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 • • • • • • • • • • • • • • • • • • • • • 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 • • • • • • • 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 • • • • • • • • • • • • • • • • • • 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 • • • • • • ↑ 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 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ↑ 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 àHx 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 àHx 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 • • • • • • • • • • • • 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 • • • • • • • • • • • • • • • 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 • • • • • • • • • • 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 • • • • • 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 • • • Acute or gradual L attempt to swallow Assoc w. Aspiration, regurgitation, Stroke, Bulbar Palsay, NMS Dx • • • • • • • • • • • 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 • • • • • • • • • • • • 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 • • • • • • 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 • • Change in frequency without structural or chemical ABN Small, hard stools w. mucous; periods of diarrhea, intermittent pain relieved by BM • • • • • • • • • 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) • • • • • • 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 = “Diarrheal Syndromes” Sigmoid Colon Cancer Ulcerative Colitis Chronic Diarrhea = “Inflammatory Bowel Dx” Chron’s Dx / Regional Enteritis • • • • Virus/Bacterial InfectionàStaph 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 • • • • OTC Mg+2 containing drugs!! Stool: Loose-watery Acute, reccurant w. drug use Assoc w. Nausea • • • • 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 • • • • • • • • • • • • • • • • • • • • • • • Malabsorption Syndrome Chronic Diarrhea = “Voluminous” “Osmotic Diarrhea” Lactose Intolerance Abuse of Ostmotic Purgatives/Laxitives • • • • • • • • 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 • 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! • • • • 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 • • • • • • • • • • 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 • • 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 • • • • 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 • • Frequency... Voiding at night with no real urge à Insomnia Polyuria • • ≠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 • Table 11-7: Urinary Incontinence Stress: • Weak Urethral sphincter • ≠ handle ↑ intra-AB p = “oops” • • • 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 • • • • ↓ 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!! • • • 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 • Motility problems à cant get there fast enough... “FML where’s the bathroom!” 2° to Drugs • Sedatives & Tranquilizers! Urge: • • Detrussor too strong! Small bladder! Table 11-10: Abdominal Sounds! Bowel Sounds “Gastric motility” • • • • ↑ 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 • • • 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 • Rare, soft hum in S & D = + ↑ Collateral circulation b/w Portal & Systemic V. = Liver Cirrhosis • • Rare, grating sound = + inflammation of peritonel surface = Liver cancer, chlamydial/gonococcal perihepatitis, liver biopsy, splenic infarct S Bruit + Frictio Rub = Liver cancer L • Starts in Ab wall & ↑ with arms raised à + NMS TTT Visceral • TTT to palp, dull with no rigidly or R.TTT Acute Pleurisity • • • • 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 • • • • 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 • • • • • • • • • 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 • • • • • • • • • • 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 • • • • • Table 9-3: ABN Arterial Pulse & Pressure Waves Normal • • Small, Weak Pulse • • • • Large, Bounding Pulse • • • Bisferien’s Pulse • • Pulsus Alterans • • Bigeminal Pulse • • Paradoxical Pulse • 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. • • • 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! • 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 • 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 • • • • • • • • 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 • • • • • • 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 • • • • • • • • • • 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 JElevation 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 • • • • • Inflammation & thrombotic small arteries/veins in smokers Intermittened claudication in arch or foot/toes & fingers L Worse at night after exercise JRest & 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 • Compartment Syndrome Acute Lymphangitis • • • • • Acute Cellulitis Mimics... Erythema Nodosum • • • • 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 • Arteriole Insufficiency • • • • Chronic Venous Insufficiency • • Neuropathic Ulcer • • • • 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 • • • 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! • • 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! • • • 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 • • • • • 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 • • • • • 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 • • • • 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 • STDs! • Female Genital Lesions... (1 question) Vulva Lesions • • Bulges & Swelling of Vulva, Vagina, Urethra • • • • • • 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 • 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 • • • 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! • • • • • • • • • • • • • 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 • • • Prostatitis • 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 • 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) • • • • Prostate Cancer • • •
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