Respiratory Exam (3-4 Questions) Table 8-1: Chest Pain Retrosternal/Anterior Chest

Respiratory Exam (3-4 Questions)
Table 8-1: Chest Pain
Angina Pectoris
Cardiovascular Dx
Myocardial
Infarction
Pericarditis
Dissecting Aortic
Aneurysm
Tracheobronchitis
Pulmonary Dx
Pleuritic Pain
Reflex Esophagitis
GI & Others
Diffuse
Esophageal
Spasm
Chest Wall Pain/
Costochonritis
Anxiety
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Temporary MI, 2° to Coronary Atherosclerosis
Retrosternal/Anterior Chest à ® Shoulder, Arms, Neck, Lower jaw, Upper Abs;
“Pressing, Squeezing, Tight, Heavy, Sometimes burning”
1-3min – 10mins
L cold, after eating, stress
J Nitroglycerin & rest
Assoc w. Dyspnea, Nausea, Sweating
Myocardial ischemia = muscle damage & necrosis!
Retrosternal/Anterior Chest à ® Shoulder, Arms, Neck, Lower jaw, Upper Abs
“Pressing, Squeezing, Tight, Heavy, Sometimes burning”
20min – hrs
Assoc w. Nausea, Vomiting, Sweating, Weakness
Irritation of Parietal pleura
Precordial à ® Tip of shoulder & neck, “Sharp, Knifelike”
Retrosternal à “Crushing”
L Breathing, changes in position/lying down, coughing
J Sitting forward
Splitting of layers in aortic wall
Anterior Chest à ® Neck, Back, Abs; “Ripping, Tearing”
L HTN
Assoc w. Syncope, Hemiplegia, Paraplegia
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Inflammation of Trachea & Large Bronchi
Upper/Side sternum à “Burning”
L Coughing
J Lay on affected side
Inflammation of Parietal pleural à Pneumonia, Pulmonary Infarction, Neoplasm
Chest wall over affected area à “sharp, knifelike”
L Inspiration, Coughing, movements of trunk
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Inflammation of Esophageal mucosa via Acid Reflux
Retrosternal à ® back; “Burning or Squeezing”
L Large meals, bending over, lying down
J Antacids, belching
Assoc w. Regurgitation, Dysphagia
Motor Dx of Esophageal muscle
Retrosternal à à ® back, arms, jaw “squeezing”
L Swallowing, cold liquids, emotional stress
J Nitroglycerin
Assoc w. Dysphagia
Below L Breast along costal cartilage
“stabbing, sticking, dull ache”
L Chest, trunk, arms movement
Assoc w. local TTT
Precordial, below L Breast or Ant Chest
“Stabbling, sticking, dull ache”
L Emotional stress or effort
Assoc w. Breathlessness, Palpitations, weakness, anxiety
8-2 Dyspnea
RS HF
LVHF or Mitral Stenosis
Chronic Bronchitis
Chronic Obstructive
Pulmonary Dx (COPD)
Asthma
Diffuse Idiopathic Lung Dx
Sarcoidosis, Neoplasms,
Asbestosis, Idiopathic
Pulmonary Fibrosis
Pneumonia
Spont. Pneumothorax
Acute Pulmonary Embolism
Anxiety w. Hyperventilation
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↑ pulmonary capillary pressure = fluid in interstitial space/alveoli = ↓ compliance = ↑ stiffness
May progress slowly or suddenly w. Pulmonary Edema
L Exertion, Laying down
J Rest, sitting up,
Assoc w. Cough, orthopnea, paroxysmal nocturnal dyspnea (PND), wheezing
Hx of Heart Dx
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↑ mucous in Bronchi = Chronic Airway obstruction
Chronic productive cough that gets worse...
L Exertion, inhaled irritants, URTI
J Expectoration, rest
Assoc w. chronic productive cough, reccurant URTI, wheezing
Hx of Smoking, Air pollutants, Recurrant URTI
Overdistention of terminal bronchioles = destruction of Alveolar septa = chronic obstruction of airway
Slowly progressive
L Exertion
J Rest
Assoc w. cough with Scant Mucoid Sputum
Hx of smoking, air pollutants, genetic deficiency in Alpha1-antitrypsin
Broncial hyperresponsivness = release inflammatory mediators = ↑ airway secretions & bronchoconstriction
Acute episodes separated by symptom free periods, Noctural episodes common
L Allergens, irritants, URTI, exercise, emotions
J avoid Environmental & Emotional conditions!
Assoc w. wheezing, cough, “tightness in chest”
ABN spread of cells, fluid & collagen into interstitial spaces b/w alveoli
Progressive
L Exertion
J Rest
Assoc w. weakness, fatigue, cough less common than other Lung Dx!
Exposure to causative agents...
Inflammation of lung parenchyma via Respiratory Bronchioles à Alveoli
Acute illness with causative agent
Assoc w. Pleuritc pain, cough, sputum, fever
Tall, skinny, young men!
Leakage of air into pleural space via Blebs on Visceral pleura = partial/full collapse of lung
Sudden onset of pleuritic pain
Sudden occlusion of all/part of Pulmonary arteriole tree via embolism from deep veins of legs/pelvis
Sudden onset
Assoc w. Retrosternal oppressive pain; Pleuritic pain, cough, hemoptysis may follow embolism
Post pardum, post-operative, prolonged bed rest, CHF, Chronic Lung Dx, Fx of Hip/Leg, DVT
Over breathing = Resp. Alkalosis = ↓pCO2
Episodic
L More often at rest, upsetting event/emotional
J breathing in a paper bag
Assoc w. light-headedness, numbness, tingling of hands/feet, palpitations, chest pain
Table 8-3: Cough & Hemoptysis
Acute
Inflammation
Laryngitis
Tracheobronchitis
Mycoplasma &
Viral Pneumonias
Bacterial Pneumonias
Postnasal drip
Chronic Bronchitis
Chronic
Inflammation
Bronchiectasis
Pulmonary TB
Lung Abscess
Asthma
Gastroesophageal Refulx
Neoplasm
Cardiovascular
Dx
Lung Cancer
LVHF or Mitral Stenosis
Pulmonary Embolism
Dry Cough à Hoarsness & Viral Nasopharyngitis
Dry Cough (maybe productive) à Viral, “Retrosternal Burning”
Dry-Hacking & productive à Acute febrile illness, malaise, HA, dyspnea
Pneumococoal = Blood-streaked/Pink Mucoid/Purulent sputum à Chills, ↑fever,
dyspnes, chest pain, preceeded by URTI
Klebsiella = Red Currant Jelly à old Alcoholic men!
Chronic cough à mucoid/purulent sputum à attempt to clear throat, Chronic Rhinitis
with/without Sinisitis
Chronic cough = Blood-streaked/Bloody sputum àHx of smoking, wheezing, dyspnea,
recurrent infections
Chronic cough à foul smelling Blood-streaked/Bloody sputum à recurrant
Bronchopulmonary infections
Dry Cough à Blood-streaked/Bloody sputum à Later in Dx Anorexia, weight loss,
fatigue, fever, night sweats!
foul smelling Blood-streaked/Bloody sputum à febrile illness, bad dental hygiene!
Cough w. thick mucoid sputum (end of attack) à Wheezing, dyspnea, allergies
Chronic cough à wheezing, night, early morning hoarsness; Hx of Heartburn
Dry or productive à Blood-streaked/Bloody sputum àHx of smoking
Dry, exertion or night à Pink-Frothy - Hemoptysis à Dyspnea, Orthopnea, PND
Dry-Productive à Dark, Bright Red à Dyspnea, anxiety, chest pain, fever, DVTs
Table 8-7: Physical Findings of Chest Dx
NORMAL J
RESSONANT
PERCUSSION NOTE
Chronic Bronchitis
LV HF
Consolidation
Pneumonia
Pulmonary Edema
Pulmonary Hemorhage
DULL PERCUSSION
NOTE
Atelectasis
Lobar Obstruction
Pleural Effusion
Pneumothorax
HYPER-RESSONANT
PERCUSSION NOTE
COPD
Chronic Bronchitis
RESONANTHYPERRESONANT
PERCUSSION NOTE
Asthma
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Trachea Midline (TM)
Vesicular breath sounds (VBS)
No Adventitious Sounds (AS)
Normal Tactile Fremitis (TF) & Transmited Voice Sounds(TVS)
TM
VBS
Scattered early-INSP Crackles, wheezes, rhonci
Normal TF & TVS
TM
VBS
Late –INSP Crackles, possible wheezes
Normal TF & TVS
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Dull due to airless area...
TM
Bronchial over involved area
Late-INSP Crackles
↑ TF, Bronchophongy (louder), Egophony (eà ay), Whispered
Pectroliligy(clearer)
Dull due to airless area...
T à affected side
Absent VBS due to bronchial plug, except RU Lobe
≠ AS
Absent due to bronchial plug, except RU Lobe
Dull due to fluid filled area...
T à affected side
↓ VBS, but Bronchial maybe heard at top of large effusion
Possible pleural friction rub
↓ TF & TVS, but maybe ↑ TF near top of large effusion
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Hyper-resonant/TYMPANIC due extra air
T ß affected side
↓ VBS
Possible pleural friction rub
↓ TF& TVS
Diffusely Hyper-resonant/TYMPANIC due extra air
TM
↓ VBS
Possible Crackles, Wheezes & Rhonci due to Chronic Bronchitis
↓ TF& TVS
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Resonant-Diffusley hyper-resonant
TM
Obscured VBS due to Wheezes
Wheezes, Possible Crackles
↓ TF& TVS
Table 11-1: Abdominal Pain!
Peptic Ulcer
Stomach Cancer
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Biliary Colic
Acute Cholecystitis
Acute Diverticulitis
Acute Appendicitis
Acute Mechanical Intestinal
Obstruction
Mesenteric Ischemia
Hepatitis
• Ulcer of Duodenum (30-60yrs) or stomach(>50yrs) & co-infection with H.Pylori
• Epigastric à ® Back; “gnawing, burning, ache, pressing, hunger like”
• Duodenal = pain wakes up & intermittently over a few wks
• J Antacids & food
• Assoc w. nausea, vomiting, belching, bloatin, heartburn, weight loss
Note: Dyspepsia(20-29yrs) has similar symptoms but ≠ ulceration!
• Adenocarcinoma 90-95%, Cardia & GE junction, distal stomach; 50-70yrs
• Hx of pain short, slow & progressive
• L food
• J NOTHING!
• Assoc w. anorexia, nausea, early satiety, weight loss, bleeding
• Acute inflammation of pancreas
• Epigastric à ® back & Ab & poorly localized! “steady pain”
• L laying supinse
• J Leaning forward with trunk flexed!
• Assoc w. nausea, vomiting, Ab dissention, fever, Hx of Gallstones & Alcoholism
• Fibrosis of pancreases 2° to recurrent inflammation
• Epigastric à ® through back “steady deep pain”
• L Alcohol, heavy or fatty meals
• J possibly leaning forward
• Assoc w. ↓ pancreatic function, fatty stool/Steatorrhea, DM
• Adenocarcinoma 95%
• Epigastric & RUQà ® back “progressive steady deep pain
• J possibly leaning forward
• Assoc w. anorexia, nausea, vomiting, weight loss, jaundice, depression
• Acute obstruction of Cystic or Common Bile duct by Gallstone
• Epigastric & RUQà ® Scapula & Shoulder “steady ache” that gradually subsides
• Assoc w. Anorexia, nausea, vomiting, restlessness!
• Inflammation of the Gallbladder from Obstruction of Cystic Duct via Gallstone
• RUQ or RUAbà ® Scapula, “steady ache that last longer than Biliary colic”
• L Jarring deep breath
• Assoc w. Anorecia, nausea, vomiting, fever
• Inflammation of the Colonic Diverticulum
• LLQ Pain “steady cramping”
• Assoc w. Fever, constipation w. initial period of diarrhea
• Inflammation of the Appendix w. distention & obstruction
• Poorly localised Peri-umbilical à “mild cramping” ~4-6hrs
• RLQ à “steady & severe” until intervention
• L Cough & move
• J If pain goes away 100%, perforation is very likely à EMERG!
• Assoc w. Anorexia, nausea, vomiting, ↓ fever
• Bowel lumen obstruction: Hernias/Adhesions of small bowel or Cancer/Diverticulitis of large bowel
• Small Bowel = Peri-umbilical & UAb, Colon = LAb, “cramping then steady pain that comes
abruptly”, paroxysmal
• Vomiting of bile & mucous = High obstruction, Fecal material = low obstruction
• Blood supply to bowel/messentary blocked via Thrombis or Embolis (Acute Arteriole occlusion) =
hypoperfusion
• Peri-umbilical then diffuse
• Assoc w. Vomiting, diarrhea (sometimes bloody), constipation, shock
AB pain/distention, Breast development in males, Dark urine and pale or clay-colored stools, Fatigue,
↓ Fever, General itching, Jaundice (yellowing of the skin or eyes), anorexia, Nausea &vomiting, Weight loss
Table 11-2: Dysphagia
Oropharangyeal Dysphagia
Due to Motos Dx affecting the Pharyngeal Muscles
Mucosal Rings & Webs
Esophageal Dysphagia
=
Mechanical Narrowing
Esophageal Stricture
Esophageal Cancer
Diffuse Esophageal Spasm
Motor Dx
Scleraderma
Achlasia
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Acute or gradual
L attempt to swallow
Assoc w. Aspiration, regurgitation, Stroke, Bulbar Palsay, NMS Dx
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Intermittent
L Solids
J Regurgitation
Intermittent & slow progressive
L Solids
J Regurgitation
Assoc w. Hx of Heartburn & Regurgitation Dx
Intermittent & progressive
L Solids & eventually liquids!
J Regurgitation
Assoc w. Chest & Back pain, weight loss
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Intermittent
L Solids & Liquids
J Repeated swallowing with straight back & raised arms
Assoc w. Chest pain that mimcs Angina or MIs, mins-hrs, Hx Heartburn
Intermittend & progressive
L Solids & liquids
J Repeated swallowing with straight back & raised arms
Assoc w. Heart burn & Scleroderma symptoms
Intermittend & progressive
L Solids & liquids
J Repeated swallowing with straight back & raised arms
Assoc w. Regurgitation at night when supine! Nocturnal cough, Chest pain
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Ignore the reflex/need to go
Hectic schedule
Who can say what regular is...
Try laxitives when not necessary!
↓ fecal bulk
Assoc w. debilitation, constipating drugs
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Change in frequency without structural or chemical ABN
Small, hard stools w. mucous; periods of diarrhea, intermittent pain relieved by
BM
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Progressive narrowing of lumen
Change in bowel habits, diarrhea, AB pain, bleeding
Rectal cancer = “pencil shaped stools”
Large, firm, immovable fecal mass in rectum
Rectal fullness, AB pain, diarrhea around impaction
Debilitated & Bed ridden ppl (elderly)
Narrowing/Complete obstruction
Colicky AB pain & dissention
Intussuscpetion = “red-currant jelly stool” (red blood & mucous)
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Pain = Ext Sphincter spasm = voluntary inhibition of reflex
Opiates, Anticholinergics, Antacids (Ca+2 or Al+2)
Fatigue, Anhedonia, Sleep disturbances, weight loss
ANS problems
Spinal Cord injury, MS, Hirschprungs Dx
Bowel motility à Pregnancy, HPT, Hypercalcemia!
Table 11-3: Constipation
Time or Setting
Lifestyle
False Expectations
Fibre deficient Diet!
Irritable Bowel Syndrome
(IBS)
Rectal or Colon Cancer
Mechanical Obstruction
Fecal Impaction
Diverticulitis, Volvus,
Intussusception, Hernia
Painful Anal Lesions
Depression
Neurologic Dx
Metabolic Dx
Table 11-2: Diarrhea
Secretary Infection
Acute Diarrhea
Inflammatory Infection
Drug Induced Diarrhea
IBS
Chronic Diarrhea
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“Diarrheal Syndromes”
Sigmoid Colon Cancer
Ulcerative Colitis
Chronic Diarrhea
=
“Inflammatory Bowel
Dx”
Chron’s Dx /
Regional Enteritis
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Virus/Bacterial InfectionàStaph A, Clostridium P., E.Coli, V.Cholera, Giardia
Stool: Watery
Few days after infection
Assoc w. Nausea, Vomiting, periumbilical cramping, fever
Ppl who travel, common food source, epidemic
Colonization of Intestinal mucosa!à Salmonella, Shigella, Yersina,
Camplyobacter, Enteropathic E.Coli, Entamoebla Histoletica
Stool: Watery, Blood, Mucous, Pus
Acute illness
Assoc w. Lower Ab cramping, rectal urgency, tenesmus, fever
Ppl who travel, contaminated food & water, anal sex
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OTC Mg+2 containing drugs!!
Stool: Loose-watery
Acute, reccurant w. drug use
Assoc w. Nausea
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Change in frequency & form without Chemical or structural ABN
Stool: Loose, may have mucous; small hard stools w. constipation
Worse in morning & with stress! (women!)
Assoc w. crampy Lower Ab, Ab distention, flatulence, nausea,
constipation
Young-middle aged women à emotional stress!
Partial obstruction due to neoplasm
Stool: blood streaked
Assoc w. change in BM, crampy Lower Ab, pain, constipation
>55yrs
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Malabsorption Syndrome
Chronic Diarrhea
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“Voluminous”
“Osmotic Diarrhea”
Lactose Intolerance
Abuse of Ostmotic
Purgatives/Laxitives
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Inflammation of Mucousa & Submucosa w. ulcerations (extends proximally)
Stool: watery w. ↑ blood
Insidius-acute, may wake up at night!
Crampy lower Ab or generalized Ab pain, anorexia, weakness, fever;
e[isclerotisi, uveitis, arthritis, erythema nodosum
Young ppl, ↑ risk of developing colon cancer L
Chronic transmural inflammation of bowel, Skip Lesions
Stool: small, soft-loose, watery, small amount of blood (<<u.colitis)
Insidius, may wake up at night
Crampy peri-umbilicarl or RLQ, anorexia, ↓ fever, weight loss,
perianal/perirectal abscesses & fistulas!
Young ppl (late teens), Jewish, ↑ risk of developing colon cancerL
Defective fat absorption & fat sol. Vits = Steatorrhea
Stool: bulky, soft, light yellow-gray, mushy, greasy, oily, frothy, foul odour,
floats
Anorexia, weight loss, fatigue, Ab distention, crampy Lower Ab;
Nutrtitional def = Bleeding (< vit k), Bone pain & fx (< vit D), glossitis (<
vitB), edema (<proteins)
≠ Lactase intestinal enzyme
Stool: watery in large volume
After ingesting dairy
Crampy Ab pain & distention, flatulence
>50% African-amerians, Asians, NAmericans, Hispanics, 5-20% whites
Stool: watery in large volume
Weight loss, dehydration, nausea, vomiting, ab cramping
Table 11-5: Black & Bloody Stool
Melena:
• Black-Tarry stool, sticky, shiny
• + occult blood test
• >60ml blood into GI
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Esophagus, Stomach, Duodenum
Black, Non-sticky:
• - occult blood test
• Iron ingestion
• NO Pathologic significance J
Red Blood in Stool:
• Colon, Rectum, Anus, Upper GI
bleed
• Rapid transit time ≠ allow for
absorption/stool to turn black!
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Peptic Ulcer à Hx of Epigastic Pain
Gastritis à Ingestion of OH, Aspirin/Anti-inflammatorys, recent trauma/sever burns,
↑ intracranial p
Esophageal/Gastric Vacicies à Cirrhosis, Portal HTN
Reflux Esophagitis = Mallory Weiss = mucosal tear à Retcjomg, vomiting, OH
ingestion
Ingestion of: Iron, Bismuth salts (Pepto Bismol), Licorice, Oreos
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Colon Cancer à BM changes
Benign Colon Polyps à asymptomatic!
Diverticuitis à asymptomatic!
Ulcerative Colitis
Chron’s Dx
Infectious Diarrhea
Proctitis à anal sex... Rectual urgency & tenesmum
Ischemic Colitis à Lower Ab pain, fever, shock, Ab soft on palp
Hemmorrhoids à blood on toilet paper
Anal fissure à blood on toilet paper & pain
Table 11-6: Frequency, Nocturia, Polyuria
• Inflammation à Infection, stones, tumours, foreign body, “burning, urgency, gross hematuria!”
Frequency:
• ↓ Elasticity à Scar tissue, tumour, “burning, urgency, gross hematuria!”
↓ Bladder Capacity
• ↓ Cortical Inhibition à CNS Dx, Stroke etc, “urgency, NMS symptoms”
Frequency:
↓ Bladder Emptying
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Mechanical obstruction à benign prostatic hyperplasia, urththral stricture, “hesitancy, hard to start stream,
↓ force & size of stream, dribbling”
Loss of PNS to Bladder à NMS Dx of Sacral N. (DM), “weakness & sensory deficits”
Nocturia:
↑ Volumes
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Polyuria...
↓ Ability of kidney to conc. Urin à Chronic Renal Dx
↑ Fluid intake before bed à Coffee & OH drinkers
↑ Fluid retaining states à CHF, Nephrotic Dx, Cirrhosis, Chronic Venous Inssuficency “Edema, sacral
accumulation of fluid =+ micturation reflex!
Nocturia:
↓ Volumes
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Frequency...
Voiding at night with no real urge à Insomnia
Polyuria
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≠ADH = Diabetes Insipidus (DI)à Pit & Hypo problem “thirst, polydispia, nocturia”
Renal Unsresponsivness to ADH = Nephrogenic DI à Hypercalcemia, Hypokalemic nephropathy, drug
toxicity “thirst, polydispia, nocturia”
Solute Diuresis = Na & Glucose à Saline infusions for Kidney Dx or DM “Thirst, polydispia, nocturia
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Table 11-7: Urinary Incontinence
Stress:
• Weak Urethral sphincter
• ≠ handle ↑ intra-AB p = “oops”
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Women with weak Pelvic floor muscles, after AB or prostate surg
Momentary leakage; cough, sneeze, laugh = ↑p = oops
Bladder not detectable on palp, Atophic vaginitis
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↓ Cortical inhibition à Stroke, Dementia, Tumor etc = oops before “I have to pee”
Hyperexcitiabilityà infection, tumor, fecal impaction = Frequency, Nocturia with small vol.
Deconditioned void reflex à infection = frequency & pain with small vol
“pseudo-stress” à voiding w. 10-20sec of position change, cough, sneeze
Overflow:
• Weak detrussor contraction!
• Large bladder!!
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Bladder outlet obstruction à BPH or tumor = continuous dribble = TTT enlarged bladder
Weak detrussor à PNS Dx = ↓ urinary stream force = PNS symptoms seen...
Impared bladder sensation à Diabetic Neuropathy = PNS Dx!
Functional:
• Can’t get to toilet fast enough b/c
poor health or environment! FML
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Motility problems à cant get there fast enough... “FML where’s the bathroom!”
2° to Drugs
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Sedatives & Tranquilizers!
Urge:
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Detrussor too strong!
Small bladder!
Table 11-10: Abdominal Sounds!
Bowel Sounds
“Gastric motility”
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↑ Diarrhea or Early Intestinal Obstruction
↓ Adynamic Ileus, Peritonitis; >2mins = EMERG N:5-35/min
“High pitched” intestinal air/fluid under tension in bowel
“Rushes of High pitched” Ab cramp or obstruction!
Bruits
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Hepatic Bruit = Liver Carinoma or OH Hepititis!
Arteriole Bruit = heard in S & D = partial occlusion of Aorta or large A. à EMERG
Partial occlusion of renal a à explain HTN in patient!
Venous Hum
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Rare, soft hum in S & D = + ↑ Collateral circulation b/w Portal & Systemic V. = Liver
Cirrhosis
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Rare, grating sound = + inflammation of peritonel surface = Liver cancer,
chlamydial/gonococcal perihepatitis, liver biopsy, splenic infarct
S Bruit + Frictio Rub = Liver cancer L
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Starts in Ab wall & ↑ with arms raised à + NMS
TTT Visceral
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TTT to palp, dull with no rigidly or R.TTT
Acute Pleurisity
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U/L AB pain & TTT à Cholesystitis (RUQ) & Appendicitis (RLQ)
R.TTT, Rigidity, Chest TTT , less common à Board like rigidity = EMERG!
B/L TTT of Falopian Tubes, worst over Inguinal Ligs!
+ R.TTT & Rigidity
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RUQ TTT, + Murphy’s Sign
Epigastric TTT, R.TTT, Soft Abs
RLQ TTT, R.Flank TTT, à Obtruator, R.Psoas test
LLQ TTT, “Left sided Appendicitis”
Friction Rub
Table 11-11: TTT Abdomens
TTT Abdominal Wall
Acute Salpingitis
Acute Cholecystitis
Acute Pancreatitis
Acute Appendicitis
Acute Diverticulitis
Urogenital/Reproduction Questions (5-6 Questions)
Table 13-5: Hernias (1 question)
Indirect Inguinal Hernia
Direct Ingunal Hernia
Femoral Hernia
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Common in Boys & Girls, mostly kids
Above Inguinal Lig @ Internal Inguinal Ring
Possibly go down into scrotum!
Less common, Men >40yrs
Above inguinal lig @ Pubic tubercle-External Inguinal Ring
Bulge anteriorly (≠ into scrotum)
Least common, Women > Men
Blow inguinal lig, lateral & hard to Diff Dx from Lymph nodes!
Empty inguinal canal
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Farily common, congenital ABN, superficial to Coccyx/Sacrum
Small tuft of hair, halo of erythema, slight drainage
Dialated Hemorrhoidal veins from below pectinate line
Acute, local pain, tender, swollen, bluish, ovid-visible mass at anal margin
Above pectinate line, not palp, may cause bright red bleeding w. prolapsed!
Anal canal maybe reddish, moist, protruding mass
Straining on BM, rectal mucosa may prolapsed through anus!
Donut or rosette red prolapsed tissue, radiating folds covered by circulating folds
Painful ulceration of anal canal, sentinel skin tag, spastic sphincter
Inflammatory tract that opens in anus/rectum to skin surface! Abscess occurs before
fistula
Fairly common, develop a stalk/pedunculated or lay/sessile, soft & difficult to palp
Biopsy needed to check for malignant lesion!
Asymptomatic Carcinoma! Firm, nodular, rolled edge of ulceration!!
Widespread peritoneal massed can push into rectal luman = “shelf”
In women must check for Mets in Rectouterine pouch!!
Table 15-2: Anorectal Lesions (1 question)
Pilonidal Cyst & Sinus
External Hemorrhoids
“Thrombosed”
Internal Hemorrhoids
“Prolapsed”
Prolapsed Rectum
Anal Fissure
Anorectal fistula
Rectal Polyps
Rectal Cancer
Rectal Shelf
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Table 9-3: ABN Arterial Pulse & Pressure Waves
Normal
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Small, Weak Pulse
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Large, Bounding Pulse
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Bisferien’s Pulse
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Pulsus Alterans
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Bigeminal Pulse
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Paradoxical Pulse
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Manello Cardiac Sounds:
Pulse Locations:
R 2 ICS = Aortic V.
L 2 ICS = Pulmonary V.
L 3 ICS = Erb’s Pt
L 3-4 ICS = Tricuspid V.
L 5 ICS = Micral V/Apical P.
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Pulse pressure 30-40mm Hg, “Smooth & Rounded pulse contour”
“Slow upstroke, prolonged peak”
↓ Stroke Vol = LV HF, Hypovolemia, Aortic Stenosis
↑ Peripheral Pressure = Exposure to Cold, CHF
“Strong & Bounding Pulse, rapid rise-fall w. brief peak”
↑ Stroke Vol & ↓ Peripheral R. = Fever, Anemia, HPT, Aortic Regurg, AV Fistula, PDA
↑ Strok Vol & ↓ HR = Bradycardia, Complete HB
↓ Compliance = Atheroslcerosis & Aging
“Increase arterial pulse w. Double Systolic Peak”
Aortic Regurg, Aortic Stenosis & Regurg, Hypertrophic Cardiomegaly
“Alternating Amplitude of each beat w. regular rhythm”
LV HF & L S3 Heart sound!
“Normal beat alternating with Premature Contractions”
Mimics Pulsus Alternans but Amplitude changes!
“palpable ↓ in amplitude w. quiet inspiration”
Pericardial Tamponade, Constrictive Pericarditis, COPD
Bell:
R 2 ICS = S2 at Base
L 5 ICS = S1 at Apex
L 4-5 ICS = S3: RV =↑INSP, LV = ↑ EXP in D
L 4-5 ICS = S4: RV =↑INSP, LV = ↑ EXP in D
Diaphragm:
R 2 ICS = Aortic AC in S
L 2 ICS = S2 Slit Insp-Exp in D
L 2 ICS = Pul. EC ↑Exp
L 4-5 ICS = S1 Split Exp in S
L 4-5 ICS = Tric. OS in D
L 5 ICS = Mit OS in D
S1 & S2 are heard at all Precodrium pts with Bell or Diaphragm
D&B = S1 > S2 at Apex
D&B = S2 > S1 at Base
D: E.Click (McTc/AoPo) = Aortic Stenosis (1) = not affected by resp in Systole
= Pulmonic Stenosis (2) = ↑ EXP, ↓ INSP in Systole or
• D:O.Snap (AcPc/MoTo) = Tricuspid Stenosis (3-4) = not affected by resp in Diastole
= Mitral Stenosis (5) = not affected by resp in Diastole • Mitral Regurg. = Apex, ® Left axilla, Apical thrill, Harsh
Pansytolic/Holostolic Murmurs • Tricuspid Regurg. = LL Sternal boarder, ® Right sternum, Xiphoid, LMCL, Blowing, ↑ Insp
• Ventricular Spetal Defect = 3-5 L ICS, thrill, harsh
• Innocent = 2-4 L ICS, disappears w. sitting, common in kids!
Midsystolic Murmurs
• Physiologic = turbulence due to ↑ blood flow = anemia, pregnancy, fever, HPT
• Aortic Stenosis = R 2 ICS, thrill, Cresendo-Decresendo, ↑ apex & lean ffw
Pathologic Midsystolic Murmurs • Hypertrophic Cardiomegaly = L 3-4 ICS Harsh, ↓ squatting & valsava, +S3 & S4
• Pulmonic Stenosis = L 2-3 ICS, loud towards L Shoulder & neck, Cresendo-decresendo, S2 Split
• Aortic Regurgitation = 2-4 L ICS, ® Apex, R Sternal boarder, blowing decressendo, ↑ lead ffw
Diastolic Murmurs
• Mitral stenosis = Apex, Bell, low rumble-decressendo, Left Lateral Decubitis!
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Venous Hum
• Continuous murmur, 1-2 ICS w. Bell
Pericardial Friction Rub
• L 3 ICS w. Diaphragm, 3 components; Ventricular S, Ventricular D, Atrial S,
Patent Ductus Arteriosus
• Continuouse murmur, loudest in late Systole, L ICS, harsh-macinery like, ® clavicle
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Table 12-1: Peripheral Vascular Dx
Intermittent Claudication
Arterial Dx:
Atherosclerosis
Rest Pain
Acute Arterial
Arterial Dx:
Raynaud’s Phenomenon
Superficial Thrombophlebitis
DVT
Venous Dx
Chronic Venous Insufficency
Thromboangitis Obliterans/Burger’s Dx
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Episodic Calf (hip, leg, thigh, foot) pain brought on by Walking/Exercise
L Exercise
J Rest, pain stops in 1-3min
Assoc w. Local fatigue, numbness, ↓ pulse, arterial insufficiency
Distal pain in the toes & foot at rest! Worse at night!!
L Elevation of the feet (like in bed)
J Sitting with leps dependent/down
Assoc w. numbness, tingling, trophic signs, colour changes
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Embolism or thrombis = sudden Distal leg pain (foot & leg)!!
Assoc w. Coldness, numbness, weakness, ≠ distal pulses 2° to vascular collagen dx, distal hands ↓ perfusion & colour changes
L Cold & stress
J Warm
Assoc w. Colour changes in distal fingers, sever pallor, cyanosis & rubor
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Pain in superfifical leg due to clot & inflammation, lasts days>
Assoc w. redness, swelling, TTT, palpable cord, fever
Tight, burning pain in calf due to DVT
L Prolonged walking
JElevation of legs
Assoc w. Swelling of foots, calf, TTT, prior Hx
Diffuse aching of the legs due to chronic venous engorment due to bad valves
L gets worse by the end of the day, standing
J Elevation of legs
Assoc w. Chronic edema, pigmentation, ulcers
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Inflammation & thrombotic small arteries/veins in smokers
Intermittened claudication in arch or foot/toes & fingers
L Worse at night after exercise
JRest & quitting smoking!
Assoc w. Distal coldness, sweating, numbness, cyanosis, ulcers, gangrene,
migratory throbophlebitis
↑p due to trauma/bleeding into LE compartment & fascia can’t expand = right
bursting pain (generally Ant Tibia) w. Dusky Red colouration
L Anabolic steroids, surgical complication, exercise
J surgical incision, avoiding exercise & elevation
Assoc w. tingling & burning in calf, tightness, full, numbness, paralysis
Acute baterical infection (STREP) that spreds in the lymph channels in the
arm/leg
Assoc w. red streaks on the skin, TTT, enlarged TTT Lymph nodes, fever
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Compartment Syndrome
Acute Lymphangitis
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Acute Cellulitis
Mimics...
Erythema Nodosum
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Acute bacterial infection of subcutaneous Arms/Legs
Local swelling, redness, TTT, enlarged TTT lymph nodes, fever
Raised TTT B/L subcutaneous lesions w. pregnancy, sarcoidosis, TB, Strep,
IBS on anterior LE
Assoc w. malaise, jt pain, fever
Table 12-3: Chronic Insufficiency of Arteries & Veins:
• Intermittend claudication à pain at rest
• Tissue ischemia
• ↓ pulses & temperature
Chronic Arteriole Insufficiency
• Pale colour on elevation, Dusky red on dependency
• Thing, shiny, atrophic skin, loss of hair, thick-rigged nails
• Possible gangrene!
• Painful L
• Venous HTN & Edema
Chronic Venous Insufficency
• N: pulse but hard to palp through edema & Temp
• Cyanotic on dependency, petechia then brown pigmentation w. chronicity
• Ulcerations at sides of ankles!
Table 12-4: Common Ulcers of Ankles & Feet
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Arteriole Insufficiency
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Chronic Venous Insufficiency
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Neuropathic Ulcer
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Toes, feet, traumatic areas, Skin maybe atrophic
Severe pain unless hidden by neuropathy
Assoc w. Gangrene, ↓ pulse, foot pallor on elevation, dusky red
Medial & Lateral malleolus
Ulcer = painful granulation tissue & fibrin, irregular flat boarders
Pain affects ADLS in 75% ppl w condition!
Assoc w. edema, reddish pigmentation, purpura, venous varicosities, eczematous changes of
stasis dermatitis (red, scales, purities), cyanosis
Pressure pt areas with ↓ sensation = Diabetic Neuropathy, Neurologic Dx & Hansen Dx
Surrounding skin in calloused
NO PAIN! So ulcer can go unnoticed
Assoc w. ↓ sensation & ≠ ankle jerks
Male Genital Lesions... (1 question)
Shaft Problems
Scrotal Problems
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Hypospadias = extra hole underneath
Peyronie’s Dx = palpable, non TTT, hard plaques on shaft à crooked, painful, erections
Carcinoma = non TTT, indurated nodule or ulcer, men who arn’t circumcised but due to
HYGEINE!
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Scrotal Edema = pitting edema in sctroum assoc w. CHF & Nephrotic Dx
Hydrocele = non TTT, flid filled mass in Tunica Vaginalis, transiluminates, fingers can get
above
Scrotal Hernia = Indirect Inguinal Hernia that comes through external ring, fingers cant get
above!
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Genital Warts/Condylomata Acuminata: round, thin, flat, raised, cauliflower like, HPV, itching
& pain, may disappear without Tx
Genital Herpes Simplex: small, scatterd vesicles, 1-3mm, on glans or shaft; assoc w. fever,
malaise, HA, arthralgais, local TTT, edema, Lymphadenopathy
Primary Syphillis: small red papule, painless chancer w. raised borders, Trep Pallidum
Chancroid: painful ulcer w. ragged edges, necrotic exudates, H.Ducreyi
Testicle Problems
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Cryptochidism: atrophied non palp testicle
Small Teste: Klinefelder’s Dx, Cirrhosis, estrogen use, Hypopituitaryism
Acute Orchitis: UL, inflamed, painful testse from MUMPS!
Tumor: painless nodule, more testing!
Testicular cancer: seems to replace entire organ, “feels heavier”, more testing!!
ABN Epididymis & Spermatic Cord
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Spermatocele & Cyst: painless, movable mass, transiluminates
Varicocele: varicose veins of scrotum “bag of worms”
Acute epididymis: TTT, swollen, inflamed vas deferens assoc w. UTI & Prostatitis
Torsion of Spermatic Cord: acutely painful, swollen and retracted upward, common in boys
TB of Epididymis: chronic inflamed TB = firm enlargement & beading of vas deferens
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Epidermoid Cyst: small, firm, round cystic nodule in labia, yellowish, dark puncta
Venereal Wart (Condyloma Acuminatum): HPV
Syphilitic Chancer: firm, painless ulcer of 1° Syphilis, develop internally & be undetected
2° Syphillis (Condyloma Latum): slightly raise, round, oval, flat, papules covered by gray
exudates & contagious!
Genital Herpes: shallow, small, painful ulcers, small local patch in reccurant
Carcinoma of Vulva: ulcerated red vulvar lesion in elderly women
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STDs!
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Female Genital Lesions... (1 question)
Vulva Lesions
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Bulges & Swelling of Vulva, Vagina,
Urethra
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Cystocele: bulge of upper 2/3 of vagina due to weak muscles
Cytourethrocele: buge of entire anterior vaginal wall & bladder
Urethral Caruncle: small, red, benign tumor on posterior part of urethral meastus in post
menopausal
Prolapse of Urethral Mucosa: prolapsed urethral mucousa forms a swollen red ring aroud
uretheal meatuse
Bartholin’s Gland Infection: trauma, gonoccoi anerobes, Chlamydia; tense, hot, tender, pus
Rectocele: herniation of rectum into posterior wall of vaginia
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Mucopurulent Cervicitis: purulent-yellow drainage from cervica os, Chlamydia Trach,
N.Gonorrheae, Herpes à STD!
Cancer: starts in area of metaplasia, irregular, extensive, cauliflower like
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Trichomonas: Yellow-green-grey, frothy, profuse, pooled; seen w. Candida
Candida Albicans: yeast infection, severe purities, pain on urination, dyspareunia
Bacterial Vaginiosis: STD, anerobic bacteria, Gray-white, thin, fishy odour!
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15-25 yrs
Single/multiple masses
Round, Disk-like, lobular, Soft-Firm, well delineated, very Mobile, NOT TTT, ≠ Retration
30-50 yrs, ↓ after menopause except w. HRTx
Round, Soft-firm-elastic, well delineated, mobile, TTT, ≠ Retration
30-90 yrs, MC>50
Single/multiple masses
Irregular-stellate, Firm/hard, not clearly delineated, Fixed to skin/tissue, NOT TTT, retraction
Retraction/Deviated of Nipple
ABN Contour of breast tissue
Skin Dimpling
Edema of skin “Peau d’orange”
Paget’s Dx of Nipple: scaly, eczema lis, weep, crust, erode = + invasive & aggressive!
Normal Prostate Gland
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Prostatitis
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Round, heart shaped, 2 lobes & median Sulcus, round & firm like a rubber ball
~2.5cm long
Acute Bacterial Prostatitis: fever, UTI, frequency, urgency, dysuria, incomplete void, LBP;
gland “boggy & warm” & TTT, + E.Coli, Enterococcus, Proteus, N.Gonnerhea, Chlamydia
Chronic Bacterial Prostatitis: recurrent UTIs, possibly asymptomatic, dysuria, pelvic pain,
normal palpating prostate gland + E.Coli culture
Chronic Pelvic Pain Syndrome: obstructive or irritative symptoms,
Non-malignant enlargement of prostate in men 50% of men >50yrs
Enlargement = compression of bladder neck & urethra = urgency, frequency, nocturia, ↓
stream, incomplete emptying, straining
Symmetrically enlarged, smooth, firm, obliteration of the median Sulcus, possible protrusion into
rectal lumen
Area of hardness, contour & boarders maynot be palpable
Cancer may grow onto surrounding tissue- not confined to prostate
Areas of hardness not 100% cancer.... maybe due to: prostatic stones, chronic inflammation etc
ABN Cervix
Discharge
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Table 10-1 Breast Masses (1 question)
Fibroadenoma
Cysts
Cancer
Visible Signs of Breast Cancer!
Table 15-3: ABN Prostate (1 question)
Benign Prostatic Hyperplasia (BPH)
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Prostate Cancer
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