the nee.
'N8E and "EET:
• ,'nion: S(ellin# o! the #reat toe. ?sually $al#us is seen too.
• F+a! Foo! & pes planus*: Rela*ation o! lon#itudinal arches, resultin# in !lattenin# o! thearch o! the !oot. Patients tend to (ear do(n the soles o! their shoes on the medial side.
• Hi7$ A("$) & pes cavus*: 2a$e e*cessi$e (ear on their soles at the base o! the heal and
under the metatarsal heads.
• H+ S#'(: Tenderness may happen at the insertion o! the plantar lon#itudinal tendon on
the calcaneous.
• Mo(!on N'(o.a: Pinchin# o! !ibrous neuromas bet(een metatarsal heads, resultin#
se$ere burnin# pain.
CHAPTER 0B: NEUROLOGICAL
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NE?ROO+%C SYMPTOMS:
• HEADACHE:
o MIGRAINE HEADACHE: O!ten preceded by aura, and associated (ith
(eaness, numbness, and paresthesias.
o
TENSION HEADACHE: ?sually is !rontal or occipital. Tends to be recurrent.
o CLUSTER HEADACHE: %n males, occurrin# at ni#ht, F&I hours a!ter !allin#
asleep. Symptoms are intense unilateral orbital pain 4o$er one eye5, (ith
lacrimation, rhinorrhea, !lushin#. ?sually lasts about hour.
o C'?SES o! SECON)'RY 2E')'C2E:
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Mnin7i).'): Sti!! nec. %! it occurs (ith the H(orst headache o! my
li!e,H then you should be suspicious o! )'ba(a"$noid $.o(($a7.
P(o5"!i+ Vo.i!in7: 2eadache (ith pro/ectile $omitin#, occurrin# in
mornin#, usually means increased intracranial pressure.
T(an)in! +o)) of Con)"io')n)): 2eadache accompanied by transientloss o! consciousness should raise 6uestion o! )!(o<.
• SYNCOPE and OSS o! CONSC%O?SNESS:
• SE%A?RES:
o Types o! Seiures:
Co.#+ Pa(!ia+ Si='(): Patients commonly ha$e !eelin#s o! !ear or
de/a $u associated (ith comple* partial seiures.
G(and Ma+ Si='(): Tonic&clonic, o!ten (ith loss o! autonomic control.
P!i! Ma+ Si='(): astin# !or a short period o! time && only a !e(
seconds.
o C'?SES o! SE%A?RE:
'dolescents 4F&FD5: %diopathic 4E#i+#)%5, Trauma, )ru# and alcohol
(ithdra(al
Youn# 'dults 4FD&IJ5: Trauma, alcoholism, brain tumor
Older adults 4IJL5: b(ain !'.o(, C-', metabolic disorders, electrolyteimbalances 4$%#ona!(.ia, hypo#lycemia, uremia5.
• C2'N+ES in -%S%ON:
o A.a'(o)i) F'7a: Transient, painless loss o! $ision in one eye, due to ischemic
chan#es in retina. ?sually due to "a(o!id a(!(% )!no)i) or some !orm o! retinal
artery occlusion.
Other symptoms, such as (eaness, paresthesias, o!ten accompany the
'maurosis "u#a*.
o
R!(ob'+ba( N'(i!i): Occurs in M'+!i#+ S"+(o)i) and may cause transient losso! $ision in one eye.
• C2'N+ES in 2E'R%N+:
• C2'N+ES in SPEEC2:
o D%)a(!$(ia: )i!!iculty in articulatin# (ords.
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o D%)#$onia: )i!!iculty speain# due to impaired phonation ability.
o A#$a)ia: %nability to produce 4.o!o( a#$a)ia5 or understand 4("#!i- a#$a)ia5
meanin#!ul speech.
• P'R'YS%S or ;E'8NESS: Pa()i) is intermittent (eaness.
o C'?SES o! Paresis:
Myasthenia +ra$is 4!ati#able (eaness5
H%#o<a+.ia can result in periodic paralysis.
T(an)in! i)"$.i" a!!a"<) &TIA1)*: Recurrent Transient (eanesses in
an upper e*tremity, accompanied by numbness and paresthesia.
Peripheral neuropathies
Polymyositis or dermatomyositis.
• N?M=NESS and P'REST2ES%':
o 2ypocalcemia, hypoma#nesemia
o 2yper$entilation syndrome
o Paraneoplastic syndrome.
o Medications: isoniaid, metronidaole.
• C2'N+ES in MOO) and SEEP P'TTERN:
• 'CO2O and )R?+ ?SE, SE9?' 2%STORY:
o S'a+ $i)!o(%: %n the neuro e*am, may in6uire about it to e$aluate ris o! 2%-
encephalopathy.
o 'lcoholism mani!ests a lot o! neurolo#ical symptoms 4;ernice, beriberi,
peripheral neuropathies5.
NE?ROO+%C E9'M:
• 'SSESSMENT o! MOTOR "?NCT%ON: Sometimes pluses and minuses can be used !or
e$en !iner #radin#.
o B: No contraction1 paralysis
o 0: Trace o! contraction.
o 2: Mo$es i! #ra$ity is eliminated.
o >: Mo$es a#ainst #ra$ity.
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o : Mo$es a#ainst #ra$ity and a#ainst some resistance.
o : Normal stren#th.
• Motor 'bnormalities:
o H%)!(ia: To test (hether (eaness in the le# is !rom hysteria or is or#anic, put ahand on both limbs and ha$e the patient li!t one limb a#ainst the hand3s resistance.
%! the cause o! motor (eaness is or#anic, then e*aminer should !eel the
other le# mo$e the opposite direction in compensation.
%! it is hysteria, then the other le# remains still.
o Fa)"i"'+a!ion): T(itchin#s in restin# muscles. May be normal i! they are
occasional or precipitated by cold. They may be a si#n o! A.%o!(o#$i" La!(a+S"+(o)i) &ALS* i! they are accompanied by (eaness.
o Ti"): Normal mo$ements o! muscle #roups 4such as (inin# or #rinnin#5occurrin# in$oluntarily, as in Tourette3s Syndrome.
o T!an%: %n$oluntary muscle spasms.
Causes: Tetanus, hypocalcemia, hypoma#nesemia, hyper$entilation
syndrome.
C$-o)!<1) Si7n: Tap o$er !acial ner$e anterior to ear, and loo !or
contraction o! the !acial muscles, especially shuttin# o! eyes.
T(o'))a'1) P$no.non: %n!late a blood&pressure cu!! to systolic
pressure and maintain !or &F minutes. %nduction o! carpal&pedal spasmindicates latent tetany.
o T(.o(): Oscillatin# mo$ements caused by in$oluntary contractions o! muscle
#roups.
• SENSORY E-'?'T%ON
o P(i#$(a+ N'(o#a!$i) tend to occur in hand-and-glove distribution && at the
distal ends o! the e*tremities.
o P'%N: ?pon pinpric, patient may e*perience $%#a+7)ia 4reduced pain5,
hyperal#esia, or anal#esia 4no pain5.
o %+2T TO?C2:
H%#)!$)ia %mpaired li#ht touch sensation. 'lso related to li#ht&touch
are hyperesthesia, paresthesia, and anesthesia 4no li#ht touch5.
o Sn)o(% E!in"!ion: %n #a(i!a+ +ob +)ion), i! you put a pinpric on both sides
o! the body o! a patient simultaneously, the patient (ill not percei$e the pric on
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the a!!ected side o! the lesion. %! the pins are placed se6uentially, then the patient
still retains normal sensation on both sides.
• STEREO+NOS%S: =ein# able to identi!y ob/ects (ith your eyes closed.
• CERE=E'R "?NCT%ON:
o D%)(7ia: %mproper coordinated !unction o! a muscle #roup.
o D%).!(ia: %nability to properly #ua#e the distance bet(een t(o points. Tested
(ith !in#er&to&nose mo$ements.
o D%)diado"$o<in)ia: %nability to do rapid alternatin# mo$ements.
o S"annin7 S#"$: Prolon#ed separation o! syllables, o!ten seen (ith cerebellar
dys!unction.
o +'%T )isturbances:
Cerebellar esions: Central cerebellar lesion sho(s unsteady #ait, but
con$entional cerebellar si#ns may be normal.
Po)!(io( Co+'.n) L)ion): oss o! proprioception results in unsteady
#ait 'hen eyes are closed , but relati$ely normal #ait (hen eyes are open.
F)!ina!in7 Gai!: Parinsonian #ait, shu!!lin# (al.
o Ro.b(7 T)!: Patient can3t maintain balance (ith le#s ti#ht to#ether, (ith eyes
closed.
o
Ti!'ba!ion: =ody tremor (hen standin# or (alin#, si#n o! cerebellar disease.
RE"E9ES:
• )eep Tendon Re!le*es:
o ?pper E*tremity:
,i"#) Rf+: Elbo( !le*ion.
T(i"#) Rf+: "orearm e*tension.
,(a"$io(adia+i) Rf+: Tap distal radius &&&&&&< !le*ion and partial
supination o! the !orearm.
o o(er E*tremity:
Pa!++a( Rf+: Contraction o! uadriceps 4stron#est muscles in body5
and e*tension o! le#.
S'#(a#a!++a( Rf+: 'bo$e the nee1 same response.
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• 'bsence o! Super!icial Re!le*es: ?nilateral suppression o! super!icial re!le*es o!ten
results !rom upper motor lesions subse6uent to a C-'.
• P(i.i!i- Rf+): Presence o! primiti$e re!le*es is o!ten a si#n o! f(on!a+ +ob lesions.
o S'"< Rf+: +ently tap or rub the upper li!t &&&&&&< elicit a re!le*i$e sucin# or
pucerin# response.
o G(a)# Rf+: Stroe the patient3s palm, causin# him to #rasp your !in#ers. '
positi$e test occurs (hen the patient does not let #o o! your !in#ers.
o Pa+.o.n!a+ Si7n: Rub the thenar eminence &&&&&&< elicit re!le*i$e contraction
o! the muscles o! the chin.
CRANIAL NERVE EVALUATION:
• CN I: OLFACTORYo
TEST: 2a$e patient identi!y ob/ects by smell.
o '=NORM':
2ead trauma (ith !racture o! cribri!orm plate
Neoplasm in anterior !ossa: menin#ioma
• CN II: OPTIC
o TEST: -isual acuity, !unduscopic e*am
o '=NORM': ots o! causes o! blindness
• CN III: OCULOMOTOR
o TEST:
2a$e patient mo$e eyes throu#h all !ields o! $ision. %ntact I rd ner$e means
that eyes can mo$e medially, superiorly, and in!eriorly.
P'#i++a(% Rf+: Chec !or pupillary response to li#ht in same eye and
contralateral eye.
P!o)i): Ptosis may occur due to Ird ner$e palsy.
o '=NORM':
?nilateral CN&%%% Palsy: Subarachnoid hemorrha#e resultin# !rom
aneurysm, diabetes, atherosclerosis.
2orner3s Syndrome: ?sually occurs !rom b(on"$o7ni" "a("ino.a
4Pan"oa)! T'.o(5 impin#in# on the Superior Cer$ical +an#lion.
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• CN IV: TROCHLEAR
o TEST:
o '=NORM':
• CN V: TRIGEMINAL
o TEST:
Sensory: Chec corneal re!le*. Test !acial sensation (ith eyes closed.
Motor: 2a$e patient clench teeth and palpate masseter muscle.
o '=NORM':
ost Corneal Re!le*: Tumor o! the cerebellopontine an#le.
Ti" Do'+o'(': %rritati$e lesions o! the CN - sensory roots.
Spasm o! muscles o! mastication: tetanus, ad$erse reaction to
Phenothiaines.
• CN VI: A,DUCENS
o TEST: oo laterally.
o '=NORM':
)iabetes, atherosclerosis, increased %CP, neoplasm.
• CN VII: FACIALo TEST: 2a$e patient smile, blin, !ro(n, (rinle !orehead.
o '=NORM': ,++1) Pa+)%
Cn!(a+ L)ion of VII: The supratrochlear muscles are spared, as they
recei$e bilateral inner$ation !rom both !acial ner$es. =elo( the eyes, the
contralateral side (ill be paralyed.
P(i#$(a+ L)ion of VII: There is an entire !acial hemiple#ia, (ith the
paralysis occurrin# on the contralateral side.
• CN VIII: VESTI,ULOCOCHLEAR
o TEST: Standard hearin# and $estibular tests.
o '=NORM': ' $ariety o! disorders
• CN IX: GLOSSOPHARYNGEAL
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o TEST: 2a$e patient open mouth and say H'aahhh.H
o '=NORM': See -a#us N. belo(.
• CN X: VAGUS
o TEST: 2a$e patient open mouth and say H'aahhh.H
o '=NORM':
'ortic 'neurysm, =roncho#enic Carcinoma may dama#e the recurrent
laryn#eal ner$e.
?$ula (ill de$iate to(ard the dama#ed side.
• CN XI: SPINAL ACCESSORY
o TEST: 2a$e patient shru# shoulders.
o '=NORM': Polymyositis
• CN XII: HYPOGLOSSAL
o TEST: 2a$e patient stic out ton#ue.
o '=NORM':
MENT' ST'T?S E9'M:
• ST'TE o! CONSC%O?SNESS: The +las#o( Coma Scale
•
OR%ENT'T%ON
• '=%%TY to COOPER'TE
• MOO)
• T2O?+2T PROCESS
• MEMORY !or RECENT and REMOTE E-ENTS
• '=%%TY to 2'N)E CONCEPTS and PRO-ER=S
• PR'CT%C' S8%S
• SPEEC2 PRO=EMS and RECO+N%T%ON o! 'P2'S%'
P'T%ENTS (ith '=NORM' NE?ROO+%C' ST'T?S:
• 'PPRO'C2 to the COM'TOSE P'T%ENT:
• 'PPRO'C2 to the )E%R%O?S P'T%ENT:
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• 'PPRO'C2 to the P'T%ENT (ith PER%P2ER' NE?ROP'T2Y:
• 'PPRO'C2 to the P'T%ENT (ith S%+NS o! MEN%N+E' %RR%T'T%ON:
CHAPTER : CARDIAC
Download a copy of this study guide
C'R)%'C SYMPTOMS, 2%STORY:
• CHEST PAINo ANGINA &ISCHEMIC CARDIAC PAIN*: S6ueein#, crushin#, stran#lin#,
constrictin# pain in center o! chest. Pain may radiate to le!t shoulder, le!t arm,
ri#ht shoulder, /a(.
S!ab+ &T%#i"a+* An7ina: 'n#ina upon e!!ort, or an#ina induced by
increased blood pressure or increased heart&rate. 'n#ina is relie$ed bynitro#lycerin, althou#h nitro#lycerin is not speci!ic to this type o! an#ina.
L-in1) Si7n: Patient maes !ist and holds it up to his chest, to
describe the pain.
S"ond8@ind P$no.non: %! patient repeats same acti$ity a!ter
the attac, he may not !eel the attac a#ain the second time.
3a+<8!$(o'7$ An7ina: The pain subsides as patient continues the
acti$ity.
A!%#i"a+ An7ina: 'typical presentation o! typical an#ina.
typical ymptoms/ Sharp or stabbin# pain, rather than crushin#
pain.
typical %auses/ 'n#ina (ith chan#e in position, !or e*ample,
rather than an#ina strictly upon e!!ort.
ngina +uivalents/ Other symptoms that are caused by
myocardial ischemia.
E*ertional dyspnea.
Nausea, indi#estion.
)iiness, s(eatin#.
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Un)!ab+ An7ina: 'n#ina e$en at rest, or an#ina that has recently #otten
(orse. %t is associated (ith sharply increased ris !or myocardial in!arct(ithin > months.
An7ina D"'bi!') is a speci!ic term !or an#ina occurrin# at rest.
Va(ian! An7ina &P(in=.!a+ An7ina*: $aradoxic angina occurrin#durin# rest but usually not durin# e*ercise. %t is caused by "o(ona(%a(!(% )#a).. %t can be hard to spot because it can coe*ist (ith typicalan#ina.
Characteristic EC+ !indin#s can help distin#uish $ariant an#ina
!rom typical an#ina.
Nitro#lycerin (ill probably still relie$e pain, as it rela*es coronary
arteries.
M%o"a(dia+ Infa("!: Typical presentation @ 1nstable angina lasting
longer than 25 minutes, that is not relieved by nitroglycerin.
Silent M%3s and M%3s (ith atypical presentation do occur.
o NON&%SC2EM%C C'R)%'C P'%N:
Mi!(a+ Va+- P(o+a#): ?sually asymptomatic, but may present (ith an
intermittent, sharp, sticin# pain o$er le!t precordium.
P(i"a(di!i): The patient feels relief by shallo' breathing and by sitting
up and leaning for'ard.
Di))"!in7 An'(%).: Sudden, se$ere tearin# pain, radiatin# to theabdomen, nec, or bac, dependin# on (here the aneurysm is #oin#.
o PE?R%T%C 4P?MON'RY5 C2EST P'%N: 'lso see pulmonary study #uide.
P'+.ona(% E.bo+i).: May be asymptomatic, or the patient may !eel a
dull ti#htness i! the embolus is lar#e enou#h.
Pa(o%).a+ D%)#na is the most common symptom o! pulmonary
embolism.
P+'(i)%: Pain upon breathin#. May be caused by pulmonary embolism,
pneumonia, bronchitis, or pleural e!!usion.
P'+.ona(% H%#(!n)ion: )yspnea is a more common symptoms than
pleuritic pain.
Pn'.o!$o(a: Pain may be con!used (ith pain o! an M%.
Mdia)!ina+ E.#$%).a: "ree air in the mediastinum produces chest
ti#htness and dyspnea.
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Ha..an1) Si7n: Crunchin#, raspin# sound heard synchronous
(ith the heartbeat, indicati$e o! mediastinal emphysema.
o +'STRO%NTEST%N' C2EST P'%N:
E)o#$a7a+ S#a).: Substernal chest pain and dyspha#ia.
E)o#$a7a+ Rf+' &GERD*: Chest pain relie$ed by antacids.
Ga++)!on Co+i": Colicy R? pain radiatin# to bac and to ri#ht
shoulder. Occasionally it may be con!used (ith an#ina.
o C2EST ;' P'%N:
TIETE1S SYNDROME &COSTOCHONDRITIS*: %n!lammation o!
Costochondral /oints. Pain is o!ten localied and can be elicited by
palpatin# the sternum o$er the in$ol$ed ribs.
HERPES OSTER : Pain may precede the appearance o! the rash. =oth pain and rash !ollo( dermatomal distribution.
DACOSTA1S SYNDROME: Psycho#enic pain usually localied to the
cardiac ape*. May be associated (ith an*iety.
May also see palpitations, hyper$entilation, dyspnea, (eaness,
depression, or other si#ns o! an*iety.
V(!b(a+ Co+'.n Di)a): %t may occasionally lead to anterior chest
pain.
• DYSPNEA: 'ir hun#er or di!!iculty breathin# may be associated (ith cardiac diseases.
o EXERTIONAL DYSPNEA: )yspnea on e*ertion is a common symptom o! mild
or se$ere Con7)!i- Ha(! Fai+'(.
o DYSPNEA a! REST:
P'+.ona(% causes o! dyspnea 4PE, COP), pneumothora*5 o!ten occur at
rest. ;ith cardiac problems, dyspnea usually does not occur at rest, or it is
o$ershado(ed by an#ina.
Ani!% D%)#na: )i!!iculty breathin# due to an*iety occurs only at rest.
o ORTHOPNEA: )yspnea occurrin# (ith patient in the supine position.
Orthopnea is a si#n o! Con7)!i- Ha(! Fai+'( that is more severe than that
associated (ith e*ertional dyspnea.
C'?SE: Supine position increases pulmonary blood !lo( &&&&&&<
e*acerbate pulmonary con#estion and pulmonary edema. The problem is
relie$ed by resumin# a more upri#ht position.
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T@o8Pi++o@/ T$(8Pi++o@ O(!$o#na: Terms to describe the se$erity o!
the orthopnea. Three pillo( is (orse than t(o&pillo(.
o PAROXYSMAL NOCTURNAL DYSPNEA &PND*: Similar to orthopnea,
e*cept it has sudden onset and occurs only a!ter the patient has been lyin# do(nat rest !or at least an hour.
?nlie orthopnea, %t is not relie$ed immediately by sittin# up.
Patient is usually able to return to sleep, e$entually.
o PULMONARY EDEMA: Pulmonary edema is usually a mani!estation o! le!t&
$entricular heart !ailure. Peripheral edema associated (ith C2" is a mani!estation
o! ri#ht&sided heart !ailure 4Cor Pulmonale5.
SYMPTOMS: Se$ere symptoms. E*treme an*iety, dyspnea, air hun#er,
cold s(eats, !ear o! impendin# death.
S%+NS: Pin, !rothy sputum, and bubbly breath sounds.
o VALVULAR HEART DISEASE: Mi!(a+ S!no)i) is associated (ith dyspnea.
o CON+EN%T' 2E'RT )%SE'SES:
T!(a+o7% of Fa++o!: E*ertional dyspnea is common.
Vn!(i"'+a( S#!a+ Df"!: Tachypnea and s(eatin#. ate cyanosis.
o C'R)%'C &$s& P?MON'RY )YSPNE':
o
OT2ER C'?SES O" S2ORTNESS O" =RE'T2:
K')).a'+ R)#i(a!ion: %ntense hyper$entilation 4respiratory alalosis5
occurrin# (ith Diab!i" K!oa"ido)i), as a compensatory mechanism to
relie$e the metabolic acidosis.
• PALPITATIONS: 'n unpleasant a(areness o! one3s o(n heart&beat. O!ten described as
!lutterin#, or sippin# a beat.
o Pa(o%).a+ A!(ia+ Ta"$%"a(dia: May cause palpitations (ith an instantaneous
onset.
o
P(.a!'( Vn!(i"'+a( Con!(a"!ion) &PVC1)*: May be e*perienced as palpitations or a sipped beat. The premature contraction is !ollo(ed by a
compensatory pause, to allo( !or $entricular !illin#.
• FATIGUE: Non&speci!ic !indin# o!ten !ound (ith heart disease.
o "'T%+?E C'?SE) =Y 2E'RT )%SE'SE: %t usually occurs later in the day or
in the e$enin#. "ati#ue early in the mornin# is usually not associated (ith heart
disease, unless the patient (as aroused !rom REM sleep.
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The heart disease #ets (orse, as the patient e*periences onset o! !ati#ue
earlier in the day.
o OT2ER C'?SES O" "'T%+?E: ots. Chronic illness o! many types, anemia,
psycholo#ical causes.
• SYNCOPE: "aintin#, transient loss o! consciousness.
o VASOVAGAL EVENTS: Most common cause o! syncope, it is caused by
e*cessi$e stimulation o! the -a#us ner$e &&&&&&< e*cessi$e bradycardia and
reduced blood&!lo( to the brain.
Ani!%: %t is usually associated (ith acute an*iety or e*cessi$e emotion.
The -a#al hyperacti$ity is thou#ht to be a hypersensiti$e response to
sympathetic out!lo(.
o CARDIOVASCULAR CAUSES:
A(($%!$.ia):
STOKES8ADAMS SYNDROME: Syncope caused by reduced
cardiac output secondary to an arrhythmia.
=oth se$ere tachycardia and bradycardia can reduce cardiac
output, leadin# to syncope. Se$ere tachycardia reduces cardiac
output by reducin# $entricular !illin# time.
Ca(dia" O'!f+o@ T(a"! Ob)!('"!ion:
Ao(!i" S!no)i) may lead to syncope.
M%o.a), beni#n myocardial tumors, may cause out!lo(
obstruction and lead to syncope.
T!(a+o7% of Fa++o! is associated (ith !aintin# attacs.
M%o"a(dia+ I)"$.ia
Ca(o!id Sin') S%n"o#: (ypersensitivity of the %arotid inus in elderly
men is common cause o! syncope.
I.#ai(d Va)o.o!o( Rf+): %mpairment o! =aroreceptors. Syncope is
associated (ith orthostatic hypotension.
D"(a)d ,+ood Vo+'.
o FLUID REMOVAL:
Mi"!'(i!ion S%n"o#: Syncope occurrin# (ith micturition but at no other
time. 'ssociated (ith remo$al o! !luid !rom the body.
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o POST8TUSSIVE SYNCOPE: Syncope a!ter a bout o! cou#hin#, or a!ter the
-alsal$a maneu$er, may occur in patients (ith COP).
• HEMOPTYSIS: Mi!(a+ Va+- S!no)i) is a cardiac disease that may cause hemoptysis.
Mitral Stenosis &&&&&&< pulmonary $enous con#estion &&&&&&< may lead to hemoptysis.
• EDEMA:
o Pi!!in7 Ed.a is a common si#n o! Con#esti$e 2eart "ailure.
o P()a"(a+ Ed.a may be !ound in bed&ridden patients, and may lead to decubitus
ulcers.
o Ana)a("a: Se$ere #eneralied edema and ascites, as seen in se$ere C2", li$er
cirrhosis, or nephrotic syndrome.
o L%.#$d.a may be caused "ilariasis or a tumor obstructin# a lymphatic $essel.
• CYANOSIS: Presence o! e*cessi$e deo*y#enated hemo#lobin in the blood. %t becomes$isible (hen the concentration o! deo*y#enated hemo#lobin e*ceeds J # 0 d && a hi#her
rate o! desaturation than is !ound in the venous blood o! normal people.
o Cn!(a+ C%ano)i): -isible in the lips, !ace, con/uncti$ae, ton#ue. %t is caused by
primary systemic hypoxia due to impaired o*y#enation o! blood. E9'MPES:
T!(a+o7% of Fa++o! or the late sta#es o! other con#enital heart de!ects
Vnoa(!(ia+ )$'n!
o P(i#$(a+ C%ano)i) &A"(o"%ano)i)*: -isible in the !in#ers and toes, earlobes,
nose. %t is caused by locali)ed hypoxia due to poor circulation, reduced blood&!lo(, C2", shoc.
+ENER' P2YS%C' E9'M: Many con#enital disorders are associated (ith $arious heartde!ects. See Table >&J, pa#e JD !or complete list. 'lso see Table o! Physical "indin#s !or a
complete list o! physical !indin#s.
• T2E "'CE:
• T2E EYES:
• T2E MO?T2:
• T2E S8%N:
o R$'.a!i" F-(: Characteristically you (ill see E(%!$.a Ma(7ina!'. and
S'b"'!ano') Nod'+).
• T2E T2OR'9:
• T2E '=)OMEN:
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• T2E E9TREM%T%ES:
o C+'bbin7 o! !in#ers and toes is a classic !indin# o! C%ano)i). May also be seen
(ith in!ecti$e endocarditis or other conditions.
,LOOD PRESSURE:
• P'P'T%ON:
• AUSCULTATION &Ko(o!<off So'nd)*:
o P$a) 0: Clear tappin# sounds representin# systolic pressure.
o P$a) 2: So!ter tones
o P$a) >: ouder once a#ain.
o P$a) : Mu!!led Tones.
o P$a) : Tones cease. )iastolic Pressure. )iastolic pressure may actually behi#her than estimated by auscultation.
• %NTERPRET'T%ON:
o A')"'+!a!o(% Ga#: Period o! silence that may occur bet(een Phase and Phase
F. The be#innin# and end o! the 'uscultatory +ap may be mistaen !or )iastolicor Systolic blood pressure, respecti$ely.
C'?SES: -enous distension or se$ere 'ortic Stenosis.
o O(!$o)!a!i" H%#o!n)ion: ?pon standin#, normal decrease in systolic blood
pressure is J&J mm 2#1 anythin# more is Orthostatic 2ypotension. )iastolic pressure normally remains constant or increases sli#htly.
o Obese Patient: ?se a lar#e cu!!.
o 2ypertension:
Coa("!a!ion of !$ Ao(!a (ill result in a systolic pressure that is 6uite
hi#h in the arm, but much lo(er in the le#.
4UGULAR VENOUS PULSES:
• Cn!(a+ Vno') P())'( &CVP*: ?se the ri#ht %nternal Bu#ular to estimate C-P because
it is strai#hter.
o ME'S?REMENT:
;ith patient sittin# up, cla$icles are D cm abo$e ri#ht atrium, thus C-P @
/u#ular $enous distension abo$e cla$icles L D cm.
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;ith patient ele$ated ID, sternal 'n#le o! ouis is normally about J cm
abo$e ri#ht atrium, and %nternal Bu#ular should be $isible about I cmdirectly $ertical 4use a ruler5, abo$e the sternal 'n#le o! ouis.
o RESP%R'T%ON: C-P should decrease (ith inspiration and increase (ith
e*piration.
KUSSMAUL1S SIGN: Parado*ical chan#e in C-P durin# inspiration
4and increase instead o! decrease5, caused by a restriction in !illin# o! the
ri#ht $entricle, such as pericardial e!!usion.
HEPATO4UGULAR REFLEX: Normally, it should only sho( a
transient increase in C-P. ;ith Cor Pulmonale, the increased C-P ismaintained throu#hout.
• 4UGULAR VENOUS 3AVES:
o a83a-: Ri#ht atrial contraction, correspondin# to pea !illin# o! the /u#ular $ein.
' lar#e a&(a$e is characteristic o! pulmonary hypertension.
' #iant a&(a$e is characteristic o! a total heart bloc.
No a&(a$e is characteristic o! atrial !ibrillation.
o 8D)"n!: "ollo(s a&(a$e, as atrium rela*es. )ecreased /u#ular $ein !illin#.
"irst heart sound is heard durin# the
o "83a-: Occurs (ith contraction o! the $entricles. ?sually not $isible at bedside.
C'ROT%) P?SE occurs durin# this, (hich is ri#ht a!ter the a&(a$e and
also durin# the *&descent.
o -83a-: Passi$e phase o! atrial !illin# durin# $entricular systole.
o %8D)"n!: =rie! decreases in /u#ular $ein pressure a!ter the Tricuspid $al$e
opens 4be#innin# o! Systole5.
ARTERIAL PULSES:
• Normal Pulses: Radial, =rachial, Carotid, "emoral, Popliteal, Posterior Tibial, )orsalis
Pedis.• Rhythm 'bnormalities:
o Sin') A(($%!$.ia: The pulse accelerates (ith inspiration.
o Premature Contractions:
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A!(ia+ P(.a!'( Con!(a"!ion) &APC*: Normally do not disturb the
cycle.
Vn!(i"'+a( P(.a!'( Con!(a"!ion) &PVC*: They are !ollo(ed by a
compensatory pause, and a ne( rhythm is established.
o P'+) Dfi"i!: ;ith A!(ia+ Fib(i++a!ion L Ta"$%"a(dia/ the radial pulse may not be e6ual to the cardiac apical pulse. T(o rapid beats in a ro( may not allo(
su!!icient $entricular !illin# !or the systole to be transmitted to the periphery. The
lapse bet(een apical and radial pulse is the pulse de!icit.
o ,i7.ina+ P'+): T(o consecuti$e heartbeats closely coupled, (ith subse6uent
pause be!ore the ne*t beat.
• -olume 'bnormalities:
o H%#(<in!i" P'+): uic up stroe and !ull $olume, seen (ith hypertension,
an*iety.
o Co((i7an1) P'+): ' bris pulse (ith lar#e $olume, or HCollapsin#H pulse, seen in
'ortic Re#ur#itation.
D'(o=i= M'(.'( should be heard across the !emoral artery
simultaneous (ith the collapsin# pulse.
o ;'in"<1) P'+): -isible capillary pulsations in the nail&bed. 'nother si#n o!
'ortic %nsu!!iciency.
o P'+)') ,i)f(in): =i!id pulse. T(o distinct impulses (ith each heartbeat. Seen
in:
'ortic Re#ur#itation
2ypertrophic Cardiomyopathy.
o P'+)') A+!(an): One pulse !eels lar#e, the ne*t one small. )ue to decreased
cardiac contractility and carries a poor pro#nosis.
o P'+)') Pa(ado'): ;eaenin# o! the pulse (ith inspiration more than normal.
Systolic pressure normally decreases by less than D mm 2#. Parado*ical
pulse occurs (hen decrease is #reater than D mm 2#.
%ndicati$e o! constricti$e cardiac disease: Pericardial e!!usion, constricti$e
pericarditis.
• +radin# Pulses: Scale o! D to >
o Scale:
B @ no pulse
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> @ normal pulse
@ boundin# pulse
o In!(.i!!n! C+a'di"a!ion: Temporary (eaenin# o! lo(er e*tremities due to
arterial insu!!iciency.
o L(i"$1) S%nd(o.: 'therosclerosis o! abdominal 'orta, reducin# !lo( to lo(er
e*tremities and leadin# to impotence.
o Ta<a%a)'1) Di)a): Pulseless disease && no pulse in arms, due to pro#ressi$e
obliterati$e arteritis.
T2E PRECOR)%?M:
• Ao(!i" Va+-: Second ri#ht interspace 4upper ri#ht && on the opposite side because the
'orta bends o$er to(ard the ri#ht side5.
•
P'+.oni" -al$e: Second le!t interspace 4upper le!t && on opposite side because thePulmonary arteries bi!urcate behind the 'orta.5
• T(i"')#id Va+-: o(er parasternum 4centrally located5
• Mi!(a+ Va+-: 'pe*
• E(b1) Poin!: Place to listen to ri#ht&sided patholo#ies, at the third le!t interspace.
PALPATION PERCUSSION:
• Poin! of Mai.a+ I.#'+) &PMI*: Should be at the ape*.
o %! it is located more centrally and do(n, that is indicati$e o! COPD due to barrelchest and constantly in!lated lun#s, displacin# the heart centrally 4ri#ht&sidedshi!t5.
o Ri#ht -entricular 2ypertrophy can shi!t the PM% posteriorly, as the ri#ht&
$entricular mass mass the le!t&$entricular PM%, main# it di!!icult to palpate.
• S$o"<: 'n impulse o! a heart sound transmitted to the e*aminin# hand.
• Ha- Lif!: "orce!ul, systolic thrust that mo$es the palpatin# hand up a little.
• T$(i++: ' palpable murmur. ' palpable $ibration that by definition is accompanied by an
audible murmur.
STETHOSCOPE: +et a #ood one. The shorter the tube, the better. )ouble&barreled tubes are
better than sin#le&barrel.
• DIAPHRAGM: 2i#h&pitched 4primarily systolic5 sounds, and press !irmly.
• ,ELL: o(&pitched 4primarily diastolic5 sounds, and press li#htly.
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HEART SOUNDS:
• NORMAL HEART SOUNDS: Normal order o! e$ents @ M0/ T0/ A2/ P2
o S0: Closin# o! Mitral 4M5 and Tricuspid 4T5 $al$es.
S is loudest near the ape*.
O?) S: Occurs (ith hi#her cardiac output, such as !e$er, e*ercise,
thyroto*icosis.
SO"T S: Occurs (ith impaired myocardial contraction, C2", mitral
re#ur#itation.
o S2: Closin# o! 'ortic 4'F5 and Pulmonic 4PF5 $al$es.
SP%TT%N+: Normally, ortic closes before $ulmonic, due to hi#her
pressure in 'orta.
3id S#+i!!in7: %NSP%R'T%ON normally increases the inter$al bet(een 'F and PF, (hich is attributed to increased pulmonary
blood !lo(, and decreased pulmonary $ascular resistance.
%NTENS%TY: ' loud SF usually is attributed to the 'ortic $al$e 4'F5, and
o!ten occurs (ith hypertension.
• THIRD HEART SOUND &S>*: Considered normal in in!ants and children.
o C'?SE: Slo(in# o! $elocity o! blood, or $ibrations !rom turbulent blood&!lo(
durin# $entricular !illin#, especially at the be#innin#.
o POS%T%ON: Patient should be in le!t lateral decubitus position !or ma*imalauscultation o! SI.
o Ga++o#: SI sound plus tachycardia, #i$in# the sound o! a #allopin# horse.
o ET%OO+%ES: Cardiac disease (hich causes increased ventricular volume, such
as:
Mitral and Tricuspid Re#ur#itation
Con#esti$e 2eart "ailure
o O#nin7 Sna# &OS*: =rie! clic heard (hen mitral $al$e opens at the be#innin#o! diastole 4around SI5. 'ssociated (ith Mitral Stenosis
o Kn!'"<%: S, SF, SI to#ether ha$e this appro*imate rhythm.
• FOURTH HEART SOUND &S*: l'ays pathological .
o C'?SE: Contraction o! the atria at the end o! diastole &&&&&&< turbulent blood !lo(
(hich is audible as S>.
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ecreased ventricular compliance is the most common etiolo#y o! S>
sound.
o ET%OO+%ES:
e!t&Sided: hypertension, aortic stenosis, an#ina pectoris.
Ri#ht&Sided: pulmonary hypertension, pulmonic stenosis.
o Tnn)): S>, S, SF sounds to#ether ha$e this appro*imate rhythm.
• SUMMATION GALLOP: SI L S> L Tachycardia, as seen in chronic hypertension
leadin# to C2".
• SYSTOLIC SOUNDS and CLICKS:
o E5"!ion So'nd): Can be innocent, or caused by abnormal 'ortic $al$es or a
dilated 'orta.
o Mi!(a+ Va+- P(o+a#) &MVP*: ;ill result in a mid or late systolic clic, as the
mitral lea!let protrudes bac into the atrium durin# $entricular contraction.
• NON&-'-?'R SO?N)S:
o P("o(dia+ Kno"< : Results !rom "on)!(i"!i- #(i"a(di!i) and can be heard o$er
the internal /u#ular at the base o! the nec.
C'?SE: thicened pericardium limits e*pansion o! $entricles durin# rapid
!illin# phase o! diastole, resultin# in bacup o! blood.
o
P(i"a(dia+ F(i"!ion R'b: Caused by #(i"a(dia+ ff')ion, and can be heardo$er a limited area in le!t parasternal space.
More e*tensi$e pericardial e!!usion may eliminate the rub, as the
pericardium #ets completely separated !rom the epicardium.,
2E'RT M?RM?RS: +eneral Properties
• Timin#
• ocation
• Con!i#uration: Crescendo 0 )ecrescendo
• %ntensity:
o G(ad I: =arely audible by an e*pert.
o G(ad III: Moderately loud (ith palpable thrill.
o G(ad VI: So loud it can be heard (ithout the stethoscope main# complete
contact (ith the sin.
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• "re6uency
• uality
• TR'NSM%SS%ON: ;here does the sound transmit to This is characteristic !or certain
patholo#ies and can be dia#nostic.
SYSTOLIC MURMURS: Cardiac disorders and their associated !indin#s.
• AORTIC STENOSIS: iamond-shaped systolic e3ection murmur .
o ocation: O$er the 'ortic $al$e, at the second ri#ht intercostal space.
o Transmission: to the carotids bilaterally.
• PULMONIC STENOSIS: iamond-shaped systolic e3ection murmur .
o ocation: Second or third le!t parasternal interspace.
• HYPERTROPHIC O,STRUCTIVE CARDIOMYOPATHY: iamond-shapedmidsystolic murmur .
o P'T2OO+Y o! )%SE'SE:
Septal re#ion o! le!t $entricle is thicened &&&&&&< e!t -entricular
2ypertrophy.
)urin# systole, anterior lea!let o! mitral $al$e is abnormal.
%mpaired rela*ation o! the le!t $entricle durin# diastole.
o SO?N): Similar to 'ortic Stenosis, but it does not transmit to the Carotids.
o E9'M%N'T%ON TEC2N%?ES: The murmur becomes louder as left
ventricular volume is reduced. This is parado*ic beha$ior as compared to most
murmurs
Hand7(i# &&&&&&< increase in le!t $entricular $olume &&&&&&< decreased
murmur . This occurs because the septal obstruction is relati$ely lesssi#ni!icant.
Va+)a+-a Man'-(: Murmur becomes louder in the late&sta#e o! the
-alsal$a Maneu$er, rather than so!ter as in most murmurs.
Murmur becomes 6uieter (hen the patient s6uats && also parado*ical
beha$ior.
• MITRAL VALVE PROLAPSE: %! it occurs (ith mitral re#ur#itation, a late systolic
murmur (ill be heard a!ter the midsystolic clic.
o E*amination Techni6ue: ie cardiomyopathy, reduce le!t $entricular $olume
&&&&&&< louder murmur 4and an earlier clic5.
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• HOLOSYSTOLIC MURMURS: They indicate that blood is !lo(in# do(n a pressure
#radient (hen it shouldn3t be, as in insu!!iciencies.
o C'?SES: Mitral re#ur#itation, Tricuspid re#ur#itation, -entricular septal de!ect.
• MITRAL REGURGITATION: The most common cause !or (olosystolic Murmur .
o Causes: 'nythin# that maes the mitral $al$e incompetent, or mitral lea!lets
dama#e:
-e#etations
papillary muscle dys!unction
shortened chordae tendineae
o Concurrent !eatures o! Mitral Re#ur#itation:
e!t -entricular 2ypertrophy &&&&&&< Shi!ted PM%
SI #allop
• VENTRICULAR SEPTAL DEFECT: =est heard at lo(er le!t parasternal border 4Erb3s
point5
• TRICUSPID REGURGITATION: (olosystolic murmur
o May result !rom %- dru# use &&&&&&< endocarditis, or Rheumatic $al$ular disease.
• OT2ER M?RM?RS:
o STRAIGHT ,ACK SYNDROME: Systolic e/ection murmur.
o Inno"n! M'(.'()
o Vno') H'.: 2eard abo$e the cla$icles in normal indi$iduals.
o Ma..a(% So'ff+: 2i#h pitched continuous !lo( heard o$er base o! heart in
pre#nancy.
DIASTOLIC MURMURS: Cardiac disorders and associated !indin#s.
• AORTIC INSUFFICIENCY: =lo(in# or ecrescendo diastolic murmur .
o Many causes: in!ectious, rheumatic, dissectin# aortic aneurysm.
o C2" maes the murmur so!ter.
o 'ssociated !indin#s:
Co((i7an1) 3a!( Ha..( P'+): Collapsin# pulse, (ith little up stroe
or do(nstroe.
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de Musset3s Si#n: to and !ro head mo$ement synchronous (ith the
heartbeat.
;'in"<1) P'+): capillary pulsation o! !in#ertips.
D'(o=i=1) Si7n: "emoral artery systolic and diastolic bruits.
Hi++1) Si7n: =lood pressure in the le#s bein# hi#her than it is in the arms.
Normal di!!erence @ FD mm 2#
'ortic %nsu!!iciency @ >D&D mm 2#.
• PULMONIC INSUFFICIENCY: ecrescendo diastolic murmur .
o GRAHAM STEELL1S MURMUR : P'+.ona(% H%#(!n)ion as the cause o!
pulmonic hypertension 4due to dilation o! pulmonic lea!lets5.
Prominent a8@a- is !ound concurrent (ith the murmur.
Pa(adoi"a+ S#+i!!in7 also occurs.
• MITRAL STENOSIS: Middiastolic murmur
o C'?SE: Chronic R$'.a!i" Ha(! Di)a) is most common cause.
• TRICUSPID STENOSIS: Middiastolic murmur
• RHEUMATIC FEVER :
o Ca(% Coo.b) M'(.'( is the characteristic murmur occurrin# durin# the
acute sta#e o! Rheumatic "e$er. %t is a blubberin# middiastolic murmur heard atape*. The murmur disappears a!ter acute disease has subsided.
o Middiastolic murmur o! mitral stenosis mi#ht then remain as a se6uel.
• PATENT DUCTUS ARTERIOSUS:
o Con!in'o') M'(.'(): Murmurs occurrin# throu#hout the cardiac cycle, caused
by blood continually !lo(in# !rom hi#her pressure to lo(er pressure. Can beheard (ith Patent )uctus 'rteriosus.
TECHNI;UES FOR ENHANCING AUSCULTATION:
• INSPIRATION: Normally you should see splittin# o! SF (ith inspiration. PF occurs later
and mo$es !urther a(ay !rom 'F.
o Pa(adoi" S#+i!!in7: SF splittin# is decreased instead o! increased (ith
inspiration.
Lf! ,'nd+8,(an"$ ,+o"< causes parado*ic splittin#. %n this condition,
under normal circumstances, 'F already occurs after PF 4instead o! be!ore5,
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because o! the le!t&sided heart&bloc. Thus, (ith inspiration, PF actually
mo$es closer to 'F and you see parado*ic splittin#.
• EXHALATION: Can be used to e$aluate right-sided heart murmurs.
o The intensity o! most ri#ht&sided heart murmurs (ill decrease (ith e*halation,
(hile le!t&sided murmurs remain unchan#ed.
• MLLER1S MANEUVER : 2a$e patient pinch the nostrils shut (ith one hand and suc
hard on a !in#er (ith the other.
o MEC2'N%SM: This creates prolon#ed n7a!i- in!(a!$o(a"i" #())'(. That
shift blood from the systemic to the pulmonary circulation, (hich ampli!ies and prolon#s the murmurs !ound (ith inspiration. %t maes it easier to hear inspiratory
murmurs.
• VALSALVA MANEUVER : 2a$e patient hold breath and bear do(n !or FD seconds. Can
be used to e$aluate le!t&sided heart murmurs.
o MEC2'N%SM: This creates a prolon#ed #o)i!i- in!(a!$o(a"i" #())'(. That
shifts blood from the pulmonary to the systemic circulation && the e*act opposite as
Mller3s Maneu$er.
o T%ME CO?RSE: Most le!t&side murmurs !irst #ro( louder, and then #ro( so!ter.
"irst D&J seconds: %nitially, cardiac output increases, and the intensity o!
le!t&sided murmurs increase accordin#ly.
'!ter D&J seconds: Cardiac then be#ins to decrease, as $enous return
!rom the lun#s decreases. Most le!t&sided murmurs then #ro( so!ter a#ain.
o E9CEPT%ONS: T(o conditions sho( di!!erent characteristics than abo$e:
H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: e!t&$entricular
hypertrophy and resultant cardiomyopathy, due to hypertension. ;ith thiscondition, the late&phase o! the murmur actually increases or may be heard
!or the !irst time.
Mi!(a+ Va+- P(o+a#): ate&phase murmur usually increases rather than
decreases, and may be heard !or the !irst time.
• STANDING !o S;UATTING: 2a$e patient s6uat do(n and breathe normally, and then
stand. S6uattin# increases stroe $olume, and standin# decreases it a#ain.
o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: 's patient s6uats, this murmur
should be decreased.
o Mi!(a+ R7'(7i!a!ion: Occasionally decreases.
• S;UATTING !o STANDING:
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o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: 's the patient stands bac, this
murmur should increase.
o Mi!(a+ R7'(7i!a!ion: Occasionally increases.
• PASSIVE LEG ELEVATION:
o H%#(!(o#$i" Ob)!('"!i- Ca(dio.%o#a!$%: Murmur should decrease, as le!t
$entricular $olume increases and the le!t $entricle enlar#es.
• ISOMETRIC HANDGRIP: ?sin# a hand#rip !or minutes increases peripheral
$ascular resistance.
o )ECRE'SE) %NTENS%TY: 2ypertrophic Obstructi$e Cardiomyopathy, 'ortic
Stenosis 4about ID o! cases5.
o %NCRE'SE) %NTENS%TY: -entricular Septal )e!ect, 'ortic Re#ur#itation,
Mitral Re#ur#itation.
o CONTR'%N)%C'T%ONS: )o not do this test on people (ith myocardial
ischemia, $entricular arrhythmias, or unstable an#ina
• TRANSIENT ARTERIAL OCCLUSION: Place blood pressure cu!! on both arms and
occlude blood&!lo( !or FD seconds.
o %NCRE'SE) %NTENS%TY: Mitral Re#ur#itation, -entricular Septal )e!ect. Most
other murmurs are una!!ected.
• AMYL NITRATE: 2a$e patient inhale amyl nitrate &&&&&&< decreased TPR. 'uscultate
sounds J&ID seconds later.
o )ECRE'SE) %NTENS%TY: Mitral Re#ur#itation, -entricular Septal )e!ect.
o %NCRE'SE) %NTENS%TY: Ri#ht&sided murmurs, aortic stenosis, hypertrophic
obstructi$e cardiomyopathy.
CHAPTER : A,DOMEN
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2%STORY T'8%N+:
• A,DOMINAL PAINo C2'R'CTER O" P'%N
PUD: =urnin# or #na(in# pain, epi#astric, may radiate to the bac.
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Precipitated by lon# periods o! no !ood or sippin# meals.
O!ten !eel pain early in mornin#, (hich is relie$ed by intae o!
!ood or antacids.
GERD: =urnin#, epi#astric or *iphisternal. Radiates to the retrosternum.
Precipitated by o$er&eatin#, bendin# o$er, or bein# in a reclined
position.
o OC'T%ON O" P'%N:
o R')%'T%ON O" P'%N
Renal Colic o!ten radiates to the #roin.
+allbladder pain o!ten radiates to bac, scapula, or ri#ht shoulder.
Splenic pain o!ten radiates to bac.
Pancreatic pain o!ten radiates to bac.
o "'CTORS PREC%P%T'T%N+ 'N) RE%E-%N+ T2E P'%N
o P'T%ENT 'SSESSMENT O" P'%N SE-ER%TY: Scale o! D to D.
o COMP'R%SON ;%T2 OT2ER TYPES O" P'%N
• ANOREXIA:
o )i!!erential dia#nosis:
Neoplasms
Chronic Renal "ailure
Psychiatric: 'nore*ia ner$osa, depression
%n!ections: 2epatitis, many chronic in!ections.
o Po+%#$a7ia: Seen in hyperthyroidism, malabsorption syndromes, especially
pancreatic insu!!iciency.
•
NAUSEA AND VOMITING:
o D+a%d Ga)!(i" E.#!%in7: %t is a common cause o! nausea. Possible causes o!
delayed #astric emptyin#:
Pyloric Outlet Obstruction: ?lcers, pyloric stenosis, Crohn3s )isease,
neoplasms.
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Neuromuscular: Scleroderma, $a#otomy, demyelinatin# diseases 4MS5,
Polio
Metabolic: Diab!i" 7a)!(o#a()i), $%#o!$%(oidi).?
)ru#s: 'nti&choliner#ics, #an#lionic blocers, opiates
Psychiatric: 'nore*ia Ner$osa
o P(o5"!i+ Vo.i!in7: Special $omitin# that can si#ni!y increased intracranial
pressure 4%CP5.
o R7'(7i!a!ion: -omitin# (ithout nasea. Causes:
O$ereatin#.
'chalasia.
)elayed #astric emptyin#
Esopha#eal rin#s and (ebs.
• DYSPHAGIA:
o Odn%o#$a7ia: Pain!ul di!!iculty s(allo(in#.
o Common Causes:
CVA/ )!(o<
Parinson3s
Re!lu* Esopha#itis
Esopha#eal rin#s and (ebs
'chalasia
Esopha#eal Tumors
Candidiasis
• DIARRHEA: E*cretion o! more than IDD # o! stool per day.
o A"'! Dia(($a:
%n!ectious +astroenteritis: higella, almonella, %ampylobacter, in$asi$e
. %oli
Symptom Cluster: "e$er, myal#ia, chills, nausea, $omitin#,
diarrhea, crampin# abdominal pain.
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actose %ntolerance
'ntibiotic&associated 4loss o! normal !lora5
%n!lammatory bo(el
o S!oo+ In"on!inn": Recurrent de!ecation in pants is not diarrhea and has a $erylimited di!!erential dia#nosis, all relatin# to ana+ )#$in"!( d%)f'n"!ion:
)iabetes Mellitus
Pre$ious rectal or perirectal sur#ery.
Errant episiotomy !rom a traumatic childbirth.
o C$(oni" dia(($a:
)ietary habits 4co!!ee5
Parasitic in!ection: #iardiasis, amebiasis.
%n!lammatory bo(el disease
• CONSTIPATION: F bo(el mo$ements per (ee is normal in some people.
o A"'! Con)!i#a!ion: Recent change in bo(el habits. Causes:
)ru#s: anticholiner#ics, psycho&acti$e dru#s, many others.
H%#o!$%(oidi).
H%#(#a(a!$%(oidi).
)ecreased !ood intae, decreased !luid intae.
Chronic debilitatin# disease 4post&stroe5.
o Hi()"$)#('n71) Di)a): '#an#lionic Me#acolon
i!elon# constipation
Ocassional passa#e o! enormous stools
'bsence or mared dimunition o! #an#lion cells in rectal tissue
Mared colonic distension.
o Idio#a!$i" C$(oni" Con)!i#a!ion may be caused by a de!ect in the pel$is !loor
in (omen, in (hich they contract the anal sphincter, rather than rela* it, (hende!ecatin#.
• HEMATEMESIS
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o Possible Causes:
P?) or erosi$e +astritis
Ma++o(%83i)) Ta( o! esopha#us
Esopha#eal $arices, portal hypertension
• HEMATOCHEIA and MELENA
o HEMATOCHEIA: Occult blood in stool.
Possible Causes
Co+o("!a+ "a("ino.a
Inf"!io') n!(i!i): higella, almonella, %ampylobacter, in$asi$e .
%oli may all cause hematocheia.
2emorrhoids
Chronic di$erticular disease
o MELENA: Passa#e o! blac or $ery dar stool, re!lectin# heme breado(n
products in stool.
Other causes o! blac stool 4other than occult blood5: %ron&containin#
dru#s, bismuth&containin# dru#s, charcoal, lots o! blac cherries.
o Ma(oon8Co+o(d S!oo+) are indicati$e o! massi$e blood loss 4F to I units o!
blood5. ?sually (ill see unstable $ital si#ns. oo !or complications o! P?),
such as per!orated ulcer.
INSPECTION:
• PROTU,ERANT OR DISTENDED A,DOMENo Pa(!ia+ ,o@+ Ob)!('"!ion: )istended abdomen plus peristaltic mo$ements
heard o$er the distension is practically dia#nostic.
o P)'do"%)i)/ P)'do#(7nan"%: ;oman (ho (ants to be pre#nancy de$elops a
distended abdomen psycho#enically.
o %ncreased air in bo(el causin# abdominal distension:
Mechanical !actors, carcinoma or adhesions
'dynamic paralytic ileus.
o A)"i!): Most common cause is alcoholic cirrhosis leadin# to portal hypertension.
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F+'id 3a-: Press do(n abdomen and create a !luid (a$e. %t is indicati$e
o! ascites.
P'dd+ Si7n: 2a$e patient lie prone and then #et on hands and nees, to
#et all ascites to #o to a dependent position. Then !lic and auscultate the
abdomen, listenin# !or chan#es in intensity o! sounds. Positi$e test
indicates ascites.
C$%+o') A)"i!) is mily 4lipid5 loo to transudate, indicatin# lymphatic
bloca#e. Occurs (ith intraabdominal lymphomas and 2od#in3s disease.
'scites can be assessed by auscultation by assessin# shi!tin# dullness
(hen patient chan#es position.
• GREY TURNER1S SIGN: Ecchymoses on the abdomen, an unusual place !or
ecchymoses. %t occurs in f'+.inan! a"'! #an"(a!i!i) and carries a #ra$e pro#nosis.
• 4AUNDICE: Most common causes
o -iral 2epatitis
o 'lcoholic i$er )isease
o )ru#&induced /aundice
o Chronic acti$e li$er disease
o Choledocolithiasis
o Pancreatic carcinoma
o Metastatic li$er disease
• A,DOMINAL HERNIAS
o 'natomical Types o! 2ernias:
In7'ina+ H(nia): Most common hernia.
Di("! In7'ina+ H(nia: 2ernia directly penetrates the in#uinal
trian#le. %t creates a bul#e ri#ht abo$e 4superior and medial to5 thein#uinal li#ament.
Indi("! In7'ina+ H(nia: 2ernia passes through the inguinal
canal , and creates a bul#e in the ri#ht o$er the in#uinal li#ament,
as it passes throu#h the in#uinal rin#.
%n men, o!ten herniates into scrotum.
F.o(a+ H(nia: Second most common. 2i#h ris o! stran#ulation, FD
o! cases.
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Ob!'(a!o( H(nia: ?nusual, occurin# in elderly, thin, emaciated (omen.
Protrusion o! peritoneal sac throu#h Obturator "oramen.
Symptom: Pain, paresthesia do(n anterior thi#h, due to
compression o! !emoral ner$e.
U.bi+i"a+ H(nia: May occur in people (ith chronic increasedintraabdominal pressure: Multiparous (omen and COP).
S#i7+ian H(nia: Occurs bet(een ubilicus and pubic symphysis.
?nusual.
o Reducability:
Rd'"ib+: The contents o! the hernia can be easily displaced.
I((d'"ib+/ In"a("(a!d: The contents o! the hernia cannot be displaced
and are stuc there.
S!(an7'+a!d: 'n incarcerated hernia that has cut o!! its blood supply,
resultin# in tissue necrosis and #an#rene.
PERCUSSION:
• T%.#an%: %ncreased tympany is heard upon percussion o! the abdomen in cases o!
#a(!ia+ bo@+ ob)!('"!ion.
• Normal i$er Span: D&F cm in men, Q& cm in (omen.
'?SC?T'T%ON:
• PERISTALTIC SOUNDS:
o 'bsent =o(el Sounds: %leus
o %ncreased =o(el Sounds: +astroenteritis.
o ,o(bo(%7.i: 2i#h&pitched bo(el sounds indicatin# small bo(el obstruction.
• SUCCUSSION SPLASH: 'udible presence o! increased amount o! !luid in stomach.
o Normal a!ter a lar#e meal.
o %! it occurs a!ter !astin#, then it is indicati$e o! #%+o(i" ob)!('"!ion?• A,DOMINAL ,RUITS: Caused by calci!ication o! aorta, celiac compression, and
alcoholic hepatitis.
• PERITONEAL FRICTION RU,S: 2earin# a peritoneal !riction rub o$er the li$er is
indicati$e o! li$er metastasis or primary hepatoma.
P'P'T%ON:
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• LIVER :o H#a!o.7a+%:
Primary or metastatic 2epatoma.
'lcoholic li$er disease 4!atty li$er5.
Se$ere C2".
%n!iltrati$e diseases o! li$er lie amyloidosis.
Myeloproli!erati$e )isorders: CM, Myelo!ibrosis.
• SPLEEN
o S#+no.7a+%:
%n!ections
euemias
Portal hypertension
• GALL,LADDER
o Co'(-o)i(1) La@: +allbladder is palpable in FJ o! cases o! #an"(a!i""a("ino.a, due to painless distension.
o M'(#$%1) Si7n: R? pain a##ra$ated by inspiration, indicati$e o! a"'!"$o+"%)!i!i).
• KIDNEYS:
o Enlar#ed 8idneys: Polycystic 8idney )isease, hypernephroma, renal cysts,
hydronephrosis.
o P!o!i" Kidn%: Normal&sied idney displaced in!eriorly into abnormal position1
pel$ic idney.
• AORTA: Pulsatile mass in midline is su##esti$e o! 'ortic 'neurysm.
• MASSES and ,O3EL LOOPS
• FEMORAL PULSES and DISTAL AORTA: )ecreased or absence !emoral pulses can be !ound in se$eral disorders:
o )issectin# 'ortic 'neurysm
o Coarctation o! 'orta
o Se$ere atherosclerotic peripheral $ascular disease
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o L(i"$1) S%nd(o.: Occlusion o! the distal 'orta.
Symptom Tetrad: bsent femoral pulses, intermittent claudication, gluteal
pain, impotence.
• RECTAL EXAM
'C?TE '=)OM%N' P'%N:
• LOCALIING PAIN !o INTRAA,DOMINAL SITES• INVOLUNTARY GUARDING AND MUSCLE RIGIDITY:
o P(fo(a!d '+"(
o P(fo(a!d bo@+
o P(i!oni!i)
• DIRECT AND INDIRECT TENDERNESS
o Rbo'nd Tnd(n)): Tenderness on sudden release o! pressure. ' reliable si#n
o! peritoneal in!lammation.
o 4a( Tnd(n)): '$oidance o! sudden mo$ements due to abdominal pain. 'lso a
si#n o! peritoneal in!lammation.
'=)OM%N' P'%N SYN)ROMES:
• 'C?TE '=)OM%N' P'%N
o )i!!erential )ia#nosis:
%n!ectious: 'ppendicitis, cholecystitis, pancreatitis, hepatitis,
+astroenteritis, )i$erticulitis.
Crohn3s )isease
,o@+ #(fo(a!ion: Peritoneal si#ns should be present. Patient doesn3t
(ant to mo$e.
,o@+ ob)!('"!ion: Patient can3t stay still and eeps mo$in# around to #et
com!ortable.
Colic: Renal or biliary colic.
)issectin# 'bdominal 'ortic 'neurysm.
o )iabetic 8etoacidosis and other metabolic disorders can simulate an acute
abdomen.
• C2RON%C '=)OM%N' P'%N
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o PEPTIC ULCER DISEASE: +na(in#, burnin#, achin#.
Pain partially relie$ed by eatin# !ood.
Chronicity, Rhythmicity, Periodicity
o CHOLELITHIASIS and ,ILIARY COLIC:
Paro*ysms o! sharp colicy R? pain, o!ten radiatin# to bac, ri#ht mid&
abdomen.
%ntolerance to #reasy !oods may be !ound.
?ltrasound is usually dia#nostic.
o DELAYED GASTRIC EMPTYING:
O!ten accompanied by nausea, emesis, and early satiety.
Pain is 'orsened by eatin#.
o CHRONIC PANCREATITIS:
Caused by alcoholism.
May be e*acerbated by eatin#
o PANCREATIC CARCINOMA
;ei#ht loss, abdominal pain, anore*ia, (eaness 0 !ati#ue, diarrhea
common
Pain is $ariable in 6uality, and o!ten ameliorated by sittin# in nee&chest
position.
o LACTASE DEFICIENCY
o IRRITA,LE ,O3EL SYNDROME: 'bdominal discom!ort (ith no
demonstrable or#anic cause.
)e!ecation relie$es the pain.
• 'NTER%OR '=)OM%N' ;' P'%N
o Neuromas, 2erpes Aoster, 2ernias.
o Ti#htenin# o! abdominal (all should aggravate symptoms, indicatin# abdominal&
(all pain. %! ti#htenin# o! abdominal (all relie$ed symptoms or (ere done as a#uardin# action, then that (ould be $isceral pain.
CHAPTER : MALE GENITALIA
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SYMPTOMS:
• )YS?R%': ?ncom!ortable or pain!ul urination
o Pain (ith urination: ?rethritis, urethral obstruction, prostatitis.
o Pain !elt after urination: b+add( "a+"'+'), prostatitis.
• "RE?ENCY o! ?R%N'T%ON:
• ?R+ENCY:
• NOCT?R%':
• POY?R%':
• ?R%N'RY %NCONT%NENCE:
• 2EM'T?R%':
o Ti. of H.a!'(ia:
4eginning o! micturition: urethral or prostatic source. =lood is ori#inatin#
near the meatus.
Throughout micturitiuon: renal source. =lood is di!!usely present in urine.
nd o! micturition: bladder source. =lood is ori#inatin# !rom bladder.
o Pain+)) H.a!'(ia: Thin no#+a).) 4renal or bladder5, renal tuberculosis,acute #lomerulo&nephritis.
• O%+?R%', 'N?R%': Renal !ailure.
o O+i7'(ia: F>&hr urine output less than >DD ml
o An'(ia: F>&hr urine output less than DD ml
• PNE?M'T?R%': Passa#e o! air or stool throu#h urinary tract. %t indicates the presence
o! !istula tracts connectin# the +% and ?+ tracts, such as a!ter sur#ery or (ith
in!lammatory bo(el disease.
• PROST'T%SM: No direct relationship e*ists bet(een $oidin# habits and !eelin#s o!
ur#ency, and the sie o! =eni#n Prostatic 2yperplasia.
• PEN%E P'%N, ?CERS, )%SC2'R+E:
o P$i.o)i): Constriction o! the penis, causin# pain in uncircumcised penises.
• OSS o! %=%)O, %MPOTENCE:
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• %N"ERT%%TY:
• SCROT' S;E%N+, TEST%C?'R P'%N: Testicular pain is usually caused by
torsion, hydrocele, $aricocele, or spermatocele. Testicular tumors are usually painless
'hen they present.
P2YS%C' E9'M:
• PEN%S
o ,a+ani!i): %n!lammation o! the #lans penis. Causes:
)iabetes mellitus
%n!ections: %andida, Trichomonas
)ru# reactions
Reiter3s Syndrome
o P%(oni1) Di)a): ateral de$iation o! penis, caused by unilateral in!lammation
o! a corpus ca$ernosum.
• SCROT?M
o A!(o#$i" T)!): Caused by orchitis, trauma, "$(oni" a+"o$o+i)., "i(($o)i).
o H%d(o"+: T(an)i++'.ina!ion o! a scrotal mass (ill illumiunate a hydrocele. %! a
pain!ul mass is present, transilluminate it.
• PROST'TE
• %N+?%N' C'N'S and +RO%N: See abdominal study #uide.
• RECT' E9'M