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6 categories for case history?
- 1. OPPQRSST
- 2. SHITA
- 3. Family
- 4. Occupation
- 5. Social: SSSDDDE
- 6. ROS
- "Let me make sure I didn't miss anything..." REPEAT EVERYTHING.
- Onset: when did it start? What happened?
- Pallative: what makes it better?
- Provocative: what makes it worse?
- Quality: what does it feel like?
- Radiation: does it TRAVEL anywhere?
- Site: Point to where it hurts.
- Severity: 1-10 for today? 1-10 when it started?
- Timing: when do you feel it?
Family: 4 questions.
- "Does anyone in your family have a HX of..."
- 1. Diabetes?
- 2. Cancer?
- 3. Cardiovascular DX?
- 4. "Does anyone in your family have ________?" (if CC applicable).
Occupation: 2 questions.
- "What do you do for a living?"
- "Has _______ affected your work?"
Social HX: SSSDDDE
- Smoke: if yes how much & for how long?
- Sleep: does _____ affect your sleep?
- Sexually active?
- Drink: how much?
- Diet: have you gained or lost weight without trying?
- Exercise: how often & for how long?
"Are there any other SX or SX that you have noticed since your ______ began ______?"
- "Let me make sure I didn't miss anything..." REPEAT EVERYTHING.
What are the normal values for blood pressure?
- *Values increase in the elderly.
- * >140/90 = hypertension.
- * <90/60 = hypotension.
- "I would do this bilaterally."
What are the 3 conditions which cause ptosis (drooping of the eyelid)?
- 1. MG: bilateral.
- 2. Horner's Syndrome: unilateral (loss of cervical sympathetics, ptosis, miosis & anhydrosis).
- 3. CN III Lesion.
Which condition is associated with iritis/uveitis?
AS: early stages.
Papilledema is associated with which condition?
- Increased intracranial pressure.
- *Going blind, feels like water pouring down arms, trauma, HBP.
What are 3 findings observed in the eye associated with arteriosclerosis?
- 1. AV nicking.
- 2. Silver wire arterioles.
- 3. Widened light reflex.
What are 3 findings observed in the eye associated with hypertension?
- 1. Flame hemorrhages.
- 2. Cotton wool spots.
- 3. Narrow light reflex.
- "The south is hot (flames), has cotton & people are narrow minded."
What is the most important eye observation associated with DM?
- *Yellow/hard/waxy exudates, microaneurysms, absent red light reflex.
Which tuning fork for Weber's?
- The small one (512).
- *Pluck with your fingers, do not bang on table or shoe.
- *Louder in one ear = air conduction on louder side OR nerve problem on other side.
Which side do you test first with Rinne's Test?
- The side that was louder during Weber's.
- *If Rinne's is abnormal on the side that was louder with Webers, there is a conduction loss on that side, or sensorineural on the opposite side.
- *Rinne's normal = air conduction is 2x as long as bone conduction.
What are the 2 locations you palpate for sinus palpation?
- 1. Medial eyebrows.
- 2. Medial zygomatic arches.
- *Tenderness = sinusitis.
Verbalization for respiratory excursion?
"I am looking for symmetrical movement of my thumbs."
What are you feeling for with tactile fremitus?
- Tactile fremitus: "I am feeling for bilateral symmetrical palpable vibrations."
- *Done both A & P (7 on the back, 6 on the front).
- *Have the pt say "99" every time you touch them.
Increased tactile fremitus is associated with which condition?
- *Decreased = emphysema.
Anterior right lung palpation:
Upper lobe: above _____ to the __ rib.
Middle lobe: __ to __ rib medially.
Lower lobe: __ to __ rib laterally.
- Upper lobe: above the clavicle to the 4th rib.
- Middle lobe: 4th to 6th rib medially.
- Lower lobe: 6th to 8th rib laterally.
Anterior left lung palpation:
Upper lobe: above _____ to the ___ rib.
Lower lobe: __ to ___ rib laterally.
Upper lobe: above the clavicle to the 6th rib. Lower lobe: 6th to 8th rib laterally.
Posterior lung palpation:
Upper lobe: __ towards the axilla.
Lower lobe: __ to __.
- Upper lobe: T3 toward the axilla (45* angle).
- Lower lobe: T4 to T10.
What is the normal range for diaphragmatic excursion?
- *Start w/ exhalation first.
- "I am listening for resonant tones -> dull -> back to resonant."
What are you listening for with lung percussion?
- "I am listening for resonant tones."
Hyperresonant percussive lung tones are associated with...
- Hyperresonant: emphysema.
- *Dull: pneumonia.
What is the normal percussive tone for the lungs?
What is the normal auscultated breath sound?
- "Every time I touch you with the diaphragm take a deep breath in & out. In my office I would do every location with the patient breathing in & out at the following locations..."
- *Use the diaphragm.
- *Trachial: over trachea.
- *Bronchial: over manubrium.
- *Bronchovesicular: 1st to 2nd ribs anteriorly, between scapulae posteriorly.
Good ideas for test day:
- 1. Anything that takes a while to do: move to the end of the order!
- 2. Move anything that you don't know to the end of the order - at least try SOMETHING!
- 3. Announce tests as you are doing them.
- 4. Do everything bilaterally except for BP.
- 5. After completing your physical exam procedures do a quick case HX to reveal more info.
- 6. The pt's pain is not real! "I understand that you're having some pain but we need to continue to get some information so we can get you better."
Verbal component for heart percussion?
(What are you looking for?)
- "I am listening for resonance to dull back to resonance, looking for cardiomegaly."
- *Percuss from the midax line to the right side of the sternum (3rd, 4th, 5th ICS's).
What are you palpating for with the heart?
- "I am palpating for abnormal palpations or THRILLS."
- *Pulsations: finger pads.
- *Thrills: ball/hand.
- *Stay for a couple of seconds so it looks like you're feeling something.
Is general auscultation of the heart done with the bell or the diaphragm?
- *Bell: low-pitched murmurs.
- *Diaphragm: high-pitched murmurs.
What are you listening for during heart auscultation?
- "I am listening for murmurs."
- *Aortic: 2nd R ICS.
- *Pulmonic: 2nd L ICS.
- *Tricuspid: 4th/5th L ICS.
- *Mitral: 5th midclavicular line.
- *If you walk into the room & the pt is breathing frantically say "I would call 911." Then do exam.
Which condition presents with jugular venous pulsations, bilateral leg swelling (pitting edema) & difficulty breathing?
- Right-sided heart failure.
- *MCC's: L sided heart failure, Cor Pulmonale.
Which heart condition is relieved by nitroglycerin?
- Angina Pectoris: coronary vasospasm.
- *Printzmetal angina: w/ rest.
What are the 3 labs for DXing MI?
- 1. CPK elevated.
- 2. SGOT increased.
- 3. LDH increased.
- *Acute heart failure, comes on w/ rest, severe substernal chest pain referring to L arm, labored breathing, D/T atherosclerosis.
- *EKG, Stress Test, ER referral.
What are the 2 best diagnostic tests for Gallbladder DX's?
- 1. US.
- 2. Oral Cholecystogram.
- *Only 10% show up on x-ray.
Grey Turner's & Cullen's Sign are associated with which condition?
- Pancreatitis: epigastric pain going straight through T10-12.
- *Grey Turner's: bleeding into flank.
- *Cullen's: periumbilical ecchymosis.
- *MCC's: gallstones (acute = 911!) & alcoholism (chronic).
Which labs are increased with pancreatitis?
- Amylase & lipase.
Who do you refer diabetic patients to?
Which condition has polydypsia & polyuria, but not polyphagia?
What is the MCC of reflux esophagitis?
- Sliding hiatal hernia.
- * (+) Valsalva.
- *DX via X-ray or upper GI-series.
A 20 year old soccer player presents with a condition caused by Epstein Barr Virus & complains of flu like symptoms for 3 weeks duration. Which organ is affected?
- Spleen = tell them to stop sports until resolved (avoiding rupture).
- *Downey cells: atypical lymphocytes in blood.
- *Allowed to adjust.
_________ A/K/A Herophile Agglutination A/K/A Paul Bunnel Test is associated with which condition?
Monospot A/K/A Herophile Agglutination A/K/A Paul Bunnel Test = Mononucleosis.
________ A/K/A CRohn's DX (Right side of intestines) presents with which appearance?
- Regional Ileitis A/K/A CRohn's DX (Right side of intestines) = Skip lesions/Cobblestone appearance.
- *"Skipping Crohn's" (Skipping Stones = cobblestone).
- *Affects distal ileum & colon.
- *Can't absurd B12.
- *RLQ pain & chronic diarrhea.
- *Malabsportion syndromes: Non-Tropical Spure/Celiac Sprue (Gluten Allergy).
Which GI condition presents with bloody diarrhea & fever?
- ULcerative Colitis: Left side of intestines.
- *MC at colon & rectum.
- *Can lead to sacroilitis (enteropathic arthropathy).
Which condition presents with a Shilling Shift to the left?
- Shilling Shift to the left (immature WBC's) = appendicitis.
Which 3 lab findings are associated with kidney stones (nephrolithiasis)?
- 1. Increased BUN.
- 2. UA.
- 3. Creatinine clearance.
- *KUB Study.
- *Heamaturia on UA.
- *Refer to internist.
Pyelonephritis presents with _____ casts.
Pyelonephritis presents with WBC casts.
Urethritis presents with ____ in the urine.
- Urethritis presents with nitrites in the urine.
- *D/T E Coli (females) & Gonorrhea (males).
In addition to experiencing burning, painful, incontince & frequent urination, pt's w/ cystitis will also have ______ & ______ pain.
In addition to experiencing burning, painful, incontince & frequent urination, pt's w/ cystitis will also have suprapubic & LB pain.
What 2 things will a pt w/ breast cancer present with in the post room?
- 1. Neck pain.
- 2. Lytic Mets.
Which 3 labs are used for DX Prostatic Carcinoma?
- 1. PSA.
- 2. Alk Phos.
- 3. Acid Phos.
- *Weirdness: the pt will deny urinary findings.
- *Mets -> lumbar spine via Batson's Plexus.
What should you do for ALL abdominal exam procedures?
Bend the knees to 30 degrees!
Which is used for abdominal auscultation: the diaphragm or bell?
- "I am listening for bruits." "I am checking bowel sounds for paralytic ileus."
- *Have the pt lift gown, not you!
Percuss ___ times in each abdominal quadrant, listening for _______.
- Percuss 3 times in each abdominal quadrant, listening for tympany.
- "I am listening for tympany." *Always end in the quadrant that is painful.
What is the normal range for percussion of the liver?
- "Normal is 6-12cm mid-clavicular, 4-8cm mid-sternal."*Percussing from tympany to dull, tympany to dull.
Which side do you stand on for percussion of the liver?
- The right.
- *Always stand on the right for abdomen exams, except for left kidney stuff.
In regards to percussion of the spleen, if the sound changes from ______ to _____ this indicates splenomegaly.
- In regards to percussion of the spleen, if the sound changes from tympany to dull this indicates splenomegaly.
- "I should be hearing tympany both times. If it is dull, splenomegaly."
Where do you percuss for the spleen?
- In the last rib interspace on the left side in the mid ax line.
- *Then repeat with the pt holding their breath.
_____ palpation of the abdomen: breath in & out & repeat 3 x's/quadrant.
- Deep palpation of the abdomen: breath in & out & repeat 3 x's/quadrant.
- *Palpate with 1 flat hand.
- *Knees bent to 30 degrees.
- *DX superficial vs deep mass by having pt do a partial sit up.
Which test for appendicitis is preformed @ McBurney's Point?
- Blumberg's Rebound Tenderness.
- *McBurney's Point: 1/3 between ASIS & umbilicus on R.
- *Rebound-Tenderness: preformed anywhere but McBurney's Point.
- *Rovsing's Sign: pressure in the LLQ = pain in the RLQ.
- *Psoas Sign: pain w/ flexion/thigh against resistance.
- *Obturator Sign: flex hip & int rot knee = pain/RLQ.