NR509 Mid-Term Study Guide • Articular structures include joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments and juxta-articular bone o Articular disease involves: Swellin
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NR509 Mid-Term Study Guide • Articular structures include joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments and juxta-articular bone o Articular disease involves: Swelling Tenderness of the joint Crepitus Instability “locking” �� Deformity Limits active and passive range of motion due to stiffness or pain • Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin o Extra-articular disease involves: “point of focal tenderness in regions adjacent to articular structures Limits active range of motion RARELY causes swelling, instability, joint deformity Know the sources of joint pain (pg. 627 algorithm) • Nonarticular conditions: trauma/fracture, fibromyalgia, polymyalgia rheumatica, bursitis, tendinitis • Intra-articular (acute, < 6 weeks): acute arthritis o infectious arthritis o gout o pseudogout o Reiter syndrome • Intra-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic noninflammatory arthritis o Chronic inflammatory arthritis with 1-3 joints involved: Indolent infection Psoriatic arthritis Reiter syndrome Periarticular JA o Chronic inflammatory arthritis with >3 joints involved: Psoriatic arthritis or Reiter syndrome (no symmetry) rheumatoid arthritis if not RA then systemic lupus, scleroderma, polymyositis *Know what causes saddle numbness and urinary retention (pg. 678?) • CES (cauda equina syndrome) most commonly results from a massive herniated disc in the lumbar region. • A single excessive strain or injury may cause a herniated disc. • However, disc material degenerates naturally as a person ages, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture. The following are other potential causes of CES: • Spinal lesions and tumors • Spinal infections or inflammation • Lumbar spinal stenosis • Violent injuries to the lower back (gunshots, falls, auto accidents) • Birth abnormalities • Spinal arteriovenous malformations (AVMs) • Spinal hemorrhages (subarachnoid, subdural, epidural) • Postoperative lumbar spine surgery complications • Spinal anesthesia Know how retinal detachment presents (p.217) • Sudden, painless vision loss that is unilateral Know what the word obtunded means (p. 769) • The obtunded patient opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. Know what cranial nerve you’re assessing when checking lateral gaze (p. 237) • Cranial nerve VI: abducens Know what should be listed under adult illnesses in health history (pg. 10) • Medical illnesses: such as diabetes, hypertension, hepatitis, asthma, and HIV. Also hospitalizations, number and gender of sexual partners, and risk-taking sexual practices • Surgical: dates, indications, and types of operations • Obstetric/Gynecologic: obstetric history, menstrual history, methods of contraception, and sexual function • Psychiatric: illness and timeframe, diagnoses, hospitalizations, and treatments Know what conditions do not have red reflexes (p. 239) • Absence of red reflex suggests an opacity of the lens (cataract), or possibly the vitreous (or even an artificial eye). • Less commonly, a detached retina, or in children a retinoblastoma may obscure this reflex. Know the signs of seasonal allergies (p. 27) • itching, watery eyes, sneezing, ear congestion, postnasal drainage Know how optic neuritis presents (p. 217) • Sudden visual loss that is unilateral and can be painful, associated with multiple sclerosis Know how pityriasis rosacea presents (p. 912) • Oval lesions on trunk, in older children often in a Christmas tree pattern, sometimes a Harold patch (a large patch that appears first) Know what is listed under present illness (p. 9) • Complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, it’s manifestation and any treatments to date. • (OLDCART) Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments (past) Know where the acromion process is (be able to identify it on a picture) • Located between the clavicle and the shoulder *Know what to do if you have a + finding on physical exam but otherwise negative work-up (p. 30) Know what can cause falsely high BP’s (p. 127) • If the brachial artery is below the heart level, the blood pressure reading will be higher. If the cuff is too small (narrow) the blood pressure will read high. • If the cuff is too large (wide) the BP will read high on a large arm Know how to check for nystagmus (p. 737) • Nystagmus is seen in cerebellar disease especially with o gait ataxia o dysarthria (increases with retinal fixation o vestibular disorders (decreases with retinal fixation) o internuclear ophthalmoplegia • Identify any nystagmus, an involuntary jerking movement of the eyes with quick and slow components. • Note the direction of the gaze in which it appears, the plane of the nystagmus (horizontal, vertical, rotary, or mixed), and the direction of the quick and slow components. • Nystagmus is named for the direction of the quick component. • Ask the patient to fix his or her vision on a distant object and observe if the nystagmus increases or decreases. Know what yellow sclera indicates (p. 234) • A yellow sclera indicates jaundice Pg. 72 - Know how to get a patient to open up when he seems upset • The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings. For example, you might simply say, “You seem upset today.” This promotes a feeling of connection. Meaningful reassurance comes later, after you have completed the interview, the physical examination, and perhaps some laboratory tests. At that point, you can explain what you think is happening and deal openly with any concerns. Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed. • Another way to affirm the patient is to validate the legitimacy of his or her emotional experience. Saying something like, “Your accident must have been very scary. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset,” validates the patient’s response as legitimate and understandable • Moving closer or making physical contact like placing your hand on the patient’s shoulder conveys empathy and can help the patient gain control of upsetting feelings. The first step to using this important technique is to notice nonverbal behaviors and bring them to conscious level. Pg. 27 - Know the signs of degenerative pain Page 696 Pg. 289 - Know how otosclerosis presents with Weber and Rinne test Otosclerosis condition that affects the tiny middle ear bone known as the stapes. • Stapes can become stuck, limiting its ability to vibrate (vibrations are crucial for hearing) • Conductive hearing loss • Weber test o Tuning fork at vertex o Sound is heard in the impaired ear o Room noise not well heard, so detection of vibrations improves • Rinne test o Tuning fork at external auditory meatus; then on mastoid bone o BC longer than or equal to AC (BC > AC or BC = AC) o While air conduction through the external or middle ear is impaired, vibrations through bone bypass the problem to reach the cochlea o The sound is heard longer through bone than air Pg. 183 – Know that cherry angiomas are benign Pg. 231 - Know how to interpret visual acuity results • Visual acuity is expressed as two numbers (e.g., 20/30): o First indicates the distance of the patient from the chart (20 feet), o Second, the distance at which a normal eye can read the line of letters Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision could read at 200 feet. • The larger the second number, the worse the vision. • “20/40 corrected” means the patient could read the 20/40 line with glasses (a correction). • A patient who cannot read the largest letter should be positioned closer to the chart; note the intervening distance. Pg. 73 - Know the order of meeting a patient and conducting an interview Preparation • Reviewing the Clinical Record o Provides important background information and suggests areas you need to explore • Setting goals o Before you talk with the patient, clarify your goals for the interview o The clinician must balance these provider-centered goals with patient-centered goals, weighing multiple agendas arising from the needs of the patient, the patient’s family, and health care agencies and facilities. • Reviewing your clinical behavior and appearance o Posture, gestures, eye contact, and tone of voice all convey the extent of your interest, attention, acceptance, and understanding. o Adjusting the environment o Private and comfortable Sequence of Interview • Greeting the patient and establishing rapport o How you greet the patient and other visitors in the room, provide for the patient’s comfort, and arrange the physical setting all shape the patient’s first impressions. o Greet the patient by name and introduce yourself, giving your own name. If possible, shake hands with the patient. o Use a formal title to address the patient o If you are unsure how to pronounce the patient’s name, don’t be afraid to ask. o When visitors are in the room, acknowledge and greet each one in turn, inquiring about each person’s name and relationship to the patient. o Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them o Always be attuned to the patient’s comfort. • Establishing the agenda o Begin with open-ended questions that allow full freedom of response: “What are your special concerns today?”, “How can I help you?” o Identifying all the concerns at the outset allows you and the patient to decide which ones are most pressing and which ones can be postponed to a later visit. o Identifying the full agenda protects time for the most important issues. • Inviting the patient's story o Invite the patient’s story by asking about the foremost concern, “Tell me more about...” o Do not inject new information or interrupt. Instead, use active listening skills o After the patient’s initial description, explore the patient’s story in more depth. Ask, “How would you describe the pain?”, “What happened next?”, or “What else did you notice?” • Exploring the patient’s perspective o The disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient o Disease is the explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis. o Illness is a construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of well-being o The clinical interview needs to incorporate both these views of reality. o The melding of these two perspectives forms the basis for planning evaluation and treatment. o FIFE • The patient’s Feelings, including fears or concerns, about the problem • The patient’s Ideas about the nature and the cause of the problem • The effect of the problem on the patient’s life and Function • The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences • Identifying and responding to the patient’s emotional cues o Check on these clues and feelings by asking, “How did you feel about that?” or “Many people would be frustrated by something like this.” o Clues to patient’s perspective on illness • Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness • Expression of feelings about the illness without naming the illness • Attempts to explain or understand symptoms • Speech clues (e.g., repetition, prolonged reflective pauses) • Sharing a personal story • Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment o Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. • A mnemonic for responding to emotional cues is NURSE: • Name—“That sounds like a scary experience” • Under- stand or legitimize—“It’s understandable that you feel that way” • Respect— “You’ve done better than most people would with this” • Support—“I will continue to work with you on this” • Explore—“How else were you feeling about it? • Expanding and clarifying the patient’s story • You must diligently clarify the attributes of each symptom, including context, associations, and chronology. • For pain and many other symptoms, understanding these essential characteristics, summarized as the seven attributes of a symptom, is critical. • OLD CARTS, or Onset, Location, Duration, Character, Aggravating/ Alleviating Factors, Radiation, and Timing, or • OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and Timing • Whenever possible, repeat back the patient’s words and expressions • Generating and testing diagnostic hypotheses • You will generate and test diagnostic hypotheses about which disease process might be present. • Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. • It is important to fully flesh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly • Each symptom has its own “cone” • Sharing the treatment plan • Shared decision-making has been called the pinnacle of patient-centered care • Experts recommend a three-step process: introducing choices and describing options using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time, if needed. • Motivational interviewing helps patients “to say why and how they might change, and is based on the use of a guiding style” of inter- viewing, rather than direct advice. • “Ask” open-ended questions—invite the patient to consider how and why they might change. • “Listen” to understand your patient’s experience—“capture” their account with brief summaries or reflective listening statements such as “quitting smoking feels beyond you at the moment”; these express empathy, encourage the patient to elaborate, and are often the best way to respond to resistance. • “Inform”—by asking permission to provide information, and then asking what the implications might be for the patient. • Closing the interview and the visit • Let the patient know that the end of the interview or the visit is approaching to allow time for any final questions. • Make sure the patient understands the mutual plans you have developed. • As you close, summarizing plans for future evaluation, treatments, and follow-up is helpful. • A useful technique to assess the patient’s understanding is to “teach back,” whereby you invite the patient to tell you, in his or her own words, the plan of care. An example would be: “Could you please tell me what you understand is our plan of care? • The patient should have a chance to ask any final questions, but the last few minutes are not a good time to bring up new topics. If this happens and the concern is not life threatening, simply assure the patient of your interest and make plans to address the problem at a future time • Taking the time for self-reflection • “purposefully and nonjudgmentally attentive to [one’s] own experience, thoughts, and feelings. • Because we bring our own values, assumptions, and biases to every encounter, we must look inward to see how our own expectations and reactions affect what we hear and how we behave Pg. 75 - Know that you need permission of the patient to carry out the visit if someone is in the room with them • When visitors are in the room, acknowledge and greet each one in turn, inquiring about each person’s name and relationship to the patient. • Whenever visitors are present, you are obligated to maintain the patient’s confidentiality. Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them. o For example, “I am comfortable with having your sister stay for the interview, Mrs. Jones, but I want to make sure that this is what you want” or “Is it better if I speak to you alone or with your sister present?” For sensitive questions, you may need to arrange another time to be with the patient alone. Pg. 7 - Know what makes up the health history (subjective info) • Identifying data • Identifying data - such as age, gender, occupation, marital status • Source of the history - usually the patient, but can be a family member or friend, letter of referral, or clinical record • If appropriate, establish the source of referral, because a written report may be needed • Reliability • Varies according to the patient’s memory, trust, mood • Chief complaints • The one or more symptoms or concerns causing the patient to seek care • Present illness • Complete, clear, and chronologic description of the problems prompting the patient’s visit • Onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. • Each principal symptom should be well characterized, and should include the seven attributes of a symptom: (1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated manifestations. • Risk factors may be relevant • The Present Illness should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life • Amplifies the chief complaint; describes how each symptom developed • Includes patient’s thoughts and feelings about the illness • Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives” • May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illness • Past history • Childhood illnesses • Adult illnesses with dates for events in at least 4 categories: medical, surgical, OB/GYN, and psychiatric • Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety • Family history • Outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents, children, and grandchildren • Documents present or absence of specific illnesses in family, Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, allergies, or type of cancer • Personal and social history • Describes educational level, family of origin, current household, personal interests, and lifestyle • Review of systems • Documents presence or absence of common symptoms related to each of the major body systems Pg. 649, 655, 700 - Know how a rotator cuff tear presents • Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead • Weakness or tears of the tendons usually start in the supraspinatus tendon and progress posterior and anterior • Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. • Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. • In a complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder and a positive “drop arm” test • Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear within 2 to 3 weeks of a rotator cuff tear; infraspinatus atrophy has a positive likelihood ratio (LR) of 2 for rotator cuff disease Pg. 37 - Know how to prioritize patient complaints • List the most active and serious problems first and their date of onset • Problems can be symptoms, signs, past health events such as a hospital admission or surgery, or diagnoses. Pg. 629 - Know what joints are condylar • Articulating surfaces that are convex or concave • These joins allow flexion, extension, rotation and motion in the coronal plane • Movement of two articulating surfaces not dissociable o Knee o Temporo-mandibular joint Pg. 703 - Know how RA presents Acute • Tender, painful, stiff joints in RA, usually with symmetric involvement on both sides of the body. • The distal interphalangeal (DIP), metacarpophalangeal (MCP) • wrist joints are the most frequently affected • Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease Chronic • In chronic disease, note the swelling and thickening of the MCP and PIP joints. • Range of motion becomes limited, and fingers may deviate toward the ulnar side. • The interosseous muscles atrophy. • The fingers may show “swan neck” deformities (hyperextension of the PIP joints with fixed flexion of the distal interphalangeal [DIP] joints). • Less common is a boutonnière deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). Rheumatoid nodules are seen in the acute or the chronic stage. • Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna in patient with RA or acute rheumatic fever. • Firm and nontender • Not attached to overlying skin but may be attached to the underlying periosteum Pg. 9 - Be able to figure out what is missing in an HPI (scenario, OLDCART method) • Onset • Location • Duration • Characteristics • Aggravating factors • Relieving factors • Treatment Pg. 6 - Know what subjective information is • What the patient tells you • The symptoms and history, from chief complaint through review of systems Ex: Mrs. G is a 54 year old hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left Know risk factors of melanoma (pg. 177) Know signs of subarachnoid hemorrhage (pg. 216) • Severe and sudden “worst headache of my life!” Nausea and vomiting can be present. Neck stiffness with resistance to flexion is present in 21-86% of patients Know how to make a pelvic exam less intimidating (pg. 76) • Avoid interviewing a patient when she is already positioned for a pelvic exam Know that if 1 patient returns from a country with malaria you still need to be selective of which patients you screen for malaria. (pg. 66?) Know what absence seizures are. (pg. 781) • A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. • Two subtypes are typical absence (lasts less than 10 sec and stops abruptly) • And atypical absence (may last more than 10 sec). • Post ictal state: no aura recalled. In typical absence, there is a prompt return to normal and in atypical there might be some postictal confusion. Know which cranial nerve you assess when you touch the soft palate and view the uvula (pg. 257). • Cranial nerve X (Vagus) Know signs of increased intracranial pressure (pg. 280). • Papilledema of the optic disc elevated ICP causes intraaxonal edema along the optic nerve leading to engorgement and swelling on the optic disc o pink, hyperemic, loss of venous pulsations, disc more visible, disc swollen with blurred margins, physiologic cup not visible) • Headache, blurred vision, feeling less alert than usual, vomiting, changes in behavior, weakness or problems with moving or talking, lack of energy or sleepiness Know the signs or respiratory distress (p. 318) • Tachypnea: greater than or equal to 25 breaths/min pneumonia and cardiac disease • Cyanosis or pallor (signals hypoxia) • Audible sounds of breathing: audible whistling during inspiration over the neck or lungs o stridor signals upper airway obstruction in the larynx or trachea • Contraction of the accessory muscles of the neck or supraclavicular retraction, contraction of the intercostal or abdominal oblique muscles o Is the trachea midline? Know what objective information is (pg. 6) • What you detect during the examination, laboratory information, & test data. All physical exam findings, or signs. Know what can cause epistaxis (p. 220) • Trauma (especially nose picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies Know the signs of otitis externa (swimmer’s ear) (pg. 245) • Painful movement of the auricle and tragus (tug test) Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear occurs in otitis media. in acute otitis externa (Fig. 7-43), the canal is often swollen, narrowed, moist, pale, and tender. It may be reddened. Know the signs of pneumonia (pg. 322-340) • Dullness replaces resonance, crackles can arise from abnormalities of the lung parenchyma, pleural rubs, localized bronchophony and egophony (in patients with fever and cough the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia. • Pleuritic pain: sharp, knifelike, aggravated by deep inspiration, coughing, movements of the trunk. Often persistent and severe. • Pg 333: dyspnea, pleuritic pain, cough, sputum, fever. Pg. 339 goes over physical findings in lobar pneumonia Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural effusion three to four times more likely, respectively. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural effusion three to four times more likely, respectively. Know the physical signs of meningitis (pg. 765) • Neck stiffness with resistance to flexion is present in approx. 84% of patients with acute bacterial meningitis (won’t be able to touch chin to chest) Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve (Brudzinski sign), and the sciatic nerve (Kernig sign). Neck stiffness with resistance to flexion is found in ∼84% of patients with acute bacterial meningitis and 21% to 86% of patients with subarachnoid hemorrhage. It is most reliably present in severe meningeal inflammation but its overall diagnostic accuracy is low. Know the signs of asthma (p. 326, 334) • Cough at times with this mucoid sputum, especially near the end of an attack. Episodic wheezing and dyspnea, but cough may occur alone, often with a history of allergies. In the advanced airway obstruction of severe asthma, wheezes and breath sounds may be absent due to low respiratory airflow (the “silent chest” which is a clinical emergency). • Abnormal retraction occurs in severe asthma. Know the signs of lyme disease (pg. 208) • Rash, often in a bull’s-eye pattern (erythema migrans) and flu-like symptoms, fever, headache, fatigue Know what acanthosis nigricans can clue into (pg. 207 & 440) Diabetes mellitus Know what Mongolian spots are pg. 816 • A dark or bluish pigmentation over the buttocks and lower lumbar regions common in newborns of African, Asian and Mediterranean descent, • Also called slate blue patches o Result from pigmented cells in the deep layers on the skin o Less noticeable with age and disappear during childhood • Document these pigmented areas to avoid later concern about bruising Know red flags for headaches (p. 216) • Progressively frequent or severe over a 3-month period • Sudden onset like a “thunderclap” or “the worst headache of my life” • New onset after age 50 • Aggravated or relieved by change in position • Precipitated by Valsalva maneuver or exertion • Associated symptoms of fever, night sweats, or weight loss • Presence of cancer, HIV infection, or pregnancy • Recent head trauma • Change in pattern from past headaches • Lack of similar headache in the past • Associated papilledema, neck stiffness, or focal neurologic deficits The three most important attributes of headache are its severity, its chronologic pattern, and its associated symptoms Know labs to check with vitiligo (pg. 191) • Thyroid panel: TSH, free T3 and free T4, CBC C-section (pg. 10) • Know that it should be listed under surgeries, make sure you include date indication and type of surgery Subjective info (p. 12) • Goes under the review of systems, includes items that the patient reports to you Where to sit when interpreter in the room (p. 90) • Arrange sitting so that you have easy eye contact with pt , have the interpreter sit close or behind you (keeps you from turning your head back and forth) Know what is included in constitutional symptoms (pg. 112) • Concerning s/s fatigue, weakness, fever, chills, night sweats, weight change and pain. (pg. 192) know how psoriasis presents • If you run ur fingers over a lesion and its palpable above the skin – its raised, over one cm its PLAGUE under one cm its PAPULE (pg. 231)know what visual acuity means, 20/100 • Means that at 20 feet the patient can read a print that a person with normal vision could read at 100 ft, the larger the second number the worse the vision First # indicates the distance from the chart (pg. 241) see the picture and know what cotton whool patches look like, • Its irregular patches seen at diabetic and hypertensive retinopathy (pg. 270) Know how a subconjunctival hemorrhage presents • Benign, no treatment required, resolves in 2 weeks , Leakage of blood outside the vessel producing homogenous red area. , no ocular discharge, vision not affected, Usually resulting from trauma, or sudden increase in venous pressure (pg. 310) Know to consider Angina Pectoris as a differentia with CP. • It can be a cause for pain in the myocardium. A clenched fist over the sternum suggest angina pectoris A clenched fist over the sternum suggests angina pectoris; a finger pointing to a tender spot on the chest wall suggests musculoskeletal pain; a hand moving from the neck to the epigastrium suggests heartburn. Olfactory CN I (pg. 736) • The decreased sense of smell is normal in elderly patients, head trauma, smoking, cocaine use and Parkinson’s d/e. Shoulder shrug (pg. 740) • Testing the CN XI Spinal Accessory nerve. Put your hands on pt shoulder and ask them to shrug against your hands- asses for strength and contraction of trapezii. Weakness noted with atrophy and points to a peripheral nerve disorder. Vasovagal syncope causes (pg. 778) • Reflex withdrawal of sympathetic tone and increased vagal tone causing a drop in BP and HR. • Usually precipitated by strong emotions such as fear or pain, prolonged standing or hot humid environment. • Predisposing factors – fatigue, hunger, dehydration, diuretics, vasodilators Know how to distinguish jugular venous pulsation vs carotid pulse (pg. 377) • Jugular: rarely palpable, soft bi-phasic undulating quality (usually with 2 elevations and characteristic inward deflection), pulsations eliminated by light pressure on the vein just above the sternal end of the clavicle, height of pulsation changes with position (normally dropping as the patient becomes more upright), height of pulsations usually falls with inspiration • Carotid: palpable, a more vigorous thrust with a single outward component, pulsations not eliminated by pressure on veins at sternal end of clavicle, height of pulsations unchanged by position, height of pulsations not affected by inspiration Know where the cricoid cartilage is (pg. 258) Know what atrium or ventricle you feel when you palpate the chest (pg. 385-389) • Left ventricular area: the apical pulse or point of maximal impulse (PMI)- best palpated with the patient lying supine in the left lateral decubitus position which displaces the apical pulse to the left. Locate the interspaces, usually the 5th or 4th which give the vertical location and the distance in cm from the midclavicular line which gives the horizontal location. • Right ventricular area: the left sternal border in the 3rd, 4th and 5th interspaces • *text makes no mention of palpation of the atria • Pulmonic Area—The Left 2nd Interspace. This interspace overlies the pulmonary artery. As the patient holds expiration, inspect and palpate for pulmonary artery pulsations and transmitted heart sounds, especially if patients are excited or examined after exercise. • Aortic Area—The Right 2nd Interspace. This interspace overlies the aortic outflow tract. Search for pulsations and palpable heart sounds. Know how to listen for aortic regurgitation pg. 392 • Ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration. • Press the diaphragm on your stethoscope on the chest and listen along the left sternal border and at the apex, pause periodically so the patient may breathe o You may miss the soft diastolic decrescendo unless you listen at this position Know what valve you are listening to when you listen to the apex of the heart Pg. 391 • Mitral valve • Have the patient roll onto left lateral decubitus position which brings the left ventricle closer to the chest wall o Place bell of your stethoscope lightly on the apical impulse S3 & S4, mitral murmurs & mitral stenosis Possibly not covered yet Know what perseveration is when talking about using words repeatedly (pg. 162) Perseveration is repetition of the words and phrases of others, occurs in schizophrenia and other psychotic disorders Know that in a 47-year-old man ED is usually psychologic rather than testosterone (pg. 546) Erectile dysfunction may be from psychogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes When performing a breast exam, know what abnormal masses should do when the arm moves (pg. 436, 439, 444) Fibroadenoma: very mobile Cysts: mobile Cancer: may be fixed to skin or underlying tissues (may cause dimpling of skin or retraction when arms are lifted over head or hands are pressed against hips) Know that a high proportion of breast masses are noted during BSE Know Tanner staging of breasts in females (pg. 897 table with pictures) Stage 1: preadolescent- elevation of nipple only Stage 2: breast bud stage- elevation of breast and nipple as a small mound; enlargement of areolar diameter Stage 3: further enlargement of elevation of breast and areola, with no separation of their contours Stage 4: projection of areola and nipple to form a secondary mound above the level of breast Stage 5: mature stage- projection of nipple only; areola has receded to general contour of the breast (although in some individuals the areola continues to form a secondary mound) Know where pain is located with pancreatitis (pg. 488) Acute: epigastric, may radiation straight to the back of other areas of the abdomen; 20% with severe sequelae of organ failure Chronic: epigastric, radiating to back Know how hepatitis A is transmitted (pg. 466) • Transmitted through fecal-oral route. Fecal shedding followed by poor handwashing contaminates water and foods leading to infection of household and sexual contacts Know different forms of incontinence (pg. 497-498) Stress incontinence: the urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance. Causes include childbirth and surgery, postmenopausal atrophy of the mucosa, and urethral infection. May follow prostate surgery in men. Urge incontinence: detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. Mechanisms: Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above sacral level. Also hyperexcitability of sensory pathways ie: bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes ie: frequent voluntary voiding at low bladder volumes. Overflow incontinence: detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void. Mechanisms: obstruction of the bladder outlet ie: BPH or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc ie: diabetic neuropathy. Functional incontinence: the patient is functionally able to reach the toilet in time because of impaired health or environmental conditions. Mechanism: problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Also environmental factors such as an unfamiliar setting, distant bathroom facilities, bedrails, or physical retraints. Incontinence secondary to medications: drugs may contribute to any type of incontinence listed. Ex: sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics. Know where lymph nodes should be with strep ?pg 260 + google • Strep throat streptococcal pharyngitis, bacterial infection that may cause a sore, scratchy throat • Common childhood infection has a classic presentation of erythema of the posterior pharynx and palatal petechiae • Enlarged swollen cervical lymph nodes superficial cervical lymph nodes o Superficial cervical superficial to the sternocleidomastoid What vaccines are safe during pregnancy pg. 937 • Tdap during each pregnancy 27-36 weeks of gestation regardless of prior immunization history • Influenza vaccine at any trimester during influenza season • Pneumococcal, meningococcal, Hepatitis B • MMR, polio and varicella NOT DURING PREGNANCY o Rubella titers drawn during pregnancy and immunized after birth if nonimmune • Check RH(D) and antibody type during first prenatal visit, at 28 weeks and delivery o Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks and again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive Know what to be concerned about if you note an irregular rectal mass Pg. 618 • Any masses with irregular borders suspicious for rectal cancer A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining ano-rectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. Know what HPV Vac protects against Pg. 577, 578 • Prevents infection from HPV subtypes 16, 18, 6 & 11 which cause 90 % of genital warts • The bivalent vaccine prevents infection from subtypes 16 and 18. • Recommended for prevention of cervical, vulvar, and vaginal cancers and precancers in females as well as anal cancer, precancers, and genital warts in both female and males • Vaccinated women should still get cervical cancer screening because vaccines do not prevent all HPV subtypes • Condoms does not eliminate the risk of cervical HPV infection • Recommended for those with compromised immune systems including HIV Know what a 3-year-old can do in regard to jumping and balancing pg. 853 • Climbs well, runs easily • Pedals a tricycle • Walks up and down stairs, one foot on each step Know where to place measuring tape when measuring uterus in a pregnant patient Pg. 944 • Measure the fundal height if gestational age is >20 weeks fundus should reach the umbilicus • Place tape measure on pubic symphysis and place the “zero” end of the tape measure when you can firmly feel that bone. • Extend the tape measure to the very top of uterine fundus and note the number of cm measured. o Subject to error between 16-36 weeks • Number should roughly equal the number of weeks of gestation o If fundal height is >4cm than expected multiple gestation, large fetus, extra amniotic fluid, uterine leiomyoma o If fundal height is < 4cm than expected low-level amniotic fluid, missed abortion, intrauterine growth retardation, or fetal anomaly Know where pain is located in pancreatitis (pg. 488) Acute pancreatitis: epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure. Chronic pancreatitis: epigastric: radiating to back Know what atrium or ventricle you feel when you palpate the chest (pg. 343) The right ventricle occupies most of the anterior cardiac surface Know what bleeding between periods is called (pg. 570) Abnormal uterine bleeding, Intermenstrual bleeding Know where pain from lateral epichondolitis presents (tennis elbow) pg. 702 Pain and tenderness develop 1 cm distal to the lateral epicondyle and possibly in the extensor muscle close to it. When pt tries to extend the wrist against resistance, pain increases. Know types of vaginosis (pg. 598) Trichomonal vaginitis: Cause: Trichomonas vaginalis (a protozoan), often but not always acquired sexually. Discharge: yellowish, green, or gray, possibly frothy. Often profuse and pooled in the vaginal fornix; may be malodorous. Other symptoms: Pruritus (not usually as severe as with candida), pain on urination, dyspareunia. Vuvlva and vaginal mucosa: Vestibule and labia minora may be erythematous; the vaginal mucosa may be diffusely reddened, with small red granular spots or petechiae in the posterior fornix. In mild cases the mucosa looks normal. Lab eval: Scan saline wet mount for trichomonads Candidal Vaginitis: Cause: Candida albicans, a yeast (normal overgrowth of vaginal flora); many factors predispose, including antibiotic therapy. Discharge: White and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous. Other symptoms: Pruritis, vaginal soreness, pain on urination (from skin inflammation); dyspareunia. Vulva and Vaginal Mucosa: The vulva and even the surrounding skin are often inflamed and sometimes swollen to a variable extent; the vaginal mucosa is often reddened, with white tenacious patches of discharge; the mucosa may bleed when these patches are scraped off; in mild cases the mucosa looks normal. Laboratory evaluation: scan potassium hydroxide (KOH) preparation for the branching hyphae of candida. Bacterial vaginosis: Cause: bacterial overgrowth probably from anaerobic bacteria; often transmitted sexually. Discharge: Gray or white, thin, homogenous, malodorous, coats the vaginal walls, usually not profuse, may be minimal. Other symptoms: unpleasant fishy or musty genital odor; reported to occur after intercourse. Vuvla and vaginal mucosa: The vulva and vaginal mucosa usually appear normal. Laboratory evaluation: Scan saline wet mount for clue cells (epithelial cells with stippled borders); sniff for fishy odor after applying KOH (“whiff test”); test the vaginal secretions for pH >4.5. Know what miliaria rubra (pg. 819) Scattered vesicles on an erythematous base, usually on the face and trunk, result from obstruction of the sweat gland ducts; disappears spontaneously within weeks (refer to pic on pg. 819) Know the characteristics of a breast cyst (pg. 423) Usually soft to firm, round, mobile and often tender. Most common between the ages of 25-50 Know the signs of peritonitis (pg. 486) When tender area is palpated for guarding, early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness. See findings suggestive of peritonitis secondary to possible appendicitis pg. 485-486) Know where pain is with diverticulitis (p. 488-489) Left lower quadrant Know what position to have pt in to listen for mitral stenosis (pg. 382 & 383) Left lateral decubitus Know what to ask in regards to cardiovascular review of systems (pick the one that belongs) (pg. 357) Ask questions related to: chest pain, palpitations, shortness of breath, swelling (edema), syncope. Review info on pages 355-358 of text Know how a bartholin’s gland infection presents (pg. 597) Acutely, the gland appears as a tense, hot, very tender abscess. Possible labial swelling. Look for pus emerging from the duct or erythema around the duct opening. Chronically, a nontender cyst is felt that may be large or small. Know where pain is with appendicitis (pg. 457, 488) RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation is suspicious for appendicitis. Know how syphilis presents genitally (pg. 291, pg. 597, pg. 557) Female: syphilitic chancre- firm, painless ulcer from primary syphilis, forms approx. 21 days after exposure to Treponema pallidum. It may remain hidden and undetected in the vagina and heals regardless of treatment in 3-6 weeks. Secondary syphilis (Condyloma lantum)- large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. These are contagious and, along with rash and mucus membrane sores in the mouth, vagina, or anus are manifestations of secondary syphilis. Male: Primary syphilis: small red papule that becomes a chancre, a painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3-8 weeks. Know the signs of proctitis (pg. 609) Anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggest proctitis. Know what causes dark, bloody emesis (pg. 458) Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or peptic ulcer disease. Know what causes an S3 heart sound (know the mechanics of the disease) (pg. 348) In children and young adults, a third heart sound (S3) may arise from rapid deceleration of the column of blood against the ventricular wall. In an older adult, an S3 usually indicates a pathologic change in ventricular compliance. Know the signs of thrombophlebitis (pg. 525) Local swelling, redness, warmth, and a subcutaneous cord signal superficial thrombophlebitis (an emerging risk factor for DVT). Know what chalazion is (pg. 275) A subacute nontender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed, but unlike a stye, usually points inside the lid rather than on the lid margin. Pic on pg 275. Know what the lungs do with age (pg. 960) Chest wall becomes stiffer and harder to move (decrease in chest wall compliance), respiratory muscles may weaken, and the lungs lose some of their elastic recoil. Lung mass and the surface area for gas exchange decline, and residual volume increases as the alveoli enlarge. An increase in closing volumes of small airways predisposes to atelectasis and risk of pneumonia. Diaphragmatic strength declines. Know what diastasis recti is (pg. 930) As tension on the abdominal wall increases with advancing pregnancy, the rectus abdominus muscles may separate at the midline, called diastasis recti. If diastasis is severe, especially in multiparous women, only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall, and fetal parts may be palpable through this muscular gap. Identify macula in the eye (pg. 228) Refer to picture on pg 228 Know the sequence of the abdomen (pg. 22) Inspect, auscultate, percuss, palpate (first palpate lightly, then deeply). Assess the liver and spleen by percussion then palpation. Try to palpate the kidneys. Palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles. Senile (Actinic) Pupura (pic) pg. 990 Know the signs of epididymitis (pg. 560) Acute epididymitis: an acutely inflamed epididymis is indurated, swollen, and notably tender, making it difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. (pic on pg. 560) Know what to do if you cannot feel a testicle in the scrotum of a newborn (pg. 840) If you feel a testis up in the inguinal canal, gently milk it downward into the scrotum. Need to differentiate between undescended testes (in the inguinal canals) and highly retractile testes. Know the sign factors of prostate cancer (pg. 610) Risk factors: age: rare in ages below 40 but incidence rates begin increasing rapidly after age 50. Median age at diagnosis is 66. Ethnicity: African American men have the highest incidence and mortality rates. Compared to white men, a higher percentage of African American men are diagnosed with prostate cancer before age 50. They are also more likely to present with advanced-stage cancer. Family history: Genetics appear to play an important role in prostate cancer risk. For men with one affected first degree relative (father, brother) risk of developing prostate cancer increases two fold. For men with 2 or 3 affected first degree relatives, risk increases 5-11 fold. The BRCA1 and BRCA2 mutations also appear to confer increased risk of prostate cancer. Other risk factors: Agent Orange exposure among Vietnam veterans, diets high in animal fat, obesity, and cigarette smoking. BPH is NOT a risk factor. Know what chicken pox looks like (will be a description) (pg. 923) Picture located on pg 923, but no description included Know the signs of candida vaginitis (pg. 598) Discharge that is white and curdy, may be thin but typically thick, not malodorous. Often accompanied by pruritis, vaginal soreness, pain on urination (from skin inflammation) and dyspareunia. Vulva and surrounding skin are often inflamed and sometimes swollen to a variable extent. The vaginal mucosa is often reddened with tenacious patches of white discharge. Know what to do if a patient has vague complaints with negative work-up screen for depression (pg. 150) Know to screen for depression with vague complaints and negative work-up Know when to order ABI (pg. 519)????? Risk factors for LE Peripheral Artery Disease: 1. Age greater than or equal to 50 with a hx of DM or smoking 2. Leg symptoms with exertion 3. Nonhealing wounds Know which lymph node group is most commonly involved in breast cancer (pg. 441) Central nodes (axillary) Know the Risk Factors for PAD (pg. 509) See answer above about ABI. Also: smoking, diabetes, obesity (BMI >30), high blood pressure, high cholesterol, increasing age (especially over 50), family hx of PAD, heart dis, or stroke. Know what Condylamata Acuminata is (pg. 557) Genital warts- single or multiple papules or plaques of variable shapes; may be round, acuminate (pointed), or thin and slender. May be raised, flat, or cauliflower like (verrucous). Caused by HPV, usually strains 6 & 11. Incubation usually weeks to months. Infected contact may have had no visible warts. Occasionally cause itching and pain. May disappear without treatment. Can arise on penis, scrotum, groin, thighs, or anus (in males). Know the differentials for epigastric pain (pg. 455) GERD, pancreatitis, and perforated ulcers, myocardial ischemia Know what a bounding pulse is on a number scale 0-3 (pg. 522) Bounding = 3+ Know what an 8-month-old child should be able to do in regards to standing, using words, and vocalizing what he wants (pg. 810) Can pull up to stand, say “mama” and “dada” and indicates wants by vocalizing and pointing Know what brief test you can do to assess memory (pg. 165) Serial 7’s: poor performance may result from delirium, the late stages of dementia, intellectual disability, anxiety or depression. Also need to consider educational level. Spelling backward New learning activity: 3 to 4 word recall- give the patient 3 words and have them repeat them so that you know they heard them. Then ask them to recall the words 3-5 minutes later. Differentiate delirium vs dementia (pg. 1001) Study table on pg. 1001 of text Know what an ulcer due to venous insufficiency looks like (pg. 525, 538) Usually appears over the medial and sometimes lateral malleolus. Ulcer contains small, painful granulation tissue and fibrin; necrosis or exposed tendons are rare. Borders are irregular, flat, or slightly steep. Pain effects QOL in 75% of patients. Associated findings include edema, reddish pigmentation and purpura, venous varicosities, the eczematous changes of stasis dermatitis (redness, scaling, and pruritis), and at times cyanosis of the foot when dependent. Gangrene is rare. Pic on page 538 Know why venous insufficiency causes edema, swelling, and ulceration (pg. 533) It arises from chronic obstruction and incompetent valves in the deep venous system. Know the causes of increased jugular venous pressure (pg. 377) Highly correlated with both acute and chronic heart failure. Also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis. Know what a retracted tympanic membrane with effusion looks like (pg. 288) Top picture on pg. 288: amber fluid behind the ear drum is characteristic Know the signs of ectopic pregnancy (pg. 603) Clinical presentations of ectopic pregnancy range from subacute, approx. 80-89%, to shock from rupture and intraperitoneal hemorrhage (10-30% of cases). Most common clinical features: abdominal pain, adnexal tenderness, and abnormal uterine bleeding. In more than half there is a palpable adnexal mass that is typically large, fixed, and ill-defined at times with adherent omentum or small or large bowel. In milder cases, there may be a prior history of amenorrhea or other symptoms of pregnancy. Know the signs of prostatitis (pg. 623) Acute bacterial prostatitis: presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding and sometimes low back pain. The gland feels tender, swollen, “boggy” and warm. Chronic bacterial prostatitis: is associated with recurrent UTI’s, usually from the same organism. Men may be asymptomatic or have symptoms of dysuria or mild pelvic pain. The prostate gland may feel normal, without tenderness or swelling. Know what atopic dermatitis looks like (pg. 911) Eczema: erythema, scaling, dry skin, and intense itching. Pic on pg. 911 Know the signs of depression (pg. 157) Early signs: low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders and difficulty concentrating or making decisions. Vulnerable populations: young, female, single, divorced, or separated, or chronically ill, bereaved, or have other psychiatric disorders, including substance abuse. Know when to give the tetanus vaccine (pg. 980) All adults age 19 or older who have not received a Tdap should receive a single dose regardless of the time interval since last Td. After receiving Tdap they should receive Td boosters at 10 year intervals. For adults 65 and older this will reduce the likelihood of transmission to infants under 12 months. Know the risk factors for breast cancer (pg. 425) ***Age: (65+ vs <65 years although risk increases across all ages until age 80) Biopsy- confirmed atypical hyperplasia Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2) Ductal carcinoma in situ Lobular carcinoma in situ Personal hx of early onset breast cancer (<40 years) Two or more 1st degree relatives diagnosed with breast cancer at an early age Age of first full term pregnancy Late menopause Breast tissue density Modifiable risk factors: breastfeeding for less than 1 year, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception. Know the signs of BPH (pg. 623) Symptoms arise from both smooth muscle contraction in the prostate and bladder neck and from compression of the urethra. They may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining), or both and are seen in more than 1/3 of men by age 65. The affected gland may be normal in size, or may feel symmetrically enlarged, smooth, and firm, though slightly elastic; there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen. Know the signs of elder abuse (pg. 985) Elder mistreatment includes abuse, neglect, exploitation, or abandonment. Prevalence is highest in adults with dementia and depression. COULD NOT FIND SPECIFIC LIST OF SIGNS Know the signs of rectal prolapse (pg. 621) On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, appearing as a doughnut or rosette of tissue. A prolapse involving only mucosa is relatively small and shows radiating folds (pic on pg. 621). When the entire bowel is involved, the prolapse is larger and covered by concentrically circular folds. Know what a onychomycosis looks like (pg. 212) See pic at the top of pg. 212 Know the signs of gestational HTN (pg. 942) Gestational is systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) > 90 mm Hg first documented after 20 weeks, without proteinuria or preeclampsia, that resolves by 12 weeks postpartum. Know that age is a big risk factor for breast cancer (425) *Included on the answer above Know what to do if you feel an abdominal mass (pg. 487) Occasionally there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again. Know the best way to examine the lateral portion of the breast (pg. 437) Ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue. Begin palpation in the axilla, moving in a straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle. Continue in vertical overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast. Know what functional syndrome is (pg. 150) The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability, than by consistently demonstrable tissue abnormality. Examples include IBS, fibromyalgia, chronic fatigue, TMJ disorder, and multiple chemical sensitivity. Functional syndromes have been shown to “frequently co-occur and share key symptoms and selected objective abnormalities.” The co-occurrence rates for common functional syndromes such as IBS, fibromyalgia, chronic fatigue, TMJ disorder, and multiple chemical sensitivity reach 30-90%, depending on the disorders compared. The prevalence of symptom overlap is high in the common functional syndromes, name complaints of fatigue, sleep disturbance, musculoskeletal pain, HA, and GI problems. The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy. Know hemorrhoid vs polyp vs cancer (pg. 621) Internal hemorrhoids: enlargements of the normal vascular cushions located above the pectinate line, usually not palpable. May cause bright red bleeding, especially during defecation. They may also prolapse through the anal canal and appear as reddish, moist, protruding masses. Pic on pg. 621 Polyps of the rectum: fairly common and variable in size and number, they can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile). They are soft and may be difficult or impossible to feel even when in reach of the examining finger. Endoscopy and biopsy are needed for differentiation of benign from malignant lesions. Pic on pg. 622 Cancer of the rectum: usually firm, nodular, rolled edge. Pic on pg. 622 Know what causes a split S2 (what is going on in the heart) (pg. 349) During inspiration the right heart filling time is increased, which increases right ventricular stroke volume and the duration of right ventricular ejection compared with the neighboring left ventricle. This delays the closure of the pulmonic valve, P2, splitting S2 into its two audible components. Can be heard at the 2nd and 3rd left intercostal spaces close to the sternum. Know that the Buerger test is for chronic arterial insufficiency (pg. 530) Postural color changes of chronic arterial insufficiency: if pain or diminished pulses suggest arterial insufficiency, consider looking for postural color changes using the Buerger test. Raise both legs to about 90 degrees for up to 2 min until there is maximal pallor of the feet. Then ask the patient to sit up with legs dangling down, compare both feeting noting the time required for: Return of pinkness of the skin, normally about 10 sec or less Filling of the veins of the feet and ankles, normally about 15 Know the causes of increased jugular venous pressure (pg. 377) Elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, SVC obstruction, cardia tamponade, and constrictive pericarditis
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